Session 4: Delivery Hospital as Safety Net

1. Lisa Jacques-Carroll, MSW NCIRD, CDC Session 4:Delivery Hospital as Safety Net

2. Learning Objectives • Explain how to work with delivery hospitals in the prevention of perinatal hepatitis B infection • describe the importance of delivery hospitals in preventing perinatal hepatitis B virus (HBV) transmission • identify methods health departments can use to work with delivery hospitals

3. Overview • Background • ACIP-recommended hospital policies • Education/working with hospitals • Assessing hospitals • Hepatitis B vaccination at birth

4. Rationale for Birth Dose Hepatitis B Vaccine • Provides safety net to prevent perinatal HBV infections • Prevents 70%-95% of transmission to infants born to HBsAg-positive women • Protects children born to HBsAg-negative women from household transmission I got hepatitis B vaccine at birth

5. Importance of Delivery Hospitals • Delivery hospital is the safety net to prevent perinatal hepatitis B: • last opportunity to determine pregnant woman’s HBsAg status • immunoprophylaxis for infants born to HBsAg-positive/unknown-status women • hepatitis B birth dose to all newborns

6. 2004 U.S. Birth Statistics* • 95.3% of births to women known to have received prenatal care (at least one visit) • 99.1% of births occurred in a hospital • 24.1% of births were to foreign-born mothers *Source: NCHS 2004 Birth Certificate Data

7. HBsAg Prevalence Among Pregnant Women by Prenatal Screening Status Philadelphia, 1991 Prenatal # of Women HBsAg-positive Screening Tested # (%) Yes 1,555 12 (0.8) No 208 14 (6.7) Source: JAMA 1991;266:2852-5

8. CDC 2006 National Hepatitis B Hospital Survey- Preliminary Data • Medical record reviews of 191 delivery hospitals revealed: • discrepancies in maternal HBsAg-status between maternal and infant records • hep B vaccine NOT given within 12 hours to: • 17%infants born to HBsAg-positive women • 39% infants born to unknown status women • HBIG NOT given within 12 hours to: • 33%infants born to HBsAg-positive women • 96% infants <2000g born to unknown-status women

9. ACIP-Recommended Hospital Policies: On Admission • On admission for delivery: • review HBsAg status of woman • include copy of original lab report in maternal and infant medical records • perform HBsAg testing on women who: • do not have a documented result • are high risk* • had clinical hepatitis since previous testing *Women with >1 sex partner in past 6 months, evaluated or treated for an STD, injection drug user, or have an HBsAg-positive sex partner

10. ACIP-Recommended Hospital Policies: After Delivery • After delivery: • administer appropriate prophylaxis to infants* born to HBsAg-positive and unknown-status women • determine status of HBsAg-unknown women • administer a dose of hepatitis B vaccine to all newborns • educate HBsAg-positive women about HBV *See 2005 ACIP recommendations for details on infants <2000 grams

11. ACIP-Recommended Hospital Policies: At Discharge • At the time infant is discharged: • provide infant’s immunization record to mother, and • remind her to take it to infant’s healthcare provider

12. Educate Hospitals on Policies • Educate hospitals on policies and standing orders that should be in place to prevent perinatal hepatitis B transmission

13. Educate Hospitals on Reporting • Encourage hospitals to report all infants born to HBsAg-positive women • consider a reporting form for hospitals to fax to health department • include HBIG and hepatitis B documentation • educate hospital staff on documenting on universal reporting mechanisms (if applicable) • maternal HBsAg status • infant HBIG and hepatitis B vaccination

14. Case Management at Hospitals • Notify hospitals of HBsAg-positive women who plan to deliver at their facility • some programs send monthly lists to hospitals • Remind hospitals to: • follow-up on HBsAg-unknown status women • treat infants born to HBsAg-positive and unknown-status women • report infants born to HBsAg-positive women

15. Hospital Quality Improvement • Carefully review care received by each infant born to an infected woman • identify any gaps/errors that occurred at the hospital • communicate these gaps/errors to appropriate hospital staff • report perinatal infections to Joint Commission if errors occurred at delivery

16. Assessing Hospitals • Conduct hospital policy surveys and medical record reviews every five years at delivery hospitals to evaluate policies and practices on: • maternal HBsAg screening • post-exposure prophylaxis (PEP) to infants born to HBsAg-positive and unknown women • universal hepatitis B birth dose vaccination

17. Assessing Hospitals- cont’d • Consider conducting medical record reviews targeting unknown status women to ensure infants receive appropriate care • use vital statistics birth data for women with no prenatal care • partner with other health department staff (HIV, STD) to review records

18. NIS Birth Hepatitis B Vaccination Rates at 0-2 Days, United States

19. NIS Birth Hepatitis B Vaccination Coverage*, 2006 NYC Philly Chicago DC Coverage (%) <30 San Antonio Houston 30-49 50-69 * 0-2 days from birth > 70

20. Hepatitis B Vaccination at Birth • Monitor state, city, and hospital-level hepatitis B birth dose rates (using National Immunization Survey (NIS), Immunization Information System (IIS), and/or medical record reviews) • Work with hospitals with low birth dose rates to identify barriers and increase coverage

21. Birth Vaccination- cont’d • Encourage hospitals to incorporate administration of the birth dose into routine infant care • Encourage delivery hospitals to enroll in the Vaccines for Children Program (VFC) to receive vaccine at no charge for VFC-eligible newborns • Projects with a universal birth dose vaccine supply have higher NIS birth dose rates

22. Conclusion • Delivery hospitals are the safety net to prevent hepatitis B virus transmission to newborns