What Obstetricians Need to Know

As you provide prenatal care:

• Test pregnant women during each pregnancy for Hepatitis B surface antigen (HBsAg), even if they were previously vaccinated or tested.  Indicate on lab requisition ‘prenatal’.

Perinatal Algorithm - Screening and Referral Algorithm for Hepatitis B Virus (HBV) Infection among Pregnant Women

• Send a copy of the original HBsAg test result for current pregnancy with prenatal records to the delivery hospital.

• Submit a report of all HBsAg+ pregnant women (with each pregnancy) to the DOH (Perinatal Hepatitis B Prevention Program [PHBPP] and HAHSTA within 48 hours.

• Conduct viral load and e-antigen testing as indicated to guide care and consider prenatal antiviral therapy. Inform and counsel HBsAg+ women about their status and refer for appropriate care with infectious disease specialist. Increase viral load of the mother has been associated with increased likelihood of transmission of perinatal Hepatitis B.

• Contact the expected delivery hospital to communicate the mother’s HBsAg+ status (with original lab work). Convey the need for Hepatitis B vaccination and Hepatitis B Immune Globulin (HBIG) for the infant within 12 hours of birth. Partner with mother’s selected pediatrician to promote the Hepatitis B vaccine birth dose for all mothers.

• Assess HBsAg negative pregnant woman’s risk for hepatitis B infection (may have high risk sexual partner). Retest high risk pregnant HBsAg+ women in their last trimester. Counsel HBsAg negative mothers on methods to prevent HBV transmission.

• Counsel HBsAg+ pregnant woman on methods to prevent HBV transmission on each visit. Talk about importance of birth dose and HBIG administration as well as post-vaccine serology testing (PVST) for infant at 9 - 12 months of age.  Adult learners often need to hear information several times before full understanding is achieved. Have clients restate understanding of counseling.

• Vaccinate pregnant women with Tdap and flu each pregnancy.

Links of Interest

• ACOG Endorses New Guidance and Algorithm for Prenatal HBsAg Tests: The Importance of Screening Pregnant Women for Hepatitis B Infection (September 2015)
• Ordering Prenatal Hepatitis B Surface Antigen (HBsAg) Test from Major Clinical Laboratories
• Effects of hepatitis B immunization on prevention of mother-to-infant transmission of hepatitis B virus and on the immune response of infants towards hepatitis B vaccine
• States Report Hundreds of Medical Errors in Perinatal Hepatitis B Prevention
• International Journal of Hepatology   
• Hepatitis B Serology 

What Hospital/ Nursing Staff Need to Know

For each intra-partum admission:

• Review the maternal HBsAg (antigen) original test result for the current pregnancy. Medical errors frequently occur as a result of second-hand incorrect transcription or misinterpreting HBsAg (antigen) versus HBsAb (antibody) results.  Refer to CDC resource Interpretation of Hepatitis B Serological Results as needed.
• Hepatitis B prevention when maternal HBsAg results are available
• Hepatitis B prevention when maternal HBsAg results are unavailable
• Flag or highlight HBsAg (antigen) positive results on both labor and delivery record and on infant’s delivery and problem summary sheet. Communicate the positive HBsAg+ status to neonatal team and nursing staff prior to delivery.
• Adopt standard CDC recommended procedures for mothers presenting for delivery with an unknown HBsAg status, without original lab report of HBsAg status, or presenting with high risk factors for hepatitis B, order a STAT HBsAg (antigen) test.
• http://www.cdc.gov/hepatitis/HBV/PerinatalXmtn.htm
• Educate mothers on HBsAg positive status on each delivery admission in primary language spoken. Give literature in their language available through various websites:
• Patient Education Tools
• Stanford Medicine Asian Liver Center 
• Report all unknown and confirmed positive HBsAg (antigen) deliveries to the state Perinatal Hepatitis B Nurse Case Coordinator for case management through:

The PHBPP Case Coordinator follows the infant to ensure communication with pediatric provider, timely dosing of Hepatitis B vaccine, and post-vaccine serology testing completion at 9 – 12 months of age.

• Refer to guide by Immunization Action Coalition What Hospitals Need to do to Protect Newborns http://www.immunize.org/protect-newborns/guide/birth-dose.pdf

For each infant admission:

• Give all infants single-antigen Hep B vaccine within 12 hours of birth. Adopt a universal birth dose policy according to the AAP and CDC recommendations.
• Obtain original HBsAg (antigen) laboratory results of mother for current pregnancy and place copy in the record of all infants.
• Upon determining positive HBsAg status, administer HBIG and Hepatitis B single antigen vaccine within 12 hours of birth. Document date and time of administration and include in report to PHBPP nurse case manager.
• Obtain in-house lab report of unknown HBsAg maternal status infants and administer HBIG before discharge if found to be HBsAg positive.  Adopt an HBIG administration policy before discharge if lab results take longer than 24 hours.
• Manage low birth weight/preterm  infants according to CDC guidelines http://www.cdc.gov/hepatitis/hbv/pdfs/correctedtable4.pdf
• Provide documentation of Hepatitis B vaccine (and HBIG administration record if given) as well as original maternal HBsAg lab results to mother upon discharge to provide to pediatrician of choice.

What Pediatric/Family Practice Providers Need to Know

The Hepatitis B Birth Dose

Pediatricians and family practice physicians have a critical role in Hepatitis B prevention. Promotion of the Hepatitis B birth dose for all infants in your care is a step to lead to the reduction of perinatal transmission of the Hepatitis B virus. According to the CDC’s Advisory Committee on Immunization Practices (ACIP), the birth dose provides a safety net for infants as medical errors lead to infant susceptibility to perinatal hepatitis B transmission.

The following are some of the ways infants who are not vaccinated at birth become infected:

• The mother is HBsAg negative but the infant is exposed to HBV infection post-natally from another family member or caregiver. This occurs in two-thirds of the cases of childhood transmission.
• The woman is tested in early pregnancy for HBsAg and is found to be negative. She develops HBV infection later in pregnancy but it is not detected, even though it is recommended by CDC that high-risk women be retested later in pregnancy. The infection is not clinically detected by her health care provider so her infant does not receive hepatitis B vaccine or HBIG at birth.
• A chronically infected pregnant woman is tested but with the wrong test, HBsAb (antibody to hepatitis B surface antigen), instead of HBsAg. This is a common mistake since these two test abbreviations differ by only one letter. Her incorrectly ordered test result is "negative," so her doctor believes her infant does not need post-exposure prophylaxis.
• The pregnant woman is tested and found to be hepatitis B surface antigen (HBsAg) positive, but her status is not communicated to the newborn nursery. The infant receives neither hepatitis B vaccine nor HBIG protection at birth.
• The pregnant woman is not tested for HBsAg either prenatally or in the hospital at the time of delivery. Her infant does not receive hepatitis B vaccine in the hospital even though the vaccine is recommended within 12 hours of birth for infants whose mothers' test results are unknown.
• The pregnant woman is HBsAg+ but her test results are misinterpreted or mis-transcribed into her prenatal record or her infant's chart. Her infant does not receive HBIG or hepatitis B vaccine.

Timely Dosing

Timely administration of the Hepatitis B vaccine for infants is important in developing immunity in all infants. For infants born to HBsAg+ mothers, it is recommended by the ACIP that all three doses of Hepatitis B be completed by the six month visit. Combination vaccines can be used to complete the series. Record of vaccines administered should be directed to the District of Columbia Immunization Information System (DOCIIS) registry within seven days.

Post Vaccine Serology Testing

Infants who are born of mothers who are HBsAg+ need to get tested for both Hepatitis B Surface Antigen (HBsAg) and Hepatitis B Surface Antibody (HBsAb). This will tell whether the infant is immune, still susceptible, or infected with the hepatitis B virus.  Begin early to tell parents that an important blood test will be done at age 9 - 12 months to give important information about the baby’s course of treatment. Across the nation only 63 % of parents complete post-vaccine serology testing (PVST). Helping to identify barriers to testing early can increase the likelihood that serology testing will be completed.  This is the only way to make sure infants have received effective treatment and are protected from to hepatitis B infection. 
 

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