Transcript Prevention of Perinatal and Childhood Hepatitis B Virus

Prevention of Perinatal and Childhood
Hepatitis B Virus Infections
Background on Where We’ve Been
Lisa Jacques-Carroll, MSW
Immunization Services Division, CDC
Hepatitis B: Burden of
Disease - United States
 ~60,000 new infections in 2004
 200,000-300,000 new infections
per year before hepatitis B vaccination programs
 1 of 20 persons have been infected with hepatitis B
virus (HBV) during their lifetime (about 12.5 million)
 1 of 200 persons have chronic HBV infection (~1.25
million)
 4000-5000 deaths from HBV related chronic liver
disease (cirrhosis, liver cancer)
Chronic Liver Disease
Caused by HBV Infection
Consequences of HBV Infection
in Infants and Young Children
• ~90% of infants and 30% of children
<5 yrs who acquire HBV infection become
chronically infected
• ~25% of those with chronic infection die
prematurely of liver cancer or cirrhosis
Estimated Age at Infection of
Persons with Chronic HBV Infection
Before Childhood Vaccination, US
Newborn 18%
Children 18%
Adult 59%
Adolescent 6%
Sources: National Health and Nutrition Examination Survey III
N Engl J Med 1989;321:1301-5
Pediatrics 1992;89:269-73
Pediatrics 1995;96:1113-6
Modes of HBV Transmission
in Early Childhood
• Vertical transmission from mother to
infant
• Horizontal transmission from infected
household contact to child

Both modes of transmission can be
prevented by vaccination of newborns!
Vaccine Efficacy in Preventing
Vertical HBV Transmission
• Without immunoprophylaxis, ~40% of infants of
Hepatitis B Surface Antigen (HBsAg) positive
mothers develop chronic HBV infection
• Immunoprophylaxis includes:
• hepatitis B vaccine & Hepatitis B Immune
Globulin (HBIG) at birth
• This is 85%-95% effective in preventing vertical
HBV transmission; hepatitis B vaccine alone at
birth prevents transmission in 70-95% of infants
Vaccine Efficacy in Preventing
Horizontal HBV Transmission
• Before implementation of perinatal hepatitis B
prevention programs, studies show:
• 61%-66% of children with chronic HBV infection
were born to HBsAg-negative mothers
• Children likely were infected by household
contacts*
• Birth dose of hepatitis B vaccine will prevent
these early childhood infections
*Pediatrics 1995; 96:1113-6;
Pediatrics, 2001, 108:5, 1123-28
Strategy to Eliminate HBV
Transmission in the United States
• Universal vaccination of infants beginning at birth
• Prevention of perinatal HBV infection
• Screen all pregnant women for HBsAg
• Immunoprophylaxis of infants born to
HBsAg-positive and unknown status women
• Vaccination of all previously unvaccinated children
and adolescents < 19 years
• Vaccination of previously unvaccinated adults in
high risk groups
Reported Acute Hepatitis B Incidence
by Age Group: US, 1990-2004
12
Cases per 100,000
10
≥20 years
94% decline
8
6
71% decline
12-19 years
4
2
<12 years
0
1990
1992
1994
1996
1998
Year
2000
2002
2004
Gaps in Prevention of Perinatal and
Early Childhood Hepatitis B Virus Infections
• <50% of expected infants born to
HBsAg-positive mothers are identified for
case-management by public health
• Medical errors in identifying and managing:
• infants born to HBsAg-positive mothers
• infants born to mothers w/unknown HBsAg status
• <50% of all infants receive first dose at birth
Identified and Expected Births to
HBsAg-Positive Mothers, US, 1993-2003
80
60
40
Expected number
19,043
20000
48% 15000
Percent identified
41%
10000
5000
20
Source: National Immunization Program, CDC
03
20
02
20
01
00
20
Year
20
99
19
98
19
97
19
96
19
95
19
19
19
94
0
93
0
Expected Number
Percent Identified
100
23,827
Case Management
Public health ensures case management of
infants born to HBsAg-positive or unknown
status women
Post-exposure prophylaxis
Hepatitis B series
If mother is HBsAg-positive, serologic testing
for hepatitis B status and immunity
Case reviews show higher completion of
prophylaxis, vaccine series, and testing among
case managed infants*
*Sources: Alabama Department of Public Health, 2004; MMWR 1996; 45:584-7
Medical Errors in Prevention of
Perinatal HBV Transmission
• During July 1999-October 2002, public health
reported more than 500 medical errors
• Examples:
• Infants born to HBsAg-positive mothers did not receive
hepatitis B vaccine and HBIG within 12 hrs of birth
• Infants of mothers with unknown HBsAg status did not
receive hepatitis B vaccine within 12 hrs of birth
• HBsAg screening test results were misordered,
misinterpreted, mistranscribed, or miscommunicated
• Incorrect hepatitis B screening tests ordered
Source: Immunization Action Coalition
Perinatal Hepatitis B Death
Michigan, 1999
3 month old baby girl died of fulminant hepatitis B
Mother tested HBsAg positive during pregnancy
Prenatal care provider:
Made a transcription error and reported mother as
“hepatitis negative” to the hospital
Used 1966 prenatal form
Did not report HBsAg positive test (Michigan law)
Hospital staff:
Relied on provider’s prenatal record
Suspended routine birth dose of Hepatitis B vaccine due
to thimerosal concern
Recent Errors in Large, Urban
Hospital 2004-2005
Hospital failed to provide HBIG and birth dose of
hepatitis B to 4 infants born to HBsAg-positive
women
Hospital received notification that the
HBsAg-positive woman would deliver at their
facility in 3 of the 4 cases
Hospital cited transcription errors, delayed
receipt of lab results, and other mistakes as
reasons for these medical errors
Receipt of Hepatitis B Vaccine at Birth
Among Infants Born to Women with
Unknown HBsAg Status*
Study
Year
# infants
identified
Rec’d
Prophylaxis
National
Washington
California
Florida
Ohio
Oregon
Michigan
1993
1994
1995
1995
1995
2000
2000
640
125
200
38
35
43
57
22%
53%
20%
29%
66%
19%
14%
*State health department surveys of hospital records
Percent of Infants
Proportion of Infants Receiving
Hepatitis B Vaccine Birth Dose,
1999-2004
100
90
80
70
60
50
40
30
20
10
0
Hepatitis B Vaccine 0-2 Days from Birth
53.7%
1999
2000
46.0%
2001
Source: CDC, National Immunization Survey
2002
Year
2003
2004
Hepatitis B Vaccine Birth Dose
Coverage*, 2004
Coverage No. of
%
states
* 0-2 days from birth
<30
9
30-39
7
40-49
7
50-59
5
60-69
15
70-79
5
>80
2
Rationale for Hepatitis B Vaccine
Birth Dose for All Infants
• Provides “safety net” for prevention of
perinatal HBV infections
• Prevents early childhood HBV infections,
including infections among children born to
HBsAg-negative women
• Associated with higher rates of on-time
completion of hepatitis B vaccine series, and
at times, with higher completion rates of other
vaccines
Perinatal and Childhood
HBV Infections, Summary
• Substantial progress in implementing
routine infant hepatitis B vaccination
• New HBV infections in children declined 94%
• Gaps in eliminating transmission remain
• New ACIP recommendations address these
gaps