texas perinatal hepatitis b prevention program 2 nd bi-annual state conference
DESCRIPTION
Designing an Effective Case Management Program Lisa Jacques-Carroll, MSW CDC, Immunization Services Division May 11, 2010. Texas Perinatal Hepatitis B Prevention Program 2 nd Bi-Annual State Conference. Learning Objectives. - PowerPoint PPT PresentationTRANSCRIPT
Texas Perinatal Hepatitis B Prevention ProgramTexas Perinatal Hepatitis B Prevention Program22ndnd Bi-Annual State Conference Bi-Annual State Conference
Designing an Effective Case Management ProgramDesigning an Effective Case Management Program
Lisa Jacques-Carroll, MSWLisa Jacques-Carroll, MSW
CDC, Immunization Services DivisionCDC, Immunization Services Division
May 11, 2010May 11, 2010
Learning ObjectivesLearning Objectives
Describe case management of HBsAg-Describe case management of HBsAg-positive and unknown pregnant womenpositive and unknown pregnant women
Describe case management of infants born Describe case management of infants born to women with positive or unknown HBsAg to women with positive or unknown HBsAg statusstatus
Describe case management of sexual and Describe case management of sexual and household contacts of pregnant women with household contacts of pregnant women with HBsAg positive or unknown statusHBsAg positive or unknown status
Define provider partnershipsDefine provider partnerships
Components of Case ManagementComponents of Case Management
Case initiationCase initiation Education of motherEducation of mother Treatment and management of infantTreatment and management of infant Management of household and sexual Management of household and sexual
contactscontacts Monitoring and evaluation of outcomesMonitoring and evaluation of outcomes
Background on Case ManagementBackground on Case Management
Benefits of Case ManagementBenefits of Case Management
Case managed infants are more likely to Case managed infants are more likely to receive post-exposure prophylaxis (PEP) receive post-exposure prophylaxis (PEP) at birth and to complete their vaccine at birth and to complete their vaccine series on timeseries on time
Household and sexual contacts are more Household and sexual contacts are more likely to be tested and vaccinatedlikely to be tested and vaccinated
Case Management in Perinatal Hepatitis B Virus (HBV) Prevention: State Examples
State State
InfantInfantReceivedReceived
case case management management No.(%)No.(%)
HBIG and HBIG and HepB at birthHepB at birth
No. (%)No. (%)
Complete Complete series series
by 8 moby 8 moNo. (%)No. (%)
AlabamaAlabama YesYes 982 (78)982 (78) 905 (92)905 (92) 828 (90)828 (90)
(1990-2002)(1990-2002) No No 318 (22)318 (22) 212 (67)212 (67) 189 (59)189 (59)
ConnecticutConnecticut YesYes 64 (52)64 (52) 64 (100)64 (100) 52 (90)52 (90)(1994-1995)(1994-1995) No 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
Case InitiationCase Initiation
Timing of IdentificationTiming of Identification
The management of an HBsAg-positive The management of an HBsAg-positive pregnant woman varies depending upon pregnant woman varies depending upon when she is identified:when she is identified: prenatallyprenatally at deliveryat delivery postnatallypostnatally
Prenatal Case InitiationPrenatal Case Initiation
1.1. Contact prenatal care provider to confirm:Contact prenatal care provider to confirm: HBsAg test resultsHBsAg test results date of testdate of test expected date of deliveryexpected date of delivery expected delivery hospitalexpected delivery hospital whether woman has been evaluated for her whether woman has been evaluated for her
HBV infection HBV infection
2.2. Notify the delivery hospitalNotify the delivery hospital
Prenatal Case Initiation - cont’dPrenatal Case Initiation - cont’d
3.3. Contact the woman to provide education Contact the woman to provide education and informationand information
4.4. Identify sex partners and household Identify sex partners and household contacts for testing, vaccination, and contacts for testing, vaccination, and follow-upfollow-up
Tips for working with the MotherTips for working with the Mother
Use mother’s first languageUse mother’s first language Use materials with visual aids/low reading Use materials with visual aids/low reading
level (if appropriate)level (if appropriate) Provide materials for review at homeProvide materials for review at home Reinforce messages with follow-up lettersReinforce messages with follow-up letters
immediately after first interviewimmediately after first interview just before due datejust before due date before each vaccination is duebefore each vaccination is due before post-vaccination testingbefore post-vaccination testing
Prior to DeliveryPrior to Delivery
Remind woman and delivery hospital of Remind woman and delivery hospital of importance of post-exposure prophylaxis importance of post-exposure prophylaxis for infant at birthfor infant at birth consider giving woman card to take to consider giving woman card to take to
hospital with instructions on care of infanthospital with instructions on care of infant consider sending hospitals monthly list of consider sending hospitals monthly list of
HBsAg-positive women expected to deliver HBsAg-positive women expected to deliver
After Expected Date of DeliveryAfter Expected Date of Delivery
Contact hospital to Contact hospital to determine:determine: date of deliverydate of delivery date/time of hepatitis date/time of hepatitis
B vaccine and HBIG B vaccine and HBIG updated contact updated contact
information for motherinformation for mother
HBsAg+ Woman Identified at Delivery HBsAg+ Woman Identified at Delivery or Post-natallyor Post-natally
Contact mother ASAP to provide Contact mother ASAP to provide information on hepatitis B virusinformation on hepatitis B virus
Ensure infant received hepatitis B Ensure infant received hepatitis B vaccine and HBIG vaccine and HBIG
Proceed with case management of infant Proceed with case management of infant Identify and manage sex partners and Identify and manage sex partners and
household contactshousehold contacts
Education of the MotherEducation of the Mother
Education of MotherEducation of Mother
Discuss with HBsAg+ pregnant woman:Discuss with HBsAg+ pregnant woman: What test results meanWhat test results mean Typical course of HBV infectionTypical course of HBV infection Seriousness of infection in newbornsSeriousness of infection in newborns How infant will be managedHow infant will be managed Perinatal concerns Perinatal concerns
(e.g., breastfeeding is safe) (e.g., breastfeeding is safe)
Education of Mother - cont’dEducation of Mother - cont’d
How she can take care of herselfHow she can take care of herself Importance of evaluation for HBV infectionImportance of evaluation for HBV infection Referral to physician for evaluationReferral to physician for evaluation How to prevent transmission to othersHow to prevent transmission to others Importance of identifying/vaccinating sex Importance of identifying/vaccinating sex
partners and household contactspartners and household contacts
Treatment and Management of Treatment and Management of InfantInfant
Management of Infant >2000g at Management of Infant >2000g at BirthBirth
Mother isMother is HBsAg positiveHBsAg positive hepatitis B vaccine within 12 hours of birthhepatitis B vaccine within 12 hours of birth HBIG within 12 hours of birthHBIG within 12 hours of birth
Mother isMother is HBsAg status unknownHBsAg status unknown hepatitis B vaccine within 12 hours of birthhepatitis B vaccine within 12 hours of birth test mother for HBsAg ASAPtest mother for HBsAg ASAP if mother is HBsAg-positive if mother is HBsAg-positive give HBIG to give HBIG to
infant ASAP but no later than 7 days after infant ASAP but no later than 7 days after birthbirth
Management of Infant <2000g at Management of Infant <2000g at BirthBirth
Mother isMother is HBsAg positiveHBsAg positive hepatitis B vaccine within 12 hours of birthhepatitis B vaccine within 12 hours of birth HBIG within 12 hours of birthHBIG within 12 hours of birth
Mother isMother is HBsAg status unknownHBsAg status unknown hepatitis B vaccine within 12 hours of birthhepatitis B vaccine within 12 hours of birth HBIG within 12 hours of birthHBIG within 12 hours of birth test mother for HBsAg ASAPtest mother for HBsAg ASAP
After Birth to HBsAg+ WomanAfter Birth to HBsAg+ Woman
Remind pediatrician and parentsRemind pediatrician and parents need for infant to receive hepatitis B vaccine need for infant to receive hepatitis B vaccine
series on timeseries on time need for post-vaccination testing of HBsAg and need for post-vaccination testing of HBsAg and
anti-HBs at 9-18 months of age; after 3 doses anti-HBs at 9-18 months of age; after 3 doses of vaccineof vaccine
Verify dates hepatitis B vaccines were givenVerify dates hepatitis B vaccines were given Review post-vaccination test results with Review post-vaccination test results with
pediatricianpediatrician
Infant Post-Vaccination Test ResultsInfant Post-Vaccination Test Results
If HBsAg-negative & anti-HBs If HBsAg-negative & anti-HBs >>10 mIU/mL10 mIU/mL infant is protectedinfant is protected
If HBsAg-negative & anti-HBs <10 mIU/mLIf HBsAg-negative & anti-HBs <10 mIU/mL
revaccinate with 3-dose hep B seriesrevaccinate with 3-dose hep B series
retest 1–2 months after final doseretest 1–2 months after final dose If HBsAg-positiveIf HBsAg-positive
refer infant for medical evaluation/ refer infant for medical evaluation/ management of chronic HBV infectionmanagement of chronic HBV infection
report perinatal infection to CDC via report perinatal infection to CDC via NNDSS (NNDSS (National Notifiable Disease Surveillance SystemNational Notifiable Disease Surveillance System))
Household and Sexual ContactsHousehold and Sexual Contacts
Management of ContactsManagement of Contacts
Identify all household and sexual contacts Identify all household and sexual contacts of HBsAg-positive pregnant womanof HBsAg-positive pregnant woman Refer contacts for serologic testingRefer contacts for serologic testing Refer susceptible contacts for hepatitis B Refer susceptible contacts for hepatitis B
vaccinationvaccination Refer infected contacts for medical evaluation Refer infected contacts for medical evaluation
Program OutcomesProgram Outcomes
Completion of Follow-up for Infants of Completion of Follow-up for Infants of HBsAg-Positive Women, U.S.,1993-2008HBsAg-Positive Women, U.S.,1993-2008
Source: National Center for Immunization and Respiratory Diseases, CDC
HBIG/vaccine at birth
3 doses by 8 months
Post-vaccination testing
95%
69%
53%
0102030405060708090
100
TX Case Management Outcomes*, 2008TX Case Management Outcomes*, 2008
*For case managed infants. Texas data excludes Houston and San *For case managed infants. Texas data excludes Houston and San Antonio.Antonio.
HBIG & HepB at
birth
3 HepB by 8
Months
PVS Testing
Texas 94% 54% 35%
U.S. Average
95% 69% 53%
Methods to Increase OutcomesMethods to Increase Outcomes
Reminder and Recall SystemsReminder and Recall Systems
Notify before (reminder) and after (recall) Notify before (reminder) and after (recall) vaccines and tests are duevaccines and tests are due
Use for parents, pediatricians, and case Use for parents, pediatricians, and case workersworkers
How?How? postcards filled out by parent to be mailed by postcards filled out by parent to be mailed by
provider or health departmentprovider or health department computer-generated letterscomputer-generated letters phone callsphone calls prompts for case workers follow upprompts for case workers follow up
Data IntegrationData Integration
Some programs’ perinatal hepatitis B data Some programs’ perinatal hepatitis B data are integrated into other systems:are integrated into other systems: Immunization Information System (IIS)Immunization Information System (IIS)
infant hepatitis B vaccinations in this systeminfant hepatitis B vaccinations in this system Communicable disease reporting systemCommunicable disease reporting system
HBsAg-positive women reported to this systemHBsAg-positive women reported to this system
Increase PVS TestingIncrease PVS Testing
Utilize electronic systems such as state Utilize electronic systems such as state Medicaid database or immunization Medicaid database or immunization registry to find updated contact inforegistry to find updated contact info
Provide incentives to families to get infants Provide incentives to families to get infants tested ($10 gift cards)tested ($10 gift cards)
Keep cases open for longer/persistent Keep cases open for longer/persistent case managerscase managers
Working with Hospitals and ProvidersWorking with Hospitals and Providers
Ongoing need for education of delivery Ongoing need for education of delivery hospital staff, prenatal care providers, hospital staff, prenatal care providers, family practitioners and pediatricians on family practitioners and pediatricians on their roles in perinatal hepatitis B their roles in perinatal hepatitis B preventionprevention
Educating Prenatal Care ProvidersEducating Prenatal Care Providers
Remind prenatal care providers to screen Remind prenatal care providers to screen all pregnant women for HBsAg and report all pregnant women for HBsAg and report infected women to public healthinfected women to public health
Encourage providers to educate all Encourage providers to educate all pregnant women on the birth dose of pregnant women on the birth dose of hepatitis B vaccinehepatitis B vaccine
Educating Delivery HospitalsEducating Delivery Hospitals
Conduct policy reviews and medical Conduct policy reviews and medical record reviewsrecord reviews
Assure hospitals have policies:Assure hospitals have policies: Universal birth dose administrationUniversal birth dose administration Review/test all delivering women for Review/test all delivering women for
HBsAgHBsAg PEP for infants born to HBsAg-positive PEP for infants born to HBsAg-positive
and unknown womenand unknown women Report all cases to the health departmentReport all cases to the health department
Educating PediatriciansEducating Pediatricians
Encourage administration of birth Encourage administration of birth dose of HepB for all infantsdose of HepB for all infants
Educate on importance of timely Educate on importance of timely receipt of HepB series for infants receipt of HepB series for infants born to HBsAg-positive women and born to HBsAg-positive women and PVS testingPVS testing
Working with Community OrganizationsWorking with Community Organizations
Engage with community Engage with community organizations to help educate key organizations to help educate key players on their roles and players on their roles and responsibilities in perinatal responsibilities in perinatal hepatitis B preventionhepatitis B prevention
Provider PartnershipsProvider Partnerships
Develop relationships with local providersDevelop relationships with local providers Identify provider champions to help educate Identify provider champions to help educate
other providers and implement hospital other providers and implement hospital policiespolicies
Work with local ACOG and AAP chaptersWork with local ACOG and AAP chapters
Evaluate Your ProgressEvaluate Your Progress
Evaluating Case ManagementEvaluating Case Management
Proportion of infants receiving:Proportion of infants receiving: HepB vaccine & HBIG within 12 hours of birthHepB vaccine & HBIG within 12 hours of birth on-time completion of HepB vaccine serieson-time completion of HepB vaccine series post-vaccination testingpost-vaccination testing
Reasons for cases lost to follow-upReasons for cases lost to follow-up Proportion of screened and vaccinated Proportion of screened and vaccinated
household and sexual contactshousehold and sexual contacts
Evaluating Case Mgmt - cont’dEvaluating Case Mgmt - cont’d
Monitor case management outcomes:Monitor case management outcomes: compare program-wide rates to national ratescompare program-wide rates to national rates locally (county level)locally (county level) quarterly or monthlyquarterly or monthly over time (trends)over time (trends)