1. Preventing Perinatal Hepatitis B Virus Infections May 11, 2010 Sandra A. Morris, MPH

2. Overview National Hepatitis B Data
Perinatal Hepatitis B Prevention Program
Texas Performance in Preventing Perinatal Hepatitis B Virus Infections 2

3. At the end of this presentation
List 2 disease complications associated with chronic hepatitis B
List at least 2 perinatal hepatitis B prevention strategies
The virus is transmitted by parenteral or mucosal exposure to HBsAg-positve body fluids from persons who have acute or chronic HBV infection. The highest concentration of virus are in blood and serous fluids. Lower titers are found in other fluids such as saliva and semen. Saliva can be a vehicle of transmission through bites; however other types of exposure to saliva such as kissing are unlikely modes of transmission. There appears to be no transmission via tears, sweat, urine, stool or droplet nuclei.
In the U.S the most important route of transmission is by sexual contact either heterosexual or homosexual acts with an infected person. Fecal-oral transmission does not appear to occur; however men who have sex with men are infected via contamination from asymptomatic rectal mucosal lesions. 3

4. The Natural History of HBV Infection
Acute Infection (short term)
May be Symptomatic
>90% of exposed persons develop lifelong immunity
Chronic Infection (persists > 6 months)
Cirrhosis
Liver Cancer
Death
It is a partially double stranded DNA virus composed of numerous antigenic components including hepatitis B surface antigen, hepatitis B core antigen, and hepatitis B e antigen. It is a relatively stable virus
This infection has 2 phases: acute and chronic.
Acute (new, short-term) hepatitis B occurs shortly after exposure to the virus. A small number of people develop a very severe, life-threatening form of acute hepatitis called fulminant hepatitis.
Chronic (ongoing, long-term) hepatitis B is an infection with HBV that lasts longer than 6 months. Once the infection becomes chronic, it may never go away completely. People with chronic HBV infection are called chronic carriers. About two-thirds of these people do not themselves get sick or die of the virus, but they can transmit it to other people. The remaining one third develop chronic hepatitis B, a disease of the liver that can be very serious.
About 90-95% of people who are infected are able to fight off the virus so their infection never becomes chronic. Only about 5-10 percent of adults infected with HBV go on to develop chronic infection. 4

5. Burden of Hepatitis B in the U.S.
800,000 to 1,400,000 persons are chronically infected
43,000 estimated new infections in 2007
3,000 deaths annually from chronic hepatitis B liver disease
4,519 acute, symptomatic cases reported in 2007
The Hepatitis B Infection is an established cause of chronic hepatitis B and cirrhosis
It is a human carcinogen and is responsible for up to 80% of the liver cancers – it is one of 3 known human carcinogens (tobacco and human papillomavirus
More than 350 million people are chronically infected worldwide
Approximately 90% of adults resolve their initial HBV infection and will develop lifelong immunity.
The remaining adults will not resolve their infection and will become chronic carriers.
Chronic carriers are capable of transmitting disease to others
As many as 90% of infants who acquire HBV from their mother at birth become chronically infected 5

6. Perinatal Hepatitis B Infections
83 perinatal hepatitis B cases reported in 2007 for 22 states
Under reporting
Chronic (ongoing, long-term) hepatitis B is an infection with HBV that lasts longer than 6 months. Once the infection becomes chronic, it may never go away completely.
Many people are at high risk of acquiring the disease: persons with multiple sexual partners, persons diagnosed with an STD, men who have sex with men, injection drug users, household contacts to an infected person, hemodialysis patients, health care workers, including persons born in countries where it is endemic such as
Asia
Pacific Islands
Africa
Caribbean islands
Areas of South America and the Middle East
Indigenous populations of Alaska, Australia and New Zealand 6

7. Purpose of Administering Hepatitis B Vaccine
Post Exposure Prophylaxis
Pre-Exposure Protection

8. Perinatal Hepatitis B Prevention Strategies
Identify HBsAg-positive pregnant women through serologic testing prenatally and at delivery for each pregnancy
Prophylactic treatment of infants born to HBsAg-positive women
Provide the birth dose to ALL newborns 8

9. Program Review
How are we doing to prevent perinatal hepatitis B infections? 9

10. Number of Reported Infants Born to HBsAg-Positive Women in Texas
Based upon the prevalence estimates from the NHANES (National Health and Examination Survey), between 800 to 1200 infants are born to HBsAg-positive women every year in Texas.
In 2006 , 553 infants were identified as born to HBsAg + women
505 were case managed ( 46 moved and 2 died)
In 2007, 654 born to HBsAg positive women in Texas a 18% increase
606 were case managed (42 moved and 6 died)
In were identified and 597 case managed (17 transferred and 2 died)
6% decrease from the previous year 10

11. Texas Challenge
1,200 infants are born to HBsAg positive women every year in Texas
In 2008, ONLY 616 or 51% of infants were reported and of these infants,
597 were case managed (17 moved 2 died)
94 % received HBIG and first dose Hep B vaccine
54% completed vaccine series by 8 months; 70% in 2007
35% received post vaccination serology testing; 52% in 2007
Based upon the prevalence estimates from the NHANES (National Health and Examination Survey), between 800 to 1200 infants are born to HBsAg-positive women every year in Texas.
In 2006, 553 infants were identified or 46% of 1200 infants (NHANES estimate)
In infants were case managed ( 46 moved, 2 died)
Of the 505 infants : 456 (90 %) received HBIG and Hep B birth dose
Only 365 (72%) received HBIG and the completed the
vaccine series by 8 months of age
and or (53%) received post vaccine serology to
determine the child’s status.
This means that based upon the prevalence estimates from NHANES, only 553/1200= 46% of infants born to HBsAg women were identified. In other words, 647 infants born to HBsAg + women were not identified . Potentially hundred of household and sexual contacts of these positive women were not identified and offered vaccination , serology testing or medical follow up. 11

12. Contact Management, 2008 Number of Contacts Identified: 494
Number of Contacts Immune to Hepatitis B: 247
Number of Infected Contacts:
Number of Contacts – No Known Status 232
Number of Susceptible Contacts:
Number of Contacts Receiving Hep B
Number of Contacts Receiving Hep B 12

13. Prevention Outcome
Increase life expectancy
Increase quality of life
Reduce health care cost
Hepatitis B vaccine series cost $27.00
A new liver costs $1,000,000.00