Perinatal Hepatitis B Prevention “The Silent Disease”

Perinatal Hepatitis B Prevention “The Silent Disease” Sheree F. Smith, RN,BSNNursing ConsultantPerinatal Hepatitis B CoordinatorNorth Carolina Immunization Branch(919) 707-5552sheree.smith@dhhs.nc.gov

Hepatitis B Worldwide • 2 billion people with evidence of previous HBV infection • 350 million people are chronic carriers of HBV, • 130 million Chinese (1 in 10) have chronic HBV • 15%-25% will die from cirrhosis or liver cancer • Risk of dying from liver cancer 100 greater for carriers than non-carriers

Worldwide- Chronic HBVPrimary Liver Cancer • Causes 80% of all primary liver cancers and • Over 500,00 people die each year • 5 year survival rate of only 10%. • 3rd leading cause of cancer death among men in China. • In the US, the 3rd leading cause of cancer death among Asian Americans and the 8th leading cause of cancer death among caucasion

Geographic Distribution -Chronic HBV Infection HBsAg Prevalence 8% - High 2-7% - Intermediate <2% - Low

BOX 2. Geographic regions* with intermediate† and high§ hepatitis B virus endemicity http://www.cdc.gov/mmwr/PDF/rr/rr5516.pdf Africa:all countries East Asia: all countries Eastern Europe and Northern Asia:all countries except Hungary South Asia:all countries except Sri Lanka Southeast Asia:all countries Australia and the South Pacific:all countries and territories except Australia and New Zealand Middle East:all countries except Cyprus Western Europe:Greece, Malta, Portugal, and Spain and indigenous populations of Greenland North America:Alaska Natives and indigenous populations of Northern Canada Central America:Belize, Guatemala, Honduras, and Panama South America:Argentina, Bolivia, Brazil, Ecuador, Guyana, Suriname, Venezuela, and the Amazonian areas of Colombia and Peru Caribbean:Antigua and Barbuda, Dominica, Dominican Republic, Grenada, Haiti, Jamaica, Puerto Rico, St. Kitts and Nevis, St. Lucia, St. Vincent and Grenadines, Trinidad and Tobago, and Turcs and Caicos * A complete list of countries in each region is available at http://www.cdc. gov/travel/destinat.htm. † Hepatitis B surface antigen (HBsAg) prevalence of 2%–7%. § HBsAg prevalence of >8%.

In the United States • Melting Pot Society • Largely a disease of young adults aged 20-50 years. • 800,000 to 1.4 million are chronic HBV carriers, • 80,000 new acute cases/year • 5-8,000 chronic infections/year • 5, 000 deaths each year due to HBV & complications

Focus Preventing Perinatal Acquired HB • Major reservoir of ongoing HBV transmission. • Undetected HBsAg + Mom • Lacks (Infant) Coordinated Case Management • Avoid HBV Complications- Infant & Mom HBV Reservoir

Acute HBV Complications Fulminant Hepatitis Failure • Severe Liver failure or severe necrosis • Mortality rates approach 63-93% • Only about 1-2% of acute infections will develop FHF. • Severe among adults aged >60 years but fatality 80-90% rates higher in infant/Children. • The fatality rate among acute cases reported to CDC is 0.5%–1%. • Death occurs in 1-2 days • No time for transplant Super Acute

Long Term Complications of Chronic HBV Infection Cirrhosis Liver slowly deteriorates and malfunctions Scar tissue replaces healthy liver tissue, Blocking the flow of blood through the liver. Scarring also impairs the liver’s ability to perform normal functions. Liver Failure Normal functions are impaired and may fail completely. The only treatment for liver failure is liver transplant. Liver failure can result in ascites Hepatocellular Carcinoma Leading cause of death in specific groups. Premature Death- Death occurs in 30, 40 and 50 yr old About 15% to 25% percent of people with chronic hepatitis B will die

Prevention vs Disease Cost • Increase life expectancy • Increase quality of life • Reduce health care cost • Hepatitis B vaccine series cost $27.00 • A new liver costs $1,000,000.00

Clinical case definition Perinatal hepatitis B in the newborn may range from asymptomatic to fulminant hepatitis. Laboratory criteria for diagnosis: Hepatitis B surface antigen (HBsAg) positive Case classification HBsAg positivity in any infant aged >1-24 months who was born in the United States or in U.S. territories to an HBsAg-positive mother Comment Infants born to HBsAg-positive mothers should receive hepatitis B immune globulin (HBIG) and the first dose of hepatitis B vaccine within 12 hours of birth, followed by the second and third doses of vaccine at 1 and 6 months of age, respectively. Postvaccination testing for HBsAg and anti-HBs (antibody to HBsAg) is recommended from 3 to 6 months following completion of the vaccine series. If HBIG and the initial dose of vaccine are delayed for >1 month after birth, testing for HBsAg may determine if the infant is already infected. Hepatitis, Viral, Perinatal Hepatitis B Virus Infection Acquired in the U.S.

Perinatal HBV Exposure CDC estimates that • 20,000 infants are born to HBsAg positive mothers each year. • Post-exposure prophylaxis is highly effective in preventing transmission of HBV from mother to infant. • Estimated 1000 of these infants become chronically infected with HBV each year because not all infected mothers are identified and not all infants received appropriate post-exposure prophylaxis. • Approximately one-fourth of whom will eventually die from chronic liver disease.

Hepatitis B Perinatal Transmission* • If mother positive for HBsAg and HBeAg • 70%-90% of infants infected • 90% of infected infants become chronically infected • If positive for HBsAg only • 5%-20% of infants infected • 90% of infected infants become chronically infected *in the absence of postexposure prophylaxis

Percentage of Risk by Age

PERINATAL HEPATITIS B CAN BE PREVENTED:No Second Chances To Protect Infants/Children Identifying HBV-infected (i.e., Hepatitis B surface antigen [HBsAg]-positive) pregnant women and Providing Hepatitis B immune globulin and Hepatitis B vaccine to their infants within 12 hours of birth. Completing HBV Series by 6-8 months of age. Obtain Post Vaccination Serology (PVS) 9-12 months

Let’s Do the Math • 2008, NC had 130,000 Births with only 82% receiving Prenatal Care • In the US-For every 1,000 pregnant women that give birth each year, • 1 to 2 have Hepatitis B Disease • CDC estimates detection of 360-594 HBsAg + mom- annually • NC is missing 131-365 M/I

NC Perinatal HB CDC Report

Horizontal Transmission • Infant and young children • 40-60% chance of horizontal transmission from close contact with family members • 30%-60% of children infected between 1 to 5 years of age compared with 2%-6% of older children and adults; • IMPORTANT: • Conduct serology testing and administer HBV series to HHC, needlesharing or sexual contacts of the Mother (before birth of child)

Division of Public Health LHD Agreement Addendum DETECTION Provide or assure case-management services to ensure that: 100% of pregnant women are tested for HBsAg during each pregnancy, and ii) 100% of infants born to HBsAg-positive women AND infants born to women with known or unknown HBsAg statues receives recommended immuniprophlylaxis and follow-up. http://www.immunizenc.org/VPD_surveillance.htm CASE MANAGEMENT

Benefits of Perinatal Case ManagementHigh Priority- (PCM) Managed infants are more likely to receive post-exposure prophylaxis (PEP) at birth and to complete their vaccine series on time Household and sexual contacts are more likely to be tested and vaccinated- NEDSS Coordination among OB-GYN, Prenatal, Hospital, Pediatrician, Outreach workers and health department staff

FIRST-CASE MANAGEMENT Test all pregnant women for hepatitis B surface antigen (HBsAg) reporT esTablish rapport Track HBsAg-positive pregnant woman when identified: prenatally at delivery postnatally

REPORT Contact prenatal care provider to confirm: HBsAg test results ( Obtain Copy) date of test expected date of delivery expected delivery hospital Referral HBV infection Evaluation Counseling Transfer prenatal record and copy of Lab Notify the delivery hospital

RAPPORT Discuss with HBsAg+ pregnant woman: What test results mean Referral to Provider Seriousness of infection in newborns What to expect from the LHD- “ Key to Success” Need of HBIG, HBV series & PVS at 9-12 months of age Perinatal concerns (e.g., breastfeeding is safe)

TRACK Remind woman and delivery hospital of importance of post-exposure prophylaxis for infant at birth consider giving woman card to take to hospital with instructions on care of infant consider sending hospitals monthly list of HBsAg-positive women expected to deliver

MANAGEMENT OF CONTACTS Identify all household and sexual contacts of HBsAg-positive pregnant woman Control Measures until status is known Refer contacts for serologic testing Refer susceptible contacts for hepatitis B vaccination- Refer infected contacts for medical evaluation Enter event into NEDSS

MANAGEMENT OF INFANT >2000G AT BIRTH Mother isHBsAg positive, the Infant hepatitis B vaccine within 12 hours of birth HBIG within 12 hours of birth Mother isHBsAg status unknown, the Infant hepatitis B vaccine within 12 hours of birth test mother for HBsAg ASAP if mother is HBsAg-positive  give HBIG to infant ASAP but no later than 7 days after birth

MANAGEMENT OF LOW BIRTH WEIGHT (LBW) <2000G AT BIRTH LBW infants born to HBsAg-positive or HBsAg-unknown status women should receive vaccine and HBIG ≤ 12 hours of birth HBV #1 (not counted); 2nd dose-1 given at age 1 month for infants born to HBsAg-positive women, High risk LBW infants non-responders respond to revaccination (similar to normal BW infants)

“TREATMENT” FOR THE INFANT • Provide HBIG and Hepatitis B vaccine to their infants within 12 hours of birth(7days) • Complete HBV Series by 6-8 months of age. • HBIG and HBV within 12 hrs • HBV #2 at 1-2 months of age • HBV # 3 after 6-8 months of age ( Not before 6 months of age • Obtain Post Vaccination Serology (PVS) 9-12 months ( Coordinate with visits) • If HBsAB negative- Revaccinate Series- Continued Exposure……………

TRACK THE INFANT After Birth to HBsAg+ Woman Remind pediatrician and parents need for infant to receive hepatitis B vaccine series on time (NOT ROUTINE VACCINATION) need for post-vaccination serology (PVS) of HBsAg and anti-HBs at 9-12 months of age; after 3 doses of vaccine Verify dates hepatitis B vaccines were given Coordinate PVS with MD office Review post-vaccination test results with pediatrician

TRANSFER OUT OF COUNTY/STATE • If a case moves to another county or state, coordination between health care providers is necessary to ensure completion • ( First, Call and transfer event in NEDSS) • Obtain forwarding address or phone number- PLEASE

USE YOUR RESOURCES TO TRACK Utilize electronic systems & Other Resources NEDSS NCIR Medicaid database or Medicaid Caseworker WIC Social Services Immunization Trackers Social Workers Be creative Others?

REMINDER AND RECALL SYSTEMS Notify before (reminder) and after (recall) vaccines and tests are due Use for parents, pediatricians, and case workers How postcards filled out by parent to be mailed by provider or health department computer-generated letters phone calls prompts for case workers follow up

COLLABORATION & EDUCATION • Develop Plan for Communication • Provide Guidelines • delivery hospital staff, prenatal care providers, family practitioners and pediatricians on their roles in perinatal hepatitis B prevention • Provide education materials

EVALUATE LHD PCM COMPARE THE DATA Proportion of infants receiving: HepB vaccine & HBIG within 12 hours of birth On-time completion of HepB vaccine series Post-vaccination Serology ( PVS) testing Reasons for cases lost to follow-up Document attempts in NEDSS Proportion of screened and vaccinated household and sexual contacts Serology & vaccination Enter into NEDSS

TAKE HOME POINTS • DETECTION • HBsAg + Mother • Assess Pregnancy status • Network/Educate Contact- Prenatal, Hospital • High Risk- Refugee/Other Countries • VACCINATION • Infant • HBIG & HBV- Treatment • Case Management & Track • INVESTIGATION • HHC & Sexual • Prevention & Serology • EDUCATION • Professional • Patient Resources STOP! The Cycle

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Perinatal Hepatitis B Prevention “The Silent Disease”