How to Develop an Evaluation for the Perinatal Hepatitis B Program: The Massachusetts Experience Good morning to all. I am…………..This morning I would like to review with you the September 2001 school entry requirements and also give you some information on what we consider to be “best practices” in immunizing your patients. We will discuss documentation, missed opportunities, how to get your patients in the door and much more. Please feel free to ask questions during the presentation. Let’s start with the September 2001 school entry requirements. MDPH Jan 03

Presenter Martha Badger, RN, BSN Nursing Supervisor Massachusetts Immunization Program Massachusetts Department of Public Health MDPH Jan 03

Massachusetts Statistics Population (pop.) ~ 6 million Birth cohort of ~ 80,000 300 - 350 HBsAg-positive pregnant women identified per year (285 target) ~ 34% of pop. living in pocket of need ~ 12% of pop. foreign-born ~ 19% of pop. PLINE MDPH Jan 03

Evaluation Benchmarks Staff Resources Referral Sources Case Management Birth Hospital Record Reviews MDPH Jan 03

“Ancient” History (1996 - 2000) MDPH Jan 03

Hepatitis B Coordinator Perinatal Hepatitis B Nurse Staff Medical Director Hepatitis B Coordinator Perinatal Hepatitis B Nurse 6 Regional Immunization Nurses MDPH Jan 03

- Clinical consultation Hepatitis B Coordinator Staff Roles Medical Director - Clinical consultation Hepatitis B Coordinator - Education, outreach, training MDPH Jan 03

Perinatal Hepatitis B Nurse - Case management, database management Staff Roles (cont’d) Perinatal Hepatitis B Nurse - Case management, database management 6 Regional Immunization Nurses - Case follow-up MDPH Jan 03

Hepatitis B Coordinator position funding lost 4 years ago (1999) Staff Challenges Hepatitis B Coordinator position funding lost 4 years ago (1999) Nursing Supervisor assumed oversight of Perinatal Hepatitis B Prevention Program Perinatal Hepatitis B Nurse limited by case management, data entry MDPH Jan 03

- One child per mother, only Resources FoxPro Database (DOS!) - Designed in 1991 - Missing data fields - One child per mother, only Perinatal Hepatitis B Prevention Project Protocol - 2 pages long, written in 1996 MDPH Jan 03

Referral Sources BOHs 27% 15% 15% Labs 9% 22% 10% 1996 1998 2000 Prenatal BOHs 27% 15% 15% Labs 9% 22% 10% Providers 20% 21% 23% 56% 58% 48% Postnatal NSP 40% 41% 52% MDPH Jan 03

Case Management HBIG + 90% 96% 99% Birth Dose Hep B 3 63% 78% 79% 1996 1998 2000 HBIG + 90% 96% 99% Birth Dose Hep B 3 63% 78% 79% by age 8 mos Post-vax 27% 47% 52% screening MDPH Jan 03

Birth Hospital Record Reviews Documentation of Maternal Screening for HBsAg 2000: 100% of maternal records 96% of newborn records 1996: 98% of maternal records 92% of newborn records MDPH Jan 03

Birth Hospital Record Reviews (cont’d) Hep B-1 Administration 2000: 91% of infants, regardless of mother’s HBsAg status, received hep B-1 in the hospital 1996: 89% of infants, regardless of mother’s HBsAg status, received hep B-1 in the hospital MDPH Jan 03

Recent History (2001 - 2002) MDPH Jan 03

Staff Medical Director Nursing Supervisor Perinatal Hepatitis B Nurse (resigned September 2002) 6 Regional Immunization Nurses MDPH Jan 03

Perinatal Hepatitis B Prevention Project Protocol Resources Unchanged since 1996: FoxPro Database (DOS!) Perinatal Hepatitis B Prevention Project Protocol - 2 pages long, written in 1996 MDPH Jan 03

Referral Sources 2001: Prenatal referrals: 49% - BOHs, dagnostic labs, providers, viral case reports Postnatal referrals: 49% - Newborn Screening Program (NSP), birth hospitals MDPH Jan 03

Referral Source Challenges 2001: Continuing low HBsAg+ reporting levels for women of childbearing age (14 - 44 yrs) from diagnostic labs (10%) and providers (18%), despite mandatory reporting laws since 1994 (105 CMR 300.200) MDPH Jan 03

Referral Source Challenges (cont’d) Increasing number of false positive reports from NSP HBs-Ag-negative confirmatory lab results - 2001: 4 / 143 (0.3%) - 2002: 31 / 140 (22%) MDPH Jan 03

2001: 98% receive hep B-1 and HBIG at birth Case Management 2001: 98% receive hep B-1 and HBIG at birth 2001: 73% receive hep-3 by age 8 months 2001: 50% receive post-vaccination serologic screening MDPH Jan 03

Effects of Joint Statement on Thimerosal: July 1999 - present 10-month effort to ensure all birth hospitals had resumed policy of vaccinating all newborns at birth, regardless of mother’s HBsAg status (July 1999 - June 2000) Affected Massachusetts 2001 NIS immunization levels and ranking MDPH Jan 03

Estimated Vaccination Coverage with Hepatitis B by Age in Massachusetts, 1998-2001 MDPH Jan 03

Massachusetts NIS Data 4-3-1-3 1998 1999 2000 2001 % UTD 87 85 85 81 US Rank 3 7 3 16 MDPH Jan 03

Future Plans (2003 and beyond) MDPH Jan 03

New Perinatal Hepatitis B Nurse Staff New Perinatal Hepatitis B Nurse - Case management, education, outreach, training Research Analyst (RA) - Database management, etc. MDPH Jan 03

6 Regional Immunization Nurses Staff (cont’d) Medical Director Nursing Supervisor 6 Regional Immunization Nurses MDPH Jan 03

Eventual Web-Based Database - Interactive case management tool Resources Access Database - Interim Eventual Web-Based Database - Interactive case management tool Perinatal Hepatitis B Prevention Project Protocol - Updated to 12 pages, so far MDPH Jan 03

Increase percentage (%) of cases identified prenatally Referral Sources Goals: Increase percentage (%) of cases identified prenatally Reduce number of false HBsAg-positive reports from NSP MDPH Jan 03

Increasing Prenatal Referrals Perinatal Hepatitis B Nurse will: Conduct inservices for OB providers to improve reporting Work with MDPH Surveillance Program to promote electronic diagnostic lab reporting MDPH Jan 03

Increasing Prenatal Referrals (cont’d) Community Health Center Quarterly Reports - Number of pregnant women screened for HBsAg - Number and names/DOB of HBsAg+ pregnant women - Include HBsAg-positive lab results with quarterly report MDPH Jan 03

Reducing NSP False Positive Reports Perinatal Hepatitis B Nurse will: Conduct trainings for birth hospital maternity unit nursing staff to improve NSP reporting - Suspect staff are checking “positive” for anti-HBs+, instead of HBsAg+ MDPH Jan 03

Case Management Recent initiative: Provide birth hospital maternity unit nurse managers with Infant Case Management Forms to complete and return to MDPH when infant born to HBsAg+ mother MDPH Jan 03

Birth Hospital Record Review Scheduled for 2003 - Further study of the impact of joint statement on thimerosal of July 1999 MDPH Jan 03

Birth Hospital Record Review (cont’d) Provides feedback to OB providers and birth hospitals Directs changes in Perinatal Hepatitis B Prevention Project protocol Ultimate evaluation tool MDPH Jan 03