1. Perinatal Hepatitis B Prevention
The Essentials of
Perinatal Hepatitis B Prevention
A Training Series for Coordinators and Case Managers

2. Session 1: Case Identification
Dr. Susan Wang
Medical Officer
Division of Viral Hepatitis
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Centers 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 program
methods 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 estimated
According 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 2005
Without 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 acquired
Among infected children, symptomatic acute hepatitis B rare; likelihood of developing chronic infection high:
Age at
infection
<1 year
1-5 years
>5 years
Risk of
acute HBV
<1%
5%-15%
20%-50%
Risk of chronic HBV
90%
25%-50%
6%-10%

8. Modes of HBV Transmission in Infancy and Early Childhood
Transmission from infected mother to neonate during delivery
Transmission from infected household contact to child
Both 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 birth
In utero transmission rare: accounts for <2% of perinatal infections
HBV not transmitted by breastfeeding
Vertical 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% effective
hepatitis 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 prophylaxis
Administered 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 pregnancy
best in early pregnancy
women not tested prenatally should be tested at delivery
high risk women^ should be retested at delivery
*Hepatitis B Surface Antigen
^Women with >1 sex partner in past six months, evaluation/treatment for
STD, 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 prenatally
HBsAg+ test results reported to health department
Health department determines pregnancy status for
reports of HBsAg+ women
Pregnant women/infants identified for case management

14. Methods of Identification
Laboratories report HBsAg+ results, pregnancy status is determined
Prenatal care providers report cases
HBsAg+ women self report
Hospitals report cases
Universal reporting mechanisms (birth certificate, newborn screening) detect cases retrospectively
1st 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 data
About 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
23,919
Expected births
19,043
50%
41%
Identified births
Source: National Center for Immunization and Respiratory Diseases, CDC

17. Gaps in Identification
Laboratory reporting often only source used and incomplete
Overwhelming volume of HBsAg test results to review for pregnancy status
Some pregnant women not tested or reported by providers
women known to be HBsAg-positive
no prenatal care (~ 5%)
Many hospitals do not report cases

18. Methods to Improve Identification
Verify all laboratories are reporting all HBsAg-positive results
Review by health department of all HBsAg-positive reports
Monitor to ensure delivery hospitals are testing and reporting
Establish universal reporting mechanisms
Remind prenatal care providers to screen and report

19. Evaluate Laboratory Reporting
Keep a list of laboratories that conduct HBsAg testing
Ensure laboratories are regularly reporting cases to the health dept
Collaborate with communicable disease program to conduct laboratory evaluations and measure:
completeness of HBsAg reporting
timeliness of HBsAg reporting
Can 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 populations
labs reporting large volumes of hepatitis serology
labs serving prenatal clinics
delivery hospital labs
How often?
ideally, once/year for priority laboratories
every 2–3 years for other laboratories
Not sure if you want the photo or not…
More on laboratory evaluations in Session 3 of this series

21. Develop Protocols
To successfully identify cases, HBV prevention activities should be implemented by:
perinatal program
health department
delivery hospitals
universal reporting
prenatal care providers
Does this photo work or not?

22. Perinatal Prevention Protocol
Describes perinatal HBV prevention activities and outlines responsibilities of all parties:
laboratories  pediatricians
delivery hospitals  health departments
prenatal care providers
Required by immunization grant to disseminate annually to partners
The 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 reports
identify results for all women of childbearing age
determine pregnancy status of those women
review 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 delivery
Hospital laboratories, obstetrics, and nurseries have policies to report HBsAg+ delivering women
More info on working with delivery hospitals will be presented in sessions 3 and 4…
Health department should
monitor these activities
More on delivery hospital evaluations in Session 4 of this series

26. Universal Reporting Mechanisms
Include maternal HBsAg status on:
electronic birth certificate (EBC) or
newborn metabolic screening (NBS) card
Gain access to these data on a regular basis to identify cases retrospectively
Work 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 HBsAg
Report HBsAg-positive pregnant women
Health department should monitor
that providers report

28. For More Detail
Chapter 1 of CDC’s Managing a Perinatal Hepatitis B Prevention Program: Guide to Life as a Program Coordinator
hepatitis/resource/perinatalhepB.htm