Advice from Hepatitis Coordinators
on How to Promote 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

"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

"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