**FTS-NCHSTP**

**Moderator: Dale Babcock**

**April 9, 2008**

**11:00 am CT**

Coordinator: Thank you for standing by. At this time all participants
are in a listen only mode. After the presentation today, we will conduct
a question and answer session. To ask a question at that time, you will
press star 1.

Today's conference is being recorded. If you have objections, you may
disconnect at this time. And I'd like to turn the meeting over to Dr.
Andrew Kroger. You may begin sir.

Andrew Kroger: Thank you and good day everybody. Welcome to Essentials
of Perinatal Hepatitis B Prevention, a Training Series for Coordinators
and Case Managers 2008.

Today is the second of this four-part series. I'm Andrew Kroger, a
medical officer in the Education Information and Partnership branch of
the National Center for Immunization and Respiratory Diseases and I will
be the moderator for today's session. To participate in today's program
you need a telephone connection and a separate Internet connection.

In this four part-series, part one focuses on case identification, part
two deals with case management; which is today's, part three addresses
assessment and evaluation and part four focuses on the delivery hospital
as safety net.

The learning objective for this session is: describe the key components
of case management in a perinatal hepatitis B prevention program. Today
is April 9, 2008 and the topic for today is case management. For today's
program we have Lisa Jacques-Carroll, Public Health Advisor with the
Program Operations Branch of the National Center for Immunization and
Respiratory Diseases and Amy Warner, a program manager in the Viral
Hepatitis Program in the Colorado Department of Public Health and
Environment.

Today they will discuss case identification and we will include multiple
question and answer sessions. Dr. Susan Wang, a medical officer and the
acting chief of the prevention branch in CDC's Division of Viral
Hepatitis will participate in the question and answer session.

There will be additional learning materials available, materials and
Power Point presentations. They are currently online at
[www.2a.cdc.gov/vaccines/ed/hepbtraning](http://www.2a.cdc.gov/vaccines/ed/hepbtraning)
Please make a note of the following information. If you have technical
trouble, please dial star 0 on your telephone. If you'd like to ask a
question, please press star 1 on the phone.

Continuing education credit is available only through the CDC ATSCR
training and continuing education online system at
[www.cdc.gov/tceonline](http://www.cdc.gov/tceonline) . You must have a
verification code specific to this program to apply for CE credit. The
code will be revealed during the course of the program.

CDC, our planners and presenters wish to disclose that they have no
financial interests or other relationships with the manufacturers of
commercial products, suppliers of commercial services or commercial
supporters.

Presentations will not include any discussion of the unlabeled use of a
product or product under investigational use. So with that, we will
begin our discussion of case management and I'll turn it over to Lisa.

Lisa Jacques-Carroll: Thanks Andrew. Hello. Today I will discuss the
importance of case management of infants born to hepatitis B virus
infected women. As Andrew mentioned, the learning objective for this
conference is to describe key components of case management in a
perinatal hepatitis B prevention program, specifically this includes the
steps in case management for infants born to hepatitis B surface antigen
or HBsAg positive women as well as the data tracking and management
systems programs use to assist with case management.

Case management has always been a major part of perinatal hepatitis B
prevention programs and with good reason. There are important benefits
of case managing infants born to HBsAg positive women. First we know
that infants that receive case management are more likely to receive the
appropriate post exposure prophylaxis of hepatitis B immune globulin or
HBIG, and the first dose of hepatitis B vaccine at birth than infants
that are not case managed.

We also know that case managed infants are more likely to complete their
hepatitis B vaccine series on time which is important because this
ensures these infants are fully protected against the hepatitis B virus.

This diagram illustrates the impact of case management on infants born
to HBsAg positive women in two states, Alabama and Connecticut. In
Alabama, a comparison of infants born between 1990 and 2002 showed that
92% of those enrolled in case management received HBIG and hepatitis B
vaccine at birth versus only 67% of infants that did not receive case
management.

Similarly, 90% of case managed infants completed the hepatitis B vaccine
series by eight months of age whereas only 59% of non-case managed
infants completed the series by eight months.

Connecticut examined outcomes of infants born in 1994 and 1995 and found
that all case managed infants received HBIG and the hepatitis B vaccine
at birth while only 90% of non-case managed infants received the
appropriate prophylaxis at birth.

Also, 90% of case managed infants in Connecticut completed their
hepatitis B vaccine series by eight months of age yet only 48% of
non-case managed infants completed the series by eight months. There is
a definite difference in outcomes for infants that are case managed
compared to those that are not.

This graph depicts the case management outcomes of infants born to HBsAg
positive women that were identified by perinatal hepatitis B prevention
programs in the United States from 1993 through 2005 as reported to the
CDC and the annual perinatal hepatitis B program report.

As you can see, in 2005, 94% of case managed infants received HBIG and
hepatitis B vaccine at birth and 71% received three doses of hepatitis B
vaccine by eight months of age. Post-vaccination testing is by far the
lowest outcome with only 53% of infants being tested in 2005.

However, the percentage of infants that received post-vaccination
testing increases each year. Post-vaccination testing is the most
difficult part of case management because it cannot be done until the
infant is at least nine months of age and many infants are lost to
follow up before receiving their serology tests.

In December of 2005, the Advisory Committee on Immunization Practices,
or ACIP, published updated recommendations on childhood hepatitis B
prevention. Within this document, there are recommended components of
perinatal hepatitis B case management programs.

The first is to identify and track all HBsAg positive pregnant women.
Next is to notify delivery hospitals where HBsAg positive pregnant women
plan to give birth. Case management programs should also ensure that
delivery hospitals appropriately manage infants born to HBsAg positive
and HBsAg unknown status women and that the appropriate standing orders
and written policies are in place.

More information on working with and assessing hospitals will be
provided in the third and fourth sessions of this series. Case
management programs should also ensure that all infants born to HBsAg
positive women complete their hepatitis B vaccine series and receive
post-vaccination serologic testing for HBsAg and the hepatitis B surface
antibodies.

Household and sex contacts of pregnant women should receive pre-
vaccination testing and vaccinations if they're susceptible. Finally,
all case management programs should be routinely monitored and evaluated
and more information on methods for program evaluations and assessments
will be provided in session three of this net conference series.

In order for cases to be managed they must first be identified. The way
in which programs manage perinatal hepatitis B cases varies depending
upon when the case is identified. The best scenario is for a case to be
identified prenatally to give the case worker enough time to educate the
mother, the delivery hospital and the pediatrician on the appropriate
care of the infant and for household and sexual contacts to be
identified, evaluated and vaccinated if appropriate. However, some cases
are not identified until the HBsAg positive woman shows up for delivery
or until some time after delivery.

I will now discuss how infants should be managed at birth depending upon
the mother's HBsAg status. For those infants born to women who are HBsAg
positive, both Hepatitis B vaccines and HBIG should be administered
within 12 hours of birth.

If an infant is born to a woman whose HBsAg status is unknown at the
time of delivery, the infant should receive a dose of hepatitis B
vaccine within 12 hours of birth and the mother should receive stat
testing for HBsAg. If the mother's test result is HBsAg positive, the
infant should receive HBIG as soon as possible but no later then seven
days of age.

The recommendations for infants weighing less than 2000 grams at birth
differ from the routine recommendation, so please follow the ACIP
guidelines for these infants.

When an HBsAg-positive pregnant woman is identified case workers should
take the following steps: first contact the woman's prenatal care
provider to confirm her HBsAg test results, the date that the test was
ordered to ensure that it was during the current pregnancy, her expected
date of delivery, the expected delivery hospital and whether or not the
woman has been evaluated for her hepatitis B virus infection.

Second, notify the delivery hospital that this HBsAg-positive woman
plans to deliver at their facility. Some programs send delivery
hospitals a list of HBsAg-positive women expected to deliver at each
hospital each month.

Next, contact the pregnant woman to provide education and information on
her hepatitis B virus infection. Finally, identify the woman's sex
partners and household contacts including other children for testing,
vaccination and follow up.

When providing education to the woman, discuss her HBsAg positive test
results and what it means to be infected with hepatitis B virus. Explain
the typical course of HBV infection and emphasize the seriousness of
infection in newborns. Make sure she understands how her infant will be
managed at delivery and through post-vaccination testing.

Discuss various other perinatal concerns such as breastfeeding which is
safe for HBsAg-positive mothers. It is important to let the woman know
how she can take care of herself and why it is important that she be
evaluated for her HBV infection. The woman should also be referred to a
physician for evaluation of her infection. There may be treatment
options available to her.

It is very important to educate the mother on how she can prevent
transmission to others and to emphasize the importance of identifying
and vaccinating her sex partners and household contacts. Doing this will
also help protect her new infant.

The following list is a compilation of tips that programs have
identified for successfully working with HBsAg-positive pregnant women.
It is important to use the mother's first language whenever possible.
This may require using a language line or an interpreter. Also try to
use materials with low reading levels if appropriate and visual aids.
Try to provide the woman with materials that she can review at home and
reinforce the messages that you cover during your discussions with
follow up letters after the first interview prior to her due date,
before each infant vaccination is due and before the infant's
post-vaccination testing is due.

Prior to delivery, remind both the woman and the delivery hospital of
the post exposure prophylaxis that the infant should receive at birth.
Some programs give the pregnant woman a card to take to the hospital
with instructions on the appropriate care of the infant. Other programs
send delivery hospitals a monthly list of the HBsAg-positive women
expected to deliver in their facility.

If you have not received information on the birth and the expected date
of delivery has passed, contact the delivery hospital to determine if
the woman has given birth and collect information on the date of
delivery, date and time of hepatitis B vaccination and HBIG
administration and updated contact information on the mother.

If your program learns of an HBsAg-positive woman that is identified at
delivery, contact the mother as soon as possible to provide her with
information on hepatitis B virus. Also ensure that her infant received
both the hepatitis B vaccine and HBIG at the hospital and if the infant
did not receive the prophylaxis, make sure it is administered as soon as
possible.

Proceed with case management of the infant and identify and manage the
mother's sex partners and household contacts. After an infant is born to
an infected woman, remind the infant's pediatrician and the parents
about when each dose of hepatitis B vaccine should be administered and
when post-vaccination serologic testing should be performed, at 9 to 18
months of age, but sooner is better, and after three doses of hepatitis
B vaccine have been administered.

Verify the dates that the hepatitis B vaccines were given. Some programs
may be able to use their immunization information system, or
immunization registry, to check for doses of hepatitis B vaccine.
Finally, review the infant's post-vaccination test results with the
pediatrician to make sure you know the infant's HBsAg status and for
those that do not become infected, to ensure the infant develops
protective antibodies against HBV.

This slide is a guide for interpreting infant post-vaccination test
results. If the infant tests HBsAg negative and has surface antibody
greater than 10 milli-international units per milliliter, the infant is
protected and the case may be closed.

If the infant tests HBsAg negative and the surface antibody is less than
10 milli-international units per milliliter, the infant is not infected
but is also not immune. Revaccinate this infant with three doses of
hepatitis B vaccine and retest one to two months after the final dose.

If the infant tests HBsAg positive, he or she is infected and needs to
be referred for medical evaluation and management for chronic hepatitis
B virus infection. This infant should also be reported to the CDC as a
perinatal hepatitis B infection via the National Notifiable Disease
Surveillance System, or NNDSS.

Many perinatal programs have reminder and recall systems to help
automate case management activities. Reminders notify before a vaccine
or test is due and recalls notify after something is due. Reminders and
recalls can be used for parents, pediatricians and case workers.

Some of the mechanisms used by programs are postcards that are filled
out by a parent and mailed by a provider or health department to remind
the parent that the infant is due for a vaccine or serology. They can
also be in the form of computer generated letters or phone calls to
parents and/or providers.

Some electronic case management systems may contain reminders that
automatically prompt case workers to follow up on deliveries,
vaccinations and serologies that are due. The ideal perinatal hepatitis
B program data tracking and management system would help both manage
cases and evaluate the overall program's success.

Many electronic case management systems allow case workers to index
cases by both the mothers' and infants' names which can be especially
helpful if they do not share the same last name. A good case management
system will also automatically generate reminders for a case manager's
patients and providers.

It is very helpful if a system can generate summary reports at regional
and program-wide levels to assess case management outcomes and identify
areas in need of improvement. Finally, a good system will allow for the
timely entry of program data by case workers.

Some perinatal hepatitis B prevention programs have integrated their
case data with other health department systems. One system that might be
beneficial to connect with is an immunization information system, or
registry, which is helpful because it should contain hepatitis B vaccine
data for infants. Another system that may make sense to connect with is
the communicable disease reporting system which is where all HBsAg
positive women should be reported.

Some programs have added a perinatal hepatitis B case management module
to their health department immunization information system or
communicable disease reporting system.

This slide lists the core data elements that perinatal hepatitis B
prevention programs should collect on HBsAg positive pregnant women. The
last two items, hepatitis B e-antigen and HBV DNA, are not core elements
but are currently being tracked by some programs.

Programs are encouraged to add these test results to their data
collections. CDC is currently developing an expanded data element list
which will eventually be shared with all perinatal hepatitis B
prevention programs.

This slide lists the core data elements that should be collected on all
infants born to HBsAg positive women. Most programs collect these data
but a few items that some programs may not currently be collecting are
the time of HBIG and birth dose hepatitis B administration, the brand of
HBIG and hepatitis B vaccines, and the reasons for loss of follow up if
the case is not completed.

This slide lists the core data elements to collect on household and sex
contacts of HBsAg positive pregnant women.

> The following is a list of program activities that can support case
> management. It is important that state and local case workers receive
> periodic training on perinatal hepatitis B prevention strategies and
> techniques, and that the program maintains the protocol listing all of
> the activities to be performed by public health, hospitals,
> laboratories, and providers.

Delivery hospital staff, prenatal care providers and pediatricians
should be periodically educated on perinatal hepatitis B prevention.
This can be done through trainings, mailings, articles and newsletters,
and various other methods. Programs should also ensure that there are
written policies and procedures in place to support perinatal hepatitis
B prevention in prenatal care settings, delivery hospitals, and
pediatric care settings.

Delivery hospitals should have standing orders to ensure all pregnant
women have been screened for HBsAg, provide prophylaxis to infants born
to HBsAg positive and unknown status mothers, and to administer a dose
of hepatitis B vaccine to all infants prior to hospital discharge.

Additional information on evaluating written policies and standing
orders will be provided in session three of this series and more details
on working with delivery hospitals will be provided in session four of
this series. Thank you for your attention.

Andrew Kroger: Thank you Lisa. We'd now like to invite our participants
to call in and ask questions. To do that, please dial star 1. Be sure to
restrict your questions to the content discussed today and please tell
us your first name and the state that you're from. I am now going to
turn the mic temporarily over to our operator.

Coordinator: Thank you. Once again, to ask a question, press star 1 and
please record your name clearly when prompted.

Andrew Kroger: I think while we wait for our first question to come in,
one of the frequently asked questions we get -- I'll direct this to Lisa
-- is the question about, should we be advising hospitals to administer
HBIG to infants born to hepatitis B surface antigen unknown status women
before they leave the hospital if the test result is not available?

Lisa Jacques-Carroll: Thanks Andrew. The ACIP recommendation states that
infants weighing more than 2000 grams and born to an HBsAg unknown
status mom should receive the hep B vaccine within 12 hours of birth and
that the mother should be tested for HBsAg as soon as possible. And then
if the mom is determined to be HBsAg positive, the infant should then
receive the HBIG as soon as possible, but no later then seven days of
age.

For infants born to HBsAg unknown status moms weighing less then 2000
grams, they should receive both the hep B vaccine and HBIG within 12
hours of birth. However, we know that there are some perinatal
prevention programs that do encourage birthing hospitals to administer
HBIG to infants shortly after birth or prior to hospital discharge if
the mom's HBsAg status remains unknown because they are concerned that
the infant may not be located within seven days of birth to receive the
HBIG if mom's HBsAg result comes back positive.

Andrew Kroger: Okay, so some of them do do it and it's probably a good
idea. Okay, great. Thank you. Why don't we take the first question
that's in the queue? Okay let's see, if we don't have any questions, why
don't we address another question that we commonly receive?

Household contacts, should they receive -- say they become vaccinated,
should they receive post vaccination serologic testing? Susan, do you
want to answer that one?

Susan Wong: Sure, I'd be happy to. The CDC recommendation is that with
regards to household sexual partner and needle sharing contact that the
only group that we routinely recommend post vaccination testing is for
the sex partners.

However, it is consistent with what we do for babies born to infected
mothers that if there are other children in the household and
particularly children of this mother who are going to be vaccinated,
that it would make sense to also do post-vaccination serology on those
children. Since they're at high risk for requiring chronic infection and
you do want to ensure that they are protected.

I also just want to add one additional comment to the previous question
that was asked with regards to HBIG, the reason CDC does not currently
recommend that all babies born to unknown status women receive HBIG
unless they're premature, unless they're less than 2000 grams, is
because HBIG is a blood product and so there are always concerns and
risks with regards to using blood products and certainly there is also
an expense.

So we don't routinely recommend that babies who are greater than 2000
grams born to women who are of unknown status, that they routinely
receive HBIG. I think that if a perinatal program has concerns about
particular abilities to follow up, then that needs to be taken into
consideration if they're automatically recommending that all of those
babies get HBIG, but it's not part of the CDC routine recommendations
because of the issue of both cost and the use of blood products where
there's not absolutely a clear indication for use of them. Thanks.

Andrew Kroger: Thank you. Thanks for the clarification Susan. Why don't
we take a question that's in the queue?

Coordinator: Thank you. Laurie from Ohio, you may ask your question.

Laurie: I have a question about a child that, with the post vaccine
serology does not convert after the first time, so we're going to do a
repeat series. Sometimes the pediatricians ask can they just give one
dose and then retest the child a month later. Should we be recommending
a three dose series, or could they do it one dose at a time and retest?
What's the best answer for them?

Andrew Kroger: Susan, do you want to take that question?

Susan Wong: Sure. The CDC-- we recommend the full three dose series for
that second vaccination. I think, though, it's clinically reasonable to
also potentially do the one dose and then with that single extra dose
challenge, to test afterwards.

I think in deciding which way to go with this, whether to test right
after that one additional dose or to test after three more doses, part
of the issue is the considerations about concern for loss to follow up
and also concern for ease of drawing the blood and potentially having
difficulty getting it from a young infant.

So sometimes the easiest thing in terms of drawing blood is simply to
give the three doses and then draw the blood but obviously that involves
more time, another six to seven months potentially. And if there're
concerns about loss to follow up, you know, getting the one dose in and
then drawing the blood and feeling confident that the baby's protected
is also there.

So the answer is basically that we don't have the strict recommendation
written is to give the three dose series, but clinically it would make
sense to do it the way described with potentially just one more dose.
And I think it's really situation dependent as to which way one is going
to go with that.

Andrew Kroger: Thank you. Excellent question. Why don't we take the next
question in the queue? Any other questions? Amy, another question we get
commonly is, how do we case manage an infant that is born to a hepatitis
B surface antigen positive mother in the United States and then has been
adopted?

Amy Warner: That is a difficult situation in these circumstances.
Typically in our state what we do is we try to get a hold of the social
worker that's managing the case and let them know, trying to protect the
infant's confidentiality and the mom's confidentiality, that we have
important medical information, and trying to figure out what the status
of the adoption is.

And if the parents are truly at this point the legal guardians of that
child, we're able to share that information with the parents and educate
the new parents, the adoptive parents, about the child's condition and
the need for follow up.

Andrew Kroger: Thank you.

Coordinator: And we do have a question from Joanne in Maryland.

Andrew Kroger: Great, hi.

Coordinator: Joanne, please unmute your phone.

Joanne: Oh, hi. I was wondering if a child receives a birth, two and
four month dose and is later tested and found to be immune, what do you
do about a dose after 24 weeks. Is that necessary?

Andrew Kroger: Lisa?

Lisa Jacques-Carroll: Yes, it is still necessary to have that final dose
for the child to be complete and I think that is also for long term
immunity against hepatitis B virus. So, definitely make sure that the
child completes the series even if they did come back as immune with
post-vaccination testing.

Joanne: Thank you.

Lisa Jacques-Carroll: Susan, do you have anything to add?

Susan Wong: No, I think that's good.

Andrew Kroger: Got to have that third dose after the minimum age. Why
don't we take the next question?

Coordinator: Pat in Illinois. Your line is open.

Pat: Hi, this is Pat from Chicago. I'm calling to verify or clarify in
terms of case management, are we, from this day forward, going to be
looking at hepatitis B e-antigen and the HBV DNA results in putting
those potential mothers into case management?

Andrew Kroger: All right, Susan?

Susan Wong: In terms of case management, currently, the routine prenatal
testing is surface antigen so if a mother is e antigen positive, and/or
has a measured HBV DNA load, they should also by definition really be
surface antigen positive as well because they're chronically infected.

So they should definitely have already sort of reached the threshold
that those women in their pregnancies should be under case management.
The addition of these data elements that Lisa described during her
presentation about including monitoring of e-antigen and DNA load is
something that is sort of on the cutting edge of issues around treatment
eventually for the pregnant woman but also the e-antigen status and the
DNA load have -- we have seen from preliminary data that knowing those
results on the pregnant woman will also give us some guidance as to how
high of a risk it is that the infant will get infected.

If the mom is e-antigen positive or has a high DNA load, the risk that
the baby can get infected is much greater than if she's e-antigen
negative or has a low DNA load. So it becomes even more important that
everything gets done on time and everything gets done carefully.

And certainly in the future, and you know down the line when we have
more clinical data, there may also be roles for other treatments besides
the HBIG and the hepatitis B vaccine. There may be reasons during late
pregnancy to consider anti-virals but again that's something that we're
looking at down the line because we certainly don't at this time have
data available to suggest that that would be a recommendation.

Pat: Okay, because we here in Chicago have been insisting that the
physicians give us the hepatitis B surface antigen when we get those
types of results. The last question I have is, or clarification, is that
for infants who test hepatitis B surface antigen positive that should go
in I-NNDSS we are only looking at the infants born in the U.S. who
should go in I-NNDSS. Is that correct?

Andrew Kroger: Lisa?

Lisa Jacques-Carroll: So you're saying that you're talking about infants
that test HBsAg positive, Pat?

Pat: Yes.

Lisa Jacques-Carroll: That they should be reported to NNDSS?

Pat: But only those who were born in the U.S. because in a lot of cases
we get positive are infants or children and they're adopted from other
countries.

Lisa Jacques-Carroll: Right, well the case definition for a perinatal
hepatitis B infection would be children that are HBsAg positive that
were born in the United States and that are between 1 and 24 months of
age. So you're right, that if you do have an infant that you know about
that is HBsAg positive but was were born internationally, they would not
be reported as a perinatal hepatitis B infection. However, you should
still report that infant to NNDSS as an acute infection.

Pat: You're saying if they're born out of the country?

Lisa Jacques-Carroll: If they were born outside of the country, yes,
they would still be reported to NNDSS but not as a perinatal infection
because they don't meet the case definition.

Pat: Oh, okay. Okay, great. Thank you.

Andrew Kroger: Thank you. I think we'll take one more question.

Coordinator: Lynn, from Georgia, your line is open.

Lynn: Hi. I have a question about the infants who need a second series
because they tested negative, negative after the first series of hep B
vaccine, is it acceptable for those babies since they are now beyond 6
months or 24 weeks of age to receive an accelerated series of hepatitis
B vaccine rather than, you know, 0, 1 and 6? Again, could it be like 0,
1 and 4 or 0, 2 and 4? Something like that?

Andrew Kroger: Susan?

Susan Wong: Strictly I guess our CDC recommendation recommends to still
to do it on a standard schedule. We don't have a recommendation to do it
accelerated. I mean I think if there's a local concern about lost to
follow up, that would be something that would be tailored to fit a
particular situation but it's not our standard recommendation to do it
on that sort of schedule.

Lynn: Right, I know it's not standard but I'm just asking like if there
was a concern about a baby leaving or the physician wanting to hurry up
and get the baby protected for some reason, if that would be -- it's not
quite the same as when they're less than 6 months of age, you know, for
protecting them but\...

Susan Wong: Right, right, right.

Lynn: Okay, thank you.

Andrew Kroger: Thanks. We'll definitely have time for additional
questions at the end of the program. Thanks everyone for asking your
questions. I would now like to turn the mic over to Amy Warner. Amy.

Amy Warner: Thanks. I'd like to go over a case study with you that I
created to address many of the points that Lisa just covered and I think
you also might recognize some of the characters and situations. I'm
sitting in an office right now with just a headset and a computer so
please jot down any questions that you have and let me know you're out
there at the end of my presentation when we have our next Q&A.

First, our case comes from Colorado. The case was identified through Web
based electronic laboratory reporting. In Colorado hepatitis results are
imported into the Web based electronic disease registry managed by the
state communicable disease program and they're immediately made
available to investigators.

The initial investigation starts with a staff call on all hep B cases
between 14 and 45 years of age to see if they are pregnant. If your
birth cohort suggests that women outside of those age ranges are giving
birth, you may want to expand the age ranges that you call on.

The initial investigation consists of collecting any additional test
results, determining pregnancy status and collecting the information
needed for future follow up. A pregnant case is imported into the
perinatal case management data system. This system is not Web based
because in Colorado all perinatal case management is done by state
staff.

The benefit to Colorado is more streamlined data collection and better
quality control. But in larger states, the staff may rely on local staff
to conduct case management, and this strategy can facilitate testing and
immunization within the local health department.

Local health departments may also be the recognized experts in their
community. They could already be working with providers on related
immunization or disease control issues.

So, now for the case example. Here we have a case of hepatitis B from
Doc Holiday's office. We call his office in order to verify information
and collect additional information. We find out that our case, Mariana,
is pregnant and due to deliver June 15. We ask the office to fax the
original hepatitis test results because sometimes the result is positive
but it's not confirmed.

The provider doesn't realize that the results need to be confirmed and
in this case Doc Holiday wasn't used to seeing pregnant women, let alone
an HBsAg positive tests.

We also want to identify any inconsistencies in the test that would
suggest a false positive HBsAg result. For example, a positive anti-HBs
in the presence of a positive anti-HBs in the presence of a positive
HBsAg suggests that one of those tests isn't right. She can't be
infected and immune at the same time.

An original copy of the laboratory report may also give you an
indication of how much additional testing has been done to assess the
mother's disease status.

If an expected delivery hospital has not been identified, it would be a
good idea to ask about insurance. Some insurance providers will only use
select hospitals. If the case is lost to follow up, you might still be
able to alert the hospital. Also, some women may not have insurance.
That can also limit their hospital choices.

When you contact the mother, you may be able to refer her to emergency
Medicaid or other programs in your state and this could help facilitate
her own care as well. It also helps to know what the provider has
already told the patient and to let the provider know that you will be
contacting the patient. In this case we learned that Doc Holiday told
Mariana that there was no problem with her hepatitis diagnosis.

We also learned that Mariana has had two other children, one born in
Texas and one in Colorado. Unfortunately, Doc Holiday doesn't have
immunization dates for the children or know if they've been tested and
he gives us Dr. Quinn's name as the pediatrician that Mariana uses.

Finally we learn from Doc Holiday's office that Mariana's sister
interprets for Mariana in Spanish, that Mariana doesn't speak English
and that Mariana's next appointment is March 15. Given that Mariana
actually lives in Mexico, it might be helpful to meet her at her next
appointment with a Spanish interpreter.

This is a lot of information and in Colorado we scribble on this page,
this one page form, to collect this initial information. The form was
included in a link along with your registration.

Now let's talk about some of the potential issues that have arisen from
this initial discussion with Doc Holiday's office. The additional labs
indicated that Mariana's HBsAg result was confirmed. We also learned
that her liver enzymes were slightly elevated. Liver enzymes can be
elevated for lots of reasons, but Doc Holiday might want to rule out
acute infection by testing for core IGMs.

And he might want to do a hepatitis B e-antigen to see if the risk of
hepatitis B infection is even higher for Mariana's baby. Viral load
tests are most often used to monitor treatment outcomes.

One common issue that Doc Holiday presented was that he told Mariana
that her hepatitis B was no problem. Doctors have lots of reasons for
telling patients there's no problem with their hepatitis B infection.
Maybe mom seems healthy despite her infection. Unfortunately, this
patient may interpret the message to mean that they don't need follow up
or can't transmit the infection.

The provider needs a message that balances living a healthy life with a
hepatitis B infection and managing the infection to prevent transmission
and severe disease outcome.

As you know, babies need healthy moms and hepatitis B infection can lead
to liver disease. Infected moms should be evaluated during pregnancy.
This is the time when mom is more likely to have some insurance. Many
states provide emergency Medicaid for pregnant women although it is
limited.

And also an earlier evaluation will increase chances that mom will get
the treatment as soon as it is medically indicated. Furthermore, it's a
good time for the family to learn prevention, learn how not to infect
others and how to stay healthy. And I'll add here, to get tested and get
vaccinated.

The initial investigation highlighted that Mariana had other children.
Whether using an electronic system or not, it's important to keep your
records up do date. It helps data analysis but it also saves time in
case management. You may already have collected the information on
contacts and siblings in a previous case or through your immunization
registry.

When you call mom, you could be prepared to ask mom about vaccination or
post-vaccination testing for a child or contact that didn't complete
services. When they can, other states will share information on a case
connected to their state as long as you have good identifying
information like a name, date of birth and an address.

Doc Holiday also mentioned that Mariana's sister interprets her Spanish.
Sometimes that may be all that you have but if it can be avoided, a
family member is the least desirable interpreter. People are often not
comfortable fully disclosing personal information to family members.
Furthermore, interpretation is a specific skill. It requires an
individual who is fluent in both languages.

An interpreter does not engage in conversation but facilitates a
discussion between you and the client in an unbiased manner. Think
carefully about your own language skills before you try to fumble
through an interview in another language.

So from our excellent case files on Mariana's previous births, we know
that Mariana was HBsAg negative with her first child in 2002 and that
Texas does not have a case file. She was HBsAg positive with the second
pregnancy in 2005. All her other files indicate that the first child
received two doses of vaccine and the second child received HBIG and two
doses of vaccine. The father tested susceptible before the second child
was born but there's no record of vaccination. They were lost to follow
up in 2006.

So now it's time to contact Mariana. I picked a date close to her March
15 doctor's appointment in hopes of catching her at her sister's house,
and luckily it works. If that isn't possible, I still have time to meet
her at her doctor's appointment.

In a brief phone conversation with Mariana, I realize that an
interpreter is needed and offered to call her back within five minutes
with a Spanish speaking AT&T interpreter. I began by explaining the
purpose of the call and the program, and then I conduct the interview,
answer any questions and offer to send information.

I also use the interview to identify any alternate contact information
like a cell phone number or the number of a family member. I also offer
testing or any helpful contacts.

Education is a big part of the conversation. I try to emphasize the need
for Mariana to get follow up testing and evaluation. We talk about
resources. Referrals to care are difficult because there isn't any money
to help with care and treatment. It's important to work with the health
care provider to access the care.

Try to find out which clinics in your area provide services on a sliding
scale and share that information. Some providers are accustomed to
working across borders or in other countries where the cost of care can
be less. Of course we all want Mariana to have a healthy baby that is
not infected with the hepatitis B virus. Having had children, Mariana is
aware of the need for prophylaxis but she isn't always able to
communicate well with hospital staff.

We talk about where she plans to have the baby and who will provide the
baby's pediatric follow up. She likes Dr. Quinn but she doesn't know
where she will deliver the baby. Explain that you will continue to work
with her until the baby receives all shots and post vaccination testing.

We also emphasize follow up of her children and sexual and household
contacts. The case file is dated and it suggests that the other children
need additional vaccines so we check the immunization registry to update
the children's records and we ask Mariana for the records in case the
children completed vaccinations in Mexico.

In this case, Mariana is taking her children to Dr. Quinn so we will
either call or fax Dr. Quinn's office with information about the needs
of the children to complete their hepatitis B series and be vaccinated.
If Mariana hadn't identified a provider, we could attempt to get her an
appointment at a federally qualified health center.

At this point I want to recognize that even with the health care
provider, lack of insurance, insurance co-pays, transportation, child
care issues -- all of these things might make it difficult for household
or sexual contacts to get services. Try to make testing and immunization
as simple as possible. Free always helps.

In Colorado there is money for testing and immunizations. We will do a
home visit in order to test people in the household. Some states do both
testing and immunization in the home. Others do testing in the home and
still others work with individual providers and clients to get testing
done.

If you are in the field, make sure that you have safety procedures in
place. Some of the larger laboratories have local draw stations. This
works well for our case manager in Colorado that has a large geographic
area to cover. Local hospitals and local health departments have also
been willing to draw blood and send it to state laboratories or private
laboratories. You may want to involve you HIPPA privacy officer before
deciding on how to structure your relationship with a private
laboratory.

So, everything is going well but it's been several weeks now and you
still don't know where Mariana's newborn will be born. The other
children completed their series but need post-vaccination testing.
Mariana hasn't been to Dr. Quinn and isn't answering the cell phone
number. This can be very frustrating. What do you do?

First, you take a minute to relax and reflect as you strategize. Here
are some ideas. Ask the sister for updated contact information like a
forwarding address. Send Mariana a letter explaining that you have
important medical information and asking her to call you.

If the letter comes back, try to verify the address with the doctor's
office or the postal service Web site and try the phone company or the
Department of Motor Vehicles. However, these aren't always as useful
because the cell phones and motor vehicle records aren't updated
frequently and in this case it might be difficult since she's in Mexico.

Mariana may have access to WIC if her children were born in the U.S. so
if you have a relationship with your WIC folks, you might be able to
locate her. If you think she is skeptical of you or suspicious of the
government in general, arranging to meet her at the doctor's office
might make you less threatening.

If you know when Mariana will be at her sister's you can visit the
house. You could consider an international call if you think there's a
good chance that she'll be returning to the U.S. to deliver. In
Colorado, this isn't an option. We can't make international calls, but
some states are successfully working across international borders.

I also want to mention here that sometimes you can't reach the woman
because of high risk behaviors. If the mother is incarcerated, has
multiple sex partners, actively uses intravenous drugs and shares
needles, you may want to manage contacts like a disease investigation
and involve your disease investigation specialist. This means checking
registries. STD or HIV registries and DIS may already be investigating
the case.

On rare occasions were we suspected co-morbidities of HIV or an STD with
hepatitis B, we coordinated follow up. We have also requested contact
information from social workers in the foster care system or parole
officers but you need to be careful about who you disclose the
information to and what you disclose.

Ideally you shouldn't need to say more then you're investigating a
report of an infectious reportable disease. If that isn't enough you
send your very official looking letter with all of your state reporting
regulations assuming that you have the reporting regulations to support
you.

Once you've identified contacts and began contact immunization, it
should be close to time to prepare for the infant. Now these things
don't always happen sequentially but it is pretty nice when they do.

I mentioned that Colorado educated Mariana during the interview. Other
states may choose to wait until closer to the birth. Education is
important whenever you do it because Mariana or her spouse can advocate
for prophylaxis in the hospital.

Mariana can give the hospital staff her testing information. We
typically call the provider's office ahead of time to verify that the
woman is still due to deliver and to ask them to fax original labs to
the hospital. Then we send a letter to the hospital and if known, to the
pediatric provider. The letter informs them of the mom's HBsAg status,
impending birth and any CDC, American Academy of Pediatrics, and
American Academy of Family Physician recommendations.

We also fax over to the hospital an HBIG and birth dose form. We do not
provide the HBIG to any hospitals and hepatitis B vaccine only to VFC
hospitals so we ensure HBIG and birth dose by reminding all providers
and the hospital of care standards in advance of the birth and by
working to make hepatitis B vaccine birth dose universal.

The HBIG form was also sent to you as a link with your registration
email. Periodically we just send out the HBIG forms to labor and
delivery units and nurseries. A few times the nursery manager has sent
the forms back on infants born to women that our staff had not
identified. In many cases the form has eliminated time intensive chart
reviews because the form includes date and time of birth, date and time
of administration of hepatitis B vaccine and maternal HBsAg test
results.

> For hospital staff, hepatitis B in a delivering mom could be a rare
> event. You want to be the resource staff think of when a hepatitis B
> positive woman comes to deliver. Keep email lists up to date, offer in
> service training, forward new recommendations as they are released.
> Ask your birthing hospital for a copy of their protocols on a yearly
> basis to ensure that they are up to date and when you visit the
> hospital, ask the nurse where they are kept.

Some hospitals prefer that you communicate with the labor and delivery
staff and other hospitals want you to communicate with the nursery. Know
each hospital's preferences. Most likely the prophylaxis will be given
in the nursery.

Often the doctor that provides pediatric care in the hospital is not the
same one that provides care outside the hospital. You need to know both.
Review the medical records, talk to the doctor on record or call the mom
to determine who will provide pediatric follow up care. In this case,
there's a good chance that Mariana will head back to Mexico before the
child receives additional doses. If you didn't find out ahead of time,
call and congratulate her and then ask her about her plans.

Now the challenge is how do you keep Mariana engaged long enough to
complete the infant's vaccine series and post vaccination testing? There
isn't a single answer but here are some strategies. Contact Dr. Quinn,
the pediatric provider. Ask her what vaccine and what schedule she will
be using. Send a letter describing your program. Strongly suggest that
the baby complete the series within six months using single antigen
vaccine or Pediarix. Then, advocate for the testing at a nine month
visit, not sooner. If there isn't a nine month visit, then test at the
12 month visit. Don't wait.

In Colorado, we let moms know where they can get free vaccine, often at
the local health department, and providers waive the administrative fee
whenever a parent is unable to pay. We typically call the provider's
office to check the immunization registry to determine if the infant
receives subsequent doses.

If the mother hasn't been in, we attempt to contact her. In Mariana's
case, there is a good chance that she won't bring the baby in on
schedule. If it's easier for her to get the child vaccinated in a border
state, then call the state and ask for assistance.

Reminder/recall can be international if you think the baby will ever be
brought back to the states and your state will allow it. Be careful not
to disclose medical information even your return address -- Viral
Hepatitis Program, Perinatal Prevention Unit -- may not be a good idea.

If Mariana knows you and has all your education materials, all you need
is a simple reminder message that says, "Please call my office
concerning your baby." You may have a budget for incentive or you might
get a local group to donate diapers, formula or other incentives. Some
states offer Target cards or other gifts.

In Colorado, families were very appreciative when they received a \$5
Target card for each dose and post-vaccination testing. However, we
couldn't show that it actually increased vaccination rates or
post-vaccination testing. A different incentive structure may have
worked better.

Sometimes dads take the lead. In one instance, we had educated the
father about what to expect at the hospital. When he saw the hospital
nurse administer HBIG and vaccine simultaneously in one syringe he
called us. We followed up with the nurse supervisor who verified the
story with her nurse. It was a training issue that may not have been
identified without dad's knowledge and concern.

Other times, a child's care is delegated to a grandparent. If you have
the parent's consent, you can work with alternate caregivers. Focus on
the need to know a child's infection status. Being vaccinated is often
enough but not always. Making assumptions about the child's infection
status can have serious consequences.

Offer a variety of testing choices. We talked about this before but the
longer you wait, the more likely the individual will be lost to follow
up. Try these different venues to increase the chances that Mariana gets
the infant immunized and tested. Don't delay.

So, you've given this case your best shot and it's time to move on. The
gold standard would be that Mariana has a healthy baby that received
HBIG and all hepatitis B vaccines, and is tested for HBsAg and anti-HBs,
and that all the contacts are tested and immunized with three doses of
vaccine.

This isn't always achievable. I wanted to mention that depending on the
state, a case may be closed at a variety of stages. It's important that
the infant receive all vaccines and get post-vaccination testing. You
will have to close cases due to lost to follow up but this should be
rare.

Contacts can be especially difficult and you must balance education with
personal responsibility. It is the adult contact's choice to be
immunized or tested. In a few cases in which the infant did not get
appropriate care because the parent did not believe in immunization or
had other reasons we have threatened to involve the county social
services. This usually happens in a good cop, meaning the county health
nurse, and the bad cop, meaning us at the state, scenario. And it has
never resulted in an actual referral. But you should understand your
state laws before you consider this type of a tactic.

In anticipation of some of your questions, I wanted to give you some
ideas about patient information packets. We always provide information
in English so the patient can share it with providers. We also try to
provide information in their native language. This often limits what we
can put in the packet.

In general, the information falls into the following categories. We have
a program description, a description about living with hepatitis B,
hepatitis B shots, and then some specific FAQ's. There are several
terrific websites of information that have things that you can tailor to
the mom's specific situation.

Providers are also often interested in seeing the information packet
that we send to their patients. And we always slip in a piece about
managing patients with hepatitis B. We also send them names of
specialists in their areas if they request them.

So, in case you were wondering what happened to our case, Mariana was
found through the WIC registry. Through the program's persistence,
Mariana's children are fully immunized and immune to hepatitis B.
Mariana saw a specialist who was working with her doctor in Mexico.

Doc Holiday was actually a dentist and he decided that this was too much
work and went back to gambling, drinking and pulling teeth before his
lifestyle and Tuberculosis took his life.

Dr. Quinn became an energetic advocate for hepatitis B vaccination and
cared for many women with hepatitis B. Thank you.

Andrew Kroger: Great! Thank you, Amy. And again, I'd like to invite our
participants to call in and ask questions. Please remember to dial star
1 and restrict your questions to the contents discussed today. And
please tell us your first name and the state that you're from. I'm now
going to turn the mic back over temporarily to our operator.

Coordinator: Thank you very much. And once again, please record your
first name and state when prompted. Please stand by, we do have a
question.

Andrew Kroger: While we're waiting for the first question I would like
to provide some continuing education credit information. For CE credit
please go to [www.cdc.gov/tceonline](http://www.cdc.gov/tceonline) . The
course number for this live event is EC1357 and that's for the live
program through May 28. After May 28 please use the course number
WD1357, and the verification code for both of these programs is DW388F.
And I will repeat that, DW388F. The archived version will remain
available for up to three years after this program, or as long as the
information remains current.

So now I\'m happy to take the first question that is in the queue.

Coordinator: Thank you, and Willie Mae in Pennsylvania your line is
open.

Willie Mae: Hi.

Andrew Kroger: Hello.

Willie Mae: Can you hear me?

Andrew Kroger: Yes, you\'re coming in loud and clear.

Willie Mae: Okay very good. Am I to understand that if an infant weighs
less than 2000 grams that HBIG is not given at birth?

Andrew Kroger: Great question, Lisa.

Lisa: For infants that are born to HBsAg positive and HBsAg unknown
status moms, and who weigh less than 2000 grams at birth, they should
receive both hepatitis B vaccine and HBIG within 12 hours.

Willie Mae: Okay. I thought that it was a difference with the weight.
That I think I was understanding that they shouldn\'t get it.

Lisa: The clarification with regards to the weight is that for babies
born to unknown status mothers, if they are greater than 2000 grams,
they should receive the birth dose within 12 hours.

But they should not receive HBIG unless mom\'s status comes back as
HBsAg positive. However, for babies less than 2000 grams born to unknown
status moms, they should receive both HBIG and hepatitis B vaccine
within 12 hours.

Willie Mae: Okay very good. So I guess what they do then is just wait to
find out the mom\'s status.

Lisa: For the bigger babies, yes.

Willie Mae: Okay very good. Thank you.

Lisa: Sure.

Andrew Kroger: Great, good question. We\'ll take the next question in
the queue.

Coordinator: Marie in Florida your line is open.

Marie: Hi I would like to know how should we proceed in a situation
where the baby has been tested negative for both surface antigen and
antibody and a second series of hepatitis B vaccines were administered
and at the time of the testing mom declined the test.

Should we close as it as refusal or as the service completed?

Lisa: This is Lisa. I would say that you should close as a refusal
because you really don\'t know for sure whether or not that infant did
develop protective antibodies.

It\'s our hope that the baby did after receiving two full series. But I
think since you don\'t have the results, and if mom\'s not going to
allow blood to be drawn, then you probably should close that as a
refusal.

And maybe if she has another infant later you can try to get PVS testing
on this child at a later date.

Marie: Thank you.

Andrew: Great question. We\'ll take the next question.

Coordinator: Phil in Washington your line is open.

Phil: Hi, I just wanted to thank you, especially for today\'s session.
It\'s very good. And I\'m just brand new to this.

The question relates back to the call from Chicago about being born out
of country. Does that also, if you\'re born to a military parent or to a
Department of Defense parent stationed overseas, does that also count as
a case, or does it not count? Or would you count that and report that as
a case?

Andrew Kroger: I Susan would you like to take that one?

Susan: That\'s an interesting situation. I think, you know, this sort of
falls into how for any infectious disease in military or, you know,
State Department or other staff who are overseas how any of them would
be reported.

The National Notifiable Disease System is really for identifying disease
in US citizens in the United States.

And usually there is some kind of separate internal system that\'s not
part of the CDC system for monitoring those cases.

So. if the infant is born overseas and then perhaps comes back, they
would be perhaps reported as a chronic case if they\'re surface antigen
positive and they are now in the United States. That would be reported
as a chronic case.

But because it wouldn\'t be under, you know State Health Department
jurisdiction and things like that, this would be an unusual situation
and I would say that in general it wouldn\'t be counted as a perinatal
case.

Phil: Okay, thank you.

Andrew Kroger: Great, thank you very much, excellent question. We\'ll
take another question in the queue.

Coordinator: Bruce your line is open.

Bruce: Yes hi, it\'s Bruce Barlow from Philadelphia. I\'d like to flip
that question. With having 60% Asian cases in the city of Philadelphia
and a vast majority of those moving in six months or sending their
children back, they stay here, to China or elsewhere.

I\'m just curious with for the goal of the program as I see it is to try
to track, and lately I\'ve been trying to keep in touch through an
interpreter with moms overseas.

What I noticed is the reports have changed with CDC and we\'re not as
much tracking the moves out of jurisdiction within the continental
United States we don't share lab work so that we don't skew data.

I just wanted some input on that.

Andrew Kroger: Yes.

Lisa: Bruce, I guess I\'m not quite sure what your question was. I
understand you\'re talking about that you\'re trying to follow up on
babies that go back to their countries and trying to complete them for
case management, which I think is great.

But, I guess I\'m not sure what your question was.

(Bruce): I don\'t know, how do you feel about that happening outside of
the United States when they move? Are we looking more at the data of how
many move out or the goal of the program I always felt was to try to,
you know, complete the case.

But if they\'re out of our jurisdiction and they go overseas, I just
always feel that commitment to continue. And if it is a positive, which
I haven\'t had yet, well I would probably enter that because usually
they send the children back.

Lisa: Yes, I was going to say; well I think that the incentive of
following those babies even though they have moved out of the country is
that there is probably a good likelihood that they will come back when
they\'re school-aged.

I know that\'s the experience of a lot of programs where they send the
babies back to their home country to live with grandparents or relatives
and then they come back for school.

And so that\'s an incentive for you to ensure that that baby gets fully
vaccinated. And that you find out about that baby\'s status so that when
they do come back and are in your jurisdiction again later, you know
that the infant is protected or that you know the infant\'s status.

So, I think it\'s definitely a great thing what you\'re doing. But I
would say that if you do find out about an infant who\'s living outside
of the United States who tests HBsAg positive, I don\'t believe that
infant should be reported to CDC because the infant is not in our
jurisdiction when they\'re being tested. So that would be another note
about that.

Bruce: All right, thanks, Lisa.

Lisa: Thanks, Bruce.

Andrew Kroger: Great, always challenging when they leave the country.
We\'ll take another question.

Coordinator: Thank you. Carol in Texas your line is open.

Carol: Yes thank you. My question pertains to providing post vaccine
serology to household contacts. At the moment we are following the 2005
ACIP recommendations where we identify that a household contact is
susceptible. We vaccinate the contact.

But we do not provide post vaccine serology to the household contact. We
do to the sexual contact. And I believe I heard earlier a different
statement. I just need clarification to see if those recommendations are
no longer valid.

Andrew Kroger: Yes, Susan?

Susan: I think what you just described that you\'re doing is correct and
follows the 2005 ACIP recommendations that the group that\'s recommended
to get post-vaccination serology testing besides the infant born to the
infected woman is the sexual partners only.

I had just added in the previous answer that one thing to consider is
that if you do have household contacts who are children, particularly
children of that mother that it would be probably logical to be
concerned about their post-vaccination status. Because they\'re going to
have ongoing intimate contact with the mother and during the infancy and
childhood years is the time of life when they are at highest risk for
developing chronic HBV infection if they were to acquire infection from
their infected mother.

So I think the purpose of what I was saying was it should be as you
described according to the 2005 ACIP recs and just don\'t forget other
children of the mother that for some reason were missed and were not on
your radar screen for follow-up. But they may be eligible and you should
consider the need of doing post-vaccination serology testing on other
children of that infected mother.

Carol: I see. Also many times, you know, extended families live
together. Would a young child for example, the sister of this infected
mother, be as much at risk as the child born to this mother who is also
living in close contact with her?

Susan: Right. I think that is something to consider. I guess the CDC
recommendations don't imagine or try to capture every different possible
living arrangement.

But I think that the issue, the core issues are that infants and
children are at highest risk. If they\'re a household contact, then we
want to make sure that they are protected.

What we don\'t routinely recommend is that people other than the sex
contacts get tested because most adults, if they were to get hepatitis B
as an adult\--most adults would demonstrate symptoms. So, you would know
they were sick. You\'d know they have acute HBV infections. Whereas,
most children when they get infected as children from a household
contact or whatever, most of them would have a silent infection so it
would be unknown to anyone until perhaps 20, 30, 40 years later when
they have liver cancer or liver cirrhosis.

So, just trying to be cautious and more careful around the children and
ensuring that they are protected is the reason for worrying more about
post- vaccination serology for them than for the other groups.

Andrew Kroger: Great thank you very much, Susan. At this time we are out
of time. So I\'m now going to move on to the closing information.

And, to do that I need to give some further housekeeping information.
For continuing education credits, please go to
[www.cdc.gov\\tceonline](http://www.dcd.gov/tceonline). The course
number for this live event is EC1357, and that\'s through May 28, 2008.

After May 28, use the course number WD1357. The verification code for
this session for both programs is DW388F, and I will repeat that,
DW388F. So specific for session two, but it\'s the code for both live
and self-study.

Once you become familiar with the online system you will find it easy to
use and a great way to keep track of CE credit earned from CDC training
programs.

If you\'re having any difficulty or are new to the system, you can get
assistance by phoning 1-800-41train. Another number you can call is
404-639-1292, or you can contact via the e-mail <ce@cdc.gov>.

Should you have any questions after this event you can always get help
by way of your state perinatal coordinator, or feel free to contact Lisa
Jacques-Carroll here at CDC.

Remember our next session will take place Wednesday, April 23, 2008 at
the same time, 12, Noon Eastern. The topic for that session will be
Evaluation. So please mark your calendars.

I\'d really like to thank everyone for joining us today with special
thanks to our subject matter experts Lisa Jacques-Carroll, Amy Warner
and Susan Wang. I\'d like to thank you very much from Atlanta and have a
great day. Good bye.

END