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Rita Espinoza, MPH Emerging and Acute Infectious Disease Branch May 11, 2010 Screening of Pregnant Women for Hepatitis B and Overview of Hepatitis B Virus.

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Presentation on theme: "Rita Espinoza, MPH Emerging and Acute Infectious Disease Branch May 11, 2010 Screening of Pregnant Women for Hepatitis B and Overview of Hepatitis B Virus."— Presentation transcript:

1 Rita Espinoza, MPH Emerging and Acute Infectious Disease Branch May 11, 2010 Screening of Pregnant Women for Hepatitis B and Overview of Hepatitis B Virus Serological Markers

2 Objectives Review screening requirements for pregnant women in Texas Review serological markers for hepatitis B virus infections

3 Outline Historical perspective/rationale Screening requirements in Texas Serologic markers –Importance of serologic markers –Review serologic markers Acute infection Chronic infection Case Studies

4 Background Information 1991 hepatitis B screening of pregnant women recommended by ACOG, AAP, ACIP Risk of perinatal transmission –HBsAg and HBeAg + at delivery % –HBsAg + only 5-20% 90% of infants infected perinatally will become chronic carriers of hepatitis B 25% of those infected will die of HBV- related disease

5 Strategies to Reduce HBV Disease Continue and enhance vaccination efforts –School and childcare requirements –HCW –Adults (20-44 years) –Birth dose Surveillance Early detection Education Perinatal hepatitis B prevention program

6 Texas Rules Health & Safety Code, Chapter 81, Section § Texas Administrative Code, Title 25, Part 1, Chapter 97 –Subchapter A, Rule §97.1 – §97.6 –Subchapter F, Rule §97.135

7 Screening Requirements in Texas – Health and Safety Code, Chapter 81, Section § Sec DIAGNOSTIC TESTING DURING PREGNANCY AND AFTER BIRTH. (a) A physician or other person permitted by law to attend a pregnant woman during gestation or at delivery of an infant shall: (1) take or cause to be taken a sample of the woman's blood or other appropriate specimen at the first examination and visit; (2) submit the sample to an appropriately certified laboratory for diagnostic testing approved by the United States Food and Drug Administration for: (A) syphilis; (B) HIV infection; and (C) hepatitis B infection; and (3) retain a report of each case for nine months and deliver the report to any successor in the case.

8 Screening Requirements in Texas – Health and Safety Code, Chapter 81, Section §81.090, (contd) (a-1) A physician or other person permitted by law to attend a pregnant woman during gestation or at delivery of an infant shall: (1) take or cause to be taken a sample of the woman's blood or other appropriate specimen at an examination in the third trimester of the pregnancy; (2) submit the sample to an appropriately certified laboratory for a diagnostic test approved by the United States Food and Drug Administration for HIV infection; and (3) retain a report of each case for nine months and deliver the report to any successor in the case. (b) A successor is presumed to have complied with this section if the successor in good faith obtains a record that indicates compliance with Subsections (a) and (a-1), if applicable.

9 Screening Requirements in Texas – Health and Safety Code, Chapter 81, Section §81.090, (contd) (c) A physician or other person in attendance at a delivery shall: (1) take or cause to be taken a sample of blood or other appropriate specimen from the mother on admission for delivery; and (2) submit the sample to an appropriately certified laboratory for diagnostic testing approved by the United States Food and Drug Administration for: (A) syphilis; and (B) hepatitis B infection.

10 Summary of Requirement Women should be tested –during pregnancy And –At delivery Women should be educated on –Transmission –Prevention –Treatment

11 Serological Markers

12 Possible Outcomes of Hepatitis B Infection

13 Clinical Manifestations of HBV Infection S/SX not unique to HBV infection Only 50% of adult infections are symptomatic Need diagnostic tests to distinguish Incubation period - 45 to 180 days (average = days) Communicability – 1 to 2 months before and after onset of symptoms; chronic carrier

14 Hepatitis B Lab Markers MarkerAbbreviationUse Hepatitis B surface antigenHBsAgDetection of acutely or chronically infected persons; antigen used in hepatitis B vaccine M class immunoglobulin antibody to hepatitis B core antigen IgM Anti-HBc Anti-HBc, IgM HBcAb, IgM Identification of acute or recent HBV infections (including those in HBsAg-negative persons during the window phase of infection) Antibody to hepatitis B core antigen Anti-HBc HBcAb Identification of persons with acute, resolved, or chronic HBV infection (not present after vaccination) Antibody to Hepatitis B surface antibody Anti-HBs HBsAb Identification of persons who have resolved infection with HBV; determination of immunity after immunization Hepatitis B e antigenHBeAgIdentification of infected persons at increased risk for transmitting HBV Antibody to Hepatitis B e antigen Anti-HBe HBeAb Identification of infected person with lower risk for transmitting HBV

15 Typical Serological Markers for Acute Hepatitis B Infection

16 HBsAg Acute Hepatitis B Virus Infection with Recovery Typical Serologic Course Weeks after Exposure Titer

17 HBsAg Acute Hepatitis B Virus Infection with Recovery Typical Serologic Course Weeks after Exposure Titer HBV DNA

18 HBsAg Acute Hepatitis B Virus Infection with Recovery Typical Serologic Course Weeks after Exposure Titer HBV DNA HBeAg

19 HBsAg Acute Hepatitis B Virus Infection with Recovery Typical Serologic Course Weeks after Exposure Titer HBeAganti-HBe HBV DNA

20 HBsAg Acute Hepatitis B Virus Infection with Recovery Typical Serologic Course Weeks after Exposure Titer HBeAganti-HBe Symptoms HBV DNA

21 IgM anti-HBc HBsAg Acute Hepatitis B Virus Infection with Recovery Typical Serologic Course Weeks after Exposure Titer HBeAganti-HBe Symptoms HBV DNA

22 IgM anti-HBc HBsAg Acute Hepatitis B Virus Infection with Recovery Typical Serologic Course Weeks after Exposure Titer HBeAganti-HBe Symptoms Total anti-HBc HBV DNA

23 IgM anti-HBc HBsAg Acute Hepatitis B Virus Infection with Recovery Typical Serologic Course Weeks after Exposure Titer HBeAganti-HBe Symptomsanti-HBs Total anti-HBc HBV DNA

24 IgM anti-HBc HBsAg Acute Hepatitis B Virus Infection with Recovery Typical Serologic Course Weeks after Exposure Titer HBeAganti-HBe Symptomsanti-HBs Total anti-HBc HBV DNA Window Period

25 Typical Serological Markers for Chronic Hepatitis B Infection

26 Typical Serologic Course Chronic Hepatitis B Virus Infection Typical Serologic Course HBsAg

27 Total anti-HBc Typical Serologic Course Chronic Hepatitis B Virus Infection Typical Serologic Course

28 HBsAg Total anti-HBc HBV DNA Typical Serologic Course Chronic Hepatitis B Virus Infection Typical Serologic Course

29 HBsAg Total anti-HBc HBV DNA IgM, anti-HBc Typical Serologic Course Chronic Hepatitis B Virus Infection Typical Serologic Course

30 HBsAg Total anti-HBc HBV DNA HBeAg Typical Serologic Course Chronic Hepatitis B Virus Infection Typical Serologic Course

31 HBsAg Total anti-HBc HBV DNA HBeAgAnti-HBe Typical Serologic Course Chronic Hepatitis B Virus Infection Typical Serologic Course

32

33 Acute vs. Chronic HBV Infection Acute HBsAg+ < 6 mos. IgM anti-HBc + positive Infection will resolve and person will have lifelong immunity HBsAb+ and HBcAb+ Chronic HBsAg + for at least 6 months Also known as a carrier Infection does not resolve and the person remains infectious HBsAb- and HBcAB+

34 Hepatitis B, acute Surveillance Case Definition Confirmed: –Positive anti-HBc, IgM with or without symptoms or –Meets clinical case definition and is HBsAg-positive and anti-HAV IgM negative, if done

35 Hepatitis B, perinatal Surveillance Case Definition Confirmed: –HBsAg-positive –< 24 months of age –Born to an HBsAg-positive woman

36 Hepatitis B, chronic Surveillance Case Definition Confirmed: case that is laboratory- confirmed (2 positives 6 months apart or HBsAg+, anti-HBc+, and IgM-) Probable: case with a single HBsAg or HBeAg or HBV DNA positive lab when no IgM anti-HBc results are available

37 CASE STUDIES

38 Case Study A

39 Patient History: John went to his doctor with jaundice, fatigue and abdominal pain. After reviewing Johns liver panel, the doctor diagnosed him with acute hepatitis B infection.

40 Question 1 What might his hepatitis B panel look like?

41 Answer MarkerResult HBsAgPositive HBeAgPositive anti-HBcPositive IgM anti-HBcPositive anti-HBeAgNegative anti-HBsNegative

42 Case Study B

43 Sara visits his doctor and has a hepatitis panel done. Her results are as follows: HBsAgPositive anti-HBcPositive IgM anti-HBcNegative anti-HBs6mIU/mL

44 Question 1 How would you interpret Saras results?

45 Answer Chronic hepatitis B infection

46 Question 2 What significance is the anti-HBs?

47 Answer No biological significance

48 Case Study C

49 Jada went to her doctor for a routine physical. A hepatitis panel was done and her results were as follows: HBsAg Negative anti-HBsPositive anti-HBcNegative

50 Question 1 How would you interpret her results?

51 Answer She received the hepatitis B vaccine and is protected (immune)

52 Case Study D

53 Jeff went in for a routine annual physical. His doctor decided to run a hepatitis panel. His results are as follows: HBsAgPositive anti-HBsNegative anti-HBcPositive anti-HBc, IgMPositive HBeAgPositive

54 Question 1 How would you interpret his results?

55 Answer He has acute hepatitis B infection.

56 Case Study E

57 Stacy is pregnant. Her prenatal HBsAg test was negative. Upon admission for delivery, the HBsAg screen was repeated. The results came back positive.

58 Scenario 1: Stacy insisted that there was no way she could have contracted hepatitis B. she had not engaged in any high-risk activities. The doctor decided to repeat the test.

59 Question 1 What tests should be ordered?

60 Answer HBsAg anti-HBc anti-HBc, IgM anti-HBs

61 Her results were as follows: HBsAg Negative anti-HBsNegative anti-HBcNegative anti-HBc, IgMNegative How would you interpret?

62 Answer False positive

63 Scenario 2: Stacys baby received the HBIG and hepatitis B vaccine at birth. The family is enrolled in the local perinatal hepatitis B prevention program. Three months post- partum, Stacys physician decides to re- test her. Her results are as follows: HBsAgNegative anti-HBcPositive anti-HBsPositive

64 Question 2 What do the results indicate?

65 Answer Resolved Infection

66 TestResultsInterpretation HBsAg anti-HBc anti-HBs Negative Susceptible (Never infected or vaccinated) HBsAg anti-HBc anti-HBs Negative Positive Immune (Due to vaccine) HBsAg anti-HBc anti-HBs Negative Positive Immune (Resolved Infection) HBsAg anti-HBc IgM anti-HBc anti-HBs Positive Negative Acutely Infected HBsAg anti-HBc anti-HBs IgM anti-HBc Positive Negative Chronically Infected HBsAg anti-HBc anti-HBs Negative Positive Negative Four Possible Interpretations Interpretation of Serological Tests

67 Four Possible Interpretations May be recovering from acute HBV infection May be distantly immune and test not sensitive enough to detect very low level of anti-HBs in serum May be susceptible with a false positive anti- HBc May be undetectable level of HBsAg present in the serum and the person is actually a carrier

68 Summary Pregnant women should be screened during pregnancy and at delivery –Eliminate perinatal transmission –Documentation necessary Determination of hepatitis status is complicated

69 Resources American Academy of Pediatrics Red Book – American Academy of Pediatrics (www.aap.org) DSHS CDC –Pink Book –On-line CE Training From CDC on Serological Markers –Online resources Immunization Action Coalition


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