Transcript Slide 1

Perinatal Hepatitis B
Lynn Pollock, RN, MSN
New York State Department of Health
[email protected]
518-473-4437
Workshop Objectives
At the conclusion of the workshop,
participants will be able to:
 Explain the risks for perinatal hepatitis B
infection
 Outline perinatal hepatitis B prevention
activities in New York State
 Understand the justification and
implementation of public health law 2500-e
Perinatal Hepatitis B Infection
and Transmisson
Hepatitis B Virus (HBV)

Most common liver infection worldwide
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350-400 million people chronically infected
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1 million deaths annually
Large proportion of perinatal acquisition
Without appropriate treatment, 1 in 4 chronically
infected persons experience liver cancer, cirrhosis or
liver failure
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80% of primary liver cancer (hepatocellular carcinoma) is
caused by chronic hepatitis B infection
Geographic Distribution of Chronic
HBV Infection
High >8%
HBsAg Prevalence
1
Intermediate 2-7%
Low <2%
HBV Disease Burden in U.S.
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~ 51,000 new infections in 2005
 5,494 acute clinical cases reported 2005
 Represents a 79% reduction from the pre-vaccine
era
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)
3,000-5,000 deaths from HBV related chronic liver
disease (cirrhosis, liver cancer)
*Disease Burden from Hepatitis A, B, and C in the US
http://www.cdc.gov/ncidod/diseases/hepatitis/
Perinatal Hepatitis B in the U.S.
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About 24,000 infants were born to
HBV-infected mothers in 2005
Without immunoprophylaxis (vaccine and
hepatitis B immune globulin [HBIG]):
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about 9,100 chronically infected with HBV
(most asymptomatic)
about 2,300 expected to die of chronic liver
disease (cirrhosis or liver cancer)
Natural History of
Hepatitis B Virus (HBV) Infection
Acute HBV infection
(may be symptomatic
or
asymptomatic)
Chronic HBV infection
Remaining chronically
infected
Cirrhosis and liver cancer
Resolved
and
immune
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!
Primary Prevention
Hepatitis B Virus is preventable
with a vaccine that has been
available for over 25 years!
Perinatal Hepatitis B in the U.S.
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About 24,000 infants were born to
HBV-infected mothers in 2005
Without immunoprophylaxis (vaccine and
hepatitis B immune globulin [HBIG]):
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about 9,100 chronically infected with HBV
(most asymptomatic)
about 2,300 expected to die of chronic liver
disease (cirrhosis or liver cancer)
Cumulative Reported Cases of Confirmed
Chronic Hepatitis B New York State
State of New York,
excluding New York City
10,968,179
54,841
4,152
Label Definition:
County name
Population (2000 U.S. Census)
HBV Estimates (0. 5% of U.S.
Population)*
* Based on upper limit of CDC
estimate range (0.2%-0.5%)
Cumulative Reported Chronic Cases
STATE OF NEW YORK
DEPARTMENT OF HEALTH
Perinatal Hepatitis B Transmission
•
•
•
Percutaneous and permucosal exposure to
mother’s blood during birth Usually occurs
during birth
In utero transmission is rare: accounts for
~2% of perinatal infections
HBV not transmitted by breastfeeding
100
100
80
80
60
60
Chronic Infection
40
40
20
20
Symptomatic Infection
0
0
Birth
1-6 months
7-12 months
Age at Infection
1-4 years
Older Children
and Adults
Symptomatic Infection (%)
Chronic Infection (%)
Outcome of Hepatitis B virus Infection by Age
Prevention of Hepatitis B Virus
Transmission: (ACIP, 2001)
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Screening of all pregnant women
Routine vaccination of all infants, with the first
dose preferably before hospital discharge
Vaccination of all children and adolescents
(though age 18)
Special efforts to vaccinate high risk children and
adolescents
Vaccination of adults in high-risk groups
Perinatal Case Identification
Women tested for
HBsAg prenatally
Delivering women
tested for HBsAg at
hospital (if not tested
previously)
HBsAg+ test results reported to health department
Health department determines pregnancy status for
reports of HBsAg+ women
Pregnant women/infants identified for case management
Basis for Perinatal
Prevention Strategy
●Infants born to HBV-infected women at highest risk
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~20,000 births to HBsAg+ women each year
10-85% infants become infected
Usually asymptomatic infection
Risk of chronic infection>90%
●HBV-infected women may be unaware of status or
deny risk factors
●Post-exposure prophylaxis (vaccine + HBIG) is
extremely effective
HBV Serology
HBV Serology
Serologic Marker
Hepatitis B surface
antigen (HBsAg)
Indication in Serum
-Marker of infectivity
-Present in acute &
chronic infection
Antibody to HBsAg
(Anti-HBs)
-Marker of immunity from
resolved infection
OR
-Previous vaccination
HBV Serology
Serologic Marker
Antibody to core
antigen
(Total Anti-HBc)
Indication in Serum
-Past or present infection
-Present in acute, chronic
& resolved infection
IgM antibody to core
antigen
(IgM anti-HBc)
-Subset of total anti-HBc
-Present in acute infection
-Diagnostic of acute
infection
HBV Serology
Serologic Marker
Hepatitis Be antigen
(HBeAg)
Indication in Serum
-High levels of infectivity
-Present in acute infection
-Variably present in chronic
infection
Antibody to HBeAg
(Anti-HBe)
-Present in resolved &
chronic infection
-Can be present in acute
infection
Acute Hepatitis B Virus Infection with Recovery
Symptoms
anti-HBe
HBeAg
Titer
Total anti-HBc
IgM anti-HBc
anti-HBs
HBsAg
0
4
8
12
16
20
24
28
32
36
Weeks after Exposure
52
100
Progression to Chronic Hepatitis B Virus
Infection
Acute
Chronic
(6 months)
(Years)
HBeAg
anti-HBe
HBsAg
Total anti-HBc
IgM anti-HBc
0 4
8 12 16 20 24 28 32 36
52
Weeks after Exposure
Years
CASE STUDY #1
Ting Nguyen immigrated to America from Vietnam as an
eleven year old girl. After twelve years of living in Kansas,
she married her college sweetheart. She became pregnant
in the first month of marriage. Included in her first
trimester prenatal screening was a serologic test for
HBsAg. She was shocked to learn that she was HBsAg
positive.
Her obstetrician informed her that she was probably
chronically infected with HBV and most likely had been
infected since birth. Neither Ting or her mother recalled
any signs or symptoms of viral hepatitis at any point in
the last 20+ years.
What additional information should Ting’s
doctor provide to Ting and her family?
Answer:
There is a vaccine and treatment available for her
baby at birth to prevent transmission of hepatitis B.
The whole family should be tested. Susceptible
family members should be vaccinated. Infected
individuals should be referred for medical
consultation.
Should Ting plan to have a C-section?
Answer:
No, data do not suggest that method of delivery is
related to maternal to fetal transmission of hepatitis
B. The important thing is that Ting’s baby receive
appropriate prophylaxis at birth
What is that prophylaxis?
Answer:
HBIG and first dose of hepatitis B vaccine within 12
hours of birth
Can Ting breastfeed her baby?
Answer: Yes - just be certain the baby gets
prophylaxed within 12 hrs of birth - instruct Ting
on good nipple care - she can even put the baby to
breast on the delivery table.
At what age should Ting’s baby be tested to
determine success or failure of prophylaxis ?
Answer: At 9-18 months
What tests should be performed?
Answer: HBsAg and anti-HBs
Prevention of HBV Transmission
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Post-exposure prophylaxis is
highly effective in preventing
HBV transmission after
exposure:
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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
Hepatitis B Vaccine: Two
Purposes
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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
NYS Public Health Law
2500-e and Regulations
Roles and Responsibilities
Pregnant Women and State HBsAg Requirements
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Currently, only 24 states require HBsAg screening
of pregnant women in the US
1990 NYSDOH PHL 2500-e Mandated Hep b
screening and reporting for all pregnant
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Goals of PHL 2500-e:
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All pregnant women screened each pregnancy
Treatment of all infants born to HBsAG- positive women
Provide STAT testing for women with unknown status and
treatment of their infants
Require reporting
Implementing Protocols for HBV Prevention
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Screen all pregnant women for HBsAg
 Identifies infants requiring immunoprophylaxis soon
after birth to prevent perinatal HBV infection
 Identifies
 Allows
household contacts needing vaccination
medical follow-up of women and other
contacts with chronic HBV infection
Infection in unvaccinated infants
The mother is HBsAg negative, but the
infant is exposed to HBV infection
postnatally from another family member or
caregiver. This occurs in 2/3 of all childhood
transmission cases.
Infection in unvaccinated infants
The woman is tested early in pregnancy and
found to be HBsAg negative.
She develops HBV infection later in pregnancy
but it is not detected, even though it is
recommended that high-risk women be tested
later in pregnancy.
The infection is not clinically detected so the
infant does not receive hepatitis B vaccine or
HBIG at birth.
Infection in unvaccinated infants
A chronically infected pregnant woman is
tested but with the wrong test, HBsAb
(antibody to hepatitis B surface antigen)
instead of HBsAg.
This is a common error because the
abbreviations for these two tests differ by
only one letter.
Her incorrectly ordered test result is “negative”
so her doctor believes her baby does not
need prophylaxis.
Infection in unvaccinated infants
The pregnant woman is tested and found
to be HBsAg positive, but her status is
not communicated to the newborn
nursery.
The infant receives neither hepatitis B
vaccine nor HBIG protection at birth.
Infection in unvaccinated infants
The pregnant woman is not tested for
HBsAg either prenatally, or in the hospital
at the time of delivery.
Her infant does not receive hepatitis B
vaccine in the hospital even though the
vaccine is recommended within 12 hours
of birth for infants whose mothers’ test
results are unknown.
Infection in unvaccinated infants
The pregnant woman is HBsAg positive but
her test results are misinterpreted or
mistranscribed into her prenatal record or
her infant’s chart. Her infant does not
receive HBIG or hepatitis B vaccine.
ALL OF THESE ERRORS HAVE OCCURRED IN
NEW YORK STATE
“Medical Errors put infants
at risk for chronic hepatitis
B virus infection–
6 case reports in NYS”
www.health.state.ny.us/diseases/communicable/
hepatitis/infants_hepb.htm
CASE STUDY #2
In September 1999, a woman of Southeast Asian descent who
tested negative for hepatitis B gave birth to a seemingly
healthy baby girl.
In December, the 3 month-old infant was hospitalized following
5 days of fever, diarrhea and jaundice.
Hepatitis B serology was performed on admission with the
following results:
HBsAg: positive
IgM anti-HBc: positive
ALT: 693; T. bili: 16.6
The mother was tested at the same time and was found to be
HBsAg positive.
What is the diagnosis?
Answer: acute hepatitis B infection
What happened and how could this have
been prevented?
At the time of birth, the mother’s test result
was falsely communicated as “hepatitis
negative” to the hospital where the infant
was born
The baby died 4 days after hospitalization from
fulminant hepatic failure secondary to
hepatitis B infection
This could have been prevented by routine
administration of birth dose regardless of
mother’s reported HBsAg status
Other Lessons
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HBsAg status should always be communicated
to the mother along with its importance
Women should have screening done for each
separate pregnancy regardless of results from
a prior pregnancy
Providers at the time of labor & delivery should
obtain actual lab report, not just verbal
communication or a result copied from one
chart to another – mistakes do occur
Improving our Prevention Efforts
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Ensure prenatal screening of all pregnant
women for HBsAg
Ensure reporting of all HBsAg+ pregnant
women
Improve electronic medical information
systems
Improving our Prevention Efforts
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Testing and vaccination of susceptible household
contacts
Post-vaccination testing of infants born to
infected mothers
Standardization of birth dose: “Safety Net”
Vaccinations &
Breastfeeding
Mothers who are breastfeeding can and should be vaccinated
Infants who breastfeed can and should be vaccinated
ACIP, 2007
Vaccinations &
Breastfeeding
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Neither inactivated nor live vaccines affect
the safety of breast feeding for infants of
mothers
Breastfeeding is not a contraindication for
any vaccine
Vaccinate infants who breastfeed
ACIP, 2007
Breast Milk and
Vaccines
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Only rubella has been detected in breast milk with
no illness or symptoms of disease in infant
No adverse effect on future response to 12 month
rubella vaccine
Increased immune response by breast feeding
infants to Hib, DT, OPV
ACIP, 2007
Sources of information on HBV & vaccination
CDC: www.cdc.gov/hepatitis
Hotline: 1-888-4HEPCDC
Schedule: http://www.cdc.gov/nip/recs/child-schedule.htm#Printable
Recommendations: http://www.cdc.gov/nip/publications/ACIP-list.htm
General & Vaccine Safety - NIP http://www.cdc.gov/nip
National Network for Immunization Info:
www.immunizationinfo.org
Immunization Action Coalition: www.immunize.org
Viral Hepatitis Prevention Board: http://www.vhpb.org
Institute of Medicine Immunization Safety Review:
www.iom.edu/IOM/IOMHome.nsf/Pages/immunization+safety+review
Acknowledgements
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Kimberly Noyes
Debra Blog
Geri Naumiac
Cindy Schulte
Betsy Herlihy