Title: Prevention of Perinatal and Childhood Hepatitis B Virus Infections Background on Where Weve Been
1Prevention of Perinatal and Childhood Hepatitis B
Virus InfectionsBackground on Where Weve Been
- Lisa Jacques-Carroll, MSW
- Immunization Services Division, CDC
2Hepatitis 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)
3Chronic Liver Disease Caused by HBV Infection
4Consequences 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
5Estimated 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
6Modes 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!
7Vaccine 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
8Vaccine 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
9Strategy 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
10Reported 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
11Gaps 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
12Identified 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
13Case 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
14Medical 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
15Perinatal 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
16Recent 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
17Receipt of Hepatitis B Vaccine at Birth Among
Infants Born to Women with Unknown HBsAg Status
State health department surveys of hospital
records
18Proportion 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
19Hepatitis 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
20Rationale 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
21Perinatal 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