Case Identification for the Missouri Perinatal Hepatitis B Prevention Program

Libby Landrum, RN, MSNViral Hepatitis Prevention Manager

Bureau HIV, STD, and Hepatitis Missouri Department of Health and Senior

Services

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

Methods of Reporting Hepatitis B

Laboratories report hepatitis Bpaper 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

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 resultsassign the appropriate hepatitis condition status according to the current CDC case definitionsenter case information into the electronic state disease registry

Types of Case Identification

Prospective Identification: identification of an HBsAg-positive pregnant womanRetrospective Identification: identification of an infant born to an HBsAg-positive pregnant woman

Case Identification in Missouri

Missouri ~ 130 infants identified per year CDC Missouri estimates (156-258)

Missouri Identification of Infants Born to Hepatitis B-infected Women By Year

0

20

40

60

80

100

120

140

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Year

Nu

mb

er

of

Infa

nts

Id

en

tifi

ed

Prospective Identification Retrospective Identification Total Infants Born to HBV-infected Women

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)

Determining Pregnancy Status

Determination of pregnancy statusassigned case manager • contacts submitting healthcare provider• documents pregnancy status on lab

report

Not pregnantpregnancy condition

– “suspect status” changed to “no case”– appropriate hepatitis B condition entered

(acute or chronic)– case investigated as usual– case closed

Opening a Case

When pregnancy is verifiedhepatitis B pregnancy condition is changed from a “suspect” to “confirmed” in the state disease registry pregnant HBsAg-positive woman is enrolled into case managementappropriate public health agency case manager notifiedappropriate case manager follows case to completion

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

Examples of Retrospective Identification

Case investigation on a new HBsAg-positive pregnant woman finds an unreported infant born prior to current pregnancyLocal public health agency identifies an unreported infant though a clinic visit or service provisionCase investigator discovers retrospective infant during a case contact investigation

Relationships with Partners

Case Managers and Program Staff

Local public health agencies • electronic notification• fax case information

Healthcare providers• consultation• technical assistance• education• interventions

Relationships with Partners (cont’d)

Birthing Hospitals, Healthcare Providers, and Local Public Health Agencies

birthing hospital site visitsmedical record reviewshepatitis B prevention education and recommendationsregional trainings• “One is Too Many” workshops• hepatitis viral markers interpretation• disease, prevention and treatment

Annual Educational Letters Physicians

MD/DO• Family Practice• Pediatrics• Obstetrics

Nurse PractitionersPediatricsFamily PracticeObstetrics

MidwivesLocal Public Health

Communicable Disease Nurses

2008 Updates

State Case Manager/Quality Assurance Coordinator now contacts physicians Verifies pregnancy statusAssigns appropriate pregnancy condition status in state disease registry

expedites case follow-up decreases unreported casesincreases prospective identification of infants at risk

Case Example

A pregnant woman without prenatal care presented in emergency care to deliverThe hospital has standing orders to test pregnant women of unknown HBsAg status upon admission for Labor and Delivery

Case Example (cont’d)

The HBsAg test results were reported back within 10 hours of the infant’s deliveryWoman tested HBsAg-positiveThe newborn nursery staff administered HBIG and the 1st dose of monovalent hepatitis B vaccine within 12 hours of birth

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

Case Outcome

Follow-up case management initiatedInfant received appropriate and timely immunoprophylaxisPost-vaccination serology testing indicated the infant was HBsAg-negative and anti-HBs >10mIU/mL (immune)

Critical Lessons Learned

Important to establish relationships

birthing hospital staff• labor and delivery physicians and nurses• newborn nursery nurses• infection control nurses

local obstetric providerslocal pediatricianslocal family practice providers

Partner Relationship Building

Provide education and materialsRespect other’s time and efforts Keep the goal of hepatitis B prevention a frequent topic of conversation

Questions?