Download 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?