Presentation on theme: "Perinatal Hepatitis B Prevention"— Presentation transcript:
1 Perinatal Hepatitis B Prevention The Essentials ofPerinatal Hepatitis B PreventionA Training Series for Coordinators and Case Managers
2 Session 1: Case Identification Dr. Susan WangMedical OfficerDivision of Viral HepatitisNational Center for HIV/AIDS, Viral Hepatitis, STD, and TB PreventionCenters for Disease Control and Prevention Atlanta, GA
3 Learning Objectives At the end of the session…. Describe key components of case identification in a perinatal hepatitis B prevention programmethods for improving identification of hepatitis B virus infected pregnant women and infants at risk
4 Natural History of Hepatitis B Virus (HBV) Infection Although substantial progress has been made in implementing hepatitis B vaccination programs, hepatitis B continues to be a major public health problem in the United States.In estimatedAccording to data from NHANES
5 Hepatitis B in the U.S.1 in 200 persons have chronic HBV infection (about 1.25 million)About 60,000 new infections in 2004 (200, ,000 annually before vaccination programs)4,000-5,000 deaths annually from hepatitis B-related chronic liver disease (cirrhosis, liver cancer)
6 Perinatal Hepatitis B in the U.S. About 24,000 infants were born to HBV-infected mothers in 2005Without immunoprophylaxis (vaccine and hepatitis B immune globulin [HBIG]):about 9,100 chronically infected with HBV (most asymptomatic)about 2,300 expected to die of chronic liver disease (cirrhosis or liver cancer)
7 Risk of Chronic HBV Infection Very dependent on age when infection is acquiredAmong infected children, symptomatic acute hepatitis B rare; likelihood of developing chronic infection high:Age atinfection<1 year1-5 years>5 yearsRisk ofacute HBV<1%5%-15%20%-50%Risk of chronic HBV90%25%-50%6%-10%
8 Modes of HBV Transmission in Infancy and Early Childhood Transmission from infected mother to neonate during deliveryTransmission from infected household contact to childBoth modes of transmission can be prevented by vaccination of newborns!How do we prevent HBV infections in infancy and early childhood?There are 2 major modes of HBV transmission in infancy and early childhood: vertical transmission from an infected mother to her infant and horizontal transmission from an infected household contact to the child. Importantly, both modes of transmission can be prevented by vaccination of newborns.Let us examine each of these modes of transmission more closely.
9 Maternal to Child HBV Transmission Percutaneous and permucosal exposure to mother’s blood during birthIn utero transmission rare: accounts for <2% of perinatal infectionsHBV not transmitted by breastfeedingVertical transmission of infection from mother to infant, generally occurs as a result of percutaneous and permucosal exposure to the mother’s infected blood during birth. In utero transmission of HBV is rare, accounting for <2% of all perinatal infections. Although HBV is found in low concentrations in breast milk, it has not been documented to be transmitted through breastfeeding.
10 Prevention of HBV Transmission Post-exposure prophylaxis is highly effective in preventing HBV transmission after exposure:when given within 24 hours of birth, hepatitis B vaccine and HBIG* is 85%-95% effectivehepatitis B vaccine alone at birth is 70%-95% effective*Hepatitis B Immune Globulin
11 Hepatitis B Vaccine: Two Purposes Administered at birth to an infant born to an HBV-infected mother, hepatitis B vaccine serves as post-exposure prophylaxisAdministered at birth to an infant born to an uninfected mother, hepatitis B vaccine serves as pre-exposure protection
12 Prenatal HBsAg* Testing All pregnant women should be tested during each pregnancybest in early pregnancywomen not tested prenatally should be tested at deliveryhigh risk women^ should be retested at delivery*Hepatitis B Surface Antigen^Women with >1 sex partner in past six months, evaluation/treatment forSTD, history of IDU, or HBsAg-positive sex partner
13 Perinatal Case Identification Delivering women tested for HBsAg at hospital (if not tested previously)Women tested for HBsAg prenatallyHBsAg+ test results reported to health departmentHealth department determines pregnancy status forreports of HBsAg+ womenPregnant women/infants identified for case management
14 Methods of Identification Laboratories report HBsAg+ results, pregnancy status is determinedPrenatal care providers report casesHBsAg+ women self reportHospitals report casesUniversal reporting mechanisms (birth certificate, newborn screening) detect cases retrospectively1st bullet: Health department determines the pregnancy status
15 Expected Births to HBsAg+ Women CDC calculates expected births to HBsAg+ women annually using NHANES* and vital statistics birth dataAbout 50% of the expected 24,000 infants are identified by health departments for case management annually*National Health and Nutrition Examination Survey
16 Identified vs Expected Births to HBsAg+ Women, U.S., 1993–2004 23,919Expected births19,04350%41%Identified birthsSource: National Center for Immunization and Respiratory Diseases, CDC
17 Gaps in Identification Laboratory reporting often only source used and incompleteOverwhelming volume of HBsAg test results to review for pregnancy statusSome pregnant women not tested or reported by providerswomen known to be HBsAg-positiveno prenatal care (~ 5%)Many hospitals do not report cases
18 Methods to Improve Identification Verify all laboratories are reporting all HBsAg-positive resultsReview by health department of all HBsAg-positive reportsMonitor to ensure delivery hospitals are testing and reportingEstablish universal reporting mechanismsRemind prenatal care providers to screen and report
19 Evaluate Laboratory Reporting Keep a list of laboratories that conduct HBsAg testingEnsure laboratories are regularly reporting cases to the health deptCollaborate with communicable disease program to conduct laboratory evaluations and measure:completeness of HBsAg reportingtimeliness of HBsAg reportingCan we talk about how to keep the list of labs—working with CD?
20 Prioritizing Laboratories to Evaluate Priority laboratories:labs serving high-morbidity areas or populationslabs reporting large volumes of hepatitis serologylabs serving prenatal clinicsdelivery hospital labsHow often?ideally, once/year for priority laboratoriesevery 2–3 years for other laboratoriesNot sure if you want the photo or not…More on laboratory evaluations in Session 3 of this series
21 Develop ProtocolsTo successfully identify cases, HBV prevention activities should be implemented by:perinatal programhealth departmentdelivery hospitalsuniversal reportingprenatal care providersDoes this photo work or not?
22 Perinatal Prevention Protocol Describes perinatal HBV prevention activities and outlines responsibilities of all parties:laboratories pediatriciansdelivery hospitals health departmentsprenatal care providersRequired by immunization grant to disseminate annually to partnersThe IPOM does refer to it as a “protocol for perinatal hepatitis B prevention”
23 Perinatal Prevention Protocol (cont’d) Examples available at CDC’s Perinatal Hepatitis B Coordinator website:hepatitis/resource/perinatalhepB.htm
24 Case Identification Protocols Health departments should have protocols in place to:review all HBsAg-positive reportsidentify results for all women of childbearing agedetermine pregnancy status of those womenreview reports in a timely manner
25 Delivery Hospital Policies Hospitals should have policies and practices to test unknown status or high risk women for HBsAg at deliveryHospital laboratories, obstetrics, and nurseries have policies to report HBsAg+ delivering womenMore info on working with delivery hospitals will be presented in sessions 3 and 4…Health department shouldmonitor these activitiesMore on delivery hospital evaluations in Session 4 of this series
26 Universal Reporting Mechanisms Include maternal HBsAg status on:electronic birth certificate (EBC) ornewborn metabolic screening (NBS) cardGain access to these data on a regular basis to identify cases retrospectivelyWork with Vital Statistics to educate hospital staff on properly completing EBC forms and with Newborn Screening staff to properly complete NBS forms
27 Prenatal Care Provider Practice Screen all pregnant women for HBsAgReport HBsAg-positive pregnant womenHealth department should monitorthat providers report
28 For More DetailChapter 1 of CDC’s Managing a Perinatal Hepatitis B Prevention Program: Guide to Life as a Program Coordinatorhepatitis/resource/perinatalhepB.htm