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Avulakunta I, Balasundaram P, Rechnitzer A, Morgan-Joseph T, Nafday S. A Improving Birth-dose Hepatitis-B Vaccination in a Tertiary Level IV Neonatal Intensive Care Unit. Pediatr Qual Saf 2023; 8:e693. [PMID: 37818203 PMCID: PMC10561802 DOI: 10.1097/pq9.0000000000000693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 08/07/2023] [Indexed: 10/12/2023] Open
Abstract
Background Perinatal hepatitis B is a global public health concern. To reduce perinatal hepatitis B and its complications, the Hepatitis B vaccine (HBV) is recommended by the New York State Department of Health and Advisory Committee on Immunization Practices within 24 hours of life for infants born with a birth weight ≥2000 g. Infants admitted to the neonatal intensive care unit (NICU) weighing over 2000 g missed their birth dose HBV frequently, which prompted the implementation of a quality improvement initiative to increase birth dose HBV immunization in a level IV NICU in New York. Methods May 2019 to April 2021 baseline data showed the birth dose HBV rate of infants born ≥2000 g at 24% and 31% within 12 and 24 hours, respectively. The multidisciplinary QI team identified barriers using an Ishikawa cause-and-effect diagram. Our interventions included multidisciplinary collaboration, electronic medical record reminders, education, posters, and improved communication between staff and parents. We aimed to achieve a 25% improvement from the baseline. Results After 19 months of QI interventions (four Plan-Do-Study-Act cycles), the rate of administering birth dose HBV within 12 hours of life increased from 24% to 56% and within 24 hours from 31% to 64%. Process measure compliance improved, exceeding the 25% target, and showed sustained improvement. Conclusion This QI initiative improved the rate of eligible infants receiving HBV within the first 24 hours of life in the NICU. This work can serve as a model for other healthcare institutions to improve HBV immunization rates in NICUs.
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Affiliation(s)
- Indirapriya Avulakunta
- From the Division of Neonatology, Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children’s Hospital, Little Rock, Ark
| | - Palanikumar Balasundaram
- Division of Neonatology, The Children’s Hospital at Montefiore and Albert Einstein College of Medicine, Bronx, N.Y
| | | | - Toshiba Morgan-Joseph
- Division of Neonatology, The Children’s Hospital at Montefiore and Albert Einstein College of Medicine, Bronx, N.Y
| | - Suhas Nafday
- Division of Neonatology, The Children’s Hospital at Montefiore and Albert Einstein College of Medicine, Bronx, N.Y
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Gontasz MM, Chalk BS, Liang C. Improving On-time Administration of the Initial Hepatitis B Vaccine in the NICU. Pediatr Qual Saf 2023; 8:e658. [PMID: 38571739 PMCID: PMC10990374 DOI: 10.1097/pq9.0000000000000658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 05/05/2023] [Indexed: 04/05/2024] Open
Abstract
Introduction Despite the updated American Academy of Pediatrics recommendation for universal administration of the hepatitis B vaccine for newborns, delays in routine prophylaxis are common in the Neonatal Intensive Care Unit (NICU). Delayed immunization can increase perinatal acquisition risks and lead to subsequent delays in routine childhood immunization. This study aimed to increase the on-time administration of the birth dose of the hepatitis B vaccine from 46% to ≥70% at a level III and level IV NICU within the same health system. Methods The stakeholder group developed project interventions using quality improvement methods, including implementing unit guidelines and a prompt in the progress note template. The outcome measure was the percent on-time administration of the initial hepatitis B vaccine for inborn NICU patients born to hepatitis B-negative mothers. The process measure was the percent on-time administration or a valid reason to delay immunization following the guidelines. Statistical process control P-charts graphically represented the measures to assess for change from January 2019 to May 2021. Results In total, 2192 patients were included. The percent on-time administration improved from 48% to 57%. The percentage of on-time administration or valid reason to delay increased from 76% to 80%. Conclusions Quality improvement methodology facilitated the identification of barriers to on-time hepatitis B prophylaxis in the NICU and the improvement of the timeliness of administration across 2 sites. Guidelines tailored to this population and changes to the progress note template successfully created and sustained change and may benefit other NICUs.
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Affiliation(s)
- Michelle M. Gontasz
- From the Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Caroline Liang
- Department of Pharmacy, Johns Hopkins Bayview Medical Center, Baltimore, MD
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Sowe A, Namatovu F, Cham B, Gustafsson PE. Impact of a performance monitoring intervention on the timeliness of Hepatitis B birth dose vaccination in the Gambia: a controlled interrupted time series analysis. BMC Public Health 2023; 23:568. [PMID: 36973797 PMCID: PMC10041491 DOI: 10.1186/s12889-023-15499-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 03/21/2023] [Indexed: 03/29/2023] Open
Abstract
INTRODUCTION The Hepatitis B virus that can cause liver cancer is highly prevalent in the Gambia, with one in ten babies at risk of infection from their mothers. Timely hepatitis B birth dose administration to protect babies is very low in The Gambia. Our study assessed whether 1) a timeliness monitoring intervention resulted in hepatitis B birth dose timeliness improvements overall, and 2) the intervention impacted differentially among health facilities with different pre-intervention performances. METHODS We used a controlled interrupted time series design including 16 intervention health facilities and 13 matched controls monitored from February 2019 to December 2020. The intervention comprised a monthly hepatitis B timeliness performance indicator sent to health workers via SMS and subsequent performance plotting on a chart. Analysis was done on the total sample and stratified by pre-intervention performance trend. RESULTS Overall, birth dose timeliness improved in the intervention compared to control health facilities. This intervention impact was, however, dependent on pre-intervention health facility performance, with large impact among poorly performing facilities, and with uncertain moderate and weak impacts among moderately and strongly performing facilities, respectively. CONCLUSION The implementation of a novel hepatitis B vaccination timeliness monitoring system in health facilities led to overall improvements in both immediate timeliness rate and trend, and was especially helpful in poorly performing health facilities. These findings highlight the overall effectiveness of the intervention in a low-income setting, and also its usefulness to aid facilities in greatest need of improvement.
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Affiliation(s)
- Alieu Sowe
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden.
- Expanded Program On Immunization, Ministry of Health, Banjul, The Gambia.
| | - Fredinah Namatovu
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
| | - Bai Cham
- Medical Research Council Unit The Gambia at the London, School of Hygiene and Tropical Medicine, Bakau, The Gambia
- School of Public Health, Georgia State University, Atlanta, GA, USA
| | - Per E Gustafsson
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
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Vereen RJ, Aden JK, Drumm CM. Newborn medication adherence and childhood under-immunization in military beneficiaries. Vaccine 2023; 41:2887-2892. [PMID: 37005102 DOI: 10.1016/j.vaccine.2023.03.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 03/03/2023] [Accepted: 03/22/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND The American Academy of Pediatrics recommends birth doses of vitamin K, erythromycin ointment, and the hepatitis B vaccine, but the relationship between birth medication administration and childhood immunization compliance is understudied. The objective of this study is to evaluate rates of newborn medication administration, and risk factors for refusal in military beneficiaries and determine the relationship between medication refusal and under-immunization at 15 months. METHODS A retrospective chart review was completed for all term and late preterm infants born at Brooke Army Medical Center, San Antonio, TX, from January 1, 2016, to December 31, 2019. The electronic medical record was queried for birth medication administration, maternal age, active-duty status, rank, and birth order. Childhood immunization records were extracted for all patients who continued care at our facility. A patient was considered completely immunized if they had received at least 22 vaccines by 15 months: three doses of the hepatitis B vaccine [PediarixTM], two doses of the rotavirus vaccine [RotarixTM], four doses of the DTAP vaccine [PediarixTM and Acel-ImmuneTM], three doses of Haemophilus influenza B vaccine [PedvaxhibTM], four doses of pneumococcal [Prevnar 13TM], three doses of IPV [PediarixTM], one dose of measles, mumps, and rubella [MMRTM], one dose of varicella [VarivaxTM] and one dose of hepatitis A vaccine [HarvixTM]. RESULTS Seven thousand one hundred and forty infants were included; 99.3% received vitamin K, 98.8% received erythromycin ointment, and 93.8% received the hepatitis B vaccine. Refusal of the erythromycin ointment and hepatitis B vaccine was associated with older maternal age and higher birth order. Childhood immunization records were available for 607 infants; 7.2% (n = 44) were under-immunized by 15 months, with no infants being non-immunized. Refusal of the hepatitis B vaccine (RR: 2.9 (CI 1.16-7.31)) only at birth was associated with a higher risk of being under-immunized. CONCLUSIONS Refusal of the hepatitis B vaccine in the nursery is associated with a risk of being under-immunized in childhood. Obstetric and pediatric providers should be aware of this association for appropriate family counseling.
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Power NM, Crous EC, North N. Participatory Methods to Improve and Develop Pediatric Nursing Practice: A Scoping Review. Compr Child Adolesc Nurs 2023; 46:41-64. [PMID: 36630534 DOI: 10.1080/24694193.2022.2153945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Children's nurses in African pediatric settings are often responsible for leading practice improvements. There is a shortage of contextually relevant guidance to inform the design of practice improvement projects in African care settings. Distinctive features of children's nursing practice in Africa include high levels of family caregiver involvement, and organizational and professional cultures which value participation. While established practice improvement methods offer many strengths, methods developed in other geographies should not be adopted uncritically. Our purpose in undertaking this review was to inform selection of methods for a multi-center practice improvement project in Africa. Our aim was to identify types of participatory methods used to improve and develop pediatric nursing practice. We used the PRISMA-ScR method to conduct a scoping review to identify published reports of participatory methods used to improve and develop pediatric nursing practice. We undertook structured searches of five bibliographic databases to identify articles. Only articles written in the English language were included and no limitation was applied to publication date. We identified 7,406 titles and abstracts. After screening, 76 articles met the inclusion criteria. A wide range of participatory methodologies were identified; just under half (n = 34) reported on methods that were not recognized or named methodologies but can be described as collaborative in nature. Plan-do-study-act cycles were reported in 22 articles. There was considerable heterogeneity in frameworks, practical tools and/or nursing models on which the participatory methods were based and there was no apparent relationship between these and the choice of participatory methods. The outcomes identified were also heterogenous in nature and were grouped according to whether they improved structure and/or processes and patient outcomes. Most of the included articles stem from high-income countries with little evidence from low-middle-income countries and none in African settings. Less than half of the included articles involved family caregivers in their practice improvement methodologies. This review highlights the need for greater application of formalized methods for practice improvement and improved rigor and consistency in reporting outcomes. There is also a need to formalize participatory practice improvement methodologies specifically suited to Africa's context of children's nursing.
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Affiliation(s)
- Nina M Power
- The Harry Crossley Children's Nursing Development Unit, Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Elijeshca C Crous
- The Harry Crossley Children's Nursing Development Unit, Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Natasha North
- The Harry Crossley Children's Nursing Development Unit, Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
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Blagden S, Newell K, Ghazarians N, Sulaiman S, Tunn L, Odumala M, Isba R, Edge R. Interventions delivered in secondary or tertiary medical care settings to improve routine vaccination uptake in children and young people: a scoping review. BMJ Open 2022; 12:e061749. [PMID: 35918116 PMCID: PMC9351315 DOI: 10.1136/bmjopen-2022-061749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To identify and analyse the interventions delivered opportunistically in secondary or tertiary medical settings, focused on improving routine vaccination uptake in children and young people. DESIGN Scoping review. SEARCH STRATEGY We searched CINAHL, Web of Science, Medline, Embase and Cochrane Database of Systematic Reviews for studies in English published between 1989 and 2021 detailing interventions delivered in secondary or tertiary care that aimed to improve childhood vaccination coverage. Title, abstract and full-text screening were performed by two independent reviewers. RESULTS After deduplication, the search returned 3456 titles. Following screening and discussion between reviewers, 53 studies were included in the review. Most papers were single-centre studies from high-income countries and varied considerably in terms of their study design, population, target vaccination, clinical setting and intervention delivered. To present and analyse the study findings, and to depict the complexity of vaccination interventions in hospital settings, findings were presented and described as a sequential pathway to opportunistic vaccination in secondary and tertiary care comprising the following stages: (1) identify patients eligible for vaccination; (2) take consent and offer immunisations; (3) order/prescribe vaccine; (4) dispense vaccine; (5) administer vaccine; (6) communicate with primary care; and (7) ongoing benefits of vaccination. CONCLUSIONS Most published studies report improved vaccination coverage associated with opportunistic vaccination interventions in secondary and tertiary care. Children attending hospital appear to have lower baseline vaccination coverage and are likely to benefit from vaccination interventions in these settings. Checking immunisation status is challenging, however, and electronic immunisation registers are required to enable this to be done quickly and accurately in hospital settings. Further research is required in this area, particularly multicentre studies and cost-effectiveness analysis of interventions.
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Affiliation(s)
- Sarah Blagden
- Lancaster University Faculty of Health and Medicine, Lancaster, UK
- Health Education England North West Liverpool, Liverpool, UK
| | - Kathryn Newell
- Lancaster University Faculty of Health and Medicine, Lancaster, UK
- Health Education England North West Liverpool, Liverpool, UK
| | - Nareh Ghazarians
- Lancaster University Faculty of Health and Medicine, Lancaster, UK
| | - Sabrena Sulaiman
- Lancaster University Faculty of Health and Medicine, Lancaster, UK
| | - Lucy Tunn
- Lancaster University Faculty of Health and Medicine, Lancaster, UK
| | - Michael Odumala
- Lancaster University Faculty of Health and Medicine, Lancaster, UK
| | - Rachel Isba
- Lancaster University Faculty of Health and Medicine, Lancaster, UK
| | - Rhiannon Edge
- Lancaster University Faculty of Health and Medicine, Lancaster, UK
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Ost K, Oster NV, Jacobson EN, deHart MP, Englund JA, Hofstetter AM. Hepatitis B Vaccination of Low Birth Weight Infants in Washington State. Am J Perinatol 2022; 39:980-986. [PMID: 33254241 DOI: 10.1055/s-0040-1721372] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The U.S. Advisory Committee on Immunization Practices (ACIP) recommends that infants born weighing less than 2,000 g receive the hepatitis B (HepB) vaccine at hospital discharge or 30 days of age. This study aimed to assess timely HepB vaccination among low birth weight infants. We hypothesized that many of these vulnerable infants would fail to receive their HepB birth dose on time. STUDY DESIGN This retrospective cohort study included Washington State infants born weighing less than 2,000 g at an academic medical center between 2008 and 2013. Data were abstracted from electronic health records and linked to vaccine data from the Washington State Immunization Information System. Multivariable logistic regression was used to examine the associations between sociodemographic, clinical, and visit characteristics and HepB vaccination by birth hospitalization discharge or 30 days of age. RESULTS Among 976 study infants, 58.4% received their HepB vaccine by birth hospitalization discharge or 30 days of age. Infants had higher odds of timely HepB vaccination if they were Hispanic (adjusted odds ratio [AOR] = 1.80, 95% confidence interval [CI]: 1.10-2.95) or non-Hispanic black (AOR = 2.28, 95% CI: 1.36-3.80) versus non-Hispanic white or if they were hospitalized 14 days or longer versus less than 14 days (AOR = 2.43, 95% CI: 1.66-3.54). Infants had lower odds of timely HepB vaccination if they were born before 34 weeks versus on or after 34 weeks of gestational age (AOR = 0.41, 95% CI: 0.27-0.63) or if they had an estimated household income less than $50,845 versus 50,845 or greater (AOR = 0.64, 95% CI: 0.48-0.86). CONCLUSION Many infants born weighing less than 2,000 g did not receive their first HepB birth dose according to ACIP recommendations. Strategies are needed to improve timely HepB vaccination in this high-risk population. KEY POINTS · Low birth weight infants are at increased risk for vaccine preventable diseases.. · Many of these vulnerable infants failed to receive their first hepatitis B vaccine on time.. · This study identified key factors associated with timely hepatitis B vaccination..
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Affiliation(s)
- Katarina Ost
- Seattle Children's Research Institute, Seattle, Washington
| | - Natalia V Oster
- Department of Biostatistics, University of Washington, Seattle, Washington
| | | | - M Patricia deHart
- Office of Immunization and Child Profile, Washington State Department of Health, Olympia, Washington
| | - Janet A Englund
- Seattle Children's Research Institute, Seattle, Washington.,Department of Pediatrics, University of Washington, Seattle, Washington
| | - Annika M Hofstetter
- Seattle Children's Research Institute, Seattle, Washington.,Department of Pediatrics, University of Washington, Seattle, Washington
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Moore E, Bauer SC, Rogers A, McFadden V. An Opportunity in Cancer Prevention: Human Papillomavirus Vaccine Delivery in the Hospital. Hosp Pediatr 2022; 12:e157-e162. [PMID: 35419598 DOI: 10.1542/hpeds.2021-006302] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Pediatric hospitalizations are a missed opportunity for delivery of the human papilloma virus (HPV) vaccination. In this study, the authors' aim was to increase HPV vaccination rates among adolescents cared for by the pediatric hospital medicine (PHM) service at our academic children's hospital. METHODS This quality improvement (QI) study included adolescents ≥13 years who were discharged from PHM. Interventions included: modification of discharge order sets to include vaccination status and provider training seminars regarding the delivery of the HPV vaccine. Follow-up materials were distributed to providers by e-mail. The primary outcome measure was adolescent HPV vaccination rates. Secondary outcome measures were adolescent meningococcal vaccination rates and accuracy of immunization status documentation. The balancing measure was length of stay (LOS). Data were collected via chart review. Statistical process control charts were used to analyze for special cause variation. RESULTS From May 2019 through February 2020, 440 patients were included in this analysis. Throughout the study, HPV and meningococcal vaccination rates increased from a baseline median of 4.6% to 21.2% and 8.3% to 26.6%, respectively. HPV vaccination was not significantly associated with sex, HPV dose due, or admitting service. Accuracy of immunization status documentation and LOS remained unchanged. CONCLUSIONS Using QI methodology we were successful in increasing HPV and meningococcal vaccination rates among hospitalized adolescents. Considering the relationship of these 2 vaccines is a potential topic of future work. Discerning the correct immunization status at time of admission may be a potential opportunity for improvement in future work.
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Affiliation(s)
| | - Sarah Corey Bauer
- Medical College of Wisconsin, Department of Pediatrics, Section of Hospital Medicine, Milwaukee, Wisconsin
| | - Amanda Rogers
- Medical College of Wisconsin, Department of Pediatrics, Section of Hospital Medicine, Milwaukee, Wisconsin
| | - Vanessa McFadden
- Medical College of Wisconsin, Department of Pediatrics, Section of Hospital Medicine, Milwaukee, Wisconsin
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Dionne-Odom J, Cozzi GD, Franco RA, Njei B, Tita AT. Treatment and prevention of viral hepatitis in pregnancy. Am J Obstet Gynecol 2022; 226:335-346. [PMID: 34516961 PMCID: PMC8907340 DOI: 10.1016/j.ajog.2021.09.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 09/03/2021] [Accepted: 09/07/2021] [Indexed: 02/06/2023]
Abstract
Viral hepatitis in pregnancy may be caused by many types of viruses that cause systemic infection or target hepatocytes in their pathogenesis. Because viral hepatitis during pregnancy may represent acute or chronic infection or the reactivation of a prior infection, a high clinical suspicion, medical history review, and awareness of risk factors for the acquisition of infection are important management principles. The route of infection varies widely and ranges from fecal-oral transmission for the hepatitis A and E viruses to vertical transmission for hepatitis B, blood-borne transmission for hepatitis C, and sexual transmission for the herpes simplex virus. For this reason, the exposure details about travel, food preferences, drug use, and sexual contacts are important to elicit. Although routine prenatal screening is recommended for chronic viral hepatitis caused by hepatitis B and C, most other causes of viral hepatitis in pregnancy are detected in the setting of compatible signs and symptoms (fatigue, abdominal discomfort, jaundice, scleral icterus) or incidentally noted transaminitis on routine labs. Serologic testing is helpful for diagnosis with molecular testing as indicated to guide the management of hepatitis B and C. Preventive vaccines for hepatitis A and B with established safety of use in pregnancy are recommended for women who are at risk of acquisition. Postexposure prophylaxis for hepatitis A is a single dose of immunoglobulin and vaccination can be used if immunoglobulin G is not available. Antiviral therapy with tenofovir disoproxil fumarate is recommended as prophylaxis in pregnant women with active hepatitis B and an elevated viral load (>200,000 IU/mL) during the third trimester to prevent vertical transmission. The neonate exposed to hepatitis B at birth should receive immunoglobulin G and a monovalent birth dose vaccine within 12 hours, followed by completion of the 3-dosage vaccine series. The prevalence of hepatitis C in women of reproductive age has increased in the United States, and the role of antiviral therapy during pregnancy is of great interest. Cesarean delivery is not currently recommended for the sole purpose of reducing vertical transmission risk in pregnant women with viral hepatitis. Breastfeeding is recommended in women with hepatitis A, B, and C. New and promising prevention and treatment options for hepatitis B and C are under investigation. Investigators and regulatory authorities should ensure that these clinical trials for promising antivirals and vaccines are designed to include pregnant and lactating women.
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Affiliation(s)
- Jodie Dionne-Odom
- Division of Infectious Diseases, Department of Medicine, The University of Alabama at Birmingham, Birmingham, AL; Center for Women's Reproductive Health, The University of Alabama at Birmingham, Birmingham, AL.
| | - Gabriella D. Cozzi
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ricardo A. Franco
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama
| | - Basile Njei
- Yale Center for Clinical Investigation, Yale School of Medicine, New Haven, Connecticut
| | - Alan T.N. Tita
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Alabama at Birmingham, Birmingham, Alabama,Center for Women’s Reproductive Health, University of Alabama at Birmingham, Birmingham, Alabama
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Pulsifer A, Puopolo KM, Skerritt L, Dhudasia MB, Pyle BA, Schumacher A, Mukhopadhyay S. Improving Compliance With Revised Newborn Hepatitis B Vaccination Policy. Hosp Pediatr 2021; 11:hpeds.2021-005969. [PMID: 34808667 PMCID: PMC9843611 DOI: 10.1542/hpeds.2021-005969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND In September 2017, the American Academy of Pediatrics issued guidance recommending hepatitis B vaccine be administered to well newborns with birth weight ≥2000 g within 24 hours after birth. At that time, ∼85% of well newborns were vaccinated before discharge at our center; however, only 35% were vaccinated within 24 hours after birth. Our aim was to vaccinate 70% of eligible newborns within 24 hours after birth by June 2018 while maintaining the overall rate of vaccination. METHODS A multidisciplinary improvement team analyzed existing vaccine administration processes in the well-newborn nursery. From October 2017 to January 2018, changes were made to activation of vaccine orders and to obtaining and documenting the consent processes. Vaccine administration was bundled with routine care given ≤24 hours after birth, and parent scripting was changed from offering vaccine as an option to stating it as a recommendation. From November 2016 to June 2019, we determined the overall rate and timing of vaccination using statistical process control methods. RESULTS Among 10 887 eligible infants, the proportion administered hepatitis B vaccine ≤24 hours after birth increased from 35.5% to 78.8% after process changes with special-cause variation on process control charts. Proportion of infants receiving vaccine any time before discharge also increased from 86.5% to 92.3%. CONCLUSIONS Specific process changes allowed our birth center to comply with the recommended timing for hepatitis B vaccination of ≤24 hours after birth among eligible newborns.
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Affiliation(s)
- Allene Pulsifer
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Pennsylvania Hospital, Philadelphia, Pennsylvania
| | - Karen M Puopolo
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania
- Division of Neonatology, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lauren Skerritt
- Internal Medicine, College of Medicine, Drexel University, Philadelphia, Pennsylvania
| | - Miren B Dhudasia
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania
| | | | | | - Sagori Mukhopadhyay
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania
- Division of Neonatology, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Germana S, Krishnan G, McCulloch M, Trinh J, Shaikh S. Improving adherence to hepatitis B vaccine administration recommendations in two newborn nurseries. BMJ Open Qual 2021; 10:bmjoq-2020-001282. [PMID: 34607903 PMCID: PMC8491416 DOI: 10.1136/bmjoq-2020-001282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 09/16/2021] [Indexed: 11/24/2022] Open
Abstract
Administration of the birth dose of hepatitis B vaccine is an important step in reducing perinatally acquired hepatitis B infection, yet the USA is below the Healthy People 2020 goal for rate of administration. In response to updated Advisory Committee on Immunisation Practices recommendations to administer the dose within 24 hours of birth, we used quality improvement methodology to implement changes that would increase the vaccination rates of healthy newborns in our nurseries. The goal was to improve the proportion of infants who receive the hepatitis B vaccine within 24 hours of birth to >90% within a 2-year period, with a secondary goal of increasing vaccination rates prior to discharge from the nursery to >95%. Multiple Plan–Do–Study–Act (PDSA) cycles were performed. Initial cycles focused on increasing nurse and provider awareness of the updated timing recommendations. Later cycles targeted nursing workflow to facilitate timely administration of the vaccine. We implemented changes at our university medical centre and community hospital newborn nurseries. At the university medical centre nursery, both primary and secondary goals were met; the rate of hepatitis B vaccine administration within 24 hours increased from 81.7% to 96.2%, with vaccine administration prior to discharge increasing from 93.4% to 97.9%. In the community hospital nursery, the baseline rate of hepatitis B vaccine administration within 24 hours was 78.1%, and this increased to 85.8% with the interventions, falling short of the target of >90%. Vaccine administration prior to discharge increased from 87.2% to 92.0%, also not meeting the secondary target of 95%. Interventions that facilitated workflow had additional benefit beyond education alone to improve timing and rates of hepatitis B vaccine administration in both a university medical centre and community hospital nursery.
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Affiliation(s)
- Sarah Germana
- Department of Pediatrics, Duke University Health System, Durham, North Carolina, USA
| | - Govind Krishnan
- Departments of Internal Medicine and Pediatrics, Duke University Health System, Durham, North Carolina, USA
| | - Matthew McCulloch
- Departments of Internal Medicine and Pediatrics, Duke University Health System, Durham, North Carolina, USA
| | - Jane Trinh
- Departments of Internal Medicine and Pediatrics, Duke University Health System, Durham, North Carolina, USA
| | - Sophie Shaikh
- Department of Pediatrics, Duke University Health System, Durham, North Carolina, USA
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Abstract
Perinatal hepatitis B (HepB) infection is a serious condition in the pediatric population, with up to 90% of exposed infants progressing to chronic infection. The cornerstone of prevention is the birth dose of the HepB vaccine. In 2018, the Advisory Committee on Immunization Practices updated their guidelines for the birth dose of the HepB vaccine. These new guidelines included a refined timeline on when the HepB vaccine should be given, including for infants born to women with known HepB infection, unknown HepB status, and universal guidelines regardless of maternal HepB status. However, despite these guidelines, up to 25% of infants do not receive the birth dose of HepB vaccine. Individual provider commitment to administration of the vaccine remains fundamental, but institutional policies also have significant influence in ensuring appropriate vaccine administration for infants. [Pediatr Ann. 2021;50(8):e343-e347.].
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Sarathy L, Cirillo C, Dehn C, Lerou PH, Prendergast M. Improving Timeliness of Hepatitis B Vaccine Birth Dose Administration. Hosp Pediatr 2021; 11:446-453. [PMID: 33879503 DOI: 10.1542/hpeds.2020-002766] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVES When given within 24 hours of birth, the hepatitis B vaccine is up to 90% effective in preventing perinatal infection. The American Academy of Pediatrics now recommends administration within 24 hours for infants with a birth weight >2 kg, but a national benchmark for compliance with this time frame has not been established. We aimed to increase the monthly average of eligible newborns receiving the vaccine on time from 40% to 80% over a 9-month period. METHODS A series of plan-do-study-act cycles were conducted to improve timeliness of hepatitis B vaccine birth dose administration among newborns in the level 1 nursery at our academic community hospital. Interventions included staff education, nurse-driven consent and vaccine ordering, and earlier initial newborn assessments performed by nursing staff. Our primary outcome was the monthly percentage of newborns receiving the vaccine within 24 hours of birth, and our secondary outcome was the frequency of nonvaccination events. Statistical process control was used to analyze the effectiveness of interventions. RESULTS Our mean monthly rate of vaccine administration within the 24-hour time frame increased from 40% to 92%. Predischarge vaccination rate improved from a mean of 13 to 61 cases between infants discharged without vaccination. CONCLUSIONS Nurse-led interventions, including the ability to obtain consent and incorporation of the vaccine into our nurse-activated admission order set, were significant contributors to improvement in the timeliness of hepatitis B vaccine administration. We propose a mean of 90% compliance with the American Academy of Pediatrics recommendations as a benchmark for other institutions.
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Affiliation(s)
- Leela Sarathy
- St. Elizabeth's Medical Center, Boston, Massachusetts; .,Massachusetts General Hospital, Boston, Massachusetts; and.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | | | - Cathleen Dehn
- St. Elizabeth's Medical Center, Boston, Massachusetts
| | - Paul H Lerou
- St. Elizabeth's Medical Center, Boston, Massachusetts.,Massachusetts General Hospital, Boston, Massachusetts; and.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Michael Prendergast
- St. Elizabeth's Medical Center, Boston, Massachusetts.,Massachusetts General Hospital, Boston, Massachusetts; and.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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Deerin JF, Clifton R, Elmi A, Lewis PE, Kuo I. Hepatitis B birth dose vaccination patterns in the military health System, 2014-2018. Vaccine 2021; 39:2094-2102. [PMID: 33741189 DOI: 10.1016/j.vaccine.2021.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Revised: 02/28/2021] [Accepted: 03/02/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Since 2005, the universal hepatitis B (HepB) birth dose has been recommended for all medically stable infants weighing ≥2,000 g at birth. The timing of the birth dose provides a critical safeguard and prevents infection among infants born to HBsAg-positive mothers not identified prenatally. We assess infant HepB vaccination in the U.S. Department of Defense's Military Health System (MHS) to identify trends in vaccination coverage and sociodemographic factors associated with non-receipt of the birth dose, receiving the first HepB vaccine >3 days of life, and not receiving any HepB vaccine in the first 18 months of life utilizing parental refusal codes. To our knowledge, this is one of the first studies assessing trends in parental refusal of the HepB birth dose utilizing administrative claims parental refusal codes. METHODS We conducted a retrospective cohort analysis of MHS live births from January 1, 2014 through December 31, 2018 utilizing administrative claims data. Data were included from 44 hospitals in 24 unique states, territories, or countries. We analyzed diagnosis codes for vaccine refusal and vaccination and current procedural terminology (CPT) codes to identify vaccination patterns. Generalized linear mixed effects models with a logit link were used to assess factors associated with vaccination patterns. RESULTS HepB birth dose vaccination coverage increased from 79.6% in 2014 to 88.1% in 2018 (p < .0001). Refusal rates also increased from 3.7% in 2014 to 4.5% in 2018 (p < .0001). The percentage of patients with missing diagnosis codes for vaccine refusal or vaccination decreased from 16.7% in 2014 to 7.4% in 2018. Factors associated with non-receipt of the birth dose included earlier year of birth, white maternal race, higher maternal age, higher birth order, and longer infant length of stay in hospital. CONCLUSION Vaccination coverage for HepB birth dose is high in the MHS and increased over time; concurrently, refusal rates also increased over time. Utilizing administrative claims data has the benefit of differentiating reasons for non-receipt of the birth dose over time.
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Affiliation(s)
- Jessica Fung Deerin
- The George Washington University, Milken Institute School of Public Health, Department of Epidemiology, United States.
| | - Rebecca Clifton
- The George Washington University, Milken Institute School of Public Health, Department of Epidemiology, United States
| | - Angelo Elmi
- The George Washington University, Milken Institute School of Public Health, Department of Biostatistics and Bioinformatics, United States
| | - Paul E Lewis
- Defense Health Agency, Armed Forces Health Surveillance Branch, United States
| | - Irene Kuo
- The George Washington University, Milken Institute School of Public Health, Department of Epidemiology, United States
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Affiliation(s)
- Shilpi Chabra
- Divisions of Neonatology and
- Seattle Children's Hospital, Seattle, Washington
| | - Annika M Hofstetter
- General Pediatrics, Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington; and
- Seattle Children's Hospital, Seattle, Washington
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Abstract
After the introduction of the hepatitis B vaccine in the United States in 1982, a greater than 90% reduction in new infections was achieved. However, approximately 1000 new cases of perinatal hepatitis B infection are still identified annually in the United States. Prevention of perinatal hepatitis B relies on the proper and timely identification of infants born to mothers who are hepatitis B surface antigen positive and to mothers with unknown status to ensure administration of appropriate postexposure immunoprophylaxis with hepatitis B vaccine and immune globulin. To reduce the incidence of perinatal hepatitis B transmission further, the American Academy of Pediatrics endorses the recommendation of the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention that all newborn infants with a birth weight of greater than or equal to 2000 g receive hepatitis B vaccine by 24 hours of age.
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