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Management of Babies Born to HBsAg- Positive Mothers

Management of Babies Born to HBsAg- Positive Mothers. Vickie Weeast Perinatal Hepatitis B Case Manager Colorado Department of Public Health & Environment. Hepatitis B Virus. About Hepatitis B Infection. Spread by: Sexual Parenteral Perinatal Acute and/or Chronic

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Management of Babies Born to HBsAg- Positive Mothers

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  1. Management of Babies Born to HBsAg- Positive Mothers Vickie Weeast Perinatal Hepatitis B Case Manager Colorado Department of Public Health & Environment Viral Hepatitis Program http://www.hepatitiscolorado.info

  2. Hepatitis B Virus Viral Hepatitis Program http://www.hepatitiscolorado.info

  3. About Hepatitis B Infection • Spread by: • Sexual • Parenteral • Perinatal • Acute and/or Chronic • Chronic infection is a leading cause of liver disease. Viral Hepatitis Program http://www.hepatitiscolorado.info

  4. Hepatitis B – Clinical Features • Incubation period: Average 120 d • Range 45-160 d • Clinical illness (jaundice): <5 yrs, <10%>5 yrs, 30%-50% • Acute case-fatality rate: 0.5%-1% • Chronic infection:<5 yrs, 25%-90%>5 yrs, 6%-10% • Premature mortality fromchronic liver disease:15%-25% Viral Hepatitis Program http://www.hepatitiscolorado.info

  5. Acute New infection Symptoms more common among adults Children often asymptomatic. Two possible outcomes: Infection resolves: person develops immunity infection does not resolve and the person continues to carry the virus Chronic Individual carries the virus for >6 months and does not develop anti-bodies to the surface antigen (anti-HBsAg) Silent infection People that become infected as children are more likely to become chronically infected. Phases of HBV Infection Viral Hepatitis Program http://www.hepatitiscolorado.info

  6. HBsAg: (hepatitis B surface antigen) Marker of current infection Neutralization HBsAb: (hepatitis B surface antibody) Marker of immunity HBeAg: (hepatitis B e antigen) Marker of high infectivity Anti-HBe (hepatitis B e antibody) Marker of low infectivity Anti-HBc IgM (hepatitis B core antibody IgM) If +, acute infection if negative and HBsAg +, chronic infection Anti-HBc (hepatitis B core antibody) Marker of current or previous infection HBV Testing

  7. People at Risk for HBV Infection • Immigrants/refugees from areas of intermediate/high (>2%) HBV endemicity • Children born in U.S. to immigrants from areas of intermediate/high HBV prevalence • Alaska Natives and Pacific Islanders • Travelers to countries with intermediate or high prevalence (>2%) of HBV infection Viral Hepatitis Program http://www.hepatitiscolorado.info

  8. Viral Hepatitis Program http://www.hepatitiscolorado.info

  9. People at Risk for HBV Infection- cont’d • Mother is hepatitis B surface antigen positive or has not been tested • Household contacts and sex partners of people with chronic HBV infection • People who have or who have had sexually transmitted diseases • Heterosexuals with >1 sex partner in 6 months Viral Hepatitis Program http://www.hepatitiscolorado.info

  10. People at Risk for HBV Infection- cont’d • Men who have sex with men • Users of illicit injectable drugs • Healthcare and Public Safety workers in contact with blood • Hemodialysis patients • Residents and staff of facilities for developmentally disabled persons Viral Hepatitis Program http://www.hepatitiscolorado.info

  11. Perinatal Hepatitis B • 24,000 pregnant women infected with hepatitis B deliver each year • CDC estimates 150,000 pregnancies each year in women from endemic countries • Causes chronic infection. Chronic carriers have up to 25% chance of death from • Cirrhosis • Hepatocellular Carcinoma Viral Hepatitis Program http://www.hepatitiscolorado.info

  12. Perinatal Hepatitis B TransmissionIn the absence of post exposure prophylaxis* • If mother positive for HBsAg and HBeAg • 70%-90% of infants infected • 90% of infected infants become chronic carriers • If positive for HBsAg only • <10% of infants infected • 90% of infected infants become chronic carriers • *MMWR 2005:54:5 Viral Hepatitis Program http://www.hepatitiscolorado.info

  13. Perinatal Hepatitis B Infections Can Be Prevented Test all pregnant women Vaccinate all newborns Viral Hepatitis Program http://www.hepatitiscolorado.info

  14. 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 Viral Hepatitis Program http://www.hepatitiscolorado.info

  15. Prenatal Testing • All pregnant women should be tested routinely for hepatitis B surface antigen during an early prenatal visit (e.g. first trimester) in each pregnancy, even if they have been previously vaccinated or tested. • MMWR 2005:54:13 • Who: Prenatal and obstetrical care providers, hospitals Viral Hepatitis Program http://www.hepatitiscolorado.info

  16. Prenatal Testing at the Time of Delivery • Review hepatitis B surface antigen status of all pregnant women • Perform hepatitis B surface antigen testing ASAP on women who: • do not have a documented test • were at risk of infection during pregnancy even if they were tested earlier. • had clinical hepatitis since testing MMWR 2005:54:15 Viral Hepatitis Program http://www.hepatitiscolorado.info

  17. Follow-up on HBsAg+ Women • All pregnant woman that are chronically infected with hepatitis B should be clinically monitored, or treated. • The following chronically infected women should receive an ultrasound for hepatacellular carcinoma • Africans >20 years • Any carrier >40 years with persistently elevated ALT or DNA >2,000 IU/ml • Any woman with a family history of HCC Viral Hepatitis Program http://www.hepatitiscolorado.info

  18. Hepatitis B Vaccine Birth Dose • Vaccinate all newborns before hospital discharge • Protects infants born to mothers that aren’t identified perinatally • Protects infants at risk for infection after the perinatal period • Associated with higher rates of on-time completion of hepatitis B vaccine series. • Some studies show an association with improved completion rates for all other infant vaccines. • MMWR 2005:54:8-9 Viral Hepatitis Program http://www.hepatitiscolorado.info

  19. Hospital Management of Infants • Dose #1 of Hepatitis B vaccine • in the thigh within 12 hours of birth. If mom is HBsAg+ or her status is unknown, also give • HBIG 0.5 ml • in the opposite thigh IM within 12 hours of birth but no later than 7 days of age. Viral Hepatitis Program http://www.hepatitiscolorado.info

  20. PCP Management of HBsAg + Exposed Infant • Complete hepatitis B vaccination series according to the recommended schedule • Dose #2 of hepatitis B vaccine at 1-2 months of age • Dose #3 of hepatitis B vaccine at 6 months of age Viral Hepatitis Program http://www.hepatitiscolorado.info

  21. PCP Management of HBsAg + Exposed Infant • Post-vaccination testing (PVT) should be completed 1-9 months after the third dose of hepatitis B vaccine (between 9 and 18 months of age). Ideally at the child’s 9 or 12 month visit • PVT consists of both • hepatitis B surface antigen (HBsAg) and • hepatitis B surface antibody (HBsAb or anti-HBs) Viral Hepatitis Program http://www.hepatitiscolorado.info

  22. Why is Post-vaccination Testing Important? • Identifies those infants who are not protected from the vaccine. • Identifies the infants that have became chronically infected and will aid in their long-term medical management Viral Hepatitis Program http://www.hepatitiscolorado.info

  23. Infant Post-Vaccination Test Results • If HBsAg-negative & anti-HBs positive >10 mIU/mL  infant is protected • If HBsAg-negative & anti-HBs <10 mIU/mL negative  revaccinate with 3-dose hep B series  retest 1–2 months after final (6th)dose • If HBsAg-positive  refer infant for medical evaluation/management of chronic hepatitis B  report perinatal infection to CDPHE Viral Hepatitis Program Viral Hepatitis Program http://www.hepatitiscolorado.info

  24. Hospital Management of Pre-term infants weighing <2000g & Born to HBsAg+ Mom • Begin treatment within 12 hours of birth if medically stable • HBIG 0.5 ml • in the thigh IM within 12 hours of birth. • Dose #1 of Hepatitis B vaccine • in the opposite thigh within 12 hours of birth. Viral Hepatitis Program http://www.hepatitiscolorado.info

  25. PCP Management of Pre-term infants weighing <2000 grams • Do not count the birth dose as part of the hepatitis B vaccination series. The infant should receive a total of 4 hepatitis B doses • Dose #2 of hepatitis B vaccine at 1-2 months of age • Dose # 3 of hepatitis B vaccine at 2-4 months of age • Dose #4 of hepatitis B vaccine at 6 months of age Viral Hepatitis Program http://www.hepatitiscolorado.info

  26. PCP Management of Pre-term infants weighing <2000 grams • PVT should be completed in the same time frame as a full term normal birth weight infant • Ideally at the child’s 9 or 12 month visit and never before 9 months of age. Viral Hepatitis Program http://www.hepatitiscolorado.info

  27. Perinatal Hepatitis B Prevention ProjectColorado Department of Public Health & Environment Strives to prevent the spread of the hepatitis B virus to newborn children and to any household and/or sexual contacts of an HBsAg-positive pregnant woman. Viral Hepatitis Program http://www.hepatitiscolorado.info

  28. Perinatal Hepatitis B Prevention Project • Perinatal Hepatitis B Prevention Coordinator • 2 Case Managers • Nurse Consultant and Educator Viral Hepatitis Program http://www.hepatitiscolorado.info

  29. The Perinatal Hepatitis Prevention Unit Provides • Hepatitis B education to HBsAg-positive pregnant women • Hepatitis B screening for household and/or sexual contacts of an HBsAg-positive pregnant woman • Hepatitis B vaccination for susceptible contacts of an HBsAg-positive pregnant woman Viral Hepatitis Program http://www.hepatitiscolorado.info

  30. The Perinatal Hepatitis Prevention Project Provides • Clinical staff training on issues related to perinatal hepatitis B • Case management of infant born to an HBsAg-positive mother • Services are provided in a variety of languages Viral Hepatitis Program http://www.hepatitiscolorado.info

  31. Benefits of Case Management • Case managed infants are more likely to receive post-exposure prophylaxis (PEP) at birth • They are more likely to complete their hepatitis B vaccine series on time • Also more likely to complete their hepatitis B post-vaccination testing Viral Hepatitis Program http://www.hepatitiscolorado.info

  32. Helpful Websites • www.hepatitiscolorado.info • www.cdc.gov/hepatitis • www.coloradoguidelines/hepbc.orgf • www.immunize.org • www.aap.org Viral Hepatitis Program http://www.hepatitiscolorado.info

  33. Questions ? • Vickie Weeast • Perinatal Hepatitis B Case Manager • Viral Hepatitis Program • Colorado Department of Public Health & Environment • (303) 692-2715 • vickie.weeast@state.co.us Viral Hepatitis Program http://www.hepatitiscolorado.info

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