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Many U.S. Babies Do Not Receive Recommended Therapy to Prevent Hepatitis B Infection

About 14% of babies born to mothers with hepatitis B virus (HBV) and about 20% born to women of unknown HBV status in the U.S. do not receive recommended vaccinations or other therapies to prevent them from acquiring the virus, according to a CDC analysis of practices at more than 200 hospitals described in the April 2010 issue of Pediatrics.

HBV can be transmitted from mother to child during pregnancy or delivery, but the risk can be minimized with post-exposure prophylaxis (PEP) using hepatitis B vaccination, injected antibodies (HBV immune globulin or HBIG), or both.

The Centers for Disease Control and Prevention (CDC) recommends that pregnant women should be tested for HBV and that infants born to HBV positive mothers should receive their first dose of the HBV vaccine at birth, with additional "booster" shots at 1 and 6 months. Beyond this recommendation, HBV vaccination is included in the schedule of routine infant immunizations.

Bayo Willis and CDC colleagues assessed hospital policies and practices to prevent perinatal transmission of HBV and to identify gaps that could be addressed to improve outcomes.

Despite availability of PEP, approximately 40-90 perinatal HBV infections are reported to the CDC each year, and experts think the true number of annual perinatal infections may be 10-20 times higher, the researchers noted as background. These infections may occur as a result of various errors including lack of maternal prenatal hepatitis B surface antigen (HBsAg) testing and reporting, failure to test all women who are admitted to delivery hospitals without prenatal HBsAg test results, lapses in reporting and documentation of test results in maternal and newborn medical records, and failure to administer timely post-exposure prophylaxis.

In March 2006, the investigators sent a policy survey to nursing supervisors or clinical nurse managers of childbirth departments at a representative sample of 242 delivery hospitals in the 50 states, Washington, DC, and Puerto Rico that oversaw at least 100 births per year. They also review paired mother-infant medical records for 25 consecutive live births between October 2005 and March 2006.

Results

• 190 of the 242 hospitals (78.5%) responded to the survey and provided medical records for 4762 mothers and 4786 infants.
  
• 63.0% to 80.6% of surveyed hospitals reported having various policies related to infant hepatitis B prevention:

• 63.0% screened pregnant women for HBV upon admission if they had no existing known test result.
• 67.0% had a policy requiring HBV vaccination of all newborns before hospital discharge;
• 77.2% had a policy to administer HBIG to infants born to mothers with HBV;
• 80.6% had a policy to give the HBV vaccine to infants born mothers with hepatitis B.

• 18 women had a documented positive prenatal HBsAg test and 3 tested positive upon hospital admission (combined prevalence 0.9%).
• 62.1% of infants born to the 18 women with positive HBsAg prenatal tests received both the HBV vaccine and HBIG within 12 hours after birth.
• However, 13.7% of these eligible infants were not vaccinated and 19.7% did not receive HBIG before hospital discharge.
• Among infants born to 320 women with unknown HBsAg status, 52.4% were vaccinated within 12 hours after birth.
• Within this group of infants, 20.1% were not vaccinated before discharge.
• Among infants born to mothers known to be HBsAg negative, 69.1% received the hepatitis B vaccine before hospital discharge.
• Overall, 68.7% of infants received the first dose of hepatitis B vaccine at birth.
• The strongest predictor of vaccine administration was having a written hospital policy for newborn hepatitis B vaccination.

"Given the existence of highly effective PEP, perinatal HBV transmission can be almost entirely prevented, but gaps in the delivery hospital prevention policies and practices persist," the study authors concluded. " Universal newborn hepatitis B vaccination, together with timely administration of appropriate prophylaxis to infants who are born to HBsAg-positive women and women of unknown HBsAg status, are essential hospital clinical practices for preventing perinatal HBV infections."

"Efforts to avoid medical errors through appropriate implementation and monitoring of hospital practices are needed to eliminate perinatal HBV transmission," they added.

Immunization Services Division and Global Immunization Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention (CDC), Atlanta, GA; National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention, Division of Viral Hepatitis, CDC, Atlanta, GA.

4/13/10

Reference

BC Willis, P Wortley, SA Wang, and others. Gaps in hospital policies and practices to prevent perinatal transmission of hepatitis B virus. Pediatrics 125(4): 704-711 (Free full text). April 2010.