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Prevention of Perinatal Hepatitis B Through Enhanced Case Management -- Connecticut, 1994-95, and United States, 1994

Each year, an estimated 20,000 infants are born to women in the United States who are positive for hepatitis B surface antigen (HBsAg). These infants are at high risk for perinatal hepatitis B virus (HBV) infection and for chronic liver disease as adults. To identify newborns who require immunoprophylaxis to prevent perinatal HBV infection (1-4), all vaccine advisory groups have recommended routine HBsAg screening of all pregnant women during an early prenatal visit in each pregnancy. Federal funding to support perinatal hepatitis B-prevention programs became available in 1990, and by 1992, programs had been implemented in all 50 states and the District of Columbia. Specific objectives of these programs are to ensure that 1) all pregnant women are tested for HBsAg, and 2) infants born to HBsAg-positive women receive hepatitis B immune globulin (HBIG) and hepatitis B vaccine at birth, with follow-up doses of vaccine at ages 1 and 6 months (5). This report describes the case-management features of successful hepatitis B-prevention programs in Connecticut during 1994-95 and in the United States during 1994.

Connecticut

In 1992, the Connecticut Department of Public Health implemented a perinatal hepatitis B-prevention program and recommended that 1) HBsAg-positive women be contacted before delivery and educated about HBV infection, 2) the infant's pediatrician and delivery hospital be informed of the mother's HBsAg status, and 3) a tracking system be used to ensure the infant receives appropriate postexposure prophylaxis. Local health departments (LHDs) initially were responsible for providing management to mother/infant pairs.

Enhanced case management (ECM) was implemented in two counties in July 1994 and a third county in April 1995. In addition to use of the basic recommendations, the ECM program employed a full-time nurse (hired by the state) who worked on a flexible schedule to manage all mother/infant pairs in the three-county area and a computer-based tracking system to identify pending births to infected mothers and the need for follow-up vaccine doses for infants. To evaluate program effectiveness, outcomes in the ECM program were compared with the LHD programs for HBsAg-positive women identified during 1994-95.

During 1994-95, the ECM program identified 64 HBsAg-positive pregnant women and maintained contact with all of these women throughout their pregnancies. During this period, LHD programs identified 71 HBsAg-positive pregnant women and established and/or maintained contact with 58 (82%). The mothers in the LHD programs resided in 27 different local health jurisdictions. Three of these jurisdictions managed greater than or equal to 10 mothers, and 18 each managed one.

Documented compliance with the recommendation to administer HBIG and the first dose of hepatitis B vaccine within 24 hours of birth was higher in the ECM group (100%) than in the LHD group (90%) (Table 1). In addition, the rate of completion of the three-dose series by 6-8 months after birth was higher in the ECM program (91%) than the LHD programs (48%). No infants were lost to follow-up in the ECM program; in comparison, seven (12%) infants in the LHD programs were lost to follow-up without documentation that the series was completed.

United States

In March 1996, CDC conducted a survey to assess the effectiveness of the 58 federally funded perinatal hepatitis B-prevention programs for infants born to HBsAg-positive women in the United States during 1994. Of 8252 infants born to HBsAg-positive women, 7362 (89%) received HBIG and the first dose of hepatitis B vaccine at birth, and 5042 (61%) completed prophylaxis by age 6-8 months.

As part of this survey, program coordinators completed a questionnaire about key programmatic elements; 48 (76%) of the 58 programs provided complete information. ECM techniques associated with an increased likelihood of vaccination of infants born to HBsAg-positive mothers (Table_1) included routine reminders to HBsAg-positive women that their status should be reported to the delivery hospital, reporting of the maternal HBsAg status on the newborn metabolic screening card or birth certificate, routine reminders to the prenatal-care providers that the mother's HBsAg status should be reported to the delivery hospital, and use of a computer-based tracking system for HBsAg-positive pregnant women and their infants.

Reported by: AJ Roome, MPH, M Rak, JL Hadler, MD, State Epidemiologist, Connecticut Dept of Public Health. Epidemiology and Surveillance Div, National Immunization Program; Hepatitis Br, Div of Viral and Rickettsial Diseases, National Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: Administration of appropriate immunoprophylaxis is approximately 90% effective in preventing perinatal HBV transmission (6). Because infants who are incompletely vaccinated with hepatitis B vaccine are at increased risk for perinatal HBV infection and less likely to be protected against infection compared with completely vaccinated children, timely provision of HBIG and the appropriate doses of vaccine is essential to prevention (7).

The findings in this report indicate that, compared with all U.S. infants born to HBsAg-positive women, a substantially higher proportion of such infants in the ECM program in Connecticut received HBIG and were completely vaccinated with hepatitis B vaccine by age 6-8 months. One potential explanation for the increase in Connecticut was the use of comprehensive case-management techniques, including employment of staff specifically for the program, use of a computer-based tracking system, and use of reminder letters. Similar techniques improved case management in the national survey. In addition, reporting of maternal HBsAg status on newborn metabolic screening cards or birth certificates may help to ensure infants are vaccinated in the hospital and entered into tracking and recall systems at the state health department.

Perinatal hepatitis B-prevention programs without intensive case management have been only moderately successful in ensuring that children of HBsAg-positive mothers are identified and complete the vaccine series by age 6-8 months. For example, in 1988, an evaluation of patients served by a large municipal hospital indicated that only 65% of infants at risk for perinatal HBV infection had received both HBIG and hepatitis B vaccine within 7 days after delivery (8). In addition, among 832 infants identified by a neonatal hepatitis B surveillance and vaccination program in New York City in 1988, only 59% had received HBIG and completed the vaccine series by age 18 months (9).

Although this report did not include cost analysis, previous studies associate substantial cost savings with prevention of perinatal HBV transmission (10). For example, the estimated lifetime medical costs for one patient with cirrhosis of the liver (without transplantation) is $87,000; however, the costs associated with the techniques employed by the ECM program were not estimated. In addition, the integration of perinatal HBV-prevention programs with existing and new perinatal screening programs (e.g., maternal screening for human immunodeficiency virus and group B streptococcal infections) may improve overall cost effectiveness of these programs and facilitate comprehensive case management for other diseases that affect newborns.

A national health objective for the year 2000 is to reduce by approximately 80% the number of perinatal HBV infections in the United States (objective 20.3). Based on the national survey described in this report, only half of all births to HBsAg-positive mothers in the United States are reported to a perinatal hepatitis B-prevention program and entered into a tracking system. Based on recent studies, widespread use of comprehensive case-management techniques similar to those used by newborn metabolic screening programs are needed to achieve the year 2000 objective.

References

  1. CDC. Protection against viral hepatitis: recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR 1990;39(no. RR-2).

  2. Committee on Obstetrics: Maternal and Fetal Medicine. Guidelines for hepatitis B virus screening and vaccination during pregnancy. Washington, DC: American College of Obstetrics and Gynecology, 1990.

  3. American Academy of Pediatrics. 1994 Red book: report of the Committee on Infectious Diseases. 23rd ed. Elk Grove Village, Illinois: American Academy of Pediatrics, 1994:224-38.

  4. American Academy of Family Physicians. Recommendations for hepatitis B preexposure vaccination and postexposure prophylaxis. Kansas City, Missouri: American Academy of Family Physicians, August 1992. (Reprint no. 529).

  5. CDC. Hepatitis surveillance report no. 56. Atlanta, Georgia: US Department of Health and Human Services, Public Health Service, CDC, 1995.

  6. Stevens CE, Taylor PE, Tong MJ, et al. Yeast-recombinant hepatitis B vaccine: efficacy with hepatitis B immune globulin in prevention of perinatal hepatitis B virus transmission. JAMA 1987;257:2612-6.

  7. Kohn MA, Farley TA, Scott C. The need for more aggressive follow-up of children born to hepatitis B surface antigen positive mothers: lessons learned from the Louisiana Perinatal Hepatitis B Immunization Program. Pediatr Infect Dis J 1996;15:535-40.

  8. Birnbaum JM, Bromberg K. Evaluation of prophylaxis against hepatitis B in a large municipal hospital. Am J Infect Control 1992;20:172-6.

  9. Henning KJ, Pollack DM, Friedman SM. A neonatal hepatitis B surveillance and vaccination program: New York City, 1987 to 1988. Am J Public Health 1992;82:885-8.

  10. Margolis HS, Coleman PJ, Brown RE, et al. Prevention of hepatitis B virus transmission by immunization: an economic analysis of current recommendations. JAMA 1995;274:1201-8.


Table_1
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TABLE 1. Number and percentage of infants who were born to HBsAg * -positive women and received hepatitis B immune
globulin (HBIG) and the vaccine series for hepatitis B, by program and characteristics -- Connecticut, 1994-95, and United
States, 1994
====================================================================================================================================
                                                   Infants who received      Infants who received third
                                  No. infants      HBIG and hepatitis B      dose of hepatitis B vaccine
                                    born to          vaccine at birth           6-8 months after birth
                                 HBsAg-positive  ------------------------    ----------------------------
Program/Characteristic               women        No.     (%)     p value     No.      (%)       p value
---------------------------------------------------------------------------------------------------------
Connecticut
 Use enhanced case-management
  (ECM) techniques
   Yes (ECM program)                    64         64    (100)     0.01 +      58      (91)      <0.01
   No (local health department
    program &)                          58         52    ( 90)                 28      (48)

United States @
 Provide reminders to HBsAg-
  positive women to report their
  status to delivery hospital
   Yes                                6717       5978    ( 89)     0.16      4500      (67)      <0.01
   No                                  949        835    ( 88)                522      (55)

 Report maternal HBsAg
  status on newborn metabolic
  screening card or birth
  certificate **
   Yes                                4995       4545    ( 91)    <0.01      3347      (67)
   No                                 2617       2224    ( 85)               1649      (63)

 Provide reminders to prenatal-
  care providers to report
  mother's HBsAg status
  to delivery hospital
   Yes                                6786       6107    ( 90)    <0.01      4547      (67)      <0.01
   No                                  880        713    ( 81)                493      (56)

 Have computerized system
  to track HBsAg-positive
  pregnant women and their
  infants
   Yes                                6778       6168    ( 91)    <0.01      4541      (67)      <0.01
   No                                  888        693    ( 78)                471      (53)
---------------------------------------------------------------------------------------------------------
 * Hepatitis B surface antigen.
 + Fisher exact two-tailed test.
 & Documented compliance with the recommendation to administer HBIG and hepatitis B vaccine was verified with a chart review.
 @ Only 48 of the 58 programs in the United States reported complete data. Data from these programs were obtained from both active
   and passive surveillance systems.
** Excludes data for 54 infants for whom data were unknown.
====================================================================================================================================


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