1. HOW GOOD ARE WE AT REDUCING THE RISK? AN AUDIT OF HEPATITIS B VACCINATION IN BABIES BORN TO DRUG USING FAMILIES Josie Murray Specialty Registrar in Public Health NHS Dumfries & Galloway Co Authors: Christine Evans, Peter Harrison, Hilda Stiven, Public Health and Health Policy, NHS Lothian

2. HEPATITIS B  Mortality Rates from liver disease in the UK are rising  Hepatitis accounts for approx. 25% of all liver disease cases  Hepatitis B is a major cause of hepatitis  Whilst hospital mortality rates of HBV are low currently, they are predicted to rise significantly  Childhood infections account for 21% of HBV [1]

3. SCOTTISH NATIONAL GUIDANCE  Scottish Government’s Sexual Health & BBV Framework 2011-2015:  ‘NHS Board vaccination plans should … reflect, promote and support the responsibilities of local community partners, including GPs, in offering hepatitis B vaccination for clinical reasons, to those at risk of infection in line with immunisation policy (Department of Health,2006) and national and local best practice guidance;’ [2]

4. SCOTTISH NATIONAL GUIDANCE  Scottish Government’s Sexual Health & BBV Framework 2011-2015:  ‘work should be done to increase the proportion of babies born to hepatitis B infected mothers, or to mothers who are otherwise identified as being at risk of infection, that receive a full course of vaccine in line with national immunisation policy (Department of Health, 2006) and national best practice guidance for neonatal immunisation (Department of Health, 2011);’ [2]

5. DEPARTMENT OF HEALTH GUIDANCE  ‘the provision of a targeted infant immunisation programme has been supported by Department of Health policy since 2000.’  However is not mandatory  Highlights that the responsibility for administering the 4 doses of vaccination to at risk babies should lie with a named person  Notes that local protocols should be developed [1]

6. NHS LOTHIAN PROTOCOL  Drug users are at risk of acquiring hepatitis B due to sharing of injecting equipment and through sexual spread.  Children of problem drug users are susceptible because they live in a high risk environment.  Children infected with Hepatitis B have a higher risk of developing chronic infection than adults (around 90% vs 5- 10% in adults).  Targeting babies at birth offers a systematic way of addressing this issue and reducing the risk of avoidable harm and premature death. [3]

8. THE GREEN BOOK SCHEDULE  Hepatitis B vaccination for newborns  Birth, 1 month, 2 months & 12 months  This should result in slightly reduced immunogenicity  However, increases likely compliance when compared to the 0, 1 and 6 months [4]

9. THE DATABASE  Started in 2012  Records information on all babies born to drug using families  Demographics  Mothers & children  Vaccination date  Hospital of birth  Date of notification to HPT  Date when HPT notified SIRS  Number of doses received

10. SETTING  NHS Lothian – two maternity units

11. METHODS

14.  Used database  Updates using SIRS and phoned GPs when SIRS not complete  Counted number of vaccines given  Compared these to  Number of vaccines expected to be given for age  Previous years figures  Babies with Hep B positive mums  Repeated audit

15. RESULTS YEAR 1 Number of doses of hepatitis b vaccine administered to babies born to problem drug users (2012-2013) Doses of Hepatitis B Vaccine Number of babies vaccinated Percentage of babies vaccinated 000% 147% 212% 31628% 43663% TOTAL57100%

17. RESULTS COMPARED TO HEPATITIS B

18. REPEATED AUDIT Number of doses of hepatitis b vaccine administered to babies born to problem drug users (2012-2013) Doses of Hepatitis B Vaccine Number of babies vaccinated Percentage of babies vaccinated 000% 147% 200% 3916% 44477% TOTAL57100%

19. REPEAT COMPARED

20. STRENGTHS  This is the first audit of the uptake of HBV vaccinations in babies born to problem drug users in NHS Lothian  Therefore a benchmark has been set  It demonstrates improvement over time  And success of increased collaboration & communication  It highlights inequity in vaccination for a specific vulnerable group who are difficult to serve

21. LIMITATIONS  Data limited  We don’t know how many drug users we should have  We don’t know how many drug users babies there are  Our sample is not representative  Therefore we cannot make valid inferences about this data  Definitions have made this difficult  Not people who inject, but problem drug use  The protocol states ‘parents’ but majority of data is for mothers  Accuracy of disclosure at booking is questionable  Small numbers

22. DISCUSSION  Is 62% good?  Is it good enough?  What is the target?  What have others said/done?  Should it be part of UK schedule?

23. NATIONAL STATISTICS  Maternities & Births recording drug misuse[5]  In Lothian from 10/11-12/13 (three year aggregate) 101 births recorded maternal drug misuse (3.6 per 1000 live births)  Estimate of babies born to current injectors [5,6]  ISD reports an average 34 maternities (Lothian) recording drug misuse p.a.  Estimate 55% injection rate = 19 PWID mothers  Estimate 2.49:1 ratio of drug using males to females nationally.  Fathers:Mothers= 48:19 (assuming all PWID mothers, father is also)  Total estimate = 48 neonates per year

24. THE WAY FORWARD  More accurate data  More published work on the topic  To continue to raise awareness of the local protocol  To increase support the dedicated services who already engage with these groups  To promote the serious risk of Hepatitis B at all levels but especially in those most vulnerable groups

25. REFERENCES  [1] Department of Health (2011) Hepatitis B antenatal screening & immunisation programme. Best practice guidance  [2] Scottish Government (2011) the Sexual Health and BBV Framework  [3] NHS Lothian (update 2014) Pre-exposure Hepatitis B immunisation for babies born to problem drug using parents  [4] Public Health England (2013) The Green Book Ch18 Hepatitis B  [5] ISD (2012) Drug Misuse Statistics Scotland 2011. Publication Date - 28 February 2012  [6] ISD(2011) Estimating the National and Local Prevalence of Problem Drug Use in Scotland 2009/10. Publication date - 29th November 2011

26. ACKNOWLEDGEMENTS:  Co-authors:  Dr Christine Evans  Peter Harrison  Hilda Stiven  NHS Lothian:  Viral Hepatitis MCN  Health Protection Team  Jim Sherval  Dona Milne  NHS Dumfries & Galloway:  Michele McCoy  Department of Public Health

28. ANY QUESTIONS?