Detection of chronic hepatitis B through antenatal screening in Northern Ireland: what happens to the mother ?

1. Detection of chronic hepatitis B through antenatal screening in Northern Ireland: what happens to the mother? Emilia Mamwa, Conall McCaughey, Peter Coyle, Say Quah, Neil McDougall Royal Victoria Hospital, Belfast HSC Trust

2. BACKGROUND • Antenatal screening for hepatitis B has been recommended for the UK since 1998 • Subsequent appropriate action for both the neonate and mother is recommended. • All antenatal hepatitis B screening in Northern Ireland is carried out in a single laboratory

3. BACKGROUND • The outcome for mothers with a positive hepatitis B result has not been assessed previously. • An increase in referrals to the RVH Liver Unit has been noted, suggesting: • either the number of positive cases detected is increasing • or referral of positive cases to appropriate specialist services is improving.

4. Aims of The Audit • To assess our compliance with national guidelines regarding referral and follow-up for antenatally diagnosed hepatitis B positive pregnant women in Northern Ireland. • To determine reasons for any non compliance with the guidelines

5. Audit Standards (based on UK guidelines) • All HBsAg positive patients should be seen within 6 weeks by either a hepatologist, gastroenterologist or GUM specialist • 2) Referral rates should be audited annually and a target rate of 100% referral should be accepted • 3) All patients who are found to be HBsAg should have the following tests performed- • HBV serology – including HBeAg status • HBV DNA level • Delta virus testing • HIV testing • HCV testing • Liver function tests, including tests of synthetic function (INR) • Liver ultrasound

6. Audit Methods (1) • A retrospective study. • The RVL database was searched for all hepatitis B positive pregnant women from January 2004 to December 2010.

7. Methods (2) Three approaches used to assess referral and follow-up: • Review of maternity case notes • Review of laboratory records (subsequent serology samples used as a marker of follow up): • Use of specimen source to indicate the speciality undertaking follow-up • Samples originating from GPs were not considered as appropriate follow-up. • No subsequent sample indicated no patient follow up. • Review of the GUM patient database for any documented evidence of follow up

8. Number of hepatitis B surface antigen (HBsAg) positive cases

9. Patient Ethnicity

10. % Positives by ethnicity per year

11. Number Followed up per Year

12. % Follow Up Over Time

13. Follow up of HBeAg Positive cases

14. Follow up by specialty

15. Hepatitis B DNA Testing

16. CONCLUSION • Vast majority of chronic hepatitis B patients detected have non-UK ethnicity • Significant improvement in referral rates over past 7 years • Appropriate testing is done on those referred • Over 50% of women with chronic hepatitis B detected through antenatal screening are not seen by appropriate specialist services.

17. RECOMMENDATIONS • Multi-language information dissemination • Appointment of Hepatitis Liaison Nurses to communicate with the mothers and arrange referral • Short referral to waiting times before first appointments • GP input in tracking down all pregnant hepatitis B patients lost to follow up. • Further audit on follow up of children born to these mothers