1. Viral Hepatitis Program http://www.cdphe.state.co.us/dc/Hepatitis Perinatal Case Management Amy E. Warner, M.P.H. Colorado Department of Public Health and Environment

2. Viral Hepatitis Program http://www.cdphe.state.co.us/dc/Hepatitis

3. Viral Hepatitis Program http://www.cdphe.state.co.us/dc/Hepatitis Initial Call to Doc Holiday’s Office Test results: Confirmed that Marianna was pregnant Will fax all hepatitis test results to case manager Date of test: January 29th Expected date of delivery: June 15th Expected delivery hospital: not sure

4. Viral Hepatitis Program http://www.cdphe.state.co.us/dc/Hepatitis Initial Call to Doc Holiday’s Office (con’t) Has Marianna been evaluated for her hepatitis infection: –Physician told her there’s “no problem” Previous births? –1 child born in Texas –1 child born in Colorado Any immunization records for the children? –Doc thinks they were immunized, but does not know if they were tested. Call pediatrician, Dr. Quinn

5. Viral Hepatitis Program http://www.cdphe.state.co.us/dc/Hepatitis Initial Call to Doc Holiday’s Office (con’t) Does Marianna speak English? –A little, but her relative interprets from Spanish When is her next appointment –March 15th Verify contact information –Marianna actually lives in Mexico but uses her sister’s address in Colorado. She plans on moving in with her sister closer to the birth

6. Viral Hepatitis Program http://www.cdphe.state.co.us/dc/Hepatitis

7. Viral Hepatitis Program http://www.cdphe.state.co.us/dc/Hepatitis Potential Issues with Positive HBsAg test Ask for a copy of the lab results Was it confirmed? Were there additional tests done Anti-HBs or anti-HBc IgM Liver enzymes HBeAg Anti-Hbe Ag DNA – Viral load

8. Viral Hepatitis Program http://www.cdphe.state.co.us/dc/Hepatitis Issue: Hepatitis B- “No Problem” Hepatitis B infection can lead to liver disease Babies need healthy moms –Evaluate HBV infection during pregnancy. Mom is more likely to have some insurance Mom may need treatment after the birth It’s a good time for the family to learn prevention How not to infect others How to stay healthy

9. Viral Hepatitis Program http://www.cdphe.state.co.us/dc/Hepatitis More Issues Previous births –Check your own records on the previous case Immunization registry Perinatal database –Call Texas to gather information on previous cases Language –Be prepared with an interpreter

10. Viral Hepatitis Program http://www.cdphe.state.co.us/dc/Hepatitis File History Marianna was HBsAg-negative with her first child in 2002. Texas does not have a case file She was HBsAg-positive with the 2 nd pregnancy in 2005 Colorado files indicate that the 1 st child received 2 doses of vaccine and the 2 nd child received HBIG and 2 doses of vaccine The father tested susceptible before the 2 nd child was born, but there is no record of vaccination They were lost to follow-up in 2006

11. Viral Hepatitis Program http://www.cdphe.state.co.us/dc/Hepatitis Contacting Marianna-March 11th Phone Interview –Use an interpretation service if needed –Explain the program –Conduct the interview –Answer questions and offer to send information –Try to identify alternate contact information.

12. Viral Hepatitis Program http://www.cdphe.state.co.us/dc/Hepatitis Caring for Marianna Emphasize the need for follow-up testing and evaluation Ask if she has resources for follow-up care Share information about local clinics that have a sliding fee or can provide free services

13. Viral Hepatitis Program http://www.cdphe.state.co.us/dc/Hepatitis Marianna & Baby Explain the baby’s needs for prophylaxis –Identify birthing hospital –Identify pediatrician Let her know that you will continue to work with her until the baby receives post- vaccination serologic testing

14. Viral Hepatitis Program http://www.cdphe.state.co.us/dc/Hepatitis Marianna & Contacts Emphasize follow-up of children, and sexual/household contacts Check your immunization registry for sibling records Speak with both Dr Quinn and Marianna about completing the children’s vaccine –Refer to local health department or Federally Qualified Health Center (FQHC)

15. Viral Hepatitis Program http://www.cdphe.state.co.us/dc/Hepatitis Contacts Assess best venue for father and the children to get immunization and/or testing –Home –Local laboratory –Provider’s office –Local health department

16. Viral Hepatitis Program http://www.cdphe.state.co.us/dc/Hepatitis Can’t Reach Marianna?

17. Viral Hepatitis Program http://www.cdphe.state.co.us/dc/Hepatitis

18. Viral Hepatitis Program http://www.cdphe.state.co.us/dc/Hepatitis Can’t Reach Marianna? Ask sister for a forwarding address and send a letter explaining that: – you have important medical information, and – asking her to call you Check registries for WIC or immunization Meet Marianna at her next appointment Consider a home visit Consider an international phone call

19. Viral Hepatitis Program http://www.cdphe.state.co.us/dc/Hepatitis High-risk Behaviors Consider Disease Investigation Specialist (DIS) –Mother may not be able to notify contacts Incarcerated Feels threatened Check registries –DIS may already be investigating/notifying contacts –Call parole officers for contact information, but do not disclose health information

20. Viral Hepatitis Program http://www.cdphe.state.co.us/dc/Hepatitis Prepare for the Infant Educate Marianna about prevention Ensure that Dr. Quinn orders HBIG and hepatitis B birth dose Ask Doc Holiday to send a copy of the original lab to the hospital or you send it Notify the hospital of the impending birth and provide guidelines for appropriate treatment of the infant

21. Viral Hepatitis Program http://www.cdphe.state.co.us/dc/Hepatitis More Preparation for the Infant Send an HBIG fax back form to the hospital Keep in touch with hospital staff Keep email lists updated Offer in-service training Forward new recommendations as they are released Review hospital protocols regularly

22. Viral Hepatitis Program http://www.cdphe.state.co.us/dc/Hepatitis Birth Follow-up with hospital –Did hospital fax the health department a completed HBIG form? Follow-up with Doc Holiday? –Did he perform the birth? –Who provided pediatric care? Dr. Quinn? Call Marianna

23. Viral Hepatitis Program http://www.cdphe.state.co.us/dc/Hepatitis Completing the Series How do you keep Marianna engaged long enough to complete the infant’s vaccine series and post-vaccination testing?

24. Viral Hepatitis Program http://www.cdphe.state.co.us/dc/Hepatitis Strategies Contact Dr. Quinn (pediatric provider) –What vaccine and what schedule will be used –Send a letter describing your program Offer free vaccine and waive the administration fee Reminder/Recall –Post-cards –Phone calls –emails

25. Viral Hepatitis Program http://www.cdphe.state.co.us/dc/Hepatitis More Strategies Incentives –Given with each service –Given once services are completed Include Dad or Grandma Focus on the need to know a child’s infection status

26. Viral Hepatitis Program http://www.cdphe.state.co.us/dc/Hepatitis Even More Strategies Offer a variety of free testing choices –In the home –At your office –Private laboratory –Their physician draws blood and sends it to your lab Don’t delay

27. Viral Hepatitis Program http://www.cdphe.state.co.us/dc/Hepatitis Case Closed Fully complete (Gold Standard) –The infant receives HBIG and all doses of vaccine and is tested for HBsAg and anti-HBsAg –All contacts are tested Susceptible contacts are immunized with 3 doses of vaccine Infected contacts are referred for care

28. Viral Hepatitis Program http://www.cdphe.state.co.us/dc/Hepatitis Patient Information Packets Language appropriate Program description Living with hepatitis B Hepatitis B shots are recommended for new babies Answers to specific questions raised by Mom

29. Viral Hepatitis Program http://www.cdphe.state.co.us/dc/Hepatitis Physician Information Packet Information given to patient Published guidelines Website links (IAC, CDC, ACOG, AAP,AAFP) Names of local specialists

30. Viral Hepatitis Program http://www.cdphe.state.co.us/dc/Hepatitis Case Status Marianna was found through the WIC registry Due to the program’s persistence, Marianna’s children are fully immunized and immune to hepatitis B Marianna saw a specialist who is working with her doctor in Mexico

31. Viral Hepatitis Program http://www.cdphe.state.co.us/dc/Hepatitis Case Status (con’t) Doc Holiday was actually a dentist. He decided that this was too much work and went back to gambling, drinking, and pulling teeth before his lifestyle and tuberculosis took his life Dr. Quinn became an energetic advocate for hepatitis B vaccination and cared for many women with hepatitis B