Prevention of Perinatal and Childhood Hepatitis B Virus Infections Background on Where Weve Been - PowerPoint PPT Presentation

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Prevention of Perinatal and Childhood Hepatitis B Virus Infections Background on Where Weve Been

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Modes of HBV Transmission. in Early Childhood. Vertical transmission from mother to infant ... Both modes of transmission can be prevented by vaccination of newborns! ... – PowerPoint PPT presentation

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Title: Prevention of Perinatal and Childhood Hepatitis B Virus Infections Background on Where Weve Been


1
Prevention of Perinatal and Childhood Hepatitis B
Virus InfectionsBackground on Where Weve Been
  • Lisa Jacques-Carroll, MSW
  • Immunization Services Division, CDC

2
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)

3
Chronic Liver Disease Caused by HBV Infection
4
Consequences of HBV Infection in Infants and
Young Children
  • 90 of infants and 30 of children lt5 yrs who
    acquire HBV infection become chronically infected
  • 25 of those with chronic infection die
    prematurely of liver cancer or cirrhosis

5
Estimated Age at Infection of Persons with
Chronic HBV Infection Before Childhood
Vaccination, US
Newborn 18
Adult 59
Children 18
Adolescent 6
Sources National Health and Nutrition
Examination Survey III N Engl J
Med 19893211301-5 Pediatrics
199289269-73 Pediatrics
1995961113-6
6
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!

7
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

8
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 961113-6 Pediatrics, 2001,
1085, 1123-28
9
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 lt 19 years
  • Vaccination of previously unvaccinated adults in
    high risk groups

10
Reported Acute Hepatitis B Incidenceby Age
Group US, 1990-2004
20 years
71 decline
94 decline
12-19 years
Cases per 100,000
lt12 years
Year
11
Gaps in Prevention of Perinatal and Early
Childhood Hepatitis B Virus Infections
  • lt50 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
  • lt50 of all infants receive first dose at birth

12
Identified and Expected Births to HBsAg-Positive
Mothers, US, 1993-2003
23,827
Expected number
19,043
48
Percent identified
41
Source National Immunization Program, CDC
13
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 45584-7
14
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
15
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 providers prenatal record
  • Suspended routine birth dose of Hepatitis B
    vaccine due to thimerosal concern

16
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

17
Receipt of Hepatitis B Vaccine at Birth Among
Infants Born to Women with Unknown HBsAg Status
State health department surveys of hospital
records
18
Proportion of Infants Receiving Hepatitis B
Vaccine Birth Dose, 1999-2004
Hepatitis B Vaccine 0-2 Days from Birth
53.7
46.0
Source CDC, National Immunization Survey
19
Hepatitis B Vaccine Birth Dose Coverage, 2004
No. of states
Coverage
lt30
9
30-39
7
40-49
7
50-59
5
60-69
15
70-79
5
0-2 days from birth
gt80
2
20
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

21
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
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