Perinatal Case Management

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

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

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

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

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

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

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

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

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

10. 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 2nd pregnancy in 2005 • Colorado files indicate that the 1st child received 2 doses of vaccine and the 2nd child received HBIG and 2 doses of vaccine • The father tested susceptible before the 2nd child was born, but there is no record of vaccination • They were lost to follow-up in 2006 Viral Hepatitis Program http://www.cdphe.state.co.us/dc/Hepatitis

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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