A Survey of Hepatitis B Disease Prevention Practices in Delivery Hospitals in Mississippi Sandor Feldman MD Immunization Consultant And Joyce Booth RN, MSN Nurse Consultant Division of Immunization MS State Department of Health 1

Objectives Determine MS’s delivery hospitals’ (N=50) policies for screening pregnant women for hepatitis B surface antigen (HBsAg) Determine MS’s delivery hospitals policies for administering hepatitis B vaccine (HBvax) to newborns (NB) prior to discharge Determine compliance with hospitals’ policies for screening of pregnant women Determine compliance with hospitals’ policies for administering HBvax to NBs prior to discharge 2

Methods Definitions Screening of pregnant women HBsAg documented in hospital record HBsAg testing before or at delivery Immunization of NB with HBvax prior to discharge Documented in hospital record Informational letter Hepatitis B virus (HBV) infection in NB Availability of thimerosal-free HBvax ACIP, AAP, AAFP and MSDH (MS State Dept. of Health) preference for birth dose of HBvax Rationale for birth dose 3

Methods Survey (questionnaire) Maternal screening for HBsAg Policies: HBvax for NBs Routine, physician order only, or no policy Standardized Maternal and NB record review Modified from CDC’s Screening Assessment Tally Sheet for HBV (1999) Maternal and NB records; 30 each per hospital If available, maternal-infant pairs 4

Methods Initial letter and questionnaire-Nov. 2001 F/u letter-Jan. 2002 F/u telephone contact for hospitals not responding to above Letter requesting review of maternal and NB records-Feb. 2002 Appointment made via telephone Completed record review, 9/2002 Births between 7/1/01-12/31/01 5

Survey Results *Telephone call back was required for 40% (N=20) of the surveys to clarify responses 6

Survey Results 7

Record Review Results OVERALL- 96% MATERNAL SCREENING FOR HBsAg 8 * Forty-six hospitals had >90% documentation of HBsAg in maternal records

Survey Results 38% 28% 34% 9

Survey Results Obstacles to routine HBvax for NBs No knowledge of AAP/AAFP/ACIP preference Do not see cases of HBV in mothers/infants Did not give in past, do not want to start now HBvax only for NBs of infected mothers Birth dose complicates schedule HBvax not thimerosal-free Medical-legal Cost/reimbursement Increased personnel time/paper work Administering vaccine, reporting to immunization registry, etc 10

Survey Results 11

Results of Record Review Compliance with Newborn HBvax Policies No. Hospitals No. Records %Compliance with policy Policy Routine 19 580 96%† MD order 12* 333 6%‡ None 15* 440 3%§ 1353 44% Overall 46 Overall 48% of NBs receive HBvax at birth † 15/19 hospitals, >93% compliance * 4 hospitals, no NB records available for review ‡ 6 hospitals, 0%; 1 hospital, 47%; remainder, <6% § 10 hospitals, 0%; remainder 3-13% 12

Post-Survey Changes in NB HBvax Policies Changed from MD order to Routine HBvax 7 hospitals; 6330 NBs Changed from No Policy to Routine HBvax 8 hospitals; 4895 NBs MS hospitals as of Nov 30, 2002 34 hospitals, 74% of birth cohort (~31,000) have routine NB HBvax Before survey/intervention, 47% were born at hospitals with routine HBvax Based on 96% compliance with routine HBvax policy, 29,697 or 71% of MS’s NB will now receive HBvax at birth 49/50 (one added) hospitals screen for maternal HBsAg, >95% compliance 13

VFC Coverage of Newborns for HBvax Impact of Survey/Intervention No. Hospitals (%) No. Births % Birth cohort VFC @Survey 12405 30% 8 (16%) 7625 18% VFC, after intervention 13 (26%) Total 21 (42%) 20030 48% 14

Goals and Post-survey Interventions 100% maternal screening, routine NB HBvax and VFC coverage of NB for HBvax Continue to address obstacles to routine HBvax for NBs telephone contact, face-face meetings with or presentations to key physicians and/or hospital nursery personnel Publication of Survey findings MS Morbidity Report, Healthy Baby Update, MS AAP chapter newsletter F/U letter with results of survey to all 50 delivery hospitals and MS Hospital Association for distribution to all Hospital Administrators 15

Summary/Conclusions/Recommendations HBsAg screening of pregnant women was 96% Initially 47% of birth cohort born in hospitals with routine HBvax Post-survey/intervention, increased to 74% Overall compliance with policy of routine HBvax for NBs was 96% (individual hospitals, range 78-100%) Hospitals with MD orders or no policy for HBvax poorly vaccinated NBs Increased VFC coverage of birth cohort for birth dose from 30% to 48%, post-survey/intervention Addressing individual hospital obstacles to routine birth HBvax increased by over 50%, NBs born at hospitals routinely administering birth dose 16