Hepatitis B Screening and Follow-up Vaccination of Infants of Carrier Mothers -- Atlanta, 1988 and 1989

Perinatal transmission is one of the most efficient modes of spread of hepatitis B virus (HBV). Infants born to mothers who are positive for both hepatitis B surface antigen (HBsAg) and hepatitis B e antigen (HBeAg) have a 70%-90% risk for HBV infection; 85%-90% of infected infants will remain chronically infected (1). For infants born to HBsAg-positive, HBeAg-negative mothers, the risk for chronic infection is as great as 31% (2-5). Children born to HBsAg-positive mothers not infected at birth have a 30%-60% risk for acquiring infection during the first 5 years of life (depending on the HBeAg status of the mother) (3,6). In 1988, the Immunization Practices Advisory Committee (ACIP) recommended HBsAg screening of all pregnant women during an early prenatal visit and treatment of infants born to HBsAg-positive mothers with hepatitis B immune globulin (HBIG) at birth and hepatitis B vaccine at birth, 1 month, and 6 months of age (7). To assess the implementation of these recommendations, records of treatment and follow-up of infants born to HBV-carrier* mothers were reviewed at a hospital in Atlanta.

The hospital is an 864-bed public urban hospital mainly serving the greater metropolitan Atlanta area; approximately 10,000 women are seen each year at the hospital's prenatal clinics. In July 1988, universal hepatitis screening of pregnant women was begun at the prenatal clinics. From July 1, 1988, through June 30, 1989, 85 HBsAg-positive women were identified through prenatal hepatitis screening at the hospital. This report presents findings for the 43 women who were HBsAg-positive, delivered their infants at the hospital, and resided in either Fulton or DeKalb counties.

At delivery, HBIG and the first dose of hepatitis B vaccine were administered to 42 and 41 of the 43 infants, respectively. One infant received the first dose of hepatitis B vaccine at 1 month of age; records and treatment information for one infant were unavailable. The 41 infants who received hepatitis B prophylaxis in the hospital were scheduled for vaccination follow-up by their respective county clinic.

The second dose of vaccine was administered to 39 of the infants, 33 of whom received their second dose before 2 months of age. Twenty-four of the 32 infants who were at least 6 months old as of March 15, 1990, received their third dose of vaccine; 18 of the 24 received the third dose within 1 month of their vaccine due date. The hepatitis B vaccination completion rate was comparable to the 73% completion rate for the third dose of diphtheria and tetanus toxoids and pertussis vaccine in the same infants. None of the infants in this study has been tested for anti-HBs.

In DeKalb County, a computer-based system is used to track childhood vaccination records, and hepatitis B vaccine is available at all the local health centers; 11 (92%) of 12 infants identified in that county completed the vaccine series. In contrast, 13 (65%) of 20 infants completed the vaccination series in Fulton County, which uses a manual "tickler file" and makes hepatitis B vaccine available at one vaccination clinic.

HBsAg tests were repeated during the prenatal period for 35 women who were identified as HBsAg-positive. Of these, 10 (29%) seroconverted to HBsAg-negative before delivery; five of the 10 women developed antibody to HBsAg or had liver enzyme elevations that resolved by the time of seroconversion, suggesting recent acute HBV infection. Reported by: B Sweeney, B Stoll, MD, D Vroon, MD, Grady Memorial Hospital, Atlanta; AM Mullen, DeKalb County Board of Health; J Sarver, Fulton County Board of Health; R Keith Sikes, DVM, State Epidemiologist, Georgia Dept of Human Resources. Hepatitis Br, Div of Viral and Rickettsial Diseases, Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: In the United States, an estimated 18,775 infants are born to HBsAg-positive women each year. Without adequate hepatitis B prophylaxis at delivery, an estimated 4000 of these infants can become chronically infected with HBV (CDC, unpublished data, 1989). More than 90% of such perinatally acquired HBV infections can be prevented through administration of HBIG and hepatitis B vaccine as soon as possible after birth, followed by completion of the hepatitis B vaccine series at 1 and 6 months of age (7). Testing infants for HBsAg and anti-HBs is also recommended at 12-15 months of age to monitor the effectiveness of therapy (7). With implementation of the ACIP recommendation that all pregnant women be screened for HBsAg, state vaccination programs must ensure that infants born to HBV-carrier mothers receive complete hepatitis B prophylaxis as a part of their routine childhood vaccination program.

Hepatitis B screening and vaccination programs for infants of carrier mothers must address specific operational issues. For example, before infants can receive their second and third doses of vaccine, information about the need for hepatitis B vaccine must be conveyed from the newborn nurseries to the infants' pediatric-care providers. For those infants who receive primary and/or preventive health services in the public sector, information is usually transmitted from the hospital where the infant was born to the county health department and/or the local health-care center. These programs may then be responsible for tracking HBV-carrier mothers and ensuring that infants receive three doses of vaccine.

Health education efforts must be directed at HBsAg-positive mothers to emphasize the importance of hepatitis B prevention; for example, vaccination reminders may be provided to HBsAg-positive mothers when they are discharged from the hospital. Local health centers and county health departments should incorporate hepatitis B vaccination into the tracking systems used to follow infants for routine childhood vaccinations to assure a high rate of follow-up. In addition, personnel in pediatric well-baby and vaccination clinics should identify infants for whom hepatitis B vaccine is indicated and ensure these infants complete the vaccine series. Centralized immunization files can be used to follow contacts of HBV-carrier women identified by prenatal screening (i.e., household members and sex partners), for whom HB vaccine is also recommended (1).

References

1. ACIP. Protection against viral hepatitis: recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR 1990;39(no. RR-2).

2. Stevens CE, Neurath RA, Beasley RP, et al. HBeAg and anti-HBe detection by radioimmunoassay: correlation with vertical transmission of hepatitis B virus in Taiwan. J Med Virol 1979;3:237-41.

3. Beasley RP, Trepo C, Stevens CE, et al. The e antigen and vertical transmission of hepatitis B surface antigen. Am J Epidemiol 1977;105:94-8.

4. Shiraki K, Yoshihara N, Sakurai M, et al. Acute hepatitis B in infants born to carrier mothers with antibody to hepatitis B e antigen. J Pediatr 1980;97:768-70.

5. Tong MJ, Sinatra FR, Thomas DW, et al. Need for immunoprophylaxis in infants born to HBsAg-positive carrier mothers who are HBeAg negative. J Pediatr 1984;105:945-7.

6. Beasley RP, Hwang LY. Postnatal infectivity of hepatitis B surface antigen-carrier mothers. J Infect Dis 1983;147:185-90.

7. ACIP. Prevention of perinatal transmission of hepatitis B virus: prenatal screening of all pregnant women for hepatitis B surface antigen. MMWR 1988;37:341-6,351. *A person who is either HBsAg-positive on at least two occasions (at least 6 months apart) or who is HBsAg-positive and IgM anti-HBc-negative when a single specimen is tested.

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