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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

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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]

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SCOTTISH NATIONAL GUIDANCE Scottish Governments 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]

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SCOTTISH NATIONAL GUIDANCE Scottish Governments 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]

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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]

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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 5- 10% 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]

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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]

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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

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SETTING NHS Lothian two maternity units

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METHODS

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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

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RESULTS YEAR 1 Number of doses of hepatitis b vaccine administered to babies born to problem drug users (2012-2013) Doses of Hepatitis B Vaccine Number of babies vaccinated Percentage of babies vaccinated 000% 147% 212% 31628% 43663% TOTAL57100%

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RESULTS COMPARED TO HEPATITIS B

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REPEATED AUDIT Number of doses of hepatitis b vaccine administered to babies born to problem drug users (2012-2013) Doses of Hepatitis B Vaccine Number of babies vaccinated Percentage of babies vaccinated 000% 147% 200% 3916% 44477% TOTAL57100%

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REPEAT COMPARED

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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

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LIMITATIONS Data limited We dont know how many drug users we should have We dont 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

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DISCUSSION Is 62% good? Is it good enough? What is the target? What have others said/done? Should it be part of UK schedule?

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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

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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

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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

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ACKNOWLEDGEMENTS: Co-authors: Dr Christine Evans Peter Harrison Hilda Stiven NHS Lothian: Viral Hepatitis MCN Health Protection Team Jim Sherval Dona Milne NHS Dumfries & Galloway: Michele McCoy Department of Public Health

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ANY QUESTIONS?