1. The Essentials of Perinatal Hepatitis B Prevention A Training Series for Coordinators and Case Managers

2. Session 2: Case Management Lisa Jacques-Carroll, MSW NCIRD, CDC

3. 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 steps in case management for infants born to HBsAg-positive women data tracking and management systems to help with case management data tracking and management systems to help with case management

4. 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

5. Case Management in Perinatal Hepatitis B Virus (HBV) Prevention: State Examples StateReceivedcasemanagementNo.(%) HBIG and HepB at birth No. (%) Complete series by 8 mo No. (%) AlabamaYes 982 (78) 905 (92) 828 (90) (1990-2002)No 318 (22) 212 (67) 189 (59) ConnecticutYes 64 (52) 64 (52) 64 (100) 64 (100) 52 (90) 52 (90) (1994-1995)No 58 (48) 58 (48) 52 (90) 52 (90) 189 (48) 189 (48) Sources: Brian Wheeler, Alabama Dept of Public Health, 2004; MMWR 1996;45:584–7

6. 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%

7. 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

8.  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 Source: ACIP statement, MMWR 2005 (RR-16), and Guide to Life Recommended Components of Case Management Programs – con’t

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

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

11. Prenatal Case Initiation 1. Contact prenatal care provider to confirm: HBsAg test results HBsAg test results date of test date of test expected date of delivery expected date of delivery expected delivery hospital expected delivery hospital whether woman has been evaluated for her HBV infection whether woman has been evaluated for her HBV infection 2. Notify the delivery hospital

12. Prenatal Case Initiation - cont’d 3. Contact the woman to provide education and information 4. Identify sex partners and household contacts for testing, vaccination, and follow-up

13. 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)

14. 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

15. 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 immediately after first interview just before due date just before due date before each vaccination is due before each vaccination is due before post-vaccination testing before post-vaccination testing

16. 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 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 consider sending hospitals monthly list of HBsAg-positive women expected to deliver

17. After Expected Date of Delivery  Contact hospital to determine: date of delivery date of delivery date/time of hepatitis B vaccine and HBIG date/time of hepatitis B vaccine and HBIG updated contact information for mother updated contact information for mother

18. 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

19. After Birth to HBsAg+ Woman  Remind pediatrician and parents about when to administer each dose of hepatitis B 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) 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

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

21. 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 postcards filled out by parent to be mailed by provider or health department computer-generated letters computer-generated letters computer-generated phone calls computer-generated phone calls prompts for case workers follow up prompts for case workers follow up

22. 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

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

24. 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)

25. Core Data Elements: Infant  Name  Date and time of birth  Birth weight  Gestational age  Delivery hospital  Pediatrician  HBIG administration date, time, brand, dosage 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)

26. Core Data Elements: Contacts  Name  Contact info  Pre-vaccination test results, date  Hepatitis B vaccine doses  Post-vaccination test results (sexual contacts)

27. Program Activities to Support Case Management  Train state and local case workers in-service trainings in-service trainings written perinatal hepatitis B prevention protocol written perinatal hepatitis B prevention protocol  Educate providers and hospitals delivery hospital staff delivery hospital staff OB/GYNs and other prenatal care staff OB/GYNs and other prenatal care staff pediatricians and family practitioners pediatricians and family practitioners

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