1. PERINATAL HEPATITIS B PREVENTION Kristin Gerard, MPH Epidemiologist, Immunization Program Connecticut Department of Public Health

2. Overview Perinatal hepatitis B and the role of DPH Reporting requirements Post-exposure prophylaxis for newborns exposed to hepatitis B How vaccination and testing differs from routine hepatitis B vaccination

3. Hepatitis B Liver infection caused by the hepatitis B virus, can be acute or chronic Transmission: Sexual contact Contact with the blood of an infected person Vertically from mother to child Estimated that 850,000-2 million people in the U.S. have chronic hepatitis B infection Higher prevalence in certain countries in Africa, eastern Europe, and eastern Asia Can lead to cirrhosis or liver cancer

4. Hepatitis B in children Young children are at the greatest risk of developing chronic hepatitis If infected with hepatitis B, approximately 90% of infants will become chronically infected, compared to about 5% of adults About 25% of people infected with hepatitis B as a child will develop cirrhosis or liver cancer

5. The role of DPH Purpose is to reduce the infant’s risk of developing hepatitis B Identify pregnant women with hepatitis B Provide education and mail information Communicate with the obstetrician about post-exposure prophylaxis for the baby Communicate with the pediatrician after delivery about vaccination and post-vaccine serological testing Track vaccine dates, obtain post-vaccine serological test results

6. Identifying pregnant women with hepatitis B Healthcare providers are required to report by mail acute hepatitis B and HBsAg+ pregnant women within 12 hours of recognition or strong suspicion Rarely happens Laboratories are required to report positive HBsAg results and positive IgM anti-HBc results These do not contain pregnancy status DPH calls the ordering provider of every HBsAg+ lab report on a woman of childbearing age to ascertain pregnancy status

7. How DPH actually learns about pregnant women with hepatitis B

8. Post-exposure prophylaxis in the hospital If mom is HBsAg positive (+) Administer hepatitis B immune globulin (HBIG) and the first hepatitis B vaccine within 12 hours of birth If mom’s hepatitis B status is unknown Administer the first hepatitis B vaccine within 12 hours of birth and test the mother for HBsAg. If results show she is positive, administer HBIG within 7 days of birth. If mom is HBsAg negative (-) Administer the first hepatitis B vaccine before hospital discharge

9. Vaccination of the newborn exposed to maternal hepatitis B Similar to the standard hepatitis B childhood schedule, but with less flexibility: It is also acceptable to use Pediarix and vaccinate at birth, 2, 4, and 6 months of age Administering the 3 rd dose at 6 months of age allows for post-vaccine serological testing to be performed at 9-12 months of age DoseRoutine schedulePerinatal hepatitis B schedule 1Birth, before hospital dischargeWithin 12 hours of birth 21-2 months of age 36-18 months of age6 months of age

10. Special circumstance: Babies weighing less than 2000g at birth Babies weighing <2000g at birth to a mom with hepatitis B require 4 hepatitis B doses: Dose 1 within 12 hours of birth (also administer HBIG). This dose does not count as part of the series. Dose 2 at 1 month, 2-3 months, and 6 months of age or at 2, 4 and 6 months of age if using Pediarix http://www.cdc.gov/hepatitis/hbv/pdfs/correctedtable4.pdf

11. Post-vaccine serological testing Performed at 9-12 months of age, at least 1 month after the last hepatitis B dose Test for HBsAg and anti-HBs quantitative Need to test for both to confirm that the infant is not infected with hepatitis B and is also immune Anti-HBs results need to be ≥10 mIU/mL DPH mails a reminder letter and form to fill out when the testing is complete

12. If the baby is not immune… If PVST results show that the baby is not immune (anti- HBs <10 mIU/ML) and is not infected (HBsAg negative) then a second hepatitis B series should be administered Repeat PVST 1-2 months after the final dose (HBsAg and anti-HBs quantitative) If PVST results show that the baby is infected (HBsAg+), refer for medical evaluation and follow-up

13. Conclusion Hepatitis B in a pregnant woman needs to be communicated between providers, the birth hospital, and the pediatrician for proper case management of the infant HBIG and the first hepatitis B vaccine must be given within 12 hours of birth Post-vaccine serological testing performed at 9-12 months

14. Questions?