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Oregon Perinatal Hepatitis B Report

Download complete report as PDF (99K)


Introduction

In Oregon each local health department is charged with providing case management services to all identified and suspected hepatitis B surface-antigen (HBsAg) positive women and their infants. The identification and management of these infants is largely dependent upon the actions of the private healthcare sector, which provide the bulk of prenatal care and obstetrics in Oregon. While perinatal transmission of the hepatitis B virus is largely a burden in the developing world, it still occurs with regularity in the United States and is a substantial cause for chronic carriage of the virus, cirrhosis, and hepatocellular carcinoma, all of which can be prevented.

While acute and chronic hepatitis B infections are reportable conditions in Oregon, there exists no mandatory screening law for pregnant women to be tested. Fortunately, the standard of practice of screening for hepatitis B during prenatal care, like rubella, remains in place and appears to be uniform across Oregon. The screening of pregnant women for hepatitis B infection is the cornerstone of effective prevention of perinatal transmission of hepatitis B. With the woman?s hepatitis B status known, effective management of the infant during its first few hours of life can occur. Treatment for exposure to hepatitis B includes the use of hepatitis B vaccine, hepatitis B immune globulin, and the timely completion of the hepatitis B vaccine series. At nine months of age, infants are screened for the first time to assess their response to the vaccine and whether they have become infected with the hepatitis B virus. The determination of immunity to the hepatitis B virus is crucial, not only because intervention is available, but because research has shown the ongoing risk of infection to the infant who resides with chronic carriers.

The Oregon Immunization Program selected the five counties with the greatest number of infants born to hepatitis B-positive women to receive one-time funding. The primary goal was to increase the effectiveness of surveillance for these infants and the completion of the recommended prophylaxis and screening through capacity building of the case-management services for infants exposed perinatally to hepatitis B. The county with the greatest number of known infants born to hepatitis B positivewomen was initially assessed as having a very sensitive surveillance system and sufficient resources allocated to this program. This health department donated their supplemental funds to a neighboring health department who was assessed as having the less effective surveillance system. Therefore this report will focus on the four counties that received funding and their results and lessons learned.

Methods

The Oregon Immunization Program identified $25,000 in early 2002 for the improvement of the perinatal hepatitis B program. An algorithm was designed to provide funds to the health departments with the greatest number of births to hepatitis B and those health departments with the greatest need to improve surveillance.

Objectives

  1. Increase the number of infants identified;
  2. Improve methods of case and contact management;
  3. Create structure and procedure that allows for efficient communication between health departments and hospitals; and
  4. Implement a computerized tracking system for hepatitis B-positive pregnant women and their contacts.

Results

In August of 2002, an assessment of the infants born to hepatitis B positive women during 2001 was conducted. Overall, great improvement was noted in a couple of areas, but most notably, all but one county reported an increase in the number of infants who were completing their three dose hepatitis B vaccine series by 8 months of age. Stable staffing patterns were associated with significant improvement programwide. Not only is the financial commitment important, but also staff time and expertise must be developed and continuous to ensure program success.

(Download complete report as PDF (99K) for more details about objective results, lessons learned, and recommendations.

Discussion

By providing targeted funding, even a relatively small amount, we got the attention of key public health players. Funding directs activities but also increases the prioritization of program activities. There has been no difference in the importance and value of years of life saved in preventing the perinatal infection of infants, yet, by focusing not only financial resources but also administrative attention on the program objectives, rapid and significant improvements were observed in more than one local health department.

Not all counties saw improvements in every activity that was assessed. Inconsistent staffing and competing priorities challenged many. Areas that need ongoing support include the surveillance for new pregnancies in hepatitis B-positive women and the maintenance of a solid working relationship with local birthing facilities and prenatal care providers.

The program requirements are challenging to carry out. The families affected by hepatitis B tend to be high-risk, mobile, and have many barriers to health care access, not least of all language barriers. Tracking these families is challenging and resourceintensive but has immense value. Hopefully, local funds will continue to be available to support this program and make it a priority for resource allocation.