Approaches to Eliminating Perinatal HBV Transmission – Report from an HHS Technical Consultation
One of the four overarching goals of the Action Plan for the Prevention, Care, and Treatment of Viral Hepatitis (Action Plan) is the elimination of mother-to-child transmission of HBV. To advance our efforts toward that goal, in September 2015, the Department of Health and Human Services (HHS) convened a one-day technical consultation, bringing together over 40 diverse experts and stakeholders. The consultation yielded a number of practical recommendations and identified model programs and policies that would, if widely implemented, reduce mother-to-child transmission of hepatitis B. The full meeting report on the Technical Consultation on the Elimination of Perinatal Hepatitis B in the United States is now available.
Perinatal Hepatitis B Transmission in the U.S.
Despite the availability of effective hepatitis B vaccines and recommendations for post-exposure prophylaxis (PEP) for babies born to hepatitis B-infected mothers, approximately 1,000 babies are perinatally infected with hepatitis B each year in the United States. (Ko, et al. 2014) Infants infected with hepatitis B have a 90% risk of developing a chronic infection, and 25% of those chronically infected as infants die prematurely due to hepatitis B-related liver disease and liver cancer. (Schillie, et al. 2015Exit Disclaimer)
Tools are available to prevent perinatal hepatitis B infection in most babies. Timely PEP is 85% - 95% effective in preventing hepatitis B transmission. (Schillie, et al. 2015)Exit Disclaimer Importantly, further reduction of transmission is possible if women at high risk are identified and referred for treatment in the third trimester. Newly released guidelines by the American Association for the Study of Liver Disease for the treatment of chronic hepatitis BExit Disclaimer now include guidance on treatment of pregnant women. To facilitate linkage of expectant women to appropriate services, since 1990 the Centers for Disease Control and Prevention (CDC) has funded the national Perinatal Hepatitis B Prevention Program (PHBPP) to identify pregnant women with chronic hepatitis B infection, provide them with health information about HBV and ensure that their infants receive timely PEP. The PHBPP provides case management to 98% of infants reported to the program; however, only half of all pregnant women with chronic HBV infection are linked to the PHBPP. (Smith, et al. 2012Exit Disclaimer)
During the consultation, participants discussed approaches to improving outcomes at each stage of the perinatal hepatitis B prevention pathway, beginning with identification of infected pregnant women, through to successful confirmation of infant vaccination.
Existing Perinatal Hepatitis B Prevention Recommendations
One of the recommendations developed during the meeting was to promote more widespread awareness of and adherence to existing perinatal hepatitis B transmission prevention guidelines among healthcare providers. The U.S. Preventive Services Task Force (USPSTF) recommendsExit Disclaimer hepatitis B screening at the first prenatal visit (Grade A). CDC recommends that all pregnant women should be routinely tested in the first trimester, even if they were previously vaccinated or tested. Both recommend:
- Screening women with unknown status or at higher risk when admitted for delivery.
- PEP within 12 hours of birth for infants born to mothers who test hepatitis B surface antigen (HBsAg) positive (i.e. chronically infected).
- Infants born to mothers with unknown hepatitis B status should receive hepatitis B vaccine within 12 hours of birth. If the mother is determined to have HBV, hepatitis B immune globulin (HBIG) should be administered to the infant as soon as possible (up to 7 days after birth).
- Pregnant women who test HBsAg positive should receive referral to the PHBPP, counseling and medical management, and information about hepatitis B.
Other Stakeholder-Recommended Approaches
Participants shared their experiences and suggested other areas in which more work is needed, offering recommendations including:
- Engaging patients and communities disproportionately impacted by hepatitis B;
- Strengthening systems to enhance prevention efforts; and
- Expanding and refining research efforts.
The technical consultation identified helpful policies and best practices, as well as gaps and areas where additional research is needed. Participants underscored that enhanced implementation of guidelines, sound policies and model practices-- as well as strategic collaborations-- are needed to improve outcomes for all babies born to mothers infected with hepatitis B and to ultimately eliminate perinatal hepatitis B in the United States. Read the full report from the HHS technical consultation on the Elimination of Perinatal Hepatitis B in the U.S.