How good are we at reducing the risk? An Audit of
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Transcript How good are we at reducing the risk? An Audit of
HOW GOOD ARE WE AT
REDUCING THE RISK?
AN AUDIT OF HEPATITIS B
VACCINATION IN BABIES
BORN TO DRUG USING
FAMILIES
Josie Murray
Specialty Registrar in Public Health
NHS Dumfries & Galloway
Co Authors: Christine Evans, Peter Harrison, Hilda Stiven,
Public Health and Health Policy, NHS Lothian
HEPATITIS B
Mortality Rates from liver disease in the UK are rising
Hepatitis accounts for approx. 25% of all liver disease cases
Hepatitis B is a major cause of hepatitis
Whilst hospital mortality rates of HBV are low currently,
they are predicted to rise significantly
Childhood infections account for 21% of HBV [1]
SCOTTISH NATIONAL GUIDANCE
Scottish Government’s Sexual Health & BBV
Framework 2011-2015:
‘NHS Board vaccination plans should … reflect, promote and
support the responsibilities of local community partners,
including GPs, in offering hepatitis B vaccination for clinical
reasons, to those at risk of infection in line with immunisation
policy (Department of Health,2006) and national and local
best practice guidance;’ [2]
SCOTTISH NATIONAL GUIDANCE
Scottish Government’s Sexual Health & BBV
Framework 2011-2015:
‘work should be done to increase the proportion of babies
born to hepatitis B infected mothers, or to mothers who
are otherwise identified as being at risk of infection, that
receive a full course of vaccine in line with national
immunisation policy (Department of Health, 2006) and
national best practice guidance for neonatal immunisation
(Department of Health, 2011);’ [2]
DEPARTMENT OF HEALTH GUIDANCE
‘the provision of a targeted infant immunisation programme
has been supported by Department of Health policy since
2000.’
However is not mandatory
Highlights that the responsibility for administering the 4
doses of vaccination to at risk babies should lie with a
named person
Notes that local protocols should be developed [1]
NHS LOTHIAN PROTOCOL
Drug users are at risk of acquiring hepatitis B due to
sharing of injecting equipment and through sexual spread.
Children of problem drug users are susceptible because
they live in a high risk environment.
Children infected with Hepatitis B have a higher risk of
developing chronic infection than adults (around 90% vs 510% in adults).
Targeting babies at birth offers a systematic way of
addressing this issue and reducing the risk of avoidable
harm and premature death. [3]
THE GREEN BOOK SCHEDULE
Hepatitis B vaccination for newborns
Birth, 1 month, 2 months & 12 months
This should result in slightly reduced immunogenicity
However, increases likely compliance when compared to the 0, 1
and 6 months [4]
THE DATABASE
Started in 2012
Records information on all babies born to drug using
families
Demographics
Mothers & children
Vaccination date
Hospital of birth
Date of notification to HPT
Date when HPT notified SIRS
Number of doses received
SETTING
NHS Lothian – two maternity units
METHODS
METHODS
Used database
Updates using SIRS and phoned GPs when SIRS not
complete
Counted number of vaccines given
Compared these to
Number of vaccines expected to be given for age
Previous years figures
Babies with Hep B positive mums
Repeated audit
RESULTS YEAR 1
Number of doses of hepatitis b vaccine administered to babies born to
problem drug users (2012-2013)
Number of babies
Doses of Hepatitis B Vaccine vaccinated
0
1
2
3
4
TOTAL
Percentage of babies
vaccinated
0
4
1
16
36
57
0%
7%
2%
28%
63%
100%
Percentage of HBV vaccinated babies born to drug using
mothers appropriate for age by year June 2012- May 2014
70%
Babies vaccinated by %
60%
50%
40%
30%
63%
61%
2012-2013
2013-2014
20%
10%
0%
Year (June to May)
RESULTS COMPARED TO HEPATITIS B
Percentage of age appropriately HBV vaccinated babies
born from June 2012 to May 2014 by parents eligibility
category
Percentage of babies vaccinated
100%
90%
80%
70%
60%
50%
95%
40%
Hep B Mums
77%
63%
30%
61%
20%
10%
0%
2012-2013
2013-2014
Year of birth
Drug User parents
REPEATED AUDIT
Number of doses of hepatitis b vaccine administered to babies born to
problem drug users (2012-2013)
Doses of Hepatitis B
Number of babies
Percentage of babies
Vaccine
vaccinated
vaccinated
0
0
0%
1
4
7%
2
0
0%
3
9
16%
4
44
77%
TOTAL
57
100%
REPEAT COMPARED
Percentage of babies vaccinated by date of audit
100%
Percentage of babies vaccinated
90%
80%
70%
60%
50%
30th June 2014
40%
30%
77%
73%
63%
61%
20%
10%
0%
2012-2013
2013-2014
Year
31st October 2014
STRENGTHS
This is the first audit of the uptake of HBV vaccinations in
babies born to problem drug users in NHS Lothian
Therefore a benchmark has been set
It demonstrates improvement over time
And success of increased collaboration & communication
It highlights inequity in vaccination for a specific vulnerable
group who are difficult to serve
LIMITATIONS
Data limited
We don’t know how many drug users we should have
We don’t know how many drug users babies there are
Our sample is not representative
Therefore we cannot make valid inferences about this data
Definitions have made this difficult
Not people who inject, but problem drug use
The protocol states ‘parents’ but majority of data is for mothers
Accuracy of disclosure at booking is questionable
Small numbers
DISCUSSION
Is 62% good?
Is it good enough?
What is the target?
What have others said/done?
Should it be part of UK schedule?
NATIONAL STATISTICS
Maternities & Births recording drug misuse[5]
In Lothian from 10/11-12/13 (three year aggregate) 101 births recorded
maternal drug misuse (3.6 per 1000 live births)
Estimate of babies born to current injectors [5,6]
ISD reports an average 34 maternities (Lothian) recording drug misuse p.a.
Estimate 55% injection rate = 19 PWID mothers
Estimate 2.49:1 ratio of drug using males to females nationally.
Fathers:Mothers= 48:19 (assuming all PWID mothers, father is also)
Total estimate = 48 neonates per year
THE WAY FORWARD
More accurate data
More published work on the topic
To continue to raise awareness of the local protocol
To increase support the dedicated services who already
engage with these groups
To promote the serious risk of Hepatitis B at all levels but
especially in those most vulnerable groups
REFERENCES
[1] Department of Health (2011) Hepatitis B antenatal screening &
immunisation programme. Best practice guidance
[2] Scottish Government (2011) the Sexual Health and BBV Framework
[3] NHS Lothian (update 2014) Pre-exposure Hepatitis B immunisation
for babies born to problem drug using parents
[4] Public Health England (2013) The Green Book Ch18 Hepatitis B
[5] ISD (2012) Drug Misuse Statistics Scotland 2011. Publication Date -
28 February 2012
[6] ISD(2011) Estimating the National and Local Prevalence of Problem
Drug Use in Scotland 2009/10. Publication date - 29th November 2011
ACKNOWLEDGEMENTS:
Co-authors:
NHS Lothian:
Dr Christine Evans
Viral Hepatitis MCN
Peter Harrison
Health Protection Team
Hilda Stiven
Jim Sherval
Dona Milne
NHS Dumfries & Galloway:
Michele McCoy
Department of Public Health
ANY QUESTIONS?