Viral Hepatitis Program Perinatal Case Management Amy E. Warner, M.P.H. Colorado Department of Public Health

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

Perinatal Case Management

Amy E. Warner, M.P.H.

Colorado Department of Public Health and Environment



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


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


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



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


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


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


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


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.


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


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


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)


Contacts

• Assess best venue for father and the children to get immunization and/or testing– Home– Local laboratory– Provider’s office– Local health department


Can’t Reach Marianna?



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


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


Prepare for the Infant

Educate Marianna about preventionEnsure that Dr. Quinn orders HBIG and

hepatitis B birth doseAsk Doc Holiday to send a copy of the

original lab to the hospital or you send itNotify the hospital of the impending birth

and provide guidelines for appropriate treatment of the infant


More Preparation for the Infant

Send an HBIG fax back form to the hospitalKeep in touch with hospital staff

Keep email lists updatedOffer in-service trainingForward new recommendations as they are

releasedReview hospital protocols regularly


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


Completing the Series

• How do you keep Marianna engaged long enough to complete the infant’s vaccine series and post-vaccination testing?


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


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


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


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


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


Physician Information Packet

• Information given to patient

• Published guidelines

• Website links (IAC, CDC, ACOG, AAP,AAFP)

• Names of local specialists


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


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

Documents

Viral Hepatitis Program Perinatal Case Management Amy E. Warner, M.P.H. Colorado Department of Public Health