1. Viral Hepatitis Program http://www.hepatitiscolorado.info Management of Babies Born to HBsAg- Positive Mothers Vickie Weeast Perinatal Hepatitis B Case Manager Colorado Department of Public Health & Environment

2. Viral Hepatitis Program http://www.hepatitiscolorado.info Hepatitis B Virus

3. Viral Hepatitis Program http://www.hepatitiscolorado.info About Hepatitis B Infection Spread by: –Sexual –Parenteral –Perinatal Acute and/or Chronic Chronic infection is a leading cause of liver disease.

4. Viral Hepatitis Program http://www.hepatitiscolorado.info Hepatitis B – Clinical Features Incubation period: Average 120 d Range 45-160 d Clinical illness (jaundice): 5 yrs, 30%-50% Acute case-fatality rate: 0.5%-1% Chronic infection: 5 yrs, 6%-10% Premature mortality from chronic liver disease: 15%-25%

5. Viral Hepatitis Program http://www.hepatitiscolorado.info Phases of HBV Infection Acute New infection Symptoms more common among adults Children often asymptomatic. Two possible outcomes: –Infection resolves: person develops immunity – infection does not resolve and the person continues to carry the virus Chronic Individual carries the virus for >6 months and does not develop anti-bodies to the surface antigen (anti-HBsAg) Silent infection People that become infected as children are more likely to become chronically infected.

6. HBV Testing HBsAg: (hepatitis B surface antigen) –Marker of current infection –Neutralization HBsAb: (hepatitis B surface antibody) –Marker of immunity HBeAg: (hepatitis B e antigen) –Marker of high infectivity Anti-HBe (hepatitis B e antibody) –Marker of low infectivity Anti-HBc IgM (hepatitis B core antibody IgM) –If +, acute infection – if negative and HBsAg +, chronic infection Anti-HBc (hepatitis B core antibody) –Marker of current or previous infection

7. Viral Hepatitis Program http://www.hepatitiscolorado.info People at Risk for HBV Infection Immigrants/refugees from areas of intermediate/high (>2%) HBV endemicity Children born in U.S. to immigrants from areas of intermediate/high HBV prevalence Alaska Natives and Pacific Islanders Travelers to countries with intermediate or high prevalence (>2%) of HBV infection

8. Viral Hepatitis Program http://www.hepatitiscolorado.info

9. Viral Hepatitis Program http://www.hepatitiscolorado.info People at Risk for HBV Infection- cont’d Mother is hepatitis B surface antigen positive or has not been tested Household contacts and sex partners of people with chronic HBV infection People who have or who have had sexually transmitted diseases Heterosexuals with >1 sex partner in 6 months

10. Viral Hepatitis Program http://www.hepatitiscolorado.info People at Risk for HBV Infection- cont’d Men who have sex with men Users of illicit injectable drugs Healthcare and Public Safety workers in contact with blood Hemodialysis patients Residents and staff of facilities for developmentally disabled persons

11. Viral Hepatitis Program http://www.hepatitiscolorado.info Perinatal Hepatitis B 24,000 pregnant women infected with hepatitis B deliver each year CDC estimates 150,000 pregnancies each year in women from endemic countries Causes chronic infection. Chronic carriers have up to 25% chance of death from –Cirrhosis –Hepatocellular Carcinoma

12. Viral Hepatitis Program http://www.hepatitiscolorado.info Perinatal Hepatitis B Transmission In the absence of post exposure prophylaxis* If mother positive for HBsAg and HBeAg –70%-90% of infants infected –90% of infected infants become chronic carriers If positive for HBsAg only –<10% of infants infected –90% of infected infants become chronic carriers *MMWR 2005:54:5

13. Viral Hepatitis Program http://www.hepatitiscolorado.info Perinatal Hepatitis B Infections Can Be Prevented Test all pregnant women Vaccinate all newborns

14. Viral Hepatitis Program http://www.hepatitiscolorado.info Prevention of Perinatal and Childhood HBV Transmission in the U.S. Requires coordinated efforts by: Providers of prenatal, obstetrical, neonatal, and pediatric care Hospitals Health departments

15. Viral Hepatitis Program http://www.hepatitiscolorado.info Prenatal Testing All pregnant women should be tested routinely for hepatitis B surface antigen during an early prenatal visit (e.g. first trimester) in each pregnancy, even if they have been previously vaccinated or tested. MMWR 2005:54:13 Who: Prenatal and obstetrical care providers, hospitals

16. Viral Hepatitis Program http://www.hepatitiscolorado.info Prenatal Testing at the Time of Delivery Review hepatitis B surface antigen status of all pregnant women Perform hepatitis B surface antigen testing ASAP on women who: –do not have a documented test –were at risk of infection during pregnancy even if they were tested earlier. –had clinical hepatitis since testing MMWR 2005:54:15

17. Viral Hepatitis Program http://www.hepatitiscolorado.info Follow-up on HBsAg+ Women All pregnant woman that are chronically infected with hepatitis B should be clinically monitored, or treated. The following chronically infected women should receive an ultrasound for hepatacellular carcinoma –Africans >20 years –Any carrier >40 years with persistently elevated ALT or DNA >2,000 IU/ml –Any woman with a family history of HCC

18. Viral Hepatitis Program http://www.hepatitiscolorado.info Hepatitis B Vaccine Birth Dose Vaccinate all newborns before hospital discharge Protects infants born to mothers that aren’t identified perinatally Protects infants at risk for infection after the perinatal period Associated with higher rates of on-time completion of hepatitis B vaccine series. Some studies show an association with improved completion rates for all other infant vaccines. MMWR 2005:54:8-9

19. Viral Hepatitis Program http://www.hepatitiscolorado.info Hospital Management of Infants Dose #1 of Hepatitis B vaccine –in the thigh within 12 hours of birth. If mom is HBsAg+ or her status is unknown, also give HBIG 0.5 ml –in the opposite thigh IM within 12 hours of birth but no later than 7 days of age.

20. Viral Hepatitis Program http://www.hepatitiscolorado.info PCP Management of HBsAg + Exposed Infant Complete hepatitis B vaccination series according to the recommended schedule Dose #2 of hepatitis B vaccine at 1-2 months of age Dose #3 of hepatitis B vaccine at 6 months of age

21. Viral Hepatitis Program http://www.hepatitiscolorado.info PCP Management of HBsAg + Exposed Infant Post-vaccination testing (PVT) should be completed 1-9 months after the third dose of hepatitis B vaccine (between 9 and 18 months of age). Ideally at the child’s 9 or 12 month visit PVT consists of both –hepatitis B surface antigen (HBsAg) and –hepatitis B surface antibody (HBsAb or anti-HBs)

22. Viral Hepatitis Program http://www.hepatitiscolorado.info Why is Post-vaccination Testing Important? Identifies those infants who are not protected from the vaccine. Identifies the infants that have became chronically infected and will aid in their long-term medical management

23. Viral Hepatitis Program http://www.hepatitiscolorado.info Infant Post-Vaccination Test Results If HBsAg-negative & anti-HBs positive >10 mIU/mL  infant is protected If HBsAg-negative & anti-HBs <10 mIU/mL negative  revaccinate with 3-dose hep B series  retest 1–2 months after final (6 th )dose If HBsAg-positive  refer infant for medical evaluation/management of chronic hepatitis B  report perinatal infection to CDPHE Viral Hepatitis Program

24. Viral Hepatitis Program http://www.hepatitiscolorado.info Hospital Management of Pre- term infants weighing <2000g & Born to HBsAg+ Mom Begin treatment within 12 hours of birth if medically stable HBIG 0.5 ml –in the thigh IM within 12 hours of birth. Dose #1 of Hepatitis B vaccine –in the opposite thigh within 12 hours of birth.

25. Viral Hepatitis Program http://www.hepatitiscolorado.info PCP Management of Pre-term infants weighing <2000 grams Do not count the birth dose as part of the hepatitis B vaccination series. The infant should receive a total of 4 hepatitis B doses Dose #2 of hepatitis B vaccine at 1-2 months of age Dose # 3 of hepatitis B vaccine at 2-4 months of age Dose #4 of hepatitis B vaccine at 6 months of age

26. Viral Hepatitis Program http://www.hepatitiscolorado.info PCP Management of Pre-term infants weighing <2000 grams PVT should be completed in the same time frame as a full term normal birth weight infant Ideally at the child’s 9 or 12 month visit and never before 9 months of age.

27. Viral Hepatitis Program http://www.hepatitiscolorado.info Perinatal Hepatitis B Prevention Project Colorado Department of Public Health & Environment Strives to prevent the spread of the hepatitis B virus to newborn children and to any household and/or sexual contacts of an HBsAg-positive pregnant woman.

28. Viral Hepatitis Program http://www.hepatitiscolorado.info Perinatal Hepatitis B Prevention Project Perinatal Hepatitis B Prevention Coordinator 2 Case Managers Nurse Consultant and Educator

29. Viral Hepatitis Program http://www.hepatitiscolorado.info The Perinatal Hepatitis Prevention Unit Provides Hepatitis B education to HBsAg-positive pregnant women Hepatitis B screening for household and/or sexual contacts of an HBsAg-positive pregnant woman Hepatitis B vaccination for susceptible contacts of an HBsAg-positive pregnant woman

30. Viral Hepatitis Program http://www.hepatitiscolorado.info The Perinatal Hepatitis Prevention Project Provides Clinical staff training on issues related to perinatal hepatitis B Case management of infant born to an HBsAg- positive mother Services are provided in a variety of languages

31. Viral Hepatitis Program http://www.hepatitiscolorado.info Benefits of Case Management Case managed infants are more likely to receive post-exposure prophylaxis (PEP) at birth They are more likely to complete their hepatitis B vaccine series on time Also more likely to complete their hepatitis B post-vaccination testing

32. Viral Hepatitis Program http://www.hepatitiscolorado.info Helpful Websites www.hepatitiscolorado.info www.cdc.gov/hepatitis www.coloradoguidelines/hepbc.orgf www.immunize.org www.aap.org

33. Viral Hepatitis Program http://www.hepatitiscolorado.info Questions ? Vickie Weeast Perinatal Hepatitis B Case Manager Viral Hepatitis Program Colorado Department of Public Health & Environment (303) 692-2715 vickie.weeast@state.co.us