1. Healthy Kansans living in safe and sustainable environments.

2. Maternal, Infant, and Hospital Level Factors Associated with Newborn Hepatitis B Vaccination – Kansas, 2009 Elizabeth Lawlor, Advanced Epidemiologist

3. BACKGROUND

4. Hepatitis B Caused by hepatitis B virus (HBV) ~ 4.4 million in US living with chronic HBV Often asymptomatic Transmission Sexual Parenteral Perinatal Perinatal: infection of infant after birth Risk of perinatal HBV infection among infants born to HBV+ mothers ranges from 10%-85%

5. Chronic HBV Major cause of: Cirrhosis of the liver Primary hepatocellular carcinoma Development of chronic HBV is age dependent Primary develops into chronic infection 5% of healthy older children and adults 30% of children <5 years old 90% of infants

6. Chronic HBV ~ 25% of infected infants will develop: Chronic liver disease Cirrhosis Hepatocellular carcinoma ~ 25% of infants with complications will die as young adults

7. Outcome of HBV Infection by Age at Infection Symptomatic Infection Chronic Infection Chronic Infection (%) Symptomatic Infection (%) Birth 1-6 months 7-12 months 1-4 years Older Children and Adults 0 20 40 60 80 100 80 60 40 20 0 Ward, John and Prevention, Centers for Disease Control and. Hapatitis A Through E: An Overview. University of Alabama at Birmingham. [Online] 2007. www.microbio.uab.edu/medmicro/lectures/ward.ppt.

8. Preventing Perinatal Infections Hepatitis B immune globulin (HBIG) and HBV vaccine birth dose administered at birth ≥ 95% effective at preventing infection for infants born to HBV+ moms HBV vaccine (without HBIG) is 70% - 95% at preventing transmission from mother to child Several case reports of infants contracting HBV because of no chemoprophylaxis at birth HBV birth dose recommended for all medically stable infants > 2,000 grams regardless of maternal status Centers for Disease Control and Prevention. Recommendations of the Advisory Committee on Immunization Practices (ACIP). A Comprehensive Immunization Strategy to Eliminate Transmission of Hepatitis B Virus Infection in the United States: Immunization of Infants, Children, and Adolescents. MMWR. 2005, Vol. 54, RR16. Centers for Disease Control and Prevention. Recommendations of the Immunization Practices Advisory Committee Prevention of Perinatal Transmission of Hepatitis B Virus: Prenatal Screening of all Pregnant Women for Hepatitis B Surface Antigen. MMWR. 1988, Vol. 37, 22.

9. Universal Birth Dose Policy Provided by Kansas Department of Health and Environment (KDHE) to hospitals enrolled in Vaccines For Children program Hepatitis B vaccine is offered, at no cost, for all infants regardless of insurance status

10. Objective To determine what factors are associated with hepatitis B birth dose receipt at Kansas hospitals

11. METHODS

12. Study Retrospective cohort study Data sources Hospital policy survey 2009 birth registry data

13. Hospital Policy Survey Survey was sent to all birthing hospitals’ labor and delivery units Assessed 2009 policies Policies to prevent perinatal infections (hepatitis B, HIV, and group B strep) Policies regarding universal newborn hepatitis B birth dose administration

14. Independent Variables (Individual Level) Maternal factors – birth registry Age (continuous) Race/ethnicity (white non-Hispanic, black non-Hispanic, Hispanic, other) Education (less than high school, high school/GED, some college, college degree and higher) Insurance (private, Medicaid, self-pay) Receipt of prenatal care (Y/N) Attending provider (MD, DO, midwife) Infant factors – birth registry Plurality (singleton, multiple)

15. Independent Variables (Hospital Level) Hospital Characteristics Hospital size (≤ 500, > 500) Urbanicity (urban, non-urban) Written hospital vaccination policy (Y/N) Policy Survey

16. Dependent Variable Vaccination with hepatitis B vaccine prior to discharge (Y/N) Recorded on the birth certificate

17. Record Exclusion Excluded the following from analysis: Infants weighing < 2,000 grams Infants born outside of a hospital Infants with unknown values for independent variables

18. Statistical Analysis Analyses were performed using SAS ® 9.3 Bivariate associations assessed Birth dose and maternal/infant factors Birth dose and hospital factors Stepwise multivariable logistic regression to assess the association of maternal, infant, and hospital level characteristics with infant hepatitis B immunization prior to discharge Goodness-of-fit test and pseudo R 2

19. Statistical Analysis Multilevel logistic regression analysis was performed Level 1 – individual characteristics (maternal/infant) Level 2 – hospital characteristics Preliminary results

20. RESULTS

21. Policy Survey Responses from 68 of 73 (93%) of hospitals

22. Birth Dose Administration 2009 Births 42,512

23. Birth Dose Administration 2009 Births 42,512 Excluded 6,106 (14%)

24. Birth Dose Administration 2009 Births 42,512 Excluded 6,106 (14%) No Policy Survey 4,340 (10%)

25. Birth Dose Administration 2009 Births 42,512 Included in Analysis 32,066 (75%) Excluded 6,106 (14%) No Policy Survey 4,340 (10%)

26. Birth Dose Administration 2009 Births 42,512 Included in Analysis 32,066 (75%) Received birth dose 25,843 (80.6%) Excluded 6,106 (14%) No Policy Survey 4,340 (10%)

27. Birth Dose Administration 2009 Births 42,512 Included in Analysis 32,066 (75%) Received birth dose 25,843 (80.6%) Excluded 6,106 (14%) No Policy Survey 4,340 (10%) Received birth dose 3,518 (81.1%)

28. Bivariate Analysis – Individual Maternal Age Education Race/ethnicity Attending provider Prenatal care Pay source Infant Plurality

29. Bivariate Analysis – Individual Maternal Age Education Race/ethnicity Attending provider Prenatal care Pay source Infant Plurality Significant

30. Bivariate Analysis – Hospital Number of births Urbanicity Vaccination orders

31. Bivariate Analysis – Hospital Number of births Urbanicity Vaccination orders Significant

32. Individual factors Age Hispanic ethnicity Maternal education Private insurance Plurality Attending (DO) Hospital factors Number of births Urbanicity Vaccination orders GOF p = 0.67 Pseudo R 2 = 0.25 Final Model x2x2 Age (continuous)29.2 Race/Ethnicity (ref. White, non-Hispanic) Black, non-Hispanic2.7 Hispanic12.7 Other0.1 Education (ref. College Degree or Higher) Less than High School45.2 High School/GED48.1 Some College14.7 Insurance (ref. Medicaid) Private7.7 Self-pay0.1 Plurality (ref. Multiple) Singleton46.9 Type of Attending (ref. MD) DO4.1 CNM/CM0.1 Size (number of births) (ref. >500) ≤500129.0 Urbanicity (ref. Urban) Non-Urban245.7 Vaccination Orders (ref. Yes) No orders89.6 Logistic Regression Significant: p < 0.05

33. Odds Ratio95% CL Age (continuous)0.980.98 – 0.99 Race/Ethnicity (ref. White, non-Hispanic) Black, non-Hispanic1.140.99 – 1.31 Hispanic1.391.22 – 1.58 Other1.381.18 -1.62 Education (ref. College Degree or Higher) Less than High School1.301.13 – 1.50 High School/GED1.341.20 – 1.49 Some College1.111.0 – 1.22 Insurance (ref. Medicaid) Private1.010.91 – 1.11 Self-pay1.080.92 – 1.26 Plurality (ref. Multiple) Singleton0.440.37 – 0.53 Prenatal Care (ref. Prenatal care) No prenatal care1.501.05 – 1.14 Type of Attending (ref. MD) DO0.980.84 – 1.13 CNM/CM0.840.69 – 1.02 Size (number of births) (ref. >500) ≤5000.700.25 – 1.99 Urbanicity (ref. Urban) Non-Urban1.870.58 – 6.01 Vaccination Orders (ref. Yes) No orders0.050.01 – 0.16 Individual factors Age Hispanic ethnicity/other race High school education or less Plurality Prenatal care Hospital factors Vaccination orders Multilevel Analysis

34. CONCLUSIONS

35. Discussion Maternal, infant, and hospital level characteristics are associated with receipt of the birth dose Disparities exist at both the individual and hospital level

36. Discussion Maternal education Less education is significantly associated with birth dose administration – higher educated women are more likely to question physicians Maternal race/ethnicity Hispanic ethnicity and races other than white non-Hispanic and black non-Hispanic are more likely to have vaccinated Plurality Potentially due to greater involvement of physicians in infants’ care as opposed to singletons?

37. Discussion No variation between urban and rural hospitals, or between large and small hospitals Vaccination orders Presence of orders was most significantly associated with the administration of the birth dose Should be implemented at all hospitals

38. Limitations Birth dose data from the birth registry Possible incorrect reports from hospitals No data on 5 hospitals’ policies Multilevel analysis did not address interactions

39. Recommendations Educational efforts are needed regarding importance of the vaccine Continued education of hospitals on importance of birth dose Further examination of the multilevel logistic regression model is needed, including other hospital factors (e.g. teaching status, ownership type, etc.)

40. Acknowledgements Suparna Bagchi, PhD – EIS officer KDHE-BEPHI staff Public Health Informatics Infectious Disease Epidemiology and Response CSTE

41. Questions?

42. Healthy Kansans living in safe and sustainable environments. www.kdheks.gov Elizabeth Lawlor, MS Advanced Epidemiologist Bureau of Epidemiology and Public Health Informatics Kansas Department of Health and Environment 785-368-8208 elawlor@kdheks.gov