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Immunization Action Coalition
Survey Results 2001
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Results from IAC's 2001 hepatitis B vaccine birth dose survey
At the Hepatitis Coordinators’ Conference in July 2001, state and local hepatitis coordinators expressed an overwhelming preference for giving the first dose of hepatitis B vaccine in the hospital. Subsequently, the Immunization Action Coalition developed a "Hepatitis B Vaccine Birth Dose Survey" to find out more about the status of perinatal hepatitis B immunization in state and local projects. The survey was sent by email to all those on CDC’s hepatitis B coordinator mailing list on September 26, 2001. This document summarizes the responses from this survey.
Polled Respondents
States: 50
Other projects: 9
Washoe County, NV; New York City, NY; Philadelphia, PA; Houston, TX; San Antonio, TX; District of Columbia; Baltimore, MD; Clark County, NV; Virgin Islands
Survey Questions
Q1: Would it help your state if ACIP expressed a preference for the administration of hepatitis B vaccine to all infants prior to hospital discharge?
Q2: During the past several years, are you aware of any babies of HBsAg-positive mothers who were not prophylaxed within 12 hours of birth with HBIG and vaccinated within 12 hours with hepatitis B vaccine? If so, please tell how many of these situations you know about and tell us how these situations happened.
Q3: Do you know of any babies born to mothers whose HBsAg status was unknown at the time of birth and who did not receive hepatitis B vaccine within 12 hours of birth? If so, please describe how these situations happened?
Q4: Do you know of babies whose mother’s lab test for HBsAg was wrongly ordered, misinterpreted, mistranscribed? If yes, please describe how these situations happened.
Q5: For coordinators in states that have been successful in reinstating the birth dose as standard policy, what worked for you to make this happen and what advice can you give others to help them reinstate the birth dose?
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Question 1: Would it help your state if ACIP expressed a preference for the administration of hepatitis B vaccine to all infants prior to hospital discharge?
Results:
RESPONDENTS
YES
NO
States (N=50) 48 2*
Federally-funded local projects (N=6) 8 1
* Both states answering "NO" supported the birth dose, but felt that an ACIP statement alone would not change physician behavior in their state.
COMMENTS FROM THOSE ANSWERING "YES" TO QUESTION 1
 
We in public health know the advantages of administering the birth dose of hepatitis B, but until ACIP states a preference, doctors and birthing facilities will not adopt it as a standard policy.
- West Virginia
We would like a strong statement recommending the birth dose of hepatitis B vaccine to be made by the ACIP. I think it would benefit many families.
- Texas
The inability of the Public Health Service and the AAP to agree on the thimerosal issue caused a major setback for states in their work to prevent perinatal hepatitis B. Routine infant hepatitis B vaccination has always provided a safety net for infants born to HBsAg-positive mothers to receive at least hepatitis B vaccine. Despite all the work to ensure that hospital staff are knowledgeable about providing HBIG and hepatitis B vaccine to these high-risk infants, there continue to be instances where these infants do not receive appropriate post-exposure prophylaxis. Agreement between these two highly influential groups will decrease confusion and present a united front to providers and assist in achievement of goals for perinatal hepatitis B prevention as well as hepatitis B prevention in general.
- Washington
Hospitals vary widely in their implementation of the birth dose and a stronger statement from ACIP would assist us in working with hospitals reluctant to implement the birth dose.
- Oregon
Yes, an ACIP recommendation would help... our medical community does not feel that hepatitis B is a concern to children.
- Iowa
Please encourage ACIP and AAP to take a stand for the first dose at birth, not 0-2 months.
- Maryland
If the preference for the first dose at birth was reflected in the ACIP recommended childhood immunization schedule it might help. If it is reflected only in an ACIP statement it would most likely not have much of an impact.
- Vermont
We must have a stronger recommendation from ACIP regarding administration of the hepatitis B vaccine at birth in order to get the attention of the providers and reintroduce this important "safety net.
- New York
Missouri has provided reinstatement of the birth dose information and letters to all birthing hospitals, pediatricians, and family practitioners, with no change.
- Missouri
In many countries with fewer resources than ours, the birth dose is the norm. The best way to provide a safety net for high-risk infants is to have a system that is simple and uniformly applied. Giving the birth dose is such a system.
- Wisconsin
Providers and consumers need a clearer understanding about the birth dose recommendation. Perhaps mention of the rationale by ACIP would help.
- Virginia
The birth dose provides a higher rate of completion for all the childhood vaccines. The birth dose serves as a safety net for all infants born to HBsAg(+) mothers.
- Clark County, NV
I think the fact that a birth dose helps overall immunization rates is an added plus. I also think that there are a large number of status unknown women for whom a birth dose of HBIG may be indicated but is not being administered."
- Colorado
How can states insist on birth dose for all newborns, if the current recommendation is to give the first dose at 0-2 months? If the first dose should be given at birth, that’s what ACIP should say.
- New Hampshire
It would help even more if the AAP would come out and also endorse vaccination before discharge.
- San Antonio, TX
Thank you so much for taking this to the ACIP meeting. This is definitely the "RIGHT" thing to do and past the "RIGHT TIME." In 1998, I conducted a chart audit at each of the larger (8) birthing hospitals in our state, using the CDC guidelines [see specific cases mentioned in following questions]. I therefore had really good data to share with the doctors when they told me that "all their mothers were tested so the birth dose was not necessary," "we are a low risk state," or "they knew their patients and the patients would disclose to them any risks."... One of the biggest struggles I combatted was "the ACIP schedule says ‘birth to two months... I am within the recommendations.
- Montana
In Pennsylvania, we are planning to conduct a hospital survey to determine their policies and practices regarding the administration of hepatitis B vaccine to newborns prior to hospital discharge. The incidence of hepatitis B infection, including perinatal hepatitis B infection, would have decreased and more time and effort could have been used to focus on other areas of vaccine-preventable diseases if the ACIP would recommend the #1 HB vaccine be given at birth universally, prior to hospital discharge. This is an opportunity for ACIP to make a clear, resolute decision.
- Pennsylvania
Birth dose is needed!
- Florida
Most birthing hospitals [here] already give the first dose of hepatitis B vaccine at birth, but a few don’t. [An ACIP statement expressing this preference] could change their hospital policy.
- Nevada
...A recommendation from the ACIP to administer hep B-1 at birth would not impede pediatricians’ "Rights to decide for themselves" (this seems to be a big argument against making the recommendation). We note that the entire childhood immunization schedule, as published and promoted by the ACIP and AAP, is a recommended schedule.
- Massachusetts
Recommendations for the birth dose should be reinforced repeatedly so that those hospitals that have not reinstated it as the standard of care will continue to receive the message.
- Baltimore, MD
In our state, we surveyed 23 hospitals that delivered babies: 10 routinely offer and give the birth dose, 2 administer it only to positive moms, 2 leave the decision to the parents, 13 do not offer or give the birth dose. The reasons cited for not offering the birth dose were difficulty with tracking, physician preference, and fear of thimerosal.
- South Dakota
I think it would be great if all hospitals gave the birth dose. Even better if vaccine were given within 12 hours. Probably would be asking too much!
- Connecticut
ACIP can recommend birth dose but unless the ACIP works for AAP approval, birth dose will be left to the pediatrician’s discretion.
- Hawaii
Comvax is making it hard to make the case to pediatricians about going back to the birth dose.
- Delaware
Encourage all states to have prenatal HBsAg testing laws. Request that physicians using Comvax in their practices allow a birth dose to also be given as a standard policy to protect the undetected infant at high risk for hepatitis B transmission.
- Ohio
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COMMENTS FROM THOSE ANSWERING "NO" TO QUESTION 1
Our current status is that 95% of our delivery facilities already perform the birth dose on the basis of educational activities we perform with infection control staff. The remaining 5% are not going to be swayed by the ACIP because they are in fact not facilities, but individual physicians, who are not cooperating… So again, while ACIP language recommending the birth dose might assist other states, we are pretty sure it will not change the situation in Alabama given the levels of efforts we have gone to so far… A state mandate for hepatitis B vaccination at birth would be needed.
- Alabama
We encourage the birth dose to hospitals and physicians in Georgia. While it is important, anecdotal evidence shows that more credence is given to recommendations of the AAP. Since this is already recommended, then an additional reinforcement may or may not matter.
- Georgia
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Question 2: During the past several years, are you aware of any babies of HBsAg-positive mothers who were not prophylaxed within 12 hours of birth with HBIG and vaccinated within 12 hours with hepatitis B vaccine? If so, please tell how many of these situations you know about and tell us how these situations happened.
COMMENTS FROM THOSE ANSWERING "YES" TO QUESTION 3
 
Yes. In 2000, there were 25 cases in which the babies did not receive HBIG at birth. Three of these babies are now infected. In one of the cases, the mother’s status was marked as unknown, another was marked as negative, and in one the status was correctly marked but the HBIG was still not given.
- Texas
[There were] 6 cases in year 2000, 2 in year 1999, and 2 in year 1998.
- Virginia
Unfortunately, from the years 1993-1999, 58 (out of approximately 1,959) newborns did not receive HBIG and the vaccine within 12 hours. Many mothers were not identified as HBsAg positive prior to delivery, had no prenatal care, the hospital did not have mom’s HBsAg test results and didn’t provide proper prophylaxis, tests were ordered stat and the results were not received within the 12 hour period and therefore immunizing the infant was delayed, mom did not disclose her status, or errors occurred because of lack of knowledge, carelessness, or turnover in staff. Also, we had a mom who was reported as HBsAg(-) by the prenatal care provider to the hospital during the time that infants born to HBsAg(-) women were to have the birth dose of hepatitis B delayed due to thimerosal being in the vaccine. Unfortunately, this woman was actually HBsAg(+), the baby did not receive HBIG or the birth dose of hepatitis B vaccine, and by three months of age developed fulminant hepatitis B and died due to liver failure and other complications.
- Michigan
"Yes. The hospital appeared not to be aware of the mother’s HBsAg status. In one case, the mother refused HBIG for her infant."
- Wisconsin
Yes. For 1999 and 2000, of the 771 infants born to HBsAg-positive women, 30 did not receive HBIG, 10 did not receive hepatitis B dose #1, and 9 did not receive either. In several situations, the mother refused immunization. However, the majority occurred due to low birth weight and other medical conditions for the infant at birth.
- Florida
The Pennsylvania Perinatal Hepatitis B Prevention Program’s records indicate that during the past four years, 13 babies of HBsAg-positive mothers were not prophylaxed within 12 hours of birth. In the majority of these situations, the mothers were tested, the HBsAg-positive results were recorded, and for unknown reasons, prophylaxis treatment (HB#1 and/or HBIG) was not provided appropriately. If all birthing hospitals offer HB vaccination for newborns prior to hospital discharge regardless of a mother’s hepatitis B status, most of these high-risk babies would have been given at least dose #1 of hepatitis B vaccine.
- Pennsylvania
Yes, one baby received the birth dose of hepatitis B vaccine but did not receive HBIG until day 3. I do not know how this situation occurred. Another baby was born to a mother who developed acute hepatitis B one week after birth. We do not know when the mother was exposed. She was tested during pregnancy, but was negative at that time.
- Name of state or local project withheld per request
Yes–mostly during the thimerosal controversy. Unable to pull files [of cases] by your deadline as our director is swamped dealing with bioterrorism issues...
- Philadelphia, PA
During 1998, 1999, and 2000, 22 babies were not given HBIG, but were vaccinated with the hepatitis B vaccine.
- Clark County, NV
In the years 1994-2000, we’ve identified 557 births to HBsAg-positive women; 536 (96%) we know were prophylaxed within 12 hours of birth with HBIG and hepatitis B vaccine. It wasn’t until 1998 that Oregon dropped below 100% in treating known exposed infants at delivery. One potential barrier is that health departments reported being too busy to establish a system for communicating with delivery hospitals in order to "prime" the staff about each mother prior to delivery.
- Oregon
I am aware of one instance where both the birth dose and HBIG were missed. The underlying issue was poor communication with the hospital and a newly hired public health staff that was uninformed.
- Idaho
According to our annual assessments, we usually have 2-3 infants every year who do not receive appropriate post-exposure prophylaxis. We are working hard to address this problem to assure that ALL infants receive appropriate treatment. The main reasons that I’ve heard are that not all hospital staff are aware of the protocol because they haven’t received adequate training and because it happens so infrequently. Most often, the hospitals had protocols in place but hospital staff didn’t look at the protocols or didn’t know where/what the protocol is.
- Washington
We are aware of two cases who were born to positive mothers who were not prophylaxed. 1) A known chronic HBsAg mother gave birth to her fourth infant. This pregnancy had never been reported to the county health department or to the state perinatal program. The provider told the mother that she was an "old case" and didn’t need to worry about this infant. I found this case during a chart review. The infant had been born six months earlier and did not receive either hepatitis B vaccine or HBIG. Unfortunately, this infant had other birth trauma and had been transferred to Seattle where she died. 2) The second case was a woman who had been identified as a contact to an IV drug-using outbreak of hepatitis B. She had been tested and the results were negative during mid-pregnancy. She even received a dose of vaccine. She was sick with flu-like symptoms when she delivered. She later tested positive for HBsAg. This hospital gave the first dose of hepatitis B to this baby at birth and the infant has since finished the series and titered positive for antibody.
- Montana
Once an infant was transferred due to complications and each hospital thought the other one had done, or would do, the birth dose.
- Kentucky
I have had six cases that I can recall in the past two years that only received hepatitis B vaccine. The pediatricians were not aware of the mother being positive. Three of these developed antibodies, two are pending results, one was adopted. One retro case in 1997 did not get HBIG or hepatitis B vaccine at birth. Received the first dose of hepatitis B vaccine at 11 days of age. We are trying to get the lab on this child.
- Name of state or local project withheld per request
September 1999—A positive pregnant woman moved out of town and was subsequently unable to be located. She returned without our being aware, and presented at a local hospital for delivery. No prenatal records were sent to the hospital and the hospital failed to check for HBsAg status. The routine universal birth dose had been discontinued at that time, due to the thimerosal issue and no treatment was provided. The hospital did have perinatal policies and procedures in place. December 1999—The mother tested positive for HBsAg during prenatal care and the prenatal records were sent to the delivery hospital. The positive status on the prenatal records was completely missed upon admission. The universal birth dose was discontinued at that time and no treatment was provided. The hospital did have perinatal policies and procedures in place.
- Arizona
Three cases: 1) Baby put up for adoption--mother had no prenatal care, 2) Mother had no prenatal care, 3) Birthing Center did not follow their own policies. Note: these events were prior to the perinatal hepatitis B program now in place.
- Indiana
In the past three years, 6 infants born to HBsAg-positive mothers did not receive the HBIG. All of these infants received the universal birth dose in the hospital. Without the birth dose being given in the hospital, these infants would not have received the hepatitis B vaccine until 2 months of age. These infants were born in different areas of the state and in different hospitals. Apparently, there was a breakdown in communication of the mothers’ HBsAg status, although we were unable to determine the exact reason HBIG was not given.
- Mississipi
In one case at a rural hospital, the mother’s hepatitis B status was documented in her and the infant’s chart which was seen by many nurses and three pediatricians, but no prophylaxis was ever initiated. For births in 2000, we are still waiting to hear about 15 infants as to whether they were treated at delivery.
- Name of state or local project withheld per request
[I know of] an HBsAg(+) mom whose prenatal chart was not available at time of delivery and mom denied status (the mother, however, knew her status–has been positive for years). HBIG was not given, the first dose of hepatitis B vaccine was given the next day.
- Baltimore, MD
One instance involved a known carrier who was not tested this pregnancy. Information was not in chart at delivery. Child got no HBIG or hepatitis B vaccine in the hospital.
- Tennessee
In 2000, there were 8 infants who never received HBIG and 6 who did not get hepatitis B vaccine within 12 hours of birth (3 of whom never received the vaccine). This is despite letters to the hospital and to the OB/Gyn prior to the birth.
- Colorado
Two cases have been identified. It appears that the babies were not appropriately prophylaxed due to poor communication and unclear documentation on the hospital record.
- Name of state or local project withheld per request
[Two cases]: 1) Infant received first dose of hepatitis B vaccine at first visit to pediatrician’s office two weeks after delivery. 2) The other case received the first dose three days after delivery. Both developed immunity.
- Hawaii
I know of two infants offhand who did not receive HBIG, but did receive the vaccine at birth. One of these did receive HBIG within the 7 day time frame, the other did not. Both have tested HBsAg negative and antibody positive.
- Rhode Island
Infants did not receive HBIG due to the non-transfer of information between their medical providers. Such as: the OB doctor screened the woman and she was HBsAg-positive, but the nursery never received this information so the baby only received hepatitis B vaccine and then was discharged. Two days later the infection control nurse finds out the mother was HBsAg-positive, she tells the delivery doctor about it, but he’s not her regular doctor so he doesn’t know what to do. By the time he locates the mother, eight days have passed. Too late for HBIG.
- Missouri
In year 2000, we investigated 5 cases where babies were not prophylaxed appropriately. In year 2001, we have so far investigated 3 cases where babies were not prophylaxed appropriately.
- Minnesota
I am aware of two incidents in Nebraska where the infant did not receive HBIG or HBV within the 12 hours of birth. One incident was when the woman delivered at her local small town hospital rather than the larger medical center as planned. She reported that she told the local physician that she was a carrier but nothing was done. This infant was immunized with HBV by a public health nurse a week later when the problem was identified by the Perinatal Coordinator. The infant was tested for antibodies and was positive after completing the vaccine series. The other instance happened in a large medical center. I am not sure what actually happened, a couple different versions were given. The doctor’s office reported that the HBsAg status was on the prenatal report sent to the hospital. The hospital blamed it on new staff, etc.
- Nebraska
Yes. Transcribing incorrect lab results; results not transferred; results overlooked or misinterpreted; patient’s refusal; doctors didn’t order or ordered HBIG late; HBIG and vaccine given later than 12 hours but before discharge; patients’ records arrive too late to hospital, only gave vaccine and not HBIG; medical contraindication; case transferred from another county, records not in place; health department notified too late.
- California
One case in 2001 where infant received only hepatitis B vaccine as the hospital staff missed HBsAg(+) result in the chart and the advance notice sent by our program... One case in 1998 when a nurse did not give HBIG even though it clearly stated HBsAg(+) in both the mother’s and the baby’s charts. The mother stated she was "OK" and the nurse left it at that. Vaccine was given. This occurred before it was included on the NBS so was not noted till the infant was several weeks old. The hospitals in both these cases had universal programs in place.
- Ohio
In four years, we had one physician refuse to administer HBIG and hepatitis B vaccine at birth. His reason: he felt the mother’s test was a false positive. Our records indicated the mother was neutralization sAg+ (lab report). He still refused.
- South Dakota
Mother received prenatal care in Louisiana, but moved to a bordering state where she delivered. The infant’s medical record did not show receiving any vaccine per the infection control nurse at the delivering hospital. The mother returned to Louisiana public health clinic one month later. Hepatitis vaccine was given and infant was tested for HBsAg. The test was negative. We are still trying to get medical record information from the delivering hospital.
- Louisiana
In 2000: Case 1: Mother was known HBsAg-positive, infant was pre-term. NICU deferred HBIG and hep B-1 because infant weighed less than 2000 g. Case 2: Mother was known HBsAg-positive, but infant did not receive HBIG due to hospital error. In 2001: Case 1: Mother was known HBsAg-positive, infant was pre-term. NICU deferred hep B-1 because infant weighed < 2000 g. Case 2: Mother was screened in hospital at time of delivery, found to be HBsAg-positive. Lab results were delayed, and infant received hepatitis B dose #1 at age 2 days, and HBIG at age 6 days.
- Massachusetts
Mom was HBsAg(+) and was being followed by state and local health department staff. Nursing supervisor of the hospital was contacted and child brought [back] in immediately for treatment. The hospital was not routinely giving the first dose of hepatitis B vaccine and overlooked this case. Three additional similar cases occurred where hospitals did not review the hepatitis B status of the mother.
- Name of state or local project withheld per request
Some do not get HBIG. We had about 7 out of 88 in 2000 who did not get HBIG. All got first dose of hepatitis B vaccine.
- Arkansas
In the year 2000 in our area, 5 infants did not receive HBIG (out of 1,436 births) due to delay in the test results since no prenatal care was given in the birthing hospital or no prenatal care was received at all.
- Name of state or local project withheld per request
About a year ago, I received a call from a woman who tested positive in a prior pregnancy. She was enrolled in the perinatal program and her child was followed. Subsequently, she became pregnant and her private provider did not notify us of her pregnancy and HBsAg status so she was not followed by us. She had a C-section and her obstetrician was on vacation and his partner delivered the infant. The mother did everything she was taught during the first pregnancy–she notified this doctor that her baby needed the HBIG and hepatitis B vaccine... According to this mother, the MD refused to give the infant the HBIG.
- Houston, TX
In the past several years we have had 5 cases in which the infant was given the birth dose only. The investigation nurses at the local health departments have not notified me as to why the infants did not receive HBIG.
- Kansas
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Question 3: Do you know of any babies born to mothers whose HBsAg status was unknown at the time of birth and who did not receive hepatitis B vaccine within 12 hours of birth? If so, please describe how these situations happened?
COMMENTS FROM THOSE ANSWERING "YES" TO QUESTION 3
 
Yes. This occurred in three cases.
- Minnesota
Yes–two cases.
- Philadelphia, PA
Two cases where mother’s status was unknown, child discharged.
- Indiana
Yes, the infant received hepatitis B vaccine before discharge. Standing orders were not followed.
- Hawaii
In one case a mother came in with no prenatal care. The intern did not think she looked high risk. She turned out positive. Child did not receive vaccine.
- Connecticut
The mother’s status was unknown at birth. She left the hospital without the baby being vaccinated. She gave a fictitious address.
- Maryland
In a recent study lead by Ann Thomas of Oregon Health Services titled "Reductions in hepatitis B (HB) vaccine coverage for infants born to women with unknown hepatitis B surface antigen (HBsAg) status: Unintended impact of changes in recommendations," her group found that HB vaccine coverage for infants born to unscreened women decreased significantly following the July 1999 announcement and remained significantly lower 10-12 months later. Infants were identified by reviewing electronic birth certificate data from 34 Oregon hospitals and the mother’s HBsAg status and the infant’s immunization status were verified through chart review.
- Oregon
Of the 22 births [from 1998-2000 who received HBV but not HBIG], eight did not have lab results in the chart, but the infants still received hepatitis B vaccine.
- Clark County, NV
Some hospitals did not have "stat" lab capabilities, so would wait more than 12 hours for results. This has been corrected when encountered during LQAs. Our state stipulates that they must have test results within 24 hours or as soon as possible.
- Name of state or local project withheld per request
September 2000—A "walk in" mother with no prenatal care was delivered and the newborn did not receive either HBIG or hepatitis B vaccine. This hospital had perinatal policies and procedures in place; however, the HBsAg status of the mother was not checked. The mother left against medical orders, and was later determined to be "lost to follow-up" by the local county health department.
- Arizona
Yes, I’m aware of misinterpreted or mistranscribed lab tests for HBsAg. All pregnant women whose HBsAg lab tests are reported positive are verified.
- Illinois
The mother was known to be HBsAg-positive with a previous pregnancy; however, with this pregnancy the woman did not receive prenatal care. With this pregnancy, she reported to a different hospital in active labor. HBIG and hepatitis B vaccine were given two days after birth when the mother was found to be HBsAg-positive.
- Name of state or local project withheld per request
We have one case that fits this category. The mother was visiting our state to attend a church conference. She delivered the baby in the bus on the way to the hospital. The mother was then admitted to the delivery room to deliver the placenta. The woman was an unmarried, 18-year-old immigrant from an endemic country, with no prenatal care. The infant was also admitted for observation because of a distended abdomen, and was released at 5 days of age. When the mother was admitted to the emergency room, blood was drawn for a HBsAg test, but it was not ordered "stat." The HBsAg(+) test result was not reported to the health department until 16 days after the infant was delivered. This hospital did not provide universal hepatitis B vaccine, so the infant did not receive any vaccine in the hospital. The infant was located on day 17 and given the first hepatitis B vaccination. This infant has just finished the series and will be tested for antibody in the near future.
- Montana
Yes. Waiting for prenatal records from provider; waiting for lab results when status unknown; refusal of vaccine; no prenatal record therefore delay in giving vaccine; HBsAg status correct but overlooked by nurses.
- California
Yes. Based on our 2000 Perinatal Hepatitis B Screening Survey, there were 4 infants born to women that had an unknown HBsAg status who did not receive the vaccine within 12 hours of birth. Reasons for this are unclear.
- Florida
My LQA survey found 36 women unscreened in a six month period. Ten infants did not get vaccine or HBIG.
- Delaware
I had one patient who got married. The hospital had prenatal records under her old maiden name. Neither the private MD nor the hospital associated her with the records sent to the hospital. The infant received only hepatitis B vaccine. When tested, she had developed antibodies.
- Name of state or local project withheld per request
Yes, we had a few women who delivered with unknown status due to no prenatal care, due to the fact that the labs were not forwarded by the prenatal care provider, or due to the mother delivering at a different hospital than she was expected to so the information was not forwarded. Some hospitals have stat turn-around time of 48 hours or more, so the immunization was delayed. Protocols indicate to give women with unknown status the hepatitis B vaccine within 12 hours, but some did not follow these procedures.
- Michigan
Recently, a baby was born to a mother who tested HBsAg-negative on the hepatitis B prenatal screening test done early in her pregnancy. She had no hepatitis screening test done at the time of delivery. About four weeks postpartum, the mother developed acute hepatitis B infection. The infant had not received the birth dose of hepatitis B vaccine. Hepatitis B vaccine and HBIG were administered when we learned of the mother’s status. We will continue to follow the infant with the hepatitis B vaccine and post-vaccine testing as routinely recommended. We are also promoting routine hepatitis B screening in delivery hospitals regardless of previous screening test, especially if the testing was done early in pregnancy.
- Mississippi
We have about 4,000 unknowns a year who don’t enter our tracking system. We can’t answer this question.
- Colorado
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Question 4: Do you know of babies whose mother’s lab test for HBsAg was wrongly ordered, misinterpreted, mistranscribed? If yes, please describe how these situations happened.
COMMENTS FROM THOSE ANSWERING "YES" TO QUESTION 4
 
Yes. No documentation on charts about status; mistranscribed as negative when positive; misinterpreted lab results; patients were negative but wanted second tests.
- California
Yes. This occurred in four cases. In two cases, the mother was tested prenatally and the mother’s chart showed a positive HBsAg test result. However, the HBsAg test result was documented as negative in the infant’s chart, resulting in neither HBIG not hepatitis B vaccine being given to the infant. In the other two cases, the positive result was transcribed incorrectly in the mother’s chart as negative.
- Minnesota
Yes, this happens occasionally. We have begun to ask for the lab report which allows us to help the provider "interpret" the information.
- Tennessee
December 1999—A prenatal client told her OB doctor that she had received immunizations in Japan and was immune. The doctor did order a hepatitis panel, but failed to interpret the positive HBsAg results. The infant did not get hepatitis B vaccine until four weeks after birth. July 2000—The mother’s OB office incorrectly interpreted the lab report and reported the maternal HBsAg status to the hospital as negative. Fortunately, the infant did get hepatitis B vaccine, but did not get HBIG
- Arizona
Yes, one case occurred in a baby born in 2000. The mother’s chart was inaccurately marked as negative. In another case, the mother’s status was marked as unknown by the hospital staff. These babies are now infected.
- Texas
We have two cases due to transcription error. Children now positive.
- Connecticut
Two charts showed the mother as HBsAg(-) but the MD had the mother as HBsAg(+) in the office records. Another situation showed the mother as positive, but no record on baby’s chart.
- Clark County, NV
No, although the mother’s HBsAg status is often misreported as positive on the newborn screening card.
- Wisconsin
Yes, there have been a few situations, usually occurring due to misinterpretation of lab results or transcription errors of lab results into the record. A recent case involved a mother whose status was mistakenly recorded as "negative" (she was HBsAg-positive), resulting in the baby receiving no Rx at birth. The baby was vaccinated at 2 weeks of age when the error was discovered, but we do not yet know the outcome of this case.
- Name of state or local project withheld per request
Yes, on numerous occasions we have discovered that the prenatal care providers have ordered the anti-HBs tests instead of the HBsAg tests. If the mother’s lab results were anti-HBs negative, the baby would not be immunized unless someone caught this at delivery. Also, [as reported under Question #2] in the case of the woman whose lab results were reported as HBsAg negative, but who was actually HBsAg positive, the baby died due to this error.... Currently, an investigation is under way regarding the death of this baby due to a transcription error.
- Michigan
This missed case was a 16-year-old, part-time homeless teenager who was an IV drug user and exchanged sex for drugs. This information was all on file in her hospital chart. This teen had very limited prenatal care and had seen a few providers, but each one only once or twice. She had been tested [for hepatitis B antigen] during one visit and had positive results. She had never returned to this provider and the information in her hospital chart showed that she had a negative HBsAg result. No "stat" draw was ordered because the chart had a "negative" result documented. We found this case because the young woman presented at the local health department–as a contact to a hepatitis A case. She disclosed that she was an IV drug partner to that positive case. A hepatitis panel was done and her HBsAg result was positive. This infant had been given the birth dose within 12 hours of birth. The infant has also finished the series and tested positive for antibody. Boy, has that birth dose helped in Montana!
- Montana
Yes, a situation happened recently where a mother’s lab test was mistranscribed, so the infant did not receive HBIG, but did receive hepatitis B vaccine. The test result was mistranscribed by hospital staff.
- Washington
One mother was followed by the Health Department for two pregnancies. The third time she used an OB/Gyn. When we checked the birth records with our old cases, she came up. I retrieved the records from the hospital. The baby had not gotten HBIG, but had received the hepatitis B vaccine. This was during the time of the thimerosal issue. When I checked with the OB/Gyn, she had a report of negative HBsAg. Since we had gotten chronic lab results twice, I asked for a repeat panel. When the lab came back, she was HBsAg and antiHBc reactive. What happened? Could be several things... mixed up lab, poor lab procedure... who knows? When the pediatrician did the post-vaccine lab, the infant had developed antibodies.
- Name of state or local project withheld per request
Mother’s HBsAg was mistranscribed, so no HBIG was given. Hepatitis B vaccine birth dose was given one day after delivery. Infant developed immunity.
- Hawaii
We see anti-HBs ordered prenatally and also in the hospitals for no test cases [patients who have not been tested]. We also see HBsAg ordered correctly in the hospitals but sent to the labs as anti-HBs. These appear to be errors and lack of knowledge on the part of the physicians and other hospital staff. Most disturbing is that it has never been noticed by the physicians, lab staff, or nursing staff until it is brought to their attention by our staff. We also see physicians order anti-HBs only when their patient has had the vaccine series and others who only order the HBsAg for the first pregnancy and none of the following pregnancies.
- Ohio
Yes, re: HBsAg(+) mom due on 2002. I was told by the nurse that this meant the woman had hepatitis B antibodies. When speaking with the MD, she said she ordered a prenatal profile, and thought the hepatitis B test was for antibodies. I corrected her and sent a packet of information (CDC and IAC materials).
- New Hampshire
Case 1: The physician’s interpretation of a mother’s prenatal HBsAg-positive lab was "hepatitis B negative." This infant was not given HBIG or vaccine prior to hospital discharge. The infant was born during the period when routine birth doses were being held for mothers who tested negative. The hospital records recorded the physician’s interpretation of the lab and not the actual lab results. This child is now HBsAg positive. Case 2: The physician’s interpretation of the mother’s prenatal HBsAg-positive lab was "hepatitis B negative." This infant was given the first dose of vaccine within 12 hours of birth because hospital policy was to offer the birth dose to all newborns prior to hospital discharge. Case #3: The physician’s interpretation of the mother’s prenatal labs (HBsAg positive, HBeAg negative) was "hepatitis B negative." The hospital did not record actual lab results. The infant did receive the vaccination within 12 hours of birth because the hospital’s policy was to offer the birth dose to all newborns.
- Name of state or local project withheld per request
Yes. On one test the provider misinterpreted the result. Routine follow-up by the Maine immunization program detected this error and the patient/birthing hospital was contacted prior to delivery.
- Maine
Hospital nursery claimed they had record of mother as being HBsAg negative. Baby was not immunized at time of birth, although state and local health departments had copies of the lab slip indicating that mom was HBsAg(+). Obstetrician’s office claimed that they did not have this lab slip in patient’s chart. Obstetrician’s office later confirmed that mom was HBsAg(+). Infant was brought to clinic for treatment.
- Name of state or local project withheld per request
Yes, one case was misinterpreted in another state. This case was referred to us when the patient relocated to this state.
- South Carolina
I am aware of several incidents where infants were given hepatitis B dose #1, and some who were given hepatitis B dose #1 and HBIG, because the mom was anti-HBc total positive.
- Washoe County, NV
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Question 5: For coordinators in states that have been successful in reinstating the birth dose as standard policy, what worked for you to make this happen and what advice can you give others to help them reinstate the birth dose?
ADVICE FROM HEPATITIS COORDINATORS:
A combination of providing immunization registry access to birthing facilities and infection control education at hospitals.
- Alabama
We sent a letter to all of the hospitals and simply said to resume.
- Arkansas
I maintained close contact with my hospitals throughout the time the birth dose was placed on hold. When the new vaccine was available, the birth dose was reinstated. I gave the hospitals all the information I could find concerning the importance of the birth dose. I kept them informed with the progress and availability of the new vaccine–free of thimerosal.
- Clark County, NV
1) Visits to all Birthing Centers, 2) E-mails/mailings updating birth dose issues, 3) Visits and mailings to OB providers, 4) Visits and mailings to immunization providers, 5) Offering VFC programs to Birth Centers. OB Providers can opt out of hospital policy or standing orders and decline the birth dose for their patients. Our staff communicating with OB providers in person has helped to get it [birth dose] reinstated. We have provided a number of educational materials to all OB providers.
- Indiana
[Materials given to providers include IAC's Labor & Delivery Unit and Nursery Unit Guidelines to Prevent HBV Transmission, Hepatitis B Shots Are Recommended for All New Babies, Hepatitis B Facts: Testing and Vaccination, Universal Prenatal Screening for Hepatitis B; ACIP's Protection Against Viral Hepatitis (2/9/90); Indiana's Checklist for Birthing Hospitals Perinatal Hepatitis B Policies and additional state-specific information.]
A comprehensive intervention including letters, phone calls, visits, and other action steps.
- Maine
1) Mailed numerous advisories around time of 1999 joint statement and follow-up MMWR report, 2) Conducted telephone survey after reinstatement of Massachusetts Department of Public Health policy to vaccinate all newborns at birth with hepatitis B dose #1, regardless of the mother's HBsAg status to determine if hospitals had resumed vaccination at birth and to encourage hospitals to do so if they had not already, 3) Made numerous follow-up telephone calls to hospitals that had indicated, when first surveyed, that they had not resumed the policy of administering the first dose of hepatitis B vaccine at birth, 4) Made site visits to hospitals that indicated they had not resumed the policy of administering hepatitis B dose #1 at birth.
- Massachusetts
Michigan currently has 72 out of 102 delivering hospitals that have their physicians offering hepatitis B vaccine to 100% of their newborns. There has been a continuous collaboration of efforts by local health department staff, immunization field staff, and state staff and hospital staff to reinstate these policies. Many meetings, educational presentations, and continued discussion have helped some hospitals reinstate or implement these policies. Also, Michigan offers free hepatitis B vaccine to all delivering hospitals for all newborns.
- Michigan
The birth dose of hepatitis B vaccine has been reinstated in some hospitals in this state. We are planning to survey all delivery hospitals in the state to determine which ones are giving hepatitis B vaccine. Results of the survey will be used to promote the vaccine in those hospitals not providing the birth dose.
- Mississippi
In 1998, I conducted a chart audit at each of the larger birthing hospitals in our state (N=8), using the CDC guidelines. I therefore, had really good data to share with the doctors when they told me that "all their mothers were tested so the birth dose was not necessary," "we are a low risk state," or "they knew their patients and the patients would disclose to them any risks." ... [Because] I had good reasons and substantial data to back the positive outcomes from the birth dose... I have finally persuaded the last "big" hospital to adapt the birth dose. Once this is in place, we will have about 95% of our Montana infants being offered the birth dose.... If I hadn't had good data and been really feisty, I don't think we would have been successful!
- Montana
Having county hepatitis coordinators helped to reinstate the birth dose as standard policy. Work closely with your hospitals.
- Nevada
Letter sent 11/99 from the Department of Health and Human Services to health care providers about the availability of thimerosal-free vaccine and encouraging birthing hospitals to reinstate universal vaccination of all newborns. Also, the state supplies the vaccine to hospitals for all children, not just the ones who qualify for the VFC program.
- New Hampshire
We have sent two letters to birthing hospitals urging them to reinstitute the birth dose. A recent survey shows that only 21% of our hospitals routinely vaccinate at birth and another 25% leave the decision to provider preference with less than 25% of the providers offering vaccination at birth. We will soon be sending a third letter urging the birth dose.
- New York
Education of medical directors and nursing staff in hospital labor and delivery and neonatal units. Sent letter with ACIP and AAP recommendations, then followed up with a telephone survey to all birthing hospitals. Special focus was given to those hospitals in indecision, and those that were not considering offering the birth dose to all newborns.
- North Carolina
Timely communication, continued universal policy for vaccine distribution, reiterating importance of birth dose, and availability and prompt distribution of thimerosal-free vaccine.
- North Dakota
We have had a fair degree of success. Part of the reason is that we have a program in Ohio that provides the vaccine free to all babies. We use state and 317 money to support the program. Immunization program staff contact hospitals not ordering routinely to see if there is a problem. However, there are several hospitals that have informed ODH that the pediatricians are not ordering the birth dose. We will be working with the Ohio AAP to address this.
- Ohio
VFC and data on transmission. Mostly making it [administering the birth dose] not a hassle to the hospitals.
- Philadelphia, PA
Communication and involvement with key people in birthing hospitals, prenatal and pediatric providers, and the state health department, as well as influential, revered individuals in the medical community who support the issue.
- Rhode Island
Survey of all birthing hospitals followed by specific education regarding the transmission of perinatal hepatitis B virus.
- South Carolina
1) Inservice of hospital staff, 2) Meetings with medical directors, neonatologist and nursing supervisors, 3) Follow-up calls.
- Virgin Islands
In our state, a joint letter from the state health officer and AAP president was sent to all birthing hospitals notifying them of the availability of thimerosal-free hepatitis B vaccine and to encourage them to reinstitute the birth dose. Local health department staff also assisted us in spreading the message to pediatric care providers. As the hepatitis coordinator, I also presented at several meetings comprised of OB managers. In addition, our office recently completed a survey of birthing hospitals to assess maternal screening policies, hepatitis vaccination policies, and routine hepatitis B vaccination practices. When I sent them the results of the survey, I reiterated the need to reinstitute routine newborn immunization.
- Washington
1) Have a physician immunization advisory group recommend the birth dose to pediatricians and family physicians. It is important to address these two groups of clinicians separately, 2) Offer to enroll hospitals in the VFC program and supply hepatitis B vaccine free for all infants born in the hospitals.
- Wisconsin
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Other comments received
All recommendations and preferences have plenty of exceptions. The gap between preferences and exceptions can be closed if there is scientific proof. 1) Is there any scientific proof that the birth dose is better than combination vaccine administered at 2 months of age for developing immunity in infants? 2) Benefit/cost analysis needed for an additional injection at birth compared to use of combination vaccine later, 3) If the national data show that completion of 3 doses of hepatitis B vaccine is 90.3% by age two, is it worthwhile to enforce birth dose? 4) Universal birth dose gives false sense of safety, which will further erode the implementation of HBsAg testing requirements for all pregnant women.
- Name of respondent withheld per request
This page was reviewed on August 19, 2009
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