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Guidelines for hepatitis B virus screening and vaccination during pregnancy
Int J Gynecol Obstet, 1993, 40: 172-174 International Federation of Gynecology and Obstetrics
172
Guidelines for hepatitis during pregnancy
B virus screening and vaccination
ACOG Committee Opinion: Committee on Obstetrics: Maternal and Fetal Medicine Number 111 - May 1992 (Replaces No. 103, March 1992) Recently, the Centers for Disease Control has recommended routine hepatitis B virus (HBV) vaccination of all infants as a means of eradicating the infection and its attendant sequelae (1, 2). However, this recommendation does not preclude the need to screen pregnant women for HBV and to consider vaccination of those who are in high-risk groups. Hepatitis B virus infection is a major cause of acute and chronic hepatitis, cirrhosis, and primary hepatocellular carcinoma. Although uncommon in the general population, infection with HBV is highly prevalent in certain groups. One of the most common modes of HBV transmission is from mother to infant at birth and during infancy. Infants born to mothers who are positive for hepatitis B surface antigen (HBsAg) are vulnerable to infection and can become chronic carriers (3,4). It is estimated that one in four infants who become chronic carriers will develop cirrhosis or hepatocellular carcinoma later in life (5). Maternal identification through screening and newborn prophylaxis can significantly reduce neonatal infection and, most likely, these potentially life-threatening sequelae as well (6-B). Screening only those pregnant women at high risk for HBV carrier status fails to identify 50% of carrier women (4,5,9). The Committee on Obstetrics: Maternal and Fetal Medicine thus supports the recommendation of the Centers for Disease Control that all pregnant women be screened for HBV, based on the following reasons: ??
Hepatitis B virus carrier mothers, not previously detected in a high-risk screening program, can be identified.
In1J
Gynecol Obstet 40
??
??
The availability of test results before delivery enables administration of hepatitis B immunoglobulin (HBIg) and the appropriate dose of vaccine to infants after birth without delay (approximately one third of hospitals in the United States do not have the capability to perform HBsAg testing). Appropriate counseling of family members can be accomplished prior to delivery.
ANTENATAL SCREENING
To determine which infants need prophylaxis against HBV infection, pregnant women should be routinely tested for HBsAg during an early prenatal visit. If at the time of admission to the hospital for delivery the test was not done previously or the results are not available, the HBsAg test should be done. Infants born to mothers who are HBsAg positive should receive HBIg in addition to the HBV vaccine. When given within the first 24 hours, prophylaxis for exposed newborns is 8595% effective in preventing neonatal infection and, probably, reducing the frequency of potentially lifethreatening sequelae (1,2). If administration of HBIg to infants of mothers with unknown HBsAg status is delayed pending results of laboratory tests, HBIg should be given as soon as the maternal HBsAg is determined to be positive. HBIg can be given up to 1 week after birth, although its efficacy is unknown when administered to infants older than 48 hours of age. If a woman tests positive for HBsAg, her liver
ACOG Committee Opinion
biochemistry should be analyzed and her children and spouse or sexual partner(s) should be informed of their need for testing and vaccination. If the test results are abnormal or if the liver is palpable, the patient should be evaluated further to determine whether the disease is acute or chronic.
173
Pregnancy is not a contraindication to the use of vaccine. Pregnant women who are at greatest risk for HBV infection (see list above) and who test negative for HBsAg should be counseled and considered for the vaccine. RECOMMENDATIONS
VACCINATION
The following guidelines are suggested:
Women who are at high risk of becoming infected with HBV should be considered for HBV vaccination. They include those with histories of:
1. HBsAg screening should be added to the
Use of illicit drugs Acute episode of any sexually transmitted disease Multiple sexual partners Work in a health care or public safety field Household contact with an HBV carrier Work or residence in an institution for the developmentally disabled Work or treatment in a hemodialysis unit Receipt of clotting factor concentrates for bleeding disorders The currently available HBV vaccines are made from yeast by using recombinant DNA technology. Two recombinant vaccines are available, Recombivax HB (Merck Sharpe and Dohme) and Engerix-B (SmithKline Beecham). The plasma-derived vaccine is no longer being produced. Recombivax HB and Engerix-B are given as a series of three doses; however, since dosages vary by manufacturer and the age of the infant, physician labeling should be consulted. Vaccine is injected into the deltoid muscle in adults. Because the prevalence of HBV infection varies widely among different populations, serologic screening to detect susceptible persons before vaccination may or may not be cost-effective; whether it is depends on the risk of prior infection, the cost of screening, and the cost of vaccine. In general, it is cost-effective to screen for antibody to HBV in women who belong to groups with a very high risk of infection such as intravenous drug abusers and immigrants from areas with a high rate of HBV infection. In most other risk groups, antibody screening prior to vaccination is probably not indicated.
battery of routine prenatal tests. 2. Women who are at the greatest risk for HBV infection and who test negative for HBsAg should be counseled about vaccination. 3. Liver function testing is recommended in women who have tested positive for HBsAg to determine whether they have active liver disease. 4. Women who test positive for HBsAg should be advised that their family members should be tested and counseled regarding HBV vaccination. 5. The physician responsible for the care of a newborn of an HBV chronic carrier mother should be notified as to the mother’s carrier status so that the appropriate doses of HBV vaccine and HBIg can be given as soon as possible following delivery.
Centers for DiseaseControl.HepatitisB virus: a comprehensive strategy for eliminating transmission in the United States through universal childhood vaccination: recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR 1991;4O(RR-13):1-25 American Academy of Pediatrics, American College of Obstetricians and Gynecologists. Guidelines for perinatal care. 3rd ed. Elk Grove Village, Illinois: AAP; Washington, DC: ACOG, 1992 Kumar ML, Dawson NV, McCullough AJ, Radivoyevitch M, King KC, Hertz R, et al. Should all pregnant women be screened for hepatitis B? Ann Intern Med 1987;107:273-277 Jonas MM, Schiff ER, O’Sullivan MJ, De Medina M, Reddy KR, Jeffers LJ, et al. Failure of Centers for Disease Control criteria to identify hepatitis B Int J Gynecol Obstet 40
174
ACOG Committee
Opinion
infection in a large municipal obstetrical population. Ann Intern Med 1987;107:335-337 Summers PR, Biswas MK, Pastorek JG II, Pernoll ML, Smith LG, Bean BE. The pregnant hepatitis B carrier: evidence favoring comprehensive antepartum screening. Obstet Gynecol 1987;69: 701-704 Wetzel AM, Kirz DS. Routine hepatitis screening in adolescent pregnancies: is it cost-effective? Am J Obstet Gynecol1987;156:166-169 Delage G, Montplaisir S, Remy-Prince S, Pierri E.
Copyright
Prevalence of hepatitis B virus infection in pregnant women in the Montreal area. Can Med Assoc J 1986;134:897-901 8. Okada K, Kamiyama I, Inomata M, Imai M, Miyakawa Y. e antigen and anti-e in the serum of asymptomatic carrier mothers as indicators of positive and negative transmission of hepatitis B virus to their infants. N Engl J Med 1976;294:746749 9. Cruz AC, Frentzen BH, Behnke M. Hepatitis B: a case for prenatal screening of all patients. Am J Obstet Gynecol1987;156:1180-1183
0 May 1992
This document reflects emerging clinical and scientific advances as of the.date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed. The American College of Obstetricians and Gynecologists 409 12th Street, SW ??Washington, DC 20024-2188
Int J Gynecol Obstet 40
172
Guidelines for hepatitis during pregnancy
B virus screening and vaccination
ACOG Committee Opinion: Committee on Obstetrics: Maternal and Fetal Medicine Number 111 - May 1992 (Replaces No. 103, March 1992) Recently, the Centers for Disease Control has recommended routine hepatitis B virus (HBV) vaccination of all infants as a means of eradicating the infection and its attendant sequelae (1, 2). However, this recommendation does not preclude the need to screen pregnant women for HBV and to consider vaccination of those who are in high-risk groups. Hepatitis B virus infection is a major cause of acute and chronic hepatitis, cirrhosis, and primary hepatocellular carcinoma. Although uncommon in the general population, infection with HBV is highly prevalent in certain groups. One of the most common modes of HBV transmission is from mother to infant at birth and during infancy. Infants born to mothers who are positive for hepatitis B surface antigen (HBsAg) are vulnerable to infection and can become chronic carriers (3,4). It is estimated that one in four infants who become chronic carriers will develop cirrhosis or hepatocellular carcinoma later in life (5). Maternal identification through screening and newborn prophylaxis can significantly reduce neonatal infection and, most likely, these potentially life-threatening sequelae as well (6-B). Screening only those pregnant women at high risk for HBV carrier status fails to identify 50% of carrier women (4,5,9). The Committee on Obstetrics: Maternal and Fetal Medicine thus supports the recommendation of the Centers for Disease Control that all pregnant women be screened for HBV, based on the following reasons: ??
Hepatitis B virus carrier mothers, not previously detected in a high-risk screening program, can be identified.
In1J
Gynecol Obstet 40
??
??
The availability of test results before delivery enables administration of hepatitis B immunoglobulin (HBIg) and the appropriate dose of vaccine to infants after birth without delay (approximately one third of hospitals in the United States do not have the capability to perform HBsAg testing). Appropriate counseling of family members can be accomplished prior to delivery.
ANTENATAL SCREENING
To determine which infants need prophylaxis against HBV infection, pregnant women should be routinely tested for HBsAg during an early prenatal visit. If at the time of admission to the hospital for delivery the test was not done previously or the results are not available, the HBsAg test should be done. Infants born to mothers who are HBsAg positive should receive HBIg in addition to the HBV vaccine. When given within the first 24 hours, prophylaxis for exposed newborns is 8595% effective in preventing neonatal infection and, probably, reducing the frequency of potentially lifethreatening sequelae (1,2). If administration of HBIg to infants of mothers with unknown HBsAg status is delayed pending results of laboratory tests, HBIg should be given as soon as the maternal HBsAg is determined to be positive. HBIg can be given up to 1 week after birth, although its efficacy is unknown when administered to infants older than 48 hours of age. If a woman tests positive for HBsAg, her liver
ACOG Committee Opinion
biochemistry should be analyzed and her children and spouse or sexual partner(s) should be informed of their need for testing and vaccination. If the test results are abnormal or if the liver is palpable, the patient should be evaluated further to determine whether the disease is acute or chronic.
173
Pregnancy is not a contraindication to the use of vaccine. Pregnant women who are at greatest risk for HBV infection (see list above) and who test negative for HBsAg should be counseled and considered for the vaccine. RECOMMENDATIONS
VACCINATION
The following guidelines are suggested:
Women who are at high risk of becoming infected with HBV should be considered for HBV vaccination. They include those with histories of:
1. HBsAg screening should be added to the
Use of illicit drugs Acute episode of any sexually transmitted disease Multiple sexual partners Work in a health care or public safety field Household contact with an HBV carrier Work or residence in an institution for the developmentally disabled Work or treatment in a hemodialysis unit Receipt of clotting factor concentrates for bleeding disorders The currently available HBV vaccines are made from yeast by using recombinant DNA technology. Two recombinant vaccines are available, Recombivax HB (Merck Sharpe and Dohme) and Engerix-B (SmithKline Beecham). The plasma-derived vaccine is no longer being produced. Recombivax HB and Engerix-B are given as a series of three doses; however, since dosages vary by manufacturer and the age of the infant, physician labeling should be consulted. Vaccine is injected into the deltoid muscle in adults. Because the prevalence of HBV infection varies widely among different populations, serologic screening to detect susceptible persons before vaccination may or may not be cost-effective; whether it is depends on the risk of prior infection, the cost of screening, and the cost of vaccine. In general, it is cost-effective to screen for antibody to HBV in women who belong to groups with a very high risk of infection such as intravenous drug abusers and immigrants from areas with a high rate of HBV infection. In most other risk groups, antibody screening prior to vaccination is probably not indicated.
battery of routine prenatal tests. 2. Women who are at the greatest risk for HBV infection and who test negative for HBsAg should be counseled about vaccination. 3. Liver function testing is recommended in women who have tested positive for HBsAg to determine whether they have active liver disease. 4. Women who test positive for HBsAg should be advised that their family members should be tested and counseled regarding HBV vaccination. 5. The physician responsible for the care of a newborn of an HBV chronic carrier mother should be notified as to the mother’s carrier status so that the appropriate doses of HBV vaccine and HBIg can be given as soon as possible following delivery.
Centers for DiseaseControl.HepatitisB virus: a comprehensive strategy for eliminating transmission in the United States through universal childhood vaccination: recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR 1991;4O(RR-13):1-25 American Academy of Pediatrics, American College of Obstetricians and Gynecologists. Guidelines for perinatal care. 3rd ed. Elk Grove Village, Illinois: AAP; Washington, DC: ACOG, 1992 Kumar ML, Dawson NV, McCullough AJ, Radivoyevitch M, King KC, Hertz R, et al. Should all pregnant women be screened for hepatitis B? Ann Intern Med 1987;107:273-277 Jonas MM, Schiff ER, O’Sullivan MJ, De Medina M, Reddy KR, Jeffers LJ, et al. Failure of Centers for Disease Control criteria to identify hepatitis B Int J Gynecol Obstet 40
174
ACOG Committee
Opinion
infection in a large municipal obstetrical population. Ann Intern Med 1987;107:335-337 Summers PR, Biswas MK, Pastorek JG II, Pernoll ML, Smith LG, Bean BE. The pregnant hepatitis B carrier: evidence favoring comprehensive antepartum screening. Obstet Gynecol 1987;69: 701-704 Wetzel AM, Kirz DS. Routine hepatitis screening in adolescent pregnancies: is it cost-effective? Am J Obstet Gynecol1987;156:166-169 Delage G, Montplaisir S, Remy-Prince S, Pierri E.
Copyright
Prevalence of hepatitis B virus infection in pregnant women in the Montreal area. Can Med Assoc J 1986;134:897-901 8. Okada K, Kamiyama I, Inomata M, Imai M, Miyakawa Y. e antigen and anti-e in the serum of asymptomatic carrier mothers as indicators of positive and negative transmission of hepatitis B virus to their infants. N Engl J Med 1976;294:746749 9. Cruz AC, Frentzen BH, Behnke M. Hepatitis B: a case for prenatal screening of all patients. Am J Obstet Gynecol1987;156:1180-1183
0 May 1992
This document reflects emerging clinical and scientific advances as of the.date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed. The American College of Obstetricians and Gynecologists 409 12th Street, SW ??Washington, DC 20024-2188
Int J Gynecol Obstet 40