# Presentation: 815502

## 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)**

**Notes:**
Although substantial progress has been made in implementing hepatitis B vaccination programs, hepatitis B continues to be a major public health problem in the United States. 
In 2003 - estimated 
According to data from NHANES

## 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 

**Children 18%**

**Adolescent 6%**

**Adult 59%**

- 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

**Estimated Age at Infection of **
**Persons with Chronic HBV Infection **
**Before Childhood Vaccination, US**

**Notes:**
Because most of the morbidity and mortality associated with HBV infection occurs in persons who develop chronic infection, the primary goal of hepatitis B immunization is to prevent chronic infection. 

This slide illustrates the estimated age at infection for persons with chronic infection before childhood vaccination programs. 

## 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

-  **≥**20 years

- 12-19 years

- <12 years

**71% decline**

**94% decline**

- Year

- Cases per 100,000

## 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

**Expected number**

**Percent identified**

- Source: National Immunization Program, CDC

**48%**

**23,827**

**19,043**

**41%**

## 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**

**Notes:**
This slide gives examples of the types of errors that can occur in tracking infants born to mothers who are known to be HBsAg positive

## 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 | 1993 | 640 | 22% |
| Washington | 1994 | 125 | 53% |
| California | 1995 | 200 | 20% |
| Florida | 1995 | 38 | 29% |
| Ohio | 1995 | 35 | 66% |
| Oregon | 2000 | 43 | 19% |
| Michigan | 2000 | 57 | 14% |

*****State health department surveys of hospital records

## Proportion of Infants Receiving Hepatitis B Vaccine Birth Dose, 1999-2004

**46.0%**

**53.7%**

- Source: CDC, National Immunization Survey

**Hepatitis B Vaccine 0-2 Days from Birth**

## Hepatitis B Vaccine Birth Dose Coverage*, 2004

**Hepatitis B Vaccine Birth Dose ****Coverage*, 2004**

**<30**** **

**30-39**** **

** ****9**

**No. of states**

**Coverage     %**

**7**** **

**40-49**** **

**50-59**** **

** ****5**** **

**60-69**** **

**15**** **

**70-79**** **

**5**** **

_**>8**_**0**** **

**2**** **

*** **0-2 days from birth

**7**** **

## 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**