# Presentation: 193835

## Preventing Hepatitis B Virus Infections

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

## ACIP Recommendations to PreventPerinatal 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**

## 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 **

## 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**

## 2005 ACIP StatementPart 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

## 2005 ACIP Statement:Prevention 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***

## 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***

## 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***

## 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**

## Testing Pregnant Women

**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****	**

- ACIP Recommendations

## Management of HBsAg-positive Pregnant Women

**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 **

- ACIP Recommendations

## Management of HBsAg-Negative Pregnant Women

**Prenatal care providers:**
**Assess for risk of HBV infection:**
**>1 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****	**

- ACIP Recommendations

## Management of HBsAg-Negative Pregnant Women

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

- ACIP Recommendations

## Testing Pregnant Women at Delivery

**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* **
*** ****>1 sex partner, STD, IDU, HBsAg-positive sex partner**

- ACIP Recommendations

## Maternal HBsAg Test Results

**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 **

- ACIP Recommendations

## Management of Infants Born to HBsAg-Positive Women

**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**

- ACIP Recommendations

## Management of Infants Born to Women with Unknown HBsAg Status

**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**

- ACIP Recommendations

## Management of Infants Born to Women with Unknown HBsAg Status

**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**

- ACIP Recommendations

## Universal Infant Vaccination Beginning at Birth

**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 **_**physician’s 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 infant’s medical record**

- ACIP Recommendations

## Universal Infant Vaccination Beginning at Birth

**If infant weighs **_**<**_**2000 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 mother’s HBsAg- negative status during this pregnancy should be included in the infant’s medical record**
**Infants of ****HBsAg-positive or HBsAg-unknown**** status mothers should receive ****PEP**** within 12 hrs of birth (see recommendations for details) **

- ACIP Recommendations

## 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**** **

## Implementing the ACIP Recommendations in Hospitals

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

## Implementing the ACIP RecommendationsHospitals

**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**

## Implementing the ACIP RecommendationsHospitals

**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**

## 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***

## Additional Resources

**For the 2005 ACIP Recommendations  **
**and resources for implementation, please**
**see: **
_**[http://www.cdc.gov/ncidod/diseases/hepatitis/_x000b_](http://www.cdc.gov/ncidod/diseases/hepatitis/%0Bb/acip.htm)**__**[b/acip.htm](http://www.cdc.gov/ncidod/diseases/hepatitis/%0Bb/acip.htm)**_