Learning Objectives for this Presentation:
By the end of the presentation participants will:
Understand how errors are made putting infants at risk for hepatitis B infection
Understand the importance of administering a hepatitis B birth dose


Background:
Although 90 percent of perinatal hepatitis B virus infections can be prevented by appropriate prophylactic treatment, many newborns don't receive such prophylaxis. Infants who become infected have a 90 percent chance of developing chronic hepatitis B infection.


Setting:
Birthing hospitals


Population:
Infants born in upstate New York


Project Description:
New York State has a law mandating hepatitis B surface antigen (HBsAg) testing of all pregnant women and treatment of infants born to positive HBsAg women. Compliance with the law is monitored through routine visits to birthing hospitals to conduct record reviews and provide education to hospital staff. Despite these efforts, medical errors continue to be made that put infants at risk for infection. Six cases were reported during 2005 from different birthing hospitals in upstate New York.


Results/Lessons Learned:
The six cases illustrate a variety of medical errors that led to high-risk infants not receiving the recommended hepatitis B prophylaxis within 12 hours of birth. These errors serve to underscore the importance of administering the first dose of hepatitis B vaccine at birth. To better protect newborns against hepatitis B infection, the New York State Department of Health Immunization Program provides free state-funded hepatitis B vaccine, free of charge, to any birthing hospital that institutes a universal hepatitis B birth dose policy.