Case Identification for the Missouri Perinatal Hepatitis B Prevention Program

1. Case Identificationfor the Missouri Perinatal Hepatitis B Prevention Program Libby Landrum, RN, MSN Viral Hepatitis Prevention Manager Bureau HIV, STD, and Hepatitis Missouri Department of Health and Senior Services

2. Hepatitis B Reporting in Missouri • Hepatitis B virus is a reportable condition in Missouri • Missouri is a dual reporting state • Mandated reporters: • laboratories • healthcare providers

3. Methods of Reporting Hepatitis B • Laboratories report hepatitis B • paper reports (mailed or faxed) • electronic reports (electronic transfer) • Healthcare providers report hepatitis B • paper reports (mailed or faxed) • communicable disease case report (CD-1) • copy of original laboratory reports

4. Processing Hepatitis B Reports • Positive hepatitis tests are submitted to: • Department of Health and Senior Services or • Local Public Health Agencies • Health department staff: • review and interpret the test results • assign the appropriate hepatitis condition status according to the current CDC case definitions • enter case information into the electronic state disease registry

5. Types of Case Identification • Prospective Identification: identification of an HBsAg-positive pregnant woman • Retrospective Identification: identification of an infant born to an HBsAg-positive pregnant woman

6. Case Identification in Missouri Missouri ~ 130 infants identified per year CDC Missouri estimates (156-258)

7. Review of HBsAg+ Women • Positive hepatitis tests for females age 11 to 55 years • earmarked for pregnancy status determination • Entered using a specialized disease condition category in the state disease registry • hepatitis B pregnancy condition • pregnancy condition • “suspect” status remains open (until pregnancy status is determined)

8. Determining Pregnancy Status • Determination of pregnancy status • assigned case manager • contacts submitting healthcare provider • documents pregnancy status on lab report • Not pregnant • pregnancy condition • “suspect status” changed to “no case” • appropriate hepatitis B condition entered (acute or chronic) • case investigated as usual • case closed

9. Opening a Case • When pregnancy is verified • hepatitis B pregnancy condition is changed from a “suspect” to “confirmed” in the state disease registry • pregnant HBsAg-positive woman is enrolled into case management • appropriate public health agency case manager notified • appropriate case manager follows case to completion

10. Retrospective Case Identification • Notifications of infants born to women with maternal risk factor of hepatitis B • memorandum of agreement with the Bureau of Viral Records • monthly report of births to mothers with hepatitis B as a maternal risk factor • Transfer of infant born in another state • Notification by healthcare provider or service provider familiar with our programs

11. Examples of Retrospective Identification • Case investigation on a new HBsAg-positive pregnant woman finds an unreported infant born prior to current pregnancy • Local public health agency identifies an unreported infant though a clinic visit or service provision • Case investigator discovers retrospective infant during a case contact investigation

12. Relationships with Partners • Case Managers and Program Staff • Local public health agencies • electronic notification • fax case information • Healthcare providers • consultation • technical assistance • education • interventions

13. Relationships with Partners (cont’d) • Birthing Hospitals, Healthcare Providers, and Local Public Health Agencies • birthing hospital site visits • medical record reviews • hepatitis B prevention education and recommendations • regional trainings • “One is Too Many” workshops • hepatitis viral markers interpretation • disease, prevention and treatment

14. Annual Educational Letters • Physicians • MD/DO • Family Practice • Pediatrics • Obstetrics • Nurse Practitioners • Pediatrics • Family Practice • Obstetrics • Midwives • Local Public Health • Communicable Disease Nurses

15. 2008 Updates • State Case Manager/Quality Assurance Coordinator now contacts physicians • Verifies pregnancy status • Assigns appropriate pregnancy condition status in state disease registry • expedites case follow-up • decreases unreported cases • increases prospective identification of infants at risk

16. Case Example • A pregnant woman without prenatal care presented in emergency care to deliver • The hospital has standing orders to test pregnant women of unknown HBsAg status upon admission for Labor and Delivery

17. Case Example (cont’d) • The HBsAg test results were reported back within 10 hours of the infant’s delivery • Woman tested HBsAg-positive • The newborn nursery staff administered HBIG and the 1st dose of monovalent hepatitis B vaccine within 12 hours of birth

18. Case Example (cont’d) • Newborn nursery nurse reported case to infection control officer • Infection control officer reported infant to Perinatal Hepatitis B Prevention Case Manager as a retrospective case

19. Case Outcome • Follow-up case management initiated • Infant received appropriate and timely immunoprophylaxis • Post-vaccination serology testing indicated the infant was HBsAg-negative and anti-HBs >10mIU/mL (immune)

20. Critical Lessons Learned • Important to establish relationships • birthing hospital staff • labor and delivery physicians and nurses • newborn nursery nurses • infection control nurses • local obstetric providers • local pediatricians • local family practice providers

21. Partner Relationship Building • Provide education and materials • Respect other’s time and efforts • Keep the goal of hepatitis B prevention a frequent topic of conversation

22. Questions?