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Emerging and Acute Infectious Disease Branch

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Presentation on theme: "Emerging and Acute Infectious Disease Branch"— Presentation transcript:

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

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 §81.090
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 §81.090
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, (cont’d)
(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, (cont’d)
(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
Abbreviation Use Hepatitis B surface antigen HBsAg Detection 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 antigen HBeAg Identification 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 Read each marker. A chronic carrier is defined as someone whose HBsAg is positive for at least 6 months. Now let’s look at the interpretation of serological tests.

15 Typical Serological Markers for Acute Hepatitis B Infection

16 Acute Hepatitis B Virus Infection with Recovery
Typical Serologic Course Titer HBsAg 4 8 12 16 20 24 28 32 36 52 100 Weeks after Exposure 30

17 Acute Hepatitis B Virus Infection with Recovery
Typical Serologic Course Titer HBV DNA HBsAg 4 8 12 16 20 24 28 32 36 52 100 Weeks after Exposure 30

18 Acute Hepatitis B Virus Infection with Recovery
Typical Serologic Course HBeAg Titer HBV DNA HBsAg 4 8 12 16 20 24 28 32 36 52 100 Weeks after Exposure 30

19 Acute Hepatitis B Virus Infection with Recovery
Typical Serologic Course HBeAg anti-HBe Titer HBV DNA HBsAg 4 8 12 16 20 24 28 32 36 52 100 Weeks after Exposure 30

20 Acute Hepatitis B Virus Infection with Recovery
Typical Serologic Course Symptoms HBeAg anti-HBe Titer HBV DNA HBsAg 4 8 12 16 20 24 28 32 36 52 100 Weeks after Exposure 30

21 Acute Hepatitis B Virus Infection with Recovery
Typical Serologic Course Symptoms HBeAg anti-HBe Titer IgM anti-HBc HBV DNA HBsAg 4 8 12 16 20 24 28 32 36 52 100 Weeks after Exposure 30

22 Acute Hepatitis B Virus Infection with Recovery
Typical Serologic Course Symptoms HBeAg anti-HBe Total anti-HBc Titer IgM anti-HBc HBV DNA HBsAg 4 8 12 16 20 24 28 32 36 52 100 Weeks after Exposure 30

23 Acute Hepatitis B Virus Infection with Recovery
Typical Serologic Course Symptoms HBeAg anti-HBe Total anti-HBc Titer IgM anti-HBc HBV DNA anti-HBs HBsAg 4 8 12 16 20 24 28 32 36 52 100 Weeks after Exposure 30

24 Acute Hepatitis B Virus Infection with Recovery
Typical Serologic Course Symptoms HBeAg anti-HBe Total anti-HBc Titer IgM anti-HBc HBV DNA anti-HBs HBsAg Window Period 4 8 12 16 20 24 28 32 36 52 100 Weeks after Exposure 30

25 Typical Serological Markers for Chronic Hepatitis B Infection

26 Chronic Hepatitis B Virus Infection Typical Serologic Course
HBsAg

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

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

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

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

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

32

33 Acute vs. Chronic HBV Infection
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 John’s liver panel, the doctor diagnosed him with acute hepatitis B infection.

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

41 Answer Marker Result HBsAg Positive HBeAg anti-HBc IgM anti-HBc
anti-HBeAg Negative anti-HBs

42 Case Study B

43 Sara visits his doctor and has a hepatitis panel done
Sara visits his doctor and has a hepatitis panel done. Her results are as follows: HBsAg Positive anti-HBc Positive IgM anti-HBc Negative anti-HBs 6mIU/mL

44 How would you interpret Sara’s results?
Question 1 How would you interpret Sara’s 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
Jada went to her doctor for a routine physical. A hepatitis panel was done and her results were as follows: HBsAg Negative anti-HBs Positive anti-HBc Negative

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
Jeff went in for a routine annual physical. His doctor decided to run a hepatitis panel. His results are as follows: HBsAg Positive anti-HBs Negative anti-HBc Positive anti-HBc, IgM Positive HBeAg Positive

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
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-HBs Negative anti-HBc Negative anti-HBc, IgM Negative How would you interpret?

62 Answer False positive

63 Scenario 2: Stacy’s 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, Stacy’s physician decides to re- test her. Her results are as follows: HBsAg Negative anti-HBc Positive anti-HBs Positive

64 Question 2 What do the results indicate?

65 Answer Resolved Infection

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

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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