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Universal Birth Dose Hepatitis B: A Safety Net

Universal Birth Dose Hepatitis B: A Safety Net. Pat Fineis Michigan Department of Community Health. Overview. History of Michigan’s Universal Hepatitis B Vaccination Program Case example and responses to tragedy

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Universal Birth Dose Hepatitis B: A Safety Net

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  1. Universal Birth Dose Hepatitis B: A Safety Net Pat Fineis Michigan Department of Community Health

  2. Overview • History of Michigan’s Universal Hepatitis B Vaccination Program • Case example and responses to tragedy • Process of adding hepatitis B (hep B) administration information to birth certificate and immunization registry • Evaluation tools and methods to increase hep B birth dose coverage levels • Barriers to implement birth dose • Hospital enrollment process

  3. Michigan’s History • 1991 Universal Hepatitis B Vaccination Program began • Goal: offer hep B vaccine to all birthing hospitals for all infants • Michigan’s birth cohort • 132,000 (1991) • 128,000 (2007) • Visited and provided education to all birthing hospitals (102)

  4. Hepatitis B Birth Dose is Postponed • July – September 1999 • Thimerosal statement released • Recommendation: • Postpone birth dose until 2 - 6 months of age if infant born to hepatitis B surface antigen (HBsAg)-negative woman • Give birth dose to infants born to HBsAg-positive and unknown HBsAg status women

  5. Case Example • Mother • 15 y.o. HBsAg-positive Laotian female • 10 prenatal visits • Lab and prenatal care provider (PCP) did not report HBsAg-positive result to local health department (LHD) • PCP reported HBsAg result as negative on prenatal record sent to delivery hospital • Infant • Healthy baby girl born (38 wks gestation) • Mom’s HBsAg status also noted as HBsAg-negative in baby’s chart • Due to recommendation to delay birth dose, no hep B vaccine was given

  6. Case Example (cont’d) • 2 months of age • 1st dose of hep B vaccine • 3 months of age • Ill with fever, diarrhea, jaundice • 5 days after onset of symptoms • Diagnosed with HBV infection and acute liver failure • 8 days after becoming ill • Infant dies

  7. Response to Situation • Presented case study in newsletters and conferences • Visited 102 birthing hospitals • Provided new CDC recommendations • Reinforced state law • Recommended original lab report with prenatal record to birthing hospital

  8. Method to Assess Efforts • Conducted hospital surveys • 1999 • 82 of 102 (80%) had written policies and standing orders to give hep B birth dose • 2001 • 92 of 102 (90%) had written polices and standing orders • Identified need for an assessment tool to measure hep B birth dose

  9. Adding Hepatitis B to Electronic Birth Certificate (EBC), 1999-2000 • Meetings with records manager and data entry staff • Goal: • Documentation of hep B vaccine dose on EBC • Box created to include hep B vaccine administration • Yes or No field • Date vaccine given (month/day/year)

  10. EBC - Hepatitis B Birth Dose

  11. Adding Hepatitis B Birth Dose to Immunization Registry, 2000-2001 • Identified need to capture hep B birth dose through the immunization registry • Meetings with immunization registry coordinator and technology staff - Michigan Care Improvement Registry (MCIR) • Goal: • Create a process to obtain the birth dose data • Develop process to download EBC birth dose data into MCIR

  12. Monitoring Hep B Birth Dose, 2002 • Began monitoring the birth dose coverage levels • Developed reports based on the information entered into Michigan Care Improvement Registry (MCIR) • County • Birthing hospital • Number of births • Number of doses given within 4 days of life • Percentages of births/number of doses • Discovered only 72% of Michigan’s babies were receiving hep B birth dose

  13. Issues and Barriers • Lag time of 2 – 3 weeks to get birth dose data into MCIR • Downloading problems • Electronic systems not compatible • Billing data conflicts • Some hospitals batching data • Documentation problems • EBC didn’t include hep B • Neonatal Intensive Care Unit (NICU) not documenting • Education and training were needed

  14. Publicizing Hepatitis B Birth Dose, 2000 • Published results in Immunization Newsletter by hospital name (>10,000 readers) • Reinstating/implementing written policies and standing orders to OFFER birth dose to all infants (based on survey results) • 82 of 102 (80%) hospitals had policies in place to offer hep B to all newborns • Generated many calls • Discussed hospital process • Reporting birth dose information to state • Documenting birth dose on EBC (yes and date) • Continued to update and publish list quarterly

  15. Publicizing Hepatitis B Birth Dose, 2002 • Published article that listed hospitals by name • Written policies and standing orders to offer hep B vaccine to ALL newborns AND • Birth dose coverage levels > 90% (based on MCIR data) • 32 of 102 hospitals named (31%) • Caused concern among hospitals and prompted • More calls • Hospitals to re-evaluate their systems • State to verify birth data

  16. Ongoing Activities • Presentations • Created and distributed program manual • Conduct hospital surveys • Identify/update contacts • Listserv for hospital and LHD contacts • Provide updates on policy/procedure information • Provide program manual updates annually • Distribute hep B birth dose coverage level reports semi-annually • Direct contact (phone call, e-mail or site visit)

  17. Hepatitis B Birth Dose Coverage Levels - MCIR • MCIR hep B birth dose coverage levels (within 4 days of life) • 76% in 2004 • 78% in 2005 • 80% in 2006 • 81% in 2007

  18. Hepatitis B Birth Dose Coverage Levels - NIS • Hep B birth dose coverage levels from the National Immunization Survey (NIS) are within 2 days of life • 2006 Michigan ranks 3rd highest in nation • National: 48.8% + 1.1 • Michigan: 78.3% + 5.0 • Detroit, MI: 81.7% + 5.6

  19. New EBC - Hepatitis B Birth Dose and HBIG Reporting, 2007 • Created new web based electronic birth certificate (EBC) worksheet • HBIG was added • New EBC now includes: • Hep B vaccine • HBIG

  20. New EBC Fields

  21. Universal Hepatitis B Vaccination Program, 2003 • Continuous need to evaluate and improve methods • Developed Enrollment Form with MI’s Vaccines for Children (VFC) Program which requires hospitals: • Minimal paperwork • Complete profile table • Total annual number of births who were: • Enrolled in Medicaid • Uninsured • American Indian/Alaska Native • Underinsured/Fully insured/Private Pay

  22. Funding of Universal Program • Develop annual population estimates to determine annual allocation of federal funds • Michigan’s birth cohort x $9.50 = ($1,200,000) • Estimate 46% are VFC eligible (enrolled in Medicaid, uninsured, American Indian, Alaska Native, and those underinsured served at FQHC/RHC) • 54% served by 317/state funding (insured, underinsured) = ($648,000)

  23. Hospital Enrollment Process • Hospital eligibility information based on: • Registry data (preferred) • Billing data • Tally Sheets • Prior year’s ordering data • Doses administered report • Shipping information (site days/hours of operation) • Forms due to state by February 15th

  24. Recruiting Hospitals to Program • VFC provides a list of hospitals not enrolled • Call LHD to determine if there are specific issues/corrective action plans • Contact hospital pharmacy manager/director to discuss: • Barriers • Universal Program • Recommendations • Ease of obtaining hep B vaccine • Cost savings

  25. Assessing Enrollment Process • 2004 • 54 of 95 birthing hospitals enrolled (57%) • 2005 • Identified barriers • Too much paperwork • Didn’t know about process or program • Purchased their own vaccine • Worked to increase participation • 2005: 86 of 95 (91%) enrolled • 2006: 88 of 95 (93%) enrolled • 2007: 92 of 94 (98%) enrolled

  26. Summary • Ensure hospitals have written policies and standing orders • Consider establishing a Universal Program and enroll hospitals • Encourage hospitals to give hep B birth dose to all infants • Provide feedback to counties and hospitals on birth dose coverage levels • Continue to provide education and materials

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