2026 Bull’s-Eye Award Winner Mississippi: The First Breath Initiative: Strengthening Maternal Screening to Protect MS Newborns

Strategy

The Perinatal Hepatitis B staff, housed within the Mississippi State Department of Health (MSDH) Immunizations Office, works in partnership with providers at 36 birthing hospitals to improve prevention of mother-to-child transmission (MTCT) of the hepatitis B virus (HBV) through the identification of hepatitis B surface antigen (HBsAg) positive pregnant women and in the case management of their infants through “The First Breath Initiative.” The goal of this initiative is to reduce perinatal risk through optimized testing, education, and coordinated care.

Challenge

The universal screening of pregnant women for HBV infection is the standard of care, and in many states, is supported by laws for screening and reporting these infections to public health agencies. In Mississippi, Hepatitis B in pregnancy is a Class 2 reportable condition that must be reported to MSDH within one week of diagnosis. This includes HBsAg-positive results in pregnancy.

While an estimated 95% of pregnant women (nationally) receive HBsAg testing, fewer than half of the expected births to HBsAg-positive women are identified. Since Mississippi is no stranger to this statistic, MSDH Immunizations Perinatal Hepatitis B Prevention Program (PHBPP) staff decided to investigate further seeking to identify potential contributing factors to under-reporting in the state.

In 2024, MSDH PHBPP received cases of infant HBV positivity to mothers that tested HBsAg-negative during the first trimester of pregnancy. These mothers were not screened again prior to delivery. On average, HBsAg results may be obtained within birthing centers in 40 minutes to 2 hours.

Solution

Public health policy has steadily been moving away from risk-based screening (only testing people who self-report high-risk behaviors) and towards universal screening during pregnancy. As was the case in Mississippi, risk-based screening notoriously misses cases because patients may not know their exposure risk or may be afraid to discuss it. With Mississippi ranking 50th in the U.S. for infant mortality rates at 9.65/1,000, “The First Breath Initiative” aligns with MSDH’s goal of constructing a unique system of care for high-risk pregnant women and their babies throughout our state to improve infant mortality rates.

The trend that was identified in the state dealt specifically with HBsAg screening. The universal HBV screening for HBsAg is recommended for all pregnant women during each pregnancy, preferably in the first trimester, regardless of vaccination status or history of testing. However, what the research uncovered was that while mothers were being screened in advance, they were not being re-screened for HBsAg upon admission for delivery. Between September 2024 to September 2025, birthing hospital visits were conducted that included meetings with hospital administrators, nurse managers, and other labor and delivery staff where staff inquired about the consideration to implement HBsAg re-checks upon labor and delivery admission.

Once it was determined that a mandate for such re-checks would be supported, staff drafted a public health policy brief in and shared it with MSDH leadership. In December 2025, the policy brief was shared through the Mississippi Health Alert Network (MS-HAN) statewide. Staff followed up in January 2026 by sending direct correspondence to all birthing hospitals about the HAN and how to access the HAN if they were not already familiar.

Staff scheduled all birthing hospital site visits for 2026 to take place between January and June. They used these visits to enhance provider education and clinical tracking mechanisms to ensure that updated prenatal screening data directly informs immediate post-birth preventative care for infants exposed to Hepatitis B. This also included addressing health care provider workflow concerns, lab coordination issues, and the immediate clinical steps taken at birth (i.e., timely administration of Hep B vaccine and HBIG).

While the new processes were being implemented in some birthing hospitals without issue, MSDH assisted others in the development of a strategy to improve efficiency/timeliness of lab reporting to avoid missed opportunities for PEP. Staff worked with MSDH’s communications team to create and print two “pocket guides” for use by OB/GYNs and birthing hospitals as educational materials and a quick reference guide for “next steps” on confirmation of a pregnant patient’s positive hepatitis B test results. Staff implemented a new digital reporting form, using SmartSheet, that is required from all birthing hospital L&D units monthly and received/reviewed by the PHBPP coordinator. Staff have since been asked to share that form with other jurisdictions through their participation in the CDC PHBPP work group over the past several months.

Outcome

Roughly 90% of birthing hospitals had successfully implemented the new practice(s) by April 2026. Staff plan to utilize the summer and fall months for remedial visits to check that they are following the new testing requirements and assist where needed. The goal is to begin auditing for the implemented screening requirements during 2027 site visits. While it is too soon to tell the full impact of the practice, preliminary data for 2026 shows an increase in identification of infants born to HBsAg+ mothers over the past two years. Mississippi hopes to see that number continue to rise along with the number of infants who receive PEP within the first 12-24 hours of birth.

The First Breath Initiative has transformed beyond just PHBPP testing and case management to become an effort to strengthen maternal screening and protect all Mississippi newborns. MSDH work groups have been established to bring key stakeholders to the table for a “call to action” of the medical community to pivot from older, risk-based screening models to a new statewide clinical standard, driving early detection and coordinated care. The potential for replication by other programs is high and the cost is minimal.

Supplemental Materials