Epidemiologic Notes and Reports Maternal Hepatitis B Screening Practices -- California, Connecticut, Kansas, and United States, 1992-1993

Each year in the United States, an estimated 22,000 infants are born to women with chronic hepatitis B virus (HBV) infection. These infants are at high risk for perinatal HBV infection and chronic liver disease as adults. The American College of Obstetrics and Gynecology, the American Academy of Pediatrics, the American Academy of Family Practice, and the Advisory Committee on Immunization Practices each have recommended that all pregnant women be routinely tested for hepatitis B surface antigen (HBsAg) during an early prenatal visit in each pregnancy to identify newborns who require immunoprophylaxis for the prevention of perinatal HBV infection (1-4). To evaluate progress in implementing this recommendation, surveys were conducted to assess the effectiveness of maternal HBsAg screening in three states -- California, Connecticut, and Kansas -- and a sample of hospitals in the United States.

California

Since 1991, universal prenatal HBsAg screening and reporting have been required by law in California. In January 1993, the California Department of Health Services (CDHS) assessed prenatal HBsAg screening and reporting of pregnant women with chronic HBV infection in Merced and Stanislaus counties. CDHS personnel reviewed the medical records of 994 (97%) of the 1027 births that occurred in the seven hospitals with obstetric services in those two counties during September 1992. Charts of each mother and her infant were reviewed for documentation of maternal HBsAg screening.

Documentation of maternal HBsAg screening was present for 979 (98%) women, of whom 10 (1%) were HBsAg-positive. All 10 HBsAg-positive women had been reported to CDHS, and all infants received hepatitis B immune globulin (HBIG) and hepatitis B vaccine at birth.

Connecticut

To evaluate the perinatal hepatitis B prevention program in Connecticut, a systematic sample of women who delivered during January 1-February 15, 1993, was selected from the birth log of each of the seven hospitals with obstetric services in Bridgeport, Hartford, and New Haven; 80 women were selected from each hospital. Charts of each mother and her infant were reviewed for written evidence of maternal HBsAG screening results, the number and provider source of prenatal-care visits, and selected risk factors for prior HBV infection (e.g., drug use and country of birth). Of the 560 selected births, charts were available and reviewed for 538 (96%) mothers, 529 (94%) infants, and 515 (92%) mother-infant pairs.

Documentation of maternal HBsAg screening was present in 484 (90%) maternal records (range by hospital: 86%-99%), 344 (65%) infant charts, and 112 (29%) of the 385 infant discharge summaries included in the infants' charts. Women without evidence of prenatal care were more likely to have no screening results (26%) than those with evidence of prenatal care (8%) (Table_1). Of 533 mothers for whom residence was known, those who resided outside of the three cities were more likely to lack screening results (12%) than city residents (6%) (Table_1). Lack of screening was not associated with source of prenatal health care or maternal risk factors for prior HBV infection.

Kansas

To determine maternal HBsAg screening practices of physicians in Kansas, birth certificates were obtained for 454 (74%) of 613 newborns randomly selected from 3984 state public health laboratory reports on screening for metabolic diseases for infants born during May 1992. A questionnaire was mailed to the 210 physicians responsible for the 454 deliveries; 204 (97%) physicians responded and returned questionnaires with usable data for 412 births.

Of the 412 mothers, 346 (84% {95% confidence interval=80%- 88%}) had been screened for HBsAg. White women were more likely to lack screening results than women of races other than white (Table_1). Maternal factors not associated with lack of prenatal HBsAg screening included age, gravidity, level of education, timing of initial prenatal visit, and number of prenatal visits. Women cared for by family or general practitioners were more likely to lack screening results than women receiving care from obstetricians (Table_1). Physician factors not associated with prenatal HBsAg screening practices included age and board certification.

United States

In 1993, a random sample of 183 hospitals with obstetric services from the 1992 member list of the American Hospital Association were surveyed to evaluate hospital policies for maternal HBsAg screening, determine the prevalence of screening on a sample of births, identify risk factors for lack of screening, and determine the treatment given to infants of HBsAg-positive women. Medical records of 3982 infants were reviewed to identify written evidence of maternal HBsAg screening; if information was missing from the infant's record, maternal records were reviewed.

Overall, 138 (75%) hospitals had policies that maternal HBsAg screening be done before or at the time of all deliveries; 70 (51%) of these hospitals had written policies. Of the 50 hospitals located in states with laws requiring maternal HBsAg screening, 27 (54%) had written policies to screen all pregnant women. In contrast, of the 133 hospitals located in states without such laws, 32% had screening policies (p less than 0.05).

Maternal HBsAg screening results were identified for 84% of infants and were present on 60% of infant's medical records. HBsAg results were present more often in the medical records of infants born in hospitals with policies requiring maternal screening compared with hospitals that had no such policies and in states with screening laws compared with states without such laws (Table_1). Other factors associated with lack of maternal HBsAg screening results included specialty of the infant's medical-care provider and birth in a rural hospital (Table_1).

Among 3342 women who had HBsAg screening, 12 (0.4%) had chronic HBV infection. Of the 12 infants born to these women, eight received hepatitis B vaccine and HBIG at birth, two received hepatitis B vaccine alone, and two received no treatment to prevent perinatal HBV transmission.

Reported by: L Burd, M Chiang, GW Rutherford, III, MD, State Epidemiologist, California Dept of Health Svcs. A Banaie, S Dutta, M Faruqi, C Ho, A Richman, K Riester, C Rohr, H Yusuf, Yale Univ Dept of Epidemiology and Public Health; A Roome, JL Hadler, MD, State Epidemiologist, Connecticut Dept of Public Health and Addiction Svcs. R Carlson, PhD, W Craft, C Keeling, L Phillips, PhD, R Ryan, PhD, C Satzler, J Schmid, M Ummel, A Pelletier, MD, Acting State Epidemiologist, Kansas Dept of Health and Environment. Div of Field Epidemiology, Epidemiology Program Office; Epidemiology and Surveillance Div, National Immunization Program; Hepatitis Br, Div of Viral and Rickettsial Diseases, National Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: The findings in this report indicate that, although maternal HBsAg screening is well integrated into routine prenatal care, screening of pregnant women and reporting of results to health-care providers is not complete in many geographic areas. In addition, these surveys suggest that perinatal screening of mothers who, on admission, do not have screening results is not consistently practiced. The prevalence of chronic HBV infection is higher among women who have not been screened or who have not received prenatal care (5). The failure to document maternal screening results in the delivery room record has been associated with inadequate immunoprophylaxis of infants born to HBsAg-positive women (6). When maternal HBsAg status is unknown at the time of delivery, infants should receive the dose of hepatitis B vaccine recommended for infants born to HBsAg-positive women within 12 hours of birth and the recommended second and third dose at ages 1 month and 6 months (2). To ensure appropriate follow-up of all infants and linkage of the hospital records with those of well-child care providers, HBsAg status should be documented on infants' discharge summaries or vaccination records. In addition, infants born to HBsAg-positive mothers should be reported to the local health department to ensure they are tracked and receive all three doses of hepatitis B vaccine.

Universal screening and treatment of exposed infants have not been achieved for at least three reasons. First, providers may be unaware of the effects of perinatal HBV infections because newborns with HBV infection are usually asymptomatic and the adverse outcomes (e.g., chronic hepatitis, cirrhosis, and hepatocellular carcinoma) occur when they are adults. Second, laws requiring maternal HBsAg screening have been enacted in only nine states, and the national survey suggests that state laws improve HBsAg screening practices. Third, some practitioners may be selectively screening patients based on the Advisory Committee on Immunization Practices recommendations made in 1984; selective screening of pregnant women for HBsAg based on race/ethnicity or other risk group criteria listed in those recommendations can miss a substantial proportion of HBsAg-positive women (7,8).

Although routine infant hepatitis B vaccination is recommended in the United States, prevention of perinatal HBV transmission requires sustained efforts to screen pregnant women for HBsAg. The findings in this report suggest several strategies for assisting in the prevention of perinatal HBV transmission. Educational efforts for health-care providers in rural areas and for primary-care providers should emphasize the importance of screening all women for HBsAg. Hospitals should develop policies to ensure that all women are screened for HBsAg before delivery, perinatal screening is conducted for women without previous HBsAg screening results, and infants born to HBsAg-positive women receive appropriate medical treatment and are reported to the local health department. In addition, hospital policies should ensure that maternal screening results are documented in the infants' medical records and conveyed to well-child care providers. Finally, legislators should be provided information that could be used in drafting laws requiring HBsAg screening of all pregnant women.

References

1. Committee on Obstetrics, Maternal and Fetal Medicine. Guidelines for hepatitis B virus screening and vaccination during pregnancy. Washington, DC: American College of Obstetrics and Gynecology, 1990.

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

3. Committee on Infectious Diseases, American Academy of Pediatrics. Report of the Committee on Infectious Diseases. 22nd ed. Elk Grove Village, Illinois: American Academy of Pediatrics, 1991:238-55.

4. American Academy of Family Physicians. Recommendations for hepatitis B preexposure vaccination and postexposure prophylaxis. Kansas City, Missouri: American Academy of Family Physicians, 1992.

5. Silverman NS, Darby MJ, Ronkin SL, Wapner RJ. Hepatitis B prevalence in an unregistered prenatal population: implications for neonatal therapy. JAMA 1991;266:2852-5.

6. Birnbaum JM, Bromberg K. Evaluation of prophylaxis against hepatitis B in a large municipal hospital. Am J Infect Control 1992;20:172-6.

7. Kumar ML, Dawson NV, McCullagh AJ, et al. Should all pregnant women be screened for hepatitis B. Ann Intern Med 1987;107:273-7.

8. Summers PR, Biswas MK, Pastorek JG, Perroll ML, Smith LG, Bean BE. The pregnant hepatitis B carrier: evidence favoring comprehensive antepartum screening. Obstet Gynecol 1987;69: 701-4.

Table_1
Note: To print large tables and graphs users may have to change their printer settings to landscape and use a small font size.

TABLE 1. Characteristics associated with lack of maternal hepatitis B surface antigen
screening -- Connecticut, Kansas, and United States, 1992-1993
=======================================================================================
                                                   Not Screened
                                   --------------------------------------------
Area/Characteristic        Total   No.      (%)     Relative risk    (95% CI *)
-------------------------------------------------------------------------------
CONNECTICUT (n=538)

Prenatal care
  No +                       61     16     (26)         3.4          (2.0- 5.7)
  Yes                       477     37     ( 8)       Referent       (1.2- 4.2)

City resident &
  No                        335     41     (12)         2.2          (1.2- 4.2)
  Yes                       198     11     ( 6)       Referent

KANSAS (n=412)

Race
  White                     374     65     (17)         6.6          (0.9-46.5)
  Other @                    38      1     ( 3)       Referent

Obstetric provider **
  Family/General
    practitioner             98     35     (36)         3.5          (2.3- 5.4)
  Obstetrician              307     31     (10)       Referent

UNITED STATES (n=3982)

Hospital Policy
  No policy                 998    384     (39)         6.6          (5.4- 8.2)
  Nonwritten               1364    162     (12)         2.1          (1.6- 2.6)
  Written                  1620     94     ( 6)       Referent

State law
 requiring screening
  No                       2945    553     (19)         2.2          (1.8- 2.8)
  Yes                      1037     87     ( 8)       Referent

Infant's medical-care
 provider
  Family practitioner      1166    259     (22)         1.7          (1.5- 2.0)
  Other                     344     63     (18)         1.4          (1.1- 1.8)
  Pediatrician             2472    318     (13)       Referent

Hospital location
  Rural                    1536    305     (20)         1.5          (1.3- 1.7)
  Urban                    2446    335     (14)       Referent
-------------------------------------------------------------------------------
 * Confidence interval.
 + No mention in mother's chart.
 & Information for five women is unknown.
 @ Includes blacks, American Indians/Alaskan Natives, and Asians/Pacific Islanders.
** Information for seven women is unknown.
=======================================================================================

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