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Immunization Action Coalition
Survey Results 2002
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Results from IAC's 2002 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 found that many babies continued to be at risk of perinatal hepatitis B infection due to improperly followed recommendations.
On October 17, 2001, the ACIP voted to recommend that the first dose of hepatitis B vaccine be given in the hospital for all infants. The Immunization Action Coalition consequently designed a follow-up survey to determine what effect, if any, this new recommendation was having on hepatitis B perinatal vaccination practices around the nation. IAC's "2002 Hepatitis B Vaccine Birth Dose Survey" was emailed to all state and local hepatitis B coordinators on October 2, 2002, and all responses were received by the end of November.
Polled Respondents
States: 50
Federally-funded local projects: 6
New York City, NY; Philadelphia, PA; Houston, TX; San Antonio, TX; District of Columbia; Chicago, IL
Survey Questions
Q1: Has the new ACIP recommendation to give the birth dose had an impact in your state (project)?
Q2: During the past year (from October 2001-October 2002), 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 YES, please estimate the number of cases you know about and describe why these situations happened.
Q3: During the past year (from October 2001-October 2002), 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 estimate how many cases you know about and describe how these situations happened.
Q4: During the past year (October 2001-October 2002), are you aware of any babies whose mothers' lab tests for HBsAg were wrongly ordered, misinterpreted, or mistranscribed? If yes, please estimate how many cases you know about and describe how these situations happened.
Q5: Are there health care providers in your state or area who do not routinely give the birth dose? If YES, in your opinion what is the main reason they don't (please check all that apply)
Q6: In your opinion, is there anything you think would help change the minds and actions of those providers not now providing the birth dose?
Q7: Please provide any other comments you'd like to share with ACIP or others about the birth dose.
Q8: In your opinion, is there anything you think would help change the minds and actions of those providers not now providing the birth dose?
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Question 1: Has the new ACIP recommendation to give the birth dose had an impact in your state (project)?
Results:
RESPONDENTS
YES
NO
N/A
States (N=50) 24 20 6
Federally-funded local projects (N=6) 3 3
COMMENTS FROM THOSE ANSWERING "YES" TO QUESTION 1
 
Yes. All 6 birthing hospitals in Delaware have gone back to having the birth dose as standard protocol.
- Delaware
"Yes. We have two large and one small hospital newly enrolled in our VFC program for the purpose of administering the hepatitis B vaccine birth dose to infants."
- West Virginia
Yes. It [the ACIP recommendation] has helped to bring some of our providers back to offering the birth dose. However, we still have a few who are not following the ACIP recommendations.
- Idaho
Yes. We have been encouraging this for a number of years in Alaska. This [the ACIP recommendation] helps to encourage those who have been dragging their feet.
- Alaska
Yes. [The new recommendation] has stronger influence with providers.
- Arizona
Yes. Most hospitals and pediatricians are administrating the birth dose. Increased numbers.
- Connecticut
Yes. The medical consultant for the Division of Immunization and I mailed HBV educational information and the new birth dose recommendations to all 50 delivery hospitals in the state. A survey was sent to each hospital requesting information regarding the hospital's birth dose immunization policy. I then visited each hospital and reviewed delivery records (30 for each hospital) of maternity clients for HBsAg screening results as well as their infants' records for documentation of vaccine administration. These three activities made the physicians and hospital staff aware of the importance of administering the birth dose of hepatitis B vaccine. Sharing the results of the survey also helped especially when there was no documentation of HBsAg status of the mother and the infant was not vaccinated with hepatitis B vaccine. I also gave the hospital contact information on the Vaccines for Children (VFC) program when the cost of the vaccine was an issue. As a result of the survey, record review, and feedback, additional hospitals enrolled in the VFC program and began providing the birth dose.
- Mississippi
Yes. We've had an increase in the number of delivery hospitals giving the birth dose from 48 to 69 [after the new recommendation].
- Georgia
Yes. Most of the Infection Control Nurses use this recommendation to get all the physicians to give the first dose of hepatitis B vaccine in the hospital before discharge. It is used as a standard of care.
- Louisiana
Yes. The Illinois Department of Public Health, Immunization Section, has collaborated with the Illinois Chapter, American Academy of Pediatrics, to develop and disseminate important information focusing on, 1) promotion and implementation of administration of the birth dose of hepatitis B vaccine as well as, 2) practices for screening, reporting, and follow-up related to hepatitis B.
- Illinois
Yes. It [the ACIP recommendation] allows us to give written backup of what the guidelines are and why to follow them. This is probably the reason hospitals and physicians are going back to the birth dose.
- Indiana
Yes. There have been additional calls requesting information on how many states provide the birth dose and how hospitals get vaccine for their patients.
- Iowa
Yes. The recommendation helps to enforce the birth dose delivery. One hundred percent of babies born to HBsAg-positive mothers get the birth dose in Maine. But the coverage for general newborn babies is not available at this point.
- Maine
Yes. I believe the new ACIP recommendation to give the birth dose has had some impact in our state. I have received some calls from smaller birthing hospitals stating that they want to be compliant with ACIP recommendations and want to implement the birth dose of hepatitis B vaccine. However, I think part of what prompted them to call was a letter that our immunization program sent out, notifying the facilities of the new ACIP recommendation regarding the birth dose of hepatitis B vaccine, and all the positive literature endorsing this practice.
- South Dakota
Yes. [The recommendation] helps convince pediatricians who visit the birth hospitals to recommend the birth dose.
- Philadelphia, PA
Yes. We had a handful of providers who were still not offering the birth dose. The Montana Chapter of the American Academy of Pediatrics voted unanimously to endorse the 'birth dose' this summer.
- Montana
Yes. We have had a few more providers requesting the vaccine for the birth dose to where virtually all rural county births get the birth dose.
- Nevada (not including Clark and Washoe counties)
Yes. We now have a new authoritative tool [the ACIP statement] to use to persuade hospitals to adopt a universal birth dose policy.
- New Mexico
Yes. Prior to the new ACIP recommendation, a survey of upstate New York birthing hospitals done in April 2001 showed that only 12% had a universal birth dose policy. Another 25% of the hospitals surveyed left the decision of administering a birth dose up to provider preference; however, in the majority of these hospitals, less than 25% of the providers preferred to administer a birth dose. Since the ACIP recommendation, we have seen an increase in the number of birthing hospitals that have established a universal birth dose policy. Although we have not yet re-surveyed the birthing hospitals, anecdotal information collected at hospital record review visits indicates an increase in the number of hospitals offering the hepatitis birth dose.
- New York (not including New York City)
Yes. The new ACIP recommendations for administration of the hepatitis B vaccine dose #1 at birth has afforded the Pennsylvania Department of Health the opportunity to re-examine our policies and make updates. These updates on the program will be sent to all hospitals and associated physicians in Pennsylvania. We will be able to determine the impact when the 2003 survey is completed and the data is analyzed.
- Pennsylvania
Yes. Rhode Island has 7 birthing hospitals, all of which have reinstated hospital policies for birth dose.
- Rhode Island
Yes. Both hospitals and pediatricians who migrated away from the practice of administering the birth dose of hepatitis B due to thimerosal concerns have returned to providing the birth dose.
- South Carolina
Yes. Ten hospitals have elected to reinstate the birth dose, out of 20 that had stopped altogether after the thimerosal issue.
- Wyoming
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COMMENTS FROM THOSE ANSWERING "NO" TO QUESTION 1
No. We continue to have physicians who only want to give three doses of the hep B/Hib combination vaccine or use a dose at one month to ensure that the baby's parents will bring the child back into their office.
- Alabama
No. Many pediatricians and OBs don't think perinatal hepatitis B exists in their clients-or as a problem-or they think the hospital will 'catch' the isolated woman who is HBsAg positive and delivers.
- Maryland
No. One third of our hospitals refuse to restart the birth dose. Comvax is an issue. Also, the doctors prefer to charge for the first dose in their office. They do not appear to understand the issue of the increased risk of hepatitis B to the infant. They also do not want to be informed [about perinatal hepatitis B risk] by nurses--we need doctor to doctor education!
- Name of state or local project withheld per request
No. Hospitals vary widely in their implementation of the birth dose and a stronger statement from ACIP, AAP, and others would assist us in working with hospitals reluctant to implement the birth dose. Many doctors are afraid that the hepatitis B vaccine still contains thimerosal, and they would rather give the first dose in the office.
- Oklahoma
No. Most delivering doctors who are still not giving the birth dose of hepatitis B vaccine to infants of HBsAg-negative mothers want to give this dose in their office. The consensus [among health department staff] regarding those giving it in their offices is it is so the doctors will be able to charge for the office visit.
- Michigan
No. If health care providers, birthing hospitals, and clinics are aware of the recommendation, some choose to give it while others do not. This may be due to fallout from the thimerosal issue and changes in protocol. We at the Chicago Department of Public Health actively promote the universal birth dose of HBV.
- Chicago
No. Don't know, but [the recommendation] probably has not had an impact. When we measured adherence to this recommendation in 2000, only 12% of birthing hospitals had a universal policy to administer the birth dose.
- Minnesota
No. There are several reasons given by physicians and hospitals regarding why they are not vaccinating at birth. Cost of vaccine in hospital, lack of reimbursement by insurance companies for the vaccine and administration, documentation issues, and finally, many physicians do not see the importance.
- Colorado
No. Some of our physicians are very conservative and do not immediately enact new changes. They have a wait and see attitude. They want to see if others have problems, if the results from the change are as good as predicted, and if the change is adopted by others in the area. After a while, they will join the group.
- San Antonio, TX
No. Prior to the 1999 concerns related to the thimerosal content in the hepatitis B vaccine, Missouri had a universal birth dose vaccination program. This is no longer true. Under Missouri law all pregnant women are screened for hepatitis B and currently HBIG and hepatitis B birth dose administration occur only if the mother is known to be positive or if her hepatitis B status is unknown. The primary contributing factors [for health professionals in Missouri not giving the birth dose] are: 1) liability issues for the physician and birthing hospital related to vaccine safety perceptions, and, 2) universal administration is seen as cost prohibitive in what is increasingly becoming a managed care dominated environment. So while information and the revised recommendations have been given to providers to support/increase birth dose administration, Missouri has not regained the consistent level of administration experienced prior to 1999.
- Missouri
No, because of resistance from physicians.
- Washoe County, NV (includes Reno and Carson City)
No. Communication between hospitals and the provider offices [(sharing patient records)] continues to be a barrier for one of our larger hospitals. We are hopeful that the statewide immunization registry will provide a tool to facilitate this communication. The registry will be piloted in early 2003, followed by a gradual statewide rollout.
- Vermont
No. It appears that physicians prefer to give the first dose in their offices. We are currently conducting a hospital survey re: the birth dose practices of hospitals. We have 64 birthing hospitals in the state; 34 returned the survey and only 10 report giving the birth dose.
- New Jersey
No. From speaking with our local health departments, it does not appear to have impacted whether physicians are ordering the birth dose or not. It is not clear that medical providers have noticed the difference in language about the birth dose. Even the ones that have noted the change in the ACIP recommendation are still sticking closely to Comvax.
- Oregon
No. I have not seen a change in practice around the state. I do not know why not.
- Tennessee
No. The hospital leaves it to the private doctor as to whether the birthing dose will be given. We have 17 birthing hospitals; only 2 of these hospitals routinely vaccinate all babies for hepatitis B.
- Houston, TX
"No. We have two benchmarks to use for measuring the impact of the ACIP recommendation. First, the data for the birth dose as recorded on the birth certificate (Center for Health Statistics, or CHS). There has been a steady but gradual increase in the number of infants whose birth dose is captured in birth certificate data. The birth certificate is used to populate the Immunization Registry. Those data are as follows:
2000: # infants entered from CHS= 79,960 # of infants with hep B vaccine recorded on certificate= 35,589 (45%)
2001: # infants entered from CHS= 79,090 # of infants with hep B vaccine recorded on certificate= 41,874 (53%)
2002: # infants entered from CHS= 61,082 # of infants with hep B vaccine recorded on certificate= 36,056 (59%)
It is important to note that not all hospitals record the birth dose on the birth certificate. In addition, some infants served through HMOs in the state receive the birth dose within 2-7 days as outpatients. Therefore, these data are not representative of the total number or percentage of infants receiving the birth dose within 7 days of birth.
- Washington
No. Many hospitals and physicians are still not giving the birth dose despite the recommendation. Physicians tend to practice the way that they want to, not necessarily the way that it is recommended.
- Utah
No. We already had a high rate of facilities giving the birth dose. Other pediatricians are "solo" on Comvax.
- Kentucky
No, we only stopped during the thimerosal issue.
- Arkansas
No. Massachusetts has never stopped recommending the birth dose of hepatitis B except during the hiatus of the summer of 1999. By June 2000, all hospitals had resumed their policy of administering the birth dose of hepatitis B
- Massachusetts
No. For the past several years we have had extremely high compliance with birth doses of hepatitis B vaccine. Providers understand the importance of vaccinating children at this age.
- North Dakota
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COMMENTS FROM THOSE WHO FELT THE IMPACT WAS UNDETERMINED IN QUESTION 1
Yes and no. It has had a positive effect: some [additional] hospitals and pediatricians are giving the birth dose; if the mothers' status were recorded incorrectly as negative, the infants benefited from the birth dose. And one could say it has not had an effect: cost and reimbursement are issues; some providers do not believe it is necessary and are still within ACIP guidelines to give it within one month [to infants of HBsAg-negative mothers]; easier to start with combination vaccine; ... some never resumed giving the birth dose after the thimerosal issue.
- California
Do not know. Currently conducting a hospital chart review to see how many hospitals have reinstated the birth dose.
- Texas
We are not sure at this time. A survey that is currently underway should provide us with information to respond to this question.
- Florida
Unknown. We have not looked into the impact of the new ACIP statement on the birth dose yet.
- Kansas
Unknown, too soon to tell. We have a fairly high percent of infants receiving hepatitis B vaccine before hospital discharge (~81% and ~76% in 1996 and 2000 birth cohort assessments respectively) and only one hospital that gives no hepatitis B vaccine to infants before discharge.
- New Hampshire
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Question 2: During the past year (from October 2001-October 2002), 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 YES, please estimate the number of cases you know about and describe why these situations happened
Results: Twenty-four states/projects reported a total of 166 cases where babies of HBsAg-positive mothers were not prophylaxed within 12 hours of birth with both HBIG and hepatitis B vaccine.
COMMENTS FROM THOSE ANSWERING "YES" TO QUESTION 2
 
Yes. Error in documentation in mother's chart (many); test result misinterpreted (many); parent refused vaccine; hospital record missing; vaccine was given but not HBIG; blood test results not received on time and HBIG/vaccine delayed (in general); delay in receiving the HBIG and vaccine ordered from hospital pharmacy; infants admitted to NICU, therefore delayed immunoprophylaxis; information about mother's status sent to health department too late; time was not recorded on chart; infant born at home; mother's HBsAg status changed during pregnancy; unknown reasons.
- California
Yes. During routine follow-up/infant tracking, we attempt to document the date of administration of HBIG and HBV given to HBsAg-positive females. In these [4] cases, there was no chart record of HBIG having been administered. Three of these cases appear to have fallen through the cracks (the HBsAg status was known but HBIG was not administered). The last case involved an unknown sero-status mother, test was ordered, but results came back after mom and baby were released.
- Chicago
Six cases of such an error. Examples: 1) Patient delivered in another state. The hospital had been notified by the Alabama Perinatal Program, but HBIG was not given. The nursing supervisor states that it was an 'oversight.' Hep B #1 was given before discharge. 2) Infant's chart [incorrectly] stated that mother was HBsAg negative. The error was caught and the baby was given HBIG and vaccine prior to discharge at 2 days of age. 3) Mother was acute at delivery. Previous lab work during prenatal period was negative.
- Alabama
The first case occurred in December 1999. The mother was of Hmong ethnicity, born in Thailand. She had been diagnosed with chronic hepatitis B in 1994 during her first pregnancy: this pregnancy was her third. In her prenatal record she was documented to be HBsAg and HBeAg positive, and this information appeared in several places on the record that was sent to the hospital. Despite this, her baby did not receive HBIG or the first dose of hepatitis B vaccine in the hospital. As a matter of fact, the hepatitis B vaccine order was crossed out in the infant's chart. Follow-up with the pediatrician on day six indicated that the baby still had not received any prophylaxis. The first dose of vaccine was given at three weeks of age, the second three months after the first, and the third six months after the first. Upon contacting the hospital where the baby was delivered to determine why HBIG and hepatitis B vaccine were not given within 12 hours of birth, the state health department representative was told that it was unclear how this baby was missed and perhaps it was because the hospital had no hepatitis B vaccine at the time of delivery. They indicated that the infant was to receive the first dose of vaccine at the pediatrician's office. However, this did not happen until the baby was three weeks of age, and only after the office was contacted by the state health department to request that it be done. The child's current status is unfortunate. Diagnosed HBsAg-positive at 19 months of age, the child is now being followed by a liver specialist for chronic hepatitis B.
- Colorado
The second case occurred in August 2001, in a different hospital and city. The mother was also of Asian descent (Indonesian) and had tested positive for HBsAg midway through her pregnancy. The HBsAg lab result was recorded on the prenatal record, which was sent to the hospital. The hospital staff also recorded the HBsAg-positive test result on the hospital's obstetrical evaluation sheet. It was not acted upon by either the delivering physician or the labor and delivery staff, nor was the mother's HBsAg-positive test result communicated to or noted by the newborn nursery. The hospital did not have a policy in place to address management of babies born to HBsAg-positive mothers or to mothers of unknown status. Hence, the infant received neither HBIG nor hepatitis B vaccine at birth. The high-risk infant did not receive the first dose of hepatitis B vaccine until two months of age. Unfortunately, this child has also tested HBsAg positive. In reviewing the case, a staff member at the state health department acknowledges that the baby should have been followed more closely. Part of the problem was that the health department field investigator didn't contact the hospital before the birth to ensure appropriate care would take place. Additionally, after the birth, the hospital sent the state an inaccurate report, stating that the child had received prophylaxis in the hospital. The investigator did not review the hospital record or call the physician to assure that the information was accurate.
- Colorado
Yes. The [2] infants were being tracked because we were aware that the mother was HBsAg positive. Prior to birth, the birthing hospitals were informed of the infant to be delivered and the proper protocol for prophylaxis. The infants did receive hepatitis B vaccine, but not HBIG.
- Kansas
Yes. We learned about [11 cases] through an informal survey of the hepatitis B coordinators in ten counties. The main reasons for the cases of babies that were not prophylaxed within 12 hours of birth were provider error and lack of a hospital policy to vaccinate at birth. Other reasons given were in one case each: 1) the doctor wrote an order not to give it, and 2) a mother delivered prematurely and her status was not noted in time for the infant to get the birth dose within 12 hours.
- Florida
Yes. One case where the baby was given hepatitis B vaccine but not HBIG for religious reasons.
- Name of state or local project withheld by request
Yes. The case was identified via perinatal hepatitis B surveillance. Information on mother's hepatitis B status was not communicated to the hospital.
- Texas
Case #1: The case manager received a copy of mom's prenatal HBsAg-positive lab results from the local health department. The OB reported to the hospital that mom's hepatitis status was HBsAg negative. The hospital did not administer HBIG or hepatitis B vaccine at this time. When the OB office was contacted, it was stated that the only labs in their chart were from 1999 and were HBsAg positive. After follow-up by case manager with the hospital, it was determined that no HBIG was given, but hepatitis B vaccine was given 2 days after birth.
- Michigan
"Case #2: This mom had no prenatal care, was a known carrier, but gave no indication of her history when admitted. The hospital ran tests on mom at delivery and the baby was treated with both HBIG and the hepatitis B vaccine when the lab results came back two days later."
- Michigan
Case #3: Mom unexpectedly delivered at home, the baby was given HBIG and the birth dose of hepatitis B vaccine two days later in the hospital. The reason for the delay told to the case manager was that the staff at the hospital did not check mom's status upon admission. As a daily practice, the infection control coordinator verifies all HBsAg-positive results and discovered that this woman had been admitted to their hospital. She contacted the nursery manager and the infant received both HBIG and hepatitis B vaccine.
- Michigan
Case #4: Mom delivered and the baby was given HBIG, but did not receive the hepatitis B vaccine until a day later. Mom's HBsAg positive status was not found in either the mother's or the baby's chart. It was later found that both the prenatal care provider and the lab didn't know they had to report chronic HBsAg-positive pregnant women to the hospital or to the state/local health departments.
- Michigan
Case #5: Mom delivered and the baby was given HBIG but no hepatitis B vaccine. The case manager received a copy of a newborn screening card that indicated mom was HBsAg positive. After reviewing the lab information and working with the Labor and Delivery manager, the hepatitis B vaccine was administered to the baby 7 days after birth.
- Michigan
Case #6: Mom presented on the weekend at a hospital after having only sporadic prenatal care through an OB not affiliated with the delivering hospital. As the hospital was not able to access mom's prenatal labs, she was tested at delivery. Her results came back borderline HBsAg positive, but unfortunately, the hospital didn't have the reagent to confirm her results. The baby received hepatitis B vaccine at this time. The hospital later received prenatal labs indicating mom was HBsAg negative and mom and baby were discharged. After the delivering hospital's lab was able to confirm that the borderline HBsAg was indeed an HBsAg positive result, they contacted mom to bring the baby back in to get HBIG, which it received twelve days after birth.
- Michigan
Yes, we are aware of 13 cases. Seven of the 13 were treated later than 12 hours after delivery . Two of the 7 (twins) were born at a facility that has not been able to document that HBIG was given. One parent refused treatment for her child. The status of the remaining 5 children is unknown; some are more recent deliveries.
- Oregon
Yes. Three cases were born to HBsAg-positive mothers, where the hospital records erroneously indicated that the mothers were negative for HBsAg. The babies were not prophylaxed within 12 hours with HBIG and HBV #1. In another case, the mother moved and changed clinics and hospitals during pregnancy. There was no documentation as to why the child did not receive the HBIG and HBV #1 within 12 hours of birth. In a fifth case, the physician did not know the appropriate prophylaxis regime, so the infant did not receive the HBIG and HBV #1 within the 12 hour period. In the final case, there was no documentation as to why the child did not receive the prophylaxis within the time frame.
- Minnesota
Yes, we know of three cases caused by hospital errors. Two were known prenatal cases; we called close to their delivery date and found they had delivered and treatment for their infants was missed. In another case, we found an HBsAg positive result on the newborn screening kit and questioned why HBIG and HBV #1 was not on kit also. Again, they had missed it.
- Name of state or local project withheld per request
Yes. The infant received hepatitis B vaccine within 12 hours of birth, but administration of HBIG was not reflected in the medical chart. Incident is still under review. Case was identified through the case tracking system and incident verified through medical record review.
- Missouri
Yes. We have two significant cases where the infants received the hepatitis B vaccine three weeks after the birth date and no HBIG. In one case, the lab results appear to have been misinterpreted by the hospital staff. In the other case, the hospital had the resident interview the patient who claimed she was not HBsAg positive.
- New Jersey
Yes. In June 2002, a situation occurred where an infant born to an HBsAg positive mother at a large upstate teaching hospital was not appropriately treated with hepatitis B vaccine and HBIG at birth. A full investigation was launched and it was found that although the mother's HBsAg status was clearly marked on the prenatal record as 'reactive,' a resident at the hospital mistranscribed the mother's HBsAg status onto the hospital chart as 'negative.' The mother, a long time hepatitis B carrier, has two other children who were successfully treated prophylactically, and she assumed this infant was being treated as well. The county discovered the error when the infant was one month old when they called to follow up and ensure that the second dose of vaccine was being administered. At that time, hepatitis B vaccine was administered immediately. It will be several months before the child can be tested to see if the HBV was actually transmitted from the mother to the infant, or if infection was avoided. This situation serves as another example of why it is so critical for birthing hospitals to have a universal hepatitis birth dose policy established as a 'safety net.'
- New York (not including New York City)
Yes. Four infants [of HBsAg positive mothers] were prophylaxed within 2-7 days and two received hepatitis B vaccine only. They were reported through our surveillance system.
- Washington
Case #1: Mother had only one prenatal visit prior to delivery and was unaware of HBsAg status. Her infant did not receive HBIG. The first dose of hepatitis B vaccine was given two days after birth.
- Name of state or local project withheld per request
Case #2: Mother was receiving prenatal care via the local health department, then switched to private provider. Health department was not aware that mother had delivered until 4 days after birth. Infant received first dose of hepatitis B vaccine but no HBIG. Health department contacted physician to give HBIG as soon as possible and prior to 7 days of age.
- Name of state or local project withheld per request
Case #3: Lab results were transcribed incorrectly. Infant received the first dose of vaccine within one day of birth. No HBIG was given.
- Name of state or local project withheld per request
Yes. In 2001, there were 7 cases [of HBsAg+ mothers] where information was transmitted incorrectly from medical chart to nursery. In one case, the mother's status was marked as unknown and another was marked as negative, and in another the status was correctly marked but the HBIG was still not given.
- Oklahoma
Yes. Two cases where the mothers were tested but the positive lab results came back after they were discharged. The hepatitis B vaccine was given but not the HBIG.
- Louisiana
Yes. We became aware of three such situations when the health department received reports of the cases after the babies were born.
- Virginia
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Question 3: During the past year (from October 2001-October 2002), 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 estimate how many cases you know about and describe how these situations happened.
Results: Some of these cases were included in the answers to Question #2. An additional 33 cases were provided, as detailed below.
COMMENTS FROM THOSE ANSWERING "YES" TO QUESTION 3
 
Yes. A record review of women who delivered between 7/1/01 and 12/31/01 was conducted in all 50 of the state's delivery hospitals to determine if HBsAg screening was documented on the maternal records. The infants' records were also reviewed for documentation of hepatitis B vaccine administration. During the time period between 10/01 and 12/01, seven maternal records had no HBsAg status documented. These deliveries were in hospitals that did not routinely administer the hepatitis B vaccine birth dose.
- Mississippi
Yes. I found 8 cases during a quality assurance survey at one hospital. Doctors and nurses were not concerned about the missing lab results. The pediatrician did not give the birth dose due to policy of first dose being given at office. Since results of the survey were shared with pediatricians and OBs the policy at the hospital has changed regarding the birth dose.
- Delaware
Two cases; in one, a mother came to the hospital with no prior prenatal care. Mother told staff she was positive for hepatitis B. Tests were done incorrectly which showed that she was negative. She was indeed positive. Child did not receive vaccination.
- Oklahoma
Yes. In one case, the mother's positive results were not received before discharge and the hospital had not re-instituted the birth dose. The infant did not receive HBIG or the first dose of vaccine within the time frame. In some cases, the hospital was administering the birth dose of vaccine and the infant received it, but didn't receive the HBIG because the results were not received prior to discharge.
- Texas
Yes. One case that involved a 'walk-in' mother with no prenatal HBsAg testing. The positive lab test did not come back before discharge, and the mother and baby were not located within 7 days after discharge. No HBIG was given, but the hepatitis B vaccine had been given at birth.
- Arizona
Yes. During a hospital audit, I found one case where the vaccine had been withheld for 25 hours while the staff awaited the results of the 'stat' HBsAg blood work on an unknown mother. The mother tested negative and vaccine was then given. This hospital is in the process of revising their written policy to ensure that this won't happen again.
- Montana
Yes. In July 2002, a mother who had no prenatal care during her pregnancy delivered at a large upstate New York birthing hospital. Since the mother had not been tested for HBsAg during the pregnancy, a test was ordered upon admission, as is recommended. Unfortunately, the wrong hepatitis test was ordered; the physician ordered hepatitis B surface antibody (anti-HBs) rather than hepatitis B surface antigen (HBsAg), as required by Public Health Law. The results of the anti-HBs were positive which means that the patient is immune due to vaccination or past infection and no hepatitis vaccine was given because the hospital did not have a universal birth dose policy established. The mother had not been compliant with postpartum care, so is now 'lost to follow-up.' There is concern that if the mother is also non-compliant with the infant's well child care visits, the infant may not even get routine hepatitis B vaccination at 2 months of age.
- New York
Yes. I learned of one case while performing a quality assurance survey at the hospital. There was no protocol in place to address unknown mothers. I have been told by several hospitals that this happens often. The test is done in the hospital at admission, but the results do not get back until after the child is discharged and the infant is not vaccinated.
- Colorado
Yes. Six cases [of unscreened mothers whose babies were not properly prophylaxed]. Reasons given: no prenatal care, prenatal care different from the place of delivery, no records, computers down, lab got lost.
- Philadelphia, PA
I know of two cases [of unscreened mothers whose babies were not properly prophylaxed] and there may have been more.
- Minnesota
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Question 4: During the past year (October 2001-October 2002), are you aware of any babies whose mothers' lab tests for HBsAg were wrongly ordered, misinterpreted, or mistranscribed? If yes, please estimate how many cases you know about and describe how these situations happened.
Results: Some of these cases were included in the answers to Question #2. Hepatitis B coordinators estimated an additional 163 cases of screening errors, some of which are detailed below. These cases include examples of mothers incorrectly being labeled both HBsAg negative and HBsAg positive.
COMMENTS FROM THOSE ANSWERING "YES" TO QUESTION 4
 
We know of one record for a positive patient being documented as negative. However, the baby was given the appropriate biologicals at the correct time. The others were documented as positive, but were in reality negative, so the infants got the vaccine and HBIG even though they did not need it.
- Alabama
Unsure of how many cases. Nurses and medical assistants are often unsure how to read test results. Phone calls from nurses and information provided by nursery staff have indicated problems with this.
- Colorado
This has occurred in three cases. In two of the 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 nor hepatitis B vaccine being given to the infant. In the other case, the information was documented as negative.
- Oklahoma
In four cases, test results were misinterpreted and the women were told they did not have hepatitis B. In one case the mother tested positive early in the pregnancy and then tested negative at the time of delivery. The physician did not give the prophylaxis to the baby at the time of delivery. In most cases, miscommunications would not come to our attention unless the mother was known to be HBsAg+. In general, communication between providers can be improved, especially for patients going to private OB/GYNs. The differences in lab forms and lack of standardization of lab tests increases the likelihood of errors.
- Florida
Hospital staff misinterpreted patient information and incorrectly marked the newborn screening card that the mother was HBsAg positive.
- Wisconsin
On an average, we receive 10 newborn screening forms each month that indicate misinterpreted or mistranscribed maternal hepatitis B status. Hospital staff completing the newborn screening form indicate maternal hepatitis B status as positive when in fact the mother's status is negative. By calling to verify maternal positive hepatitis B status, misinterpreted or mistranscribed situations are identified and training is provided to staff.
- Illinois
Eight cases: hepatitis surface antigen (HBsAg) and hepatitis core antibody (anti-HBc) were misinterpreted.
- Louisiana
We get reports of wrong screening test ordered, including HBcAb and HBV DNA.
- Maine
1) Two maternal records were found to have anti-HBc documented instead of HBsAg, 2) In one hospital, cord blood was used to test mother's HBsAg status, 3) In another incident, a maternity client had one positive HBsAg test at one lab and two negative HBsAg test results at another lab. Explanation for the discrepancy from the first lab was a possibility of 'cross contamination of the blood specimen,' 4) A mother's serum was sent to the lab for HBsAg testing (result was HBsAg positive). The specimen was labeled with the newborn's name.
- Mississippi
Types of such mistakes found: results not documented in record; HBsAb ordered instead of HBsAg; interpretation of the wrong test (HBcAb positive); results were mistranscribed; wrong patient's test was included; test not ordered by hospital, thought it would be ordered by provider.
- California
Examples of approximately 25 cases: we ask for copies of the labs of unknowns and what we find is that anti-HBs has been frequently ordered--error by residents or by lab. We find examples on the triage sheet the hospital has to fax to us if they use HBIG, which we furnish to them and replace when we get the sheet. Also find errors when they leave the mom's test info blank on the newborn screening form (we try to call on these). Also, doctors' offices sometimes have positive result in chart and neglect to look at it! Or they order labs and neglect to notice that they were never drawn!
- Name of state or local project withheld by request
The OB insisted that the mother was vaccinated and could not be positive for hepatitis B. Said the positive HBsAg result was from the vaccine, not infection. Infant did receive HBIG and vaccine at birth.
- Connecticut
The lab results were misinterpreted [four cases]. The cases were received through the Houston Department of Health Epidemiology Department who forwarded them to our program. These cases were investigated and the families were followed. The lab states results were inconclusive or not enough blood was obtained and they are working to correct the problem.
- Houston, TX
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Question 5A: Are there health care providers in your state or area who do not routinely give the birth dose?
Results:
RESPONDENTS
YES
NO
N/A
States/Federally-funded local projects (N=56) 49 5 2
Question 5B: If YES, in your opinion what is the main reason they don't (please check all that apply)
Results:
They don't know about the ACIP and AAP statements recommending the birth dose for all infants
14
They don't understand the ACIP and AAP statements recommending the birth dose for all infants 14
They don't agree with the ACIP and AAP statements recommending the birth dose for all infants 34
They use Comvax and don't know how to correctly coordinate its use with single-antigen hepatitis B vaccine 18
They use Comvax and don't believe that it is necessary to begin the hepatitis B vaccine series before 2 months of age on infants born to HBsAg-negative women 32
They are confused about the hepatitis B vaccine recommendations for premature infants 10
Other (see following statements) 20
STATEMENTS FROM THOSE ANSWERING "OTHER" TO QUESTION 5
 
I have been told that it is often due to the desire of docs to bill out of their office for the shot.
- Michigan
One MD stated that Alabama is a rural state and should not be compared to studies done in larger states. Another consensus reached among our perinatal staff is that doctors want that extra visit at one month of age.
- Alabama
Not covered by insurance; want to give vaccine at their practice to be reimbursed; financial reason.
- California
Physicians prefer to administer the first dose in their office and bill patient's insurance. Some providers have reviewed the ACIP and AAP statements and have decided not to reinstate the birth dose policy, [temporarily] suspended in July 1999.
- New Jersey
Want to give first dose in office due to convenience and revenue.
- Colorado
Think that immunizations will be less expensive in the pediatrician's office or the local health department and some physicians think that insurance will not pay for birth dose. Both these assumptions are true in some cases.
- Indiana
Providers' reasons for not giving the birth dose:
1. Hospital reimbursement issues, even with VFC vaccine (How can you give vaccine free for some and charge others who do not qualify for VFC?)
2. Fee collections when a fourth dose of hepatitis B vaccine is administered using Comvax
3. Few cases of hepatitis B virus disease in this population (no need)
4. Fear of lawsuits-physician already involved in vaccination lawsuits 'fearful of vaccinating newborns'
5. Questions about when to get mother's consent for vaccine administration (under influence of anesthesia or in pain)
6. Extra work for nursery workers (immunization registry reporting forms, ordering vaccine, etc.)
7. Parental concern about vaccine given at birth
8. Hospital administration refuses
9. No routine policy/standing order at hospital to vaccinate
10. Waiting for recommendations
11. Some choose to wait until infant is older
12. Questions about the minute amount of thimerosal in one brand of the hepatitis B vaccine as mentioned in the vaccine package insert. One provider wanted a guarantee that VFC would provide only the brand of vaccine without any thimerosal.
- Mississippi
Thimerosal content still concerns some providers.
- Wisconsin
Many hospitals are concerned about cost because the cost of hepatitis B immunization is bundled into the perinatal care rate and there is no separate mechanism for billing for the cost of vaccinating. We are currently exploring the possibility of providing free hepatitis B vaccine to our birthing hospitals that agree to establish a universal birthing dose policy.
- New York
Insurance problem for reimbursement.
- Name of state or local project withheld by request
They want to make money by giving vaccinations at the first doctor appointment.
- Oklahoma
Some physicians are in the habit of calling the babies born to negative mothers into their office at 2 weeks of age. They do a well baby check and give the first dose of hepatitis B vaccine at that time.
- South Dakota
They believe that the continuity of care for the infant is better when the vaccine is administered in their office.
- Tennessee
They want the first visit in 2 weeks at their office.
- Houston, TX
They want to charge for the first dose in their office.
- Name of state or local project withheld by request
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Question 6:  In your opinion, is there anything you think would help change the minds and actions of those providers not now providing the birth dose?
Education at a national level for physicians at their conventions would be helpful. Physicians need to hear from other physicians, not from nurses begging them to participate in programs to vaccinate children.
- Alabama
In Michigan, we have a quarterly newsletter that is distributed to over 10,000 providers. The newsletter includes a list of hospitals in Michigan which have a policy of offering hepatitis B vaccine to 100% of newborns [editor's note: you can view/adapt a copy of this article at: www.immunize.org/birthdose/mibirth1.pdf]. We also include articles that compare the list of delivering hospitals with a list that includes the number of infants born at these hospitals and how many of these infants have received the birth dose of hepatitis B vaccine. Our birth records can be electronically submitted to the state and then imported into our Michigan Childhood Immunization Registry (MCIR). Through this process we can generate a report that includes the hospital name, the number of births for a specific time frame, and the percentage of infants who received hepatitis B vaccine at birth. This helps encourage feedback from our hospital staff to verify their records and prompts numerous inquiries on how they can improve their reporting. The communication regarding the importance of providing the birth dose and being able to publicly acknowledge those for their hard work is very important.
- Michigan
Need information on cost effectiveness and how significant this disease can be. How to address cost and reimbursement.
- Colorado
Stronger information sent to them by AAP, telling members more about why the birth dose is there--to protect the infant at increased risk who is missed due to all the errors made!
- Name of state or local project withheld by request
Consistent recommendations by CDC and AAP and also regarding type and dose of vaccine, as opposed to wordy instructions and inconsistent guidance; make it a law with waivers allowed; make it a requirement instead of a recommendation; free vaccine; education on the importance and recommendation; improved registry systems to track the birth dose; incentives; education to providers about the incidence of hepatitis B; recommendation should be done when certifying hospitals; a bad experience (lawsuits) may work; a clear letter from CDC to pediatric/OB nurseries may work; increase knowledge about the impact of the mother's disease.
- California
Continued support of the local health departments in getting the message out to labor and delivery and nursery units.
- Chicago
More peer education.
- Georgia
Not sure. It has been my experience that nothing you can say will change the way providers practice medicine.
- Idaho
Hospitals perceive that it's hard to comply with the VFC program since inventory and billing systems in hospitals are not easily changed.
- Illinois
Additional education and outreach programs.
- Alaska
Letters directly from CDC to providers.
- Arizona
Keep doing what you are doing! Continue publicity!
- Indiana
The next approach that we are considering here is to inform the providers of the liability they could face if the child develops hepatitis B as a result of missing the birth dose.
- Kansas
Education of providers, especially regarding the use of Comvax.
- Connecticut
Education to health care providers, 2) Routinely check labor room protocol.
- Maine
Finding a way to sell the birth dose + Comvax to medical providers; even though they know the extra dose is okay they still prefer to use only Comvax in the office setting. There is often an issue of better reimbursement to the physician if the child is immunized in the office versus the hospital. Need to find new ways and incentives to help market the birth dose to hospitals.
- Oregon
The ACIP statement should say 'Give the birth dose,' period, not 'soon after birth' or 'at 2 months of age.' The pediatricians don't see that the new statement is any different from the old statement. Comvax is an anti-birth dose product. It confuses everyone. VFC should stop providing it.
- Maryland
Statistics and actual case scenarios that describe the number of missed and delayed cases with the subsequent consequences, 2) Funding for birth dose through health care providers and encouraging hospitals to enroll in the VFC program.
- Minnesota
The responses I hear from these providers relate to how they consider their clients, and the infants born to them, to be low-risk for infection. Perhaps, as you are doing, collecting data on missed cases and why they occur, will show them that even with the best efforts and assumptions errors can and do occur.
- Name of state or local project withheld by request
Contact the physicians who do not provide the birth dose to determine why they do not recommend the vaccine for newborns, 2) Provide current information/recommendations when applicable, 3) Provide survey results and other identified information related to the hospitals where they are on staff to show current and potential problems, 4) Provide information regarding the safety of hepatitis B vaccine for newborns to parents.
- Mississippi
Having it included as part of the hospital's reimbursement from Medicaid and insurance would help.
- Nebraska
Making it a regulation, with medical or parental exemptions, 2) Financial support of hepatitis B vaccine and HBIG, 3) At the national level, develop educational information targeted to OB/GYNs, pediatricians, hospital administration, and hospital infection control staff clearly documenting the liability, long-term cost associated with not administering the birth dose. It is hard to promote disease prevention for conditions that are not symptomatic for years. Unfortunately, money seems to drive many health care decisions, so unless providers are advised of the potential fiscal risk of not administering the birth dose, they will continue to weigh the cost of administering the birth dose higher than the liability associated with omission.
- Missouri
Fear of a lawsuit. Sharing cases where the hospital or physician did not follow ACIP recommendations and was sued.
- Delaware
More communication and support from both the national and local level. As more positions are frozen in our health department, it gets more and more difficult to do the legwork that is needed to convince providers to change practice.
- Washoe County, NV (includes Reno and Carson City)
Providers would benefit from general education. Materials for pediatricians that stress the importance of giving the first dose at the hospital would be helpful. Pediatricians also need information on how to handle the high-risk newborns and post-vaccine testing (antigen and antibody). Private infant care providers often do not get good documentation from the hospital (and mothers don't bring the discharge papers with them.). Frequently, they do not know if the infant got the birth dose. Another suggestion is to standardize the abbreviations used for the different serologic markers.
- Florida
We continue to provide educational outreach and encourage 'peer pressure.' Unfortunately, it might take the loss of one of their infants to change their practice. (But I think retirement may be the only real hope!)
- Montana
National experts to come talk to them directly.
- Nevada (except Clark and Washoe counties)
Providing the ACIP and AAP statements to health care providers might help. Our plan is to send these statements to all pediatrics care providers, especially the one hospital that doesn't provide the birth dose.
- New Hampshire
IAC has done an excellent job of developing useful tools for use in educating the providers. Even with all of our educational efforts, many providers are still resistance to the birth dose idea. Perhaps an even stronger recommendation is needed. ACIP should consider making a recommendation that all infants get a routine birth dose of hepatitis B vaccine regardless of maternal HBsAg status.
- New York
State law to provide first dose universally to all infants born.
- Name of state or local project withheld by request
More promotion of the need for the birth dose in newsletters and websites by the AAP and its local chapters and the AAFP.
- New Jersey
Comprehensive statewide birthing hospital education (we will be doing this as soon as the hepatitis B coordinator position is filled). Testimonials from other hospitals and/or physicians explaining the benefits and reasons for a birth dose policy. Legislation.
- New Mexico
The responses I hear from these providers relate to how they consider their clients, and the infants born to them, to be low-risk for infection. Perhaps, as you are doing, collecting data on missed cases and why they occur, will show them that even with the best efforts and assumptions errors can and do occur.
- Name of state or local project withheld by request
A combination vaccine that does not contain hepatitis B vaccine needs to be licensed in the U.S. at an affordable cost. It may make sense to tell people to vaccinate at birth and then give 3 doses of Comvax as there are no known adverse effects in giving an extra dose of hepatitis B vaccine. The problem and issue that cannot be ignored is that this costs a great deal of money for the states, health care providers, and parents, the only entity benefiting from this recommendation being the vaccine manufacturer.
- North Dakota
Having standing orders/hospital protocol for all hospitals in the state.
- Oklahoma
Continued efforts to educate providers about the importance of the birth dose of vaccine and education about the ACIP recommendations. Additionally, education to providers about the existence of and services rendered by the states' perinatal hepatitis B prevention programs.
- Virginia
Continue to publicize the miscommunications, etc., about test results, the number of children who get hepatitis B horizontally from other high risk family members, AND the fact that many carrier mums do not tell their pediatrician their own status!
- Philadelphia, PA
In my opinion, we need more media coverage directed at the general public regarding the importance of hepatitis B vaccine. There has been so much negative publicity regarding thimerosal, etc., that a lot of providers are still shying away from the vaccine. Some providers continue to be resistant regarding the use of Engerix B just because there is a 'trace' of thimerosal in it. I have access to the statement made by Dr. Neal Halsey, Director of the Institute for Vaccine Safety, where he states that this trace amount has no clinically relevant effect, i.e., Engerix B is equivalent to a 'thimerosal-free' product. I have faxed this statement more times than I can count to physicians. More publicity like this needs to occur.
- South Dakota
More education and training is needed. Many doctors will wait to administer the first dose of vaccine until the first office visit. Many are unaware of the liability issues.
- Texas
The first step would be to educate health care providers including physicians, PA's, nurses, certified nurse midwives, nurse practitioners, and MA's in newborn labor and delivery units. Usually, if there is one breakdown in communication, there are several more to follow.
- Pennsylvania
Peer to peer mentoring.
- Washington
Not sure. It has been my experience that nothing you can say will change the way providers practice medicine.
- Idaho
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Question 7: Please provide any other comments you'd like to share with ACIP or others about the birth dose.
Ensure universal abbreviations for lab markers are used and educate providers in their meaning.
- Alabama
Make instructions clearer; have a standard policy for birth dose requirement for all infants; pediatricians should ask parents for immunization records to avoid repeating a dose at the 1-2 week visit; recommendations must be strongly reinforced to have all hospitals adopt the policy; educate the parents so that they can insist on the appropriate immunoprophylaxis; the hospital that gives the birth dose should also be enrolled in the VFC program to cover the cost of vaccine.
- California
Incorporate the ACIP recommendation in discussions with national and state hospital associations.
- Texas
The Vermont Immunization Program strongly encourages the birth dose of hepatitis B vaccine and will continue to work to educate providers. We continue to assess barriers and work to remove them whenever possible. Any data that will help in education are appreciated.
- Vermont
I would like to see ACIP collaborate to amend the Clinical Lab Improvement Amendments (CLIA) to require labs to indicate that a hepatitis B positive report was part of "prenatal testing" when this is the case. Also, we need a clear statement about whether or not one can administer Comvax to infants born to HBsAg-positive mothers.
- Illinois
Our hospital survey and record review enlightened us regarding HBsAg screening and hepatitis B vaccine administration policies for newborns in the state's 50 delivery hospitals. The survey and record review also helped enlighten health care providers regarding their colleague's activities in screening of maternity clients and vaccination of newborns. The information obtained also helped in answering your [IAC's] questionnaire.
- Mississippi
There is no state that does not have babies born to mothers who are positive for the hepatitis B virus.
- Iowa
Get the OB/GYN and midwife societies involved.
- Maine
With the pentavalent vaccine becoming available in the future, it will become more difficult to gain the support of hospitals/physicians to give the birth dose. In cases where an infant was born to a HBsAg-positive woman and the hospital has missed the first dose, after much discussion and review of the recommendations with hospital staff, most of these hospitals are now routinely giving the birth dose.
- New Jersey
Please give all doctors and clinic information on the above-listed errors. These will always happen, so the first dose should be no choice for doctors. Also, providers need more education on chronic hepatitis B being infectious! They need to counsel the sexual contacts and household contacts instead of passing it off to Public Health. They also need to re-test for HBsAg status in the third trimester of pregnancy for high risk women!
- Name of state or local project withheld by request
Provide effective ways to educate doctors and nurses of the importance of hepatitis B vaccine. We are developing a packet for Oklahoma infants, which will include an immunization card, pen, information on various diseases, contact numbers, etc. This is something tangible for the patient to have after discharge. Maybe this will increase awareness and make doctors more apt to vaccinate.
- Oklahoma
Many physicians feel 'they know' their patients and which pregnant women are at risk for hepatitis B.
- Wyoming
More positive media coverage!
- South Dakota
We have educated our birthing facilities though memoranda concerning the ACIP recommendations of vaccinating infants within 12 hours of birth, but some may continue to misunderstand or mistrust the information provided concerning the removal of thimerosal from hepatitis B vaccines.
- West Virginia
Although New York State has had a perinatal hepatitis B screening and reporting law in place since 1990, we know errors have occurred in the past, and will continue to occur, unnecessarily exposing our infants to HBV infection. The only way to prevent infants from being unnecessarily exposed to HBV due to these errors is to strengthen the recommendation for the hepatitis B birth dose. ACIP should state that all infants should receive hepatitis B vaccine at birth (unless medically contraindicated or the parents file for a state-recognized exemption). Leave out the option of waiting up until 2 months of age to vaccinate infants born to mothers who are HBsAg negative.
- New York
In the cases [of babies born to positive moms] we documented above, every baby did at least get vaccine, albeit sometimes delayed. This happened because the hospitals involved all give the birth dose. Each case is a different scenario, and illustrates how life is messy and giving the birth dose is the best way to avoid worst-case scenarios.
- Michigan
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Question 8: In your opinion, is there anything you think would help change the minds and actions of those providers not now providing the birth dose?
ADVICE FROM HEPATITIS COORDINATORS:
Education at a national level for physicians at their conventions would be helpful. Physicians need to hear from other physicians, not from nurses begging them to participate in programs to vaccinate children.
- Alabama
In Michigan, we have a quarterly newsletter that is distributed to over 10,000 providers. The newsletter includes a list of hospitals in Michigan which have a policy of offering hepatitis B vaccine to 100% of newborns [editor's note: you can view/adapt a copy of this article at: www.immunize.org/birthdose/mibirth1.pdf]. We also include articles that compare the list of delivering hospitals with a list that includes the number of infants born at these hospitals and how many of these infants have received the birth dose of hepatitis B vaccine. Our birth records can be electronically submitted to the state and then imported into our Michigan Childhood Immunization Registry (MCIR). Through this process we can generate a report that includes the hospital name, the number of births for a specific time frame, and the percentage of infants who received hepatitis B vaccine at birth. This helps encourage feedback from our hospital staff to verify their records and prompts numerous inquiries on how they can improve their reporting. The communication regarding the importance of providing the birth dose and being able to publicly acknowledge those for their hard work is very important.
- Michigan
Need information on cost effectiveness and how significant this disease can be. How to address cost and reimbursement.
- Colorado
Stronger information sent to them by AAP, telling members more about why the birth dose is there--to protect the infant at increased risk who is missed due to all the errors made!
- Name of state or local project withheld by request
Consistent recommendations by CDC and AAP and also regarding type and dose of vaccine, as opposed to wordy instructions and inconsistent guidance; make it a law with waivers allowed; make it a requirement instead of a recommendation; free vaccine; education on the importance and recommendation; improved registry systems to track the birth dose; incentives; education to providers about the incidence of hepatitis B; recommendation should be done when certifying hospitals; a bad experience (lawsuits) may work; a clear letter from CDC to pediatric/OB nurseries may work; increase knowledge about the impact of the mother's disease.
- California
Yes. Most hospitals and pediatricians are administrating the birth dose. Increased numbers.
- Connecticut
Continued support of the local health departments in getting the message out to labor and delivery and nursery units.
- Chicago
More peer education.
- Georgia
Not sure. It has been my experience that nothing you can say will change the way providers practice medicine.
- Idaho
Hospitals perceive that it's hard to comply with the VFC program since inventory and billing systems in hospitals are not easily changed.
- Illinois
Additional education and outreach programs.
- Alaska
Letters directly from CDC to providers.
- Arizona
Keep doing what you are doing! Continue publicity!
- Indiana
The next approach that we are considering here is to inform the providers of the liability they could face if the child develops hepatitis B as a result of missing the birth dose.
- Kansas
Education of providers, especially regarding the use of Comvax.
- Connecticut
1) Education to health care providers, 2) Routinely check labor room protocol.
- Maine
Finding a way to sell the birth dose + Comvax to medical providers; even though they know the extra dose is okay they still prefer to use only Comvax in the office setting. There is often an issue of better reimbursement to the physician if the child is immunized in the office versus the hospital. Need to find new ways and incentives to help market the birth dose to hospitals.
- Oregon
The ACIP statement should say 'Give the birth dose,' period, not 'soon after birth' or 'at 2 months of age.' The pediatricians don't see that the new statement is any different from the old statement. Comvax is an anti-birth dose product. It confuses everyone. VFC should stop providing it.
- Maryland
1) Statistics and actual case scenarios that describe the number of missed and delayed cases with the subsequent consequences, 2) Funding for birth dose through health care providers and encouraging hospitals to enroll in the VFC program.
- Minnesota
Making it a mandatory action for babies to receive the birth dose.
- Houston, TX
1) Contact the physicians who do not provide the birth dose to determine why they do not recommend the vaccine for newborns, 2) Provide current information/recommendations when applicable, 3) Provide survey results and other identified information related to the hospitals where they are on staff to show current and potential problems, 4) Provide information regarding the safety of hepatitis B vaccine for newborns to parents.
- Mississippi
Having it included as part of the hospital's reimbursement from Medicaid and insurance would help.
- Nebraska
1) Making it a regulation, with medical or parental exemptions, 2) Financial support of hepatitis B vaccine and HBIG, 3) At the national level, develop educational information targeted to OB/GYNs, pediatricians, hospital administration, and hospital infection control staff clearly documenting the liability, long-term cost associated with not administering the birth dose. It is hard to promote disease prevention for conditions that are not symptomatic for years. Unfortunately, money seems to drive many health care decisions, so unless providers are advised of the potential fiscal risk of not administering the birth dose, they will continue to weigh the cost of administering the birth dose higher than the liability associated with omission.
- Missouri
Fear of a lawsuit. Sharing cases where the hospital or physician did not follow ACIP recommendations and was sued.
- Delaware
More communication and support from both the national and local level. As more positions are frozen in our health department, it gets more and more difficult to do the legwork that is needed to convince providers to change practice.
- Washoe County, NV (includes Reno and Carson City)
Providers would benefit from general education. Materials for pediatricians that stress the importance of giving the first dose at the hospital would be helpful. Pediatricians also need information on how to handle the high-risk newborns and post-vaccine testing (antigen and antibody). Private infant care providers often do not get good documentation from the hospital (and mothers don't bring the discharge papers with them.). Frequently, they do not know if the infant got the birth dose. Another suggestion is to standardize the abbreviations used for the different serologic markers.
- Florida
We continue to provide educational outreach and encourage 'peer pressure.' Unfortunately, it might take the loss of one of their infants to change their practice. (But I think retirement may be the only real hope!)
- Montana
National experts to come talk to them directly.
- Nevada (except Clark and Washoe counties)
Providing the ACIP and AAP statements to health care providers might help. Our plan is to send these statements to all pediatrics care providers, especially the one hospital that doesn't provide the birth dose.
- New Hampshire
IAC has done an excellent job of developing useful tools for use in educating the providers. Even with all of our educational efforts, many providers are still resistance to the birth dose idea. Perhaps an even stronger recommendation is needed. ACIP should consider making a recommendation that all infants get a routine birth dose of hepatitis B vaccine regardless of maternal HBsAg status.
- New York
State law to provide first dose universally to all infants born.
- Name of state or local project withheld by request
More promotion of the need for the birth dose in newsletters and websites by the AAP and its local chapters and the AAFP.
- New Jersey
Comprehensive statewide birthing hospital education (we will be doing this as soon as the hepatitis B coordinator position is filled). Testimonials from other hospitals and/or physicians explaining the benefits and reasons for a birth dose policy. Legislation.
- New Mexico
The responses I hear from these providers relate to how they consider their clients, and the infants born to them, to be low-risk for infection. Perhaps, as you are doing, collecting data on missed cases and why they occur, will show them that even with the best efforts and assumptions errors can and do occur.
- Name of state or local project withheld by request
A combination vaccine that does not contain hepatitis B vaccine needs to be licensed in the U.S. at an affordable cost. It may make sense to tell people to vaccinate at birth and then give 3 doses of Comvax as there are no known adverse effects in giving an extra dose of hepatitis B vaccine. The problem and issue that cannot be ignored is that this costs a great deal of money for the states, health care providers, and parents, the only entity benefiting from this recommendation being the vaccine manufacturer.
- North Dakota
Having standing orders/hospital protocol for all hospitals in the state.
- Oklahoma
Continued efforts to educate providers about the importance of the birth dose of vaccine and education about the ACIP recommendations. Additionally, education to providers about the existence of and services rendered by the states' perinatal hepatitis B prevention programs.
- Virginia
Continue to publicize the miscommunications, etc., about test results, the number of children who get hepatitis B horizontally from other high risk family members, AND the fact that many carrier mums do not tell their pediatrician their own status!
- Philadelphia, PA
In my opinion, we need more media coverage directed at the general public regarding the importance of hepatitis B vaccine. There has been so much negative publicity regarding thimerosal, etc., that a lot of providers are still shying away from the vaccine. Some providers continue to be resistant regarding the use of Engerix B just because there is a 'trace' of thimerosal in it. I have access to the statement made by Dr. Neal Halsey, Director of the Institute for Vaccine Safety, where he states that this trace amount has no clinically relevant effect, i.e., Engerix B is equivalent to a 'thimerosal-free' product. I have faxed this statement more times than I can count to physicians. More publicity like this needs to occur.
- South Dakota
More education and training is needed. Many doctors will wait to administer the first dose of vaccine until the first office visit. Many are unaware of the liability issues.
- Texas
The first step would be to educate health care providers including physicians, PA's, nurses, certified nurse midwives, nurse practitioners, and MA's in newborn labor and delivery units. Usually, if there is one breakdown in communication, there are several more to follow.
- Pennsylvania
Peer to peer mentoring.
- Washington
Not sure. It has been my experience that nothing you can say will change the way providers practice medicine.
- Idaho
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This page was reviewed on August 19, 2009
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