# Presentation: 687079

## The Essentials of 
Perinatal Hepatitis B Prevention 

A Training Series for Coordinators and Case Managers

- Perinatal Hepatitis B Prevention
- A Training Series for Coordinators and Case Managers

## Session 2: Case Management

- Lisa Jacques-Carroll, MSW
- NCIRD, CDC

## Learning Objectives

- Describe key components of case management in a perinatal hepatitis B prevention program
- steps in case management for infants born to HBsAg-positive women
- data tracking and management systems to help with case management

## Benefits of Case Management

- Case managed infants are more likely to receive post-exposure prophylaxis (PEP) at birth
- Also more likely to complete their vaccine series on time

## Case Management in Perinatal Hepatitis B Virus (HBV) Prevention: State Examples

| 

State  | 

Received
case 
management  |  |  | 

No.(%) | 

HBIG and HepB at birth 
No. (%) | 

Complete series 
by 8 mo
No. (%) |
| --- | --- | --- | --- | --- | --- | --- |
| Alabama |  | Yes | 982 (78) |  | 905 (92) | 828 (90) |
| (1990-2002) |  | No    | 318 (22) |  | 212 (67) | 189 (59) |
| Connecticut |  | Yes |   64 (52) |  |  64 (100) |    52 (90) |
| (1994-1995) |  | No    |   58 (48) |  |   52 (90) |   189 (48) |

**Sources**: Brian Wheeler, Alabama Dept of Public Health, 2004;   MMWR 1996;45:584–7

## Completion of Follow-up for IdentifiedInfants of HBsAg+ Mothers, 1993-2005

**Source:** NCIRD program data, CDC

- HBIG/vaccine at birth

- 3 doses by 6-8 months

- Postvaccination testing

- 94%

- 71%

- 53%

## ACIP Recommended Components of Case Management Programs

- Identify and track HBsAg-positive pregnant women
- Notify delivery hospitals where HBsAg-positive pregnant women plan to give birth
- Ensure hospitals appropriately manage infants born to HBsAg-positive and HBsAg-unknown status women
- Ensure hospitals have appropriate standing orders and written policies

**Advisory Committee on Immunization Practices (ACIP)**
**Sources:**  ACIP statement, *MMWR* 2005 (RR-16), and *Guide to Life*

## Ensure completion of infant’s hepatitis B vaccine series
Ensure post-vaccination testing of infant
Ensure pre-vaccination testing and vaccination of household and sex contacts of women
Monitor and evaluate the case management program

- Ensure post-vaccination testing of infant
- Ensure pre-vaccination testing and vaccination of household and sex contacts of women
- Monitor and evaluate the case management program

**Source:** ACIP statement, *MMWR* 2005 (RR-16), and *Guide to Life*

- Recommended Components of Case Management Programs – con’t

## Timing of Identification

- The management of an HBsAg-positive pregnant woman varies depending upon when she is identified:
- prenatally
- at delivery
- postnatally

## Management of Infant at Birth*

- Mother is **HBsAg positive**
- hepatitis B vaccine within 12 hours of birth
- HBIG within 12 hours of birth
- Mother is **HBsAg status unknown**
- hepatitis B vaccine within 12 hours of birth
- test mother for HBsAg ASAP
- if mother is HBsAg-positive  give HBIG to infant ASAP but no later than 7 days after birth

***For infants <2000 g, follow ACIP guidelines**

## Prenatal Case Initiation

-   Contact prenatal care provider to confirm:
- HBsAg test results
- date of test
- expected date of delivery
- expected delivery hospital
- whether woman has been evaluated for her HBV infection
-   Notify the delivery hospital

## Prenatal Case Initiation - cont’d

- Contact the woman to provide education and information
- Identify sex partners and household contacts for testing, vaccination, and follow-up

## Education of Mother

- Discuss with HBsAg+ pregnant woman:
- What test results mean
- Typical course of HBV infection
- Seriousness of infection in newborns
- How infant will be managed
- Perinatal concerns     (e.g., breastfeeding is safe)

## Education of Mother - cont’d

- How she can take care of herself
- Importance of evaluation for HBV infection
- Referral to physician for evaluation
- How to prevent transmission to others
- Importance of identifying/vaccinating sex partners and household contacts

## Tips for working with the Mother

- Use mother’s first language
- Use materials with visual aids/low reading level (if appropriate)
- Provide materials for review at home
- Reinforce messages with follow-up letters
- immediately after first interview
- just before due date
- before each vaccination is due
- before post-vaccination testing

## Prior to Delivery

- Remind woman and delivery hospital of importance of postexposure prophylaxis for infant at birth
- consider giving woman card to take to hospital with instructions on care of infant
- consider sending  hospitals monthly list of            HBsAg-positive women expected to deliver

## After Expected Date of Delivery

- Contact hospital to determine:
- date of delivery
- date/time of hepatitis B vaccine and HBIG
- updated contact information for mother

## HBsAg+ Woman Identified at Delivery

- Contact mother ASAP to provide information on hepatitis B virus
- Ensure receipt of hepatitis B vaccine and HBIG
- Proceed with case management of infant
- Identify and manage sex partners and household contacts

## After Birth to HBsAg+ Woman

- Remind pediatrician and parents about
- when to administer each dose of hepatitis B
- when to perform post-vaccination testing (at 9-18 months of age, after 3 doses of vaccine)
- Verify dates hepatitis B vaccine was given
- Review post-vaccination test results with pediatrician

## Infant Post-Vaccination Test Results

- If HBsAg-negative & anti-HBs _>_10 mIU/mL
-     infant is protected
- If HBsAg-negative & anti-HBs <10 mIU/mL
-     revaccinate with 3-dose hep B series
-     retest 1–2 months after final dose
- If HBsAg-positive
-     refer infant for medical evaluation/     management of chronic HBV
-  	 report perinatal infection to CDC via NNDSS (National Notifiable Disease Surveillance System)

## Reminder and Recall Systems

- Notify before (reminder) and after (recall) vaccines and tests are due
- Use for parents, pediatricians, and case workers
- How?
- postcards filled out by parent to be mailed by provider or health department
- computer-generated letters
- computer-generated phone calls
- prompts for case workers follow up

## Ideal Data Tracking & Management

- Helps manage cases _and_ evaluate success
- Allows indexing by mother/infant names
- Generates reminders for case managers
- Generates reminders for patients and providers
- Generates reports at regional/program level
- Allows timely entry of program data

## Benefits of Data Integration

- Some programs’ perinatal hepatitis B data are integrated into other systems:
- Immunization Information System (IIS)
- infant hepatitis B vaccinations in this system
- communicable disease reporting system
- HBsAg-positive women reported to this system

## Core Data Elements: Mother

- Name
- Contact info
- Emergency contact
- Insurance status
- Prenatal care provider
- Liver disease specialist
- Date of first appointment with specialist
- Date of birth
- Country of birth

- Race/ethnicity
- Primary language
- Due date
- No. of previous deliveries
- Complete HBV test results and dates of specimens
- 	-HBsAg
- 	-HBeAg (encouraged)
- 	-HBV DNA (encouraged)

## Core Data Elements: Infant

- Name
- Date and time of birth
- Birth weight
- Gestational age
- Delivery hospital
- Pediatrician
- HBIG administration
- date, time, brand, dosage

- Birth dose of vaccine
- date, time, brand, dosage
- Subsequent doses
- date, brand, dosage
- Post-vaccination test
- HBsAg status
- Anti-HBs level
- date
- Reasons for loss to follow-up (if applicable)

## Core Data Elements: Contacts

- Name
- Contact info
- Pre-vaccination test results, date
- Hepatitis B vaccine doses
- Post-vaccination test results (sexual contacts)

## Program Activities to Support Case Management

- Train state and local case workers
- in-service trainings
- written perinatal hepatitis B prevention protocol
- Educate providers and hospitals
- delivery hospital staff
- OB/GYNs and other prenatal care staff
- pediatricians and family practitioners

## Program Activities - cont’d 

- Having written policies and procedures in place
- prenatal care settings
- delivery hospitals
- pediatric care settings
- Ensuring hospitals have standing orders
- screen delivering women
- prophylaxis to infants born to HBsAg-positive and unknown status mothers
- universal birth dose