viral hepatitis program management of babies born to hbsag- positive mothers vickie weeast...

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

Management of Babies Born to HBsAg- Positive Mothers

Vickie WeeastPerinatal Hepatitis B Case Manager

Colorado Department of Public Health & Environment


Hepatitis B Virus


About Hepatitis B Infection

• Spread by:– Sexual– Parenteral– Perinatal

• Acute and/or Chronic • Chronic infection is a leading cause of liver

disease.


Hepatitis B – Clinical Features• Incubation period: Average 120 d

Range 45-160 d• Clinical illness (jaundice): <5 yrs, <10%

>5 yrs, 30%-50%

• Acute case-fatality rate: 0.5%-1%• Chronic infection: <5 yrs, 25%-90%

>5 yrs, 6%-10% • Premature mortality from

chronic liver disease: 15%-25%


Phases of HBV InfectionAcute

•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.

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 infectivityAnti-HBc IgM (hepatitis B core antibody IgM)

– If +, acute infection– if negative and HBsAg +,

chronic infectionAnti-HBc (hepatitis B core antibody)

– Marker of current or previous infection


People at Risk for HBV InfectionPeople 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


People at Risk for HBV People at Risk for HBV Infection- cont’dInfection- 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


People at Risk for HBV People at Risk for HBV Infection- cont’dInfection- 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


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


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


Perinatal Hepatitis B Infections Can Be Prevented

Test all pregnant women Vaccinate all newborns


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


Prenatal TestingAll 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


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


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


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


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.


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


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)


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


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 (6th)dose

• If HBsAg-positive refer infant for medical evaluation/management of

chronic hepatitis B report perinatal infection to CDPHE Viral Hepatitis

Program


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.


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


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.


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.


Perinatal Hepatitis B Prevention Project

Perinatal Hepatitis B Prevention Coordinator

2 Case Managers

Nurse Consultant and Educator


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


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


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


Helpful Websites

• www.hepatitiscolorado.info• www.cdc.gov/hepatitis• www.coloradoguidelines/hepbc.orgf• www.immunize.org• www.aap.org


Questions ?

Vickie WeeastPerinatal Hepatitis B Case ManagerViral Hepatitis ProgramColorado Department of Public Health & Environment(303) [email protected]

viral hepatitis program management of babies born to hbsag- positive mothers vickie weeast...

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