RISK R isk of Perinatal and Early Childhood Infection Incidence and Consequences of Hepatitis B Infection Significance of Quality Assurance Key Elements of the Illinois Perinatal Hepatitis B Prevention Program

Hepatitis B Virus Modes of Transmission Infected Blood Child - Household Contact Percutaneous Exposure Sexual Transmission

Concentration of Hepatitis B Virus in Various Body Fluids

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

Typical Serologic Course Progression to Chronic Hepatitis B Virus Infection Typical Serologic Course Acute (6 months) Chronic (Years) HBeAg anti-HBe HBsAg Total anti-HBc Titer IgM anti-HBc 4 8 12 16 20 24 28 32 36 52 Years Weeks after Exposure

Age at Aquisition of Acute and Chronic HBV Infection United States, 1989 Estimates (4% ) Perinatal (24%) (4%) Children (12%) (1-10 yrs) (8%) Adolescent (6%) Adult (59%) Adult (83%) Acute HBV Infections Chronic HBV Infections

Outcome of Hepatitis B Virus Infection by Age at Infection 100 100 80 80 60 60 Chronic Infection (%) Chronic Infection Symptomatic Infection (%) 40 40 20 20 Symptomatic Infection Birth 1-6 months 7-12 months 1-4 years Older Children and Adults Age at Infection

Burden of Disease From Viral Hepatitis B in the United States 5 % lifetime risk of infection 130,000 acute infections annually 1.25 million persons with chronic infection 4,000 to 5,000 deaths per year due to chronic liver disease

Strategy to Eliminate HBV Transmission in Illinois Prevention of Perinatal Transmission Routine Vaccination of all Newborns Catch-up Vaccination of High Risk Children Vaccination of all children and adolescents 0-18 years (especially those 11-12 years) Vaccination of High Risk Adults

Significance of Quality Assurance 1. 40% to 50% of the children born to hepatitis B positive women become infected with the hepatitis B virus. 2. 85% to 90% of those children become chronically infected. 3. 25% of those carriers die from cirrhosis or hepatocellular carcinoma. 4. Household and sexual contacts of these women are at risk. Without appropriate intervention using hepatitis B immune globulin and vaccination,

Significance of Quality Assurance Cont. The U.S. Centers for Disease Control and Prevention estimates that there are a minimum of 905 births to hepatitis B positive women in Illinois each year. However, in 1996, only 146 infants were identified.

IDPH Reporting Guidelines Local health departments should submit an initial and then an updated copy of the reporting form for each case to the IDPH regional immunization staff person in their region 30 days after ---

IDPH Reporting Guidelines Cont. Receipt of a hepatitis B positive report of a pregnant woman An infant completes the three-dose series of hepatitis B vaccine and post-vaccination testing

IDPH Reporting Guidelines Cont. An infant moves out of the local health department’s jurisdiction or is otherwise lost to follow-up Household contacts complete the three-dose series of hepatitis B vaccine, or become non-compliant or are lost to follow-up.

The Purpose of this Perinatal Investigation is - To identify and immunize potentially susceptible close contacts To provide prophylaxis for the infant To meet state regulation by reporting to the Illinois Department of Public Health

The Purpose of this Perinatal Investigation is--- Cont. To follow recommendations by the CDC Advisory Committee on Immunization Practices (ACIP) contained in “Hepatitis B Virus: A Comprehensive Strategy for Eliminating Transmission in the United States Through Universal Childhood Vaccination” (MMWR, Nov . 22, 1991, Vol. 40, No. RR-13)

IDPH Rules and Regulations Screening of all pregnant women for hepatitis B surface antigen is a requirement by the Illinois Department of Public Health’s rules and regulations for the control of communicable diseases.

IDPH Rules and Regulations Cont. This requirement is endorsed by the- American Academy of Family Physicians American Academy of Pediatrics American College of Obstetricians and Gynecologists U.S. Centers for Disease Control and Prevention Advisory Committee on Immunization Practices

Hospital Policy Wash Baby Administer HBIG within 12 hours of birth Administer hepatitis B vaccine within 12 hours of birth. Administer the second dose of hepatitis B vaccine one month after first dose.

Hospital Policy Cont. Administer the third dose of hepatitis B vaccine six months after the first dose. Conduct serological post vaccination testing of infants at 9 to 15 months for presence of antibodies to the virus.

Hospital Procedure Mark the Illinois neonatal screening form indicating maternal “hepatitis B results.” Document maternal hepatitis B positive status in nursery log. Record date, time and dose of HBIG administered. Record date, time, dose and manufacturer of Hep B-1 vaccine.

Hospital Procedure Cont. Record hepatitis B status on discharge summary/newborn referral form. Provide parents with vaccination information and remind them of the importance of complying with vaccination schedule. Provide parents with an immunization record card.

Hospital Procedure Cont. Communicate maternal hepatitis B status and treatment of infant to infection control nurse in hospital, pediatric provider and local health department (Discharge summary sheet should be sent to the child’s pediatrician.)

Key Elements of the Illinois Perinatal Program Hepatitis B surface antigen screening of all pregnant women Identification and reporting of hepatitis B positive women Immunoprophylaxis of newborns at birth (HBIG and vaccine)

Key Elements of the Illinois Perinatal Program - Cont. Tracking of infants to ensure -- Vaccination by 6 months of age Post-vaccination serological testing Identification, screening and vaccination of household contacts