Preventing Hepatitis B Virus Infections

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Preventing Hepatitis B Virus Infections

• 2005 ACIP Update Immunization of Infants and
  Children
• Susan A. Wang, MD, MPH
• Division of Viral Hepatitis, CDC

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ACIP Recommendations to PreventPerinatal and
Early Childhood HBV Transmission A Chronology

• 1984 Hepatitis B surface antigen (HBsAg)
  screening of pregnant women at high-risk
• 1988 HBsAg screening of all pregnant women

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ACIP Recommendations to Prevent Perinatal and
Early Childhood HBV Transmission A Chronology

• 1991 Universal infant hepatitis B vaccination
• First dose at birth or at age 1-2 mo for infants
  born to HBsAg-negative mothers
• 2002 Preference to give first hepatitis B
  vaccine dose at birth
• 2005 First hepatitis B vaccine dose should be
  given at birth

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ACIP Recommendations A Comprehensive
Immunization Strategy to Eliminate Transmission
of Hepatitis B Virus Infection in the United
States

• Part I Immunization of infants, children, and
  adolescents published December 23, 2005 in the
  Morbidity and Mortality Weekly Report
• Part II Immunization of adults to be
  published in 2006

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2005 ACIP StatementPart I Immunization of
Infants, Children, and Adolescents

• Two groups of recommendations
• Prevention of perinatal and early childhood
  transmission of HBV
• Vaccination of children and adolescents who were
  not previously vaccinated

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2005 ACIP StatementPrevention of Perinatal and
Childhood HBV Transmission

• Three things we need to do
• 1. Test all pregnant women for HBsAg during an
  early prenatal visit test women upon admission
  to labor and delivery, as indicated
• Who Prenatal and obstetrical care providers,
  hospitals

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2005 ACIP Statement Prevention of Perinatal
and Childhood HBV Transmission

• Three things we need to do
• 2. Ensure all infants of HBsAg-positive and of
  HBsAg-unknown status mothers receive appropriate,
  timely post-exposure prophylaxis (PEP) and
  complete follow-up (i.e., case management)
• Who Neonatal and pediatric healthcare
  providers, health departments

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2005 ACIP Statement Prevention of Perinatal and
Childhood HBV Transmission

• Three things we need to do
• 3. Vaccinate all newborns before hospital
  discharge
• Who Neonatal and pediatric care providers,
  hospitals

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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

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Testing Pregnant Women
ACIP Recommendations

• Prenatal care providers
• Test all pregnant women for HBsAg during an early
  prenatal visit
• Transfer copy of original laboratory HBsAg report
  to delivery hospital for all pregnant women
• Include HBsAg test results on all forms that
  transmit information about pregnancy care

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Management of HBsAg-positive Pregnant Women
ACIP Recommendations

• Prenatal care providers
• Report cases to health department for assistance
  with transmission prevention
• Provide or refer for counseling, medical
  evaluation, and possible treatment of chronic
  hepatitis B
• Inform women of need for HBV PEP for their
  newborns

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Management of HBsAg-Negative Pregnant Women
ACIP Recommendations

• Prenatal care providers
• Assess for risk of HBV infection
• gt1 sex partner in past 6 months
• Evaluation or treatment for STD
• Recent or current injection drug use (IDU)
• HBsAg-positive sex partner
• Vaccinate women at risk counsel them about
  other ways to prevent HBV infection

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Management of HBsAg-Negative Pregnant Women
ACIP Recommendations

• Prenatal care providers
• Inform women of the importance of newborn
  hepatitis B vaccination

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Testing Pregnant Women at Delivery
ACIP Recommendations

• Hospitals and obstetrical providers
• Review HBsAg status of all pregnant women on
  admission
• Perform HBsAg testing if
• HBsAg result is not available, or
• History of clinical hepatitis since last test, or
• At risk for HBV infection
• gt1 sex partner, STD, IDU, HBsAg-positive sex
  partner

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Maternal HBsAg Test Results
ACIP Recommendations

• Hospitals and obstetrical providers
• Report newly identified HBsAg-positive women to
  the health department
• Document maternal HBsAg results with dates of
  testing in all infant medical records

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Management of Infants Born to HBsAg-Positive
Women
ACIP Recommendations

• Hospitals and neonatal care providers
• Provide PEP by administering hepatitis B vaccine
  and hepatitis B immune globulin (HBIG) to infants
  within 12 hrs of birth
• Pediatric care providers
• Complete hepatitis B vaccine series according to
  recommended schedule
• Perform post-vaccination testing for antibody to
  HBsAg (anti-HBs) and HBsAg after completion of
  vaccine series

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Management of Infants Born to Women with Unknown
HBsAg Status
ACIP Recommendations

• Hospitals and obstetrical care providers
• Perform HBsAg testing of the mother soon after
  admission for delivery
• If mother is HBsAg positive, report to health
  dept
• Hospitals and neonatal care providers
• Provide PEP with hepatitis B vaccine to infants
  within 12 hrs of birth
• If mother is HBsAg positive, infant should also
  receive HBIG

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Management of Infants Born to Women with Unknown
HBsAg Status
ACIP Recommendations

• Pediatric care providers
• Complete hepatitis B vaccine series according to
  recommended schedule based on maternal HBsAg
  status
• Perform post-vaccination testing, if mother is
  HBsAg positive

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Universal Infant Vaccination Beginning at Birth
ACIP Recommendations

• All medically stable infants weighing 2000 g at
  birth and born to HBsAg-negative women should be
  vaccinated before hospital discharge (birth dose)
• Delaying vaccination until after hospital
  discharge should be rare
• If hepatitis B vaccination is not provided before
  hospital discharge, both a physicians order to
  withhold the birth dose and a copy of the
  laboratory report indicating that the mother was
  HBsAg negative during this pregnancy should be
  documented in the infants medical record

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Universal Infant Vaccination Beginning at Birth
ACIP Recommendations

• If infant weighs lt2000 g at birth and mother is
  HBsAg negative, delay first hepatitis B vaccine
  dose to 1 month after birth or hospital discharge
• A copy of the laboratory report indicating the
  mothers HBsAg- negative status during this
  pregnancy should be included in the infants
  medical record
• Infants of HBsAg-positive or HBsAg-unknown status
  mothers should receive PEP within 12 hrs of birth
  (see recommendations for details)

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ACIP Statement Blueprint for next steps to
achieve elimination of perinatal and childhood
HBV infections

• The hospital is a safety net to eliminate
• HBV transmission through
• Universal verification of maternal HBsAg testing
• Identification of infants born to HBsAg-positive
  and HBsAg-unknown status women, administration of
  appropriate PEP and initiation of follow-up (case
  management)
• Universal birth dose administration

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Implementing the ACIP Recommendations in Hospitals

• All delivery hospitals should implement
• policies and procedures, including
• standing orders, to ensure prevention of
• perinatal HBV transmission

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Implementing the ACIP RecommendationsHospitals

• The following standing orders should be
• implemented
• Review of HBsAg status of all pregnant women on
  admission
• HBsAg testing of pregnant women on admission, as
  indicated
• Administration of appropriate PEP within 12 hrs
  of delivery to
• All infants of HBsAg-positive mothers
• All infants of HBsAg-unknown status mothers
• Administration of hepatitis B vaccine to all
  newborns before discharge

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Implementing the ACIP RecommendationsHospitals

• Should enroll in state Vaccines for Children
  (VFC) programs to obtain free vaccine for all
  infants who qualify
• State VFC contacts are listed at
  http//www.cdc.gov/nip/vfc/contacts_vfc_coord.htm

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Implementing the ACIP Recommendations Health
Departments

• Should ensure all pregnant women are tested for
  HBsAg each pregnancy
• Should monitor infants born to HBsAg-positive and
  HBsAg-unknown status women to ensure
• appropriate PEP
• completion of vaccine series
• post-vaccination testing
• This will require hospital medical record audits

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Additional Resources

• For the 2005 ACIP Recommendations
• and resources for implementation, please
• see
• http//www.cdc.gov/ncidod/diseases/hepatitis/b/ac
  ip.htm

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