The Perinatal Hepatitis B Prevention Program of Santa Clara County focuses on preventing the spread of hepatitis B from infected mothers to newborn infants. The success of perinatal hepatitis B transmission prevention requires the collaboration between the public health department, laboratories, prenatal and infant care providers, delivery hospitals, and infected mothers.

    Test All Pregnant women

    • Providers are mandated to test pregnant women for hepatitis B surface antigen (HBsAg) (California Health and Safety Code, Section 125085). The HBsAg test should be ordered at an early prenatal visit and should be ordered during every pregnancy. 
    • Re-test an HBsAg-negative woman before delivery if she has clinical hepatitis or if she was at risk for hepatitis B exposure during pregnancy. Risk factors include recent or current intravenous drug use, an HBsAg-positive sex partner, more than one sex partner in the past 6 months, or recent treatment for an STI. 
    • Test all HBsAg-positive pregnant women for HBV DNA (viral load). Patient with HBV DNA ≥200,000 IU/mL are at increased risk of perinatal transmission of hepatitis B virus and are recommended to receive antiviral treatment. 
    • In cases of unexpected HBsAg-positive test results or results with discrepant HBsAg findings, repeat HBsAg testing, as well as ordering total anti-HBc, IgM anti-HBc and HBV DNA testing. If the woman’s status remains unclear at the time of delivery, the healthcare provider should consider providing PEP to the infant. 

    Refer HBsAg-Positive Women

    • Primary and prenatal care providers should report pregnant women who test positive for HBsAg. To refer an HBsAg-positive pregnant or post-partum woman to the Perinatal Hepatitis B Prevention Program, please complete and fax the following form to (408) 792-1304: 

     

     

    Ensure Post-Exposure Prophylaxis for At-Risk Infants

    • For infants of HBsAg-positive mothers: Administer hepatitis B vaccine and HBIG <12 hours of birth. 
    • For infants of mothers whose HBsAg status is unknown:
      •  For infants weighing <2 kg – administer hepatitis B vaccine and HBIG <12 hours of birth.
      • For infants weighing ≥2 kg – administer hepatitis B vaccine <12 hours of birth. If mother is found to be HBsAg-positive, administer HBIG as soon as possible and no later than 7 days after birth; discharged infants should be recalled and given HBIG.
    • For infants of HBsAg-negative mothers: Administer hepatitis B vaccine 2 kg. If the infant weights <2kg at birth, administer hepatitis B vaccine at chronological age 1 month or hospital discharge (whichever is earlier, even if weight is still <2kg).

    Follow-Up of Infants Born to Women of Positive Results

    • Make sure that the infant completes the hepatitis B vaccine series on schedule  
    • Document vaccine administration and provide the Hepatitis B Vaccine Information Statement  
    • Educate HBsAg-positive mothers that their test results indicate that they have chronic HBV infection and that they should follow up with their primary care provider or a liver specialist.
    • Advise HBsAg-positive women that breastfeeding is safe once their infant has received HBIG and hepatitis B vaccine at birth.
    • Ask about household contacts and siblings. Refer close contacts and family members for HBsAg and anti-HBs testing to determine if they are chronically infected with HBV or are unprotected against HBV infection and should be vaccinated.
    • Perform post-vaccination serologic testing
      • HBsAg and anti-HBs testing should be performed 1-2 months after completion of the vaccine series, but not before 9 months of age.
      • If the vaccine series has been completed on schedule, testing should occur at 9-12 months of age. Testing performed at 13-18 months of age is still valid, but there may be a higher occurrence of falsely negative anti-HBs results.
      • Testing should not be performed before age 9 months to avoid detection of passive anti-HBs from HBIG administered at birth and to maximize the likelihood of detecting late HBV infection. If testing is done before age 9 months, it will need to be repeated.

    Follow-Up of Infants Born to Women of Unknown Results

    • If it is not possible to determine the mother’s HBsAg status (e.g., when a parent or person with lawful custody safely surrenders an infant confidentially after birth), the vaccine series should be completed according to a recommended schedule for infants born to HBsAg-positive mothers.
    • These infants should also receive post-vaccination serologic testing at age 9–12 months according to the testing recommendations outlined for infants for infants born to HBsAg-positive mothers.

    Refer Infants and Children

    Infant care providers should ensure that infants born to HBsAg positive women complete the hepatitis B vaccine series and receive post vaccine serologic testing. Infant care providers should report any cases of an HBsAg exposed infant/child. To notify the Perinatal Hepatitis B Prevention Program about an HBsAg-exposed infant/child, please complete and fax this form to (408) 792-1304: 

     

    Vaccine Schedules:

    Management of Children with Chronic Hepatitis B

    • Perform a yearly physical exam on all children chronically infected with HBV (HBsAg remains positive after 6 months).
    • Determine if there is a family history of hepatocellular carcinoma or liver disease.
    • Refer to a pediatric gastroenterologist for baseline tests and long-term monitoring.
      • Baseline labs include ALT, CBC, HBeAg, Anti-HBe, Anti-HBc, HBV DNA by PCR, AFP; and
      • Baseline abdominal ultrasound.
    • Long-term monitoring:
      • ALT and AFP every 6-12 months;
      • Abdominal ultrasound (usually every 1-2 yrs, but sooner if there is a family history of HCC, if ALT or AFP are elevated, or if cirrhosis is present).
    • Treatment with antiviral medication may be initiated under guidance of a pediatric gastroenterologist.

     

    Guidelines for Delivery Hospitals

    Delivery hospitals should review the HBsAg status of all women admitted for labor and delivery, administer the hepatitis B birth dose vaccine and the hepatitis B immune globulin as necessary, and advise that her newborn complete the vaccine series with the pediatrician. 
     

    AT THE TIME OF ADMISSION

    1. Review the hepatitis B surface antigen (HBsAg) status of all pregnant women.
    2. Refer to laboratory report for documentation of hepatitis B status. Accepting results that were not issued by the lab performing the test is not acceptable because transcription and interpretation errors can occur. 
    3. Perform HBsAg testing immediately upon admission if there is no documentation of HBsAg status. Instruct the lab to call the labor and delivery unit as soon as results are obtained.
    4. Women at risk for acquiring hepatitis B infection during pregnancy (more than one sex partner in the previous 6 months, evaluation or treatment for a sexually transmitted disease, recent or current injection-drug use, or an HBsAg-positive sex partner) should be retested close to the time of delivery.
    5. Women with unknown HBsAg status, but with other evidence suggestive of maternal HBV infection (e.g., presence of HBV DNA, HBsAg-positive, or mother known to be chronically infected with HBV) should be managed as if HBsAg-positive.
    6. Women who test negative in early pregnancy (>6 months before delivery) may need retesting if clinical hepatitis is noted or if they have engaged in behaviors that place them at risk for acquiring hepatitis B infection during pregnancy.

    AFTER DELIVERY

    1. Notify the Santa Clara County Perinatal Hepatitis B Prevention Program of all births to women with positive or unknown HBsAg status by faxing the   within 24 hours of delivery to (408) 792-1304. 
    2. Advise HBsAg positive women that their infants who receive post exposure prophylaxis may be breastfed beginning immediately after birth.

    Vaccine Schedules:

    ENSURE APPROPRIATE ADMINISTRATION OF HEPATITIS B VACCINE AND HBIG

    • HBsAg-positive mothers: Administer hepatitis B vaccine and HBIG within 12 hours of birth to all infants.
    • HBsAg unknown status mothers (without evidence suggestive of maternal HBV infection):
      • Infants weighing <2 kg - Administer hepatitis B vaccine and HBIG within 12 hours of birth
      • Infants weighing ≥2 kg - Administer hepatitis B vaccine within 12 hours. If the mother is found to be HBsAg positive, administer HBIG as soon as possible and no later than 7 days after birth. If infant has already been discharged when HBsAg positive results are obtained, it is the responsibility of the hospital to recall the infant and to administer HBIG. 
    • HBsAg-negative mothers:
      • Infants weighing ≥2 kg: Administer hepatitis B vaccine within 24 hours of birth.
      • Infants weighing <2 kg: Administer hepatitis B vaccine at chronological age 1 month or hospital discharge (whichever is earlier, even if weight is still <2kg).

    AT HOSPITAL DISCHARGE

    • Document administration of hepatitis B vaccine in the infant’s immunization record and provide this record to parents. Hospitals are encouraged to enter all vaccine doses in the California Immunization Registry.
    • Federal law requires providers to give parents a Hepatitis B Vaccine Information Statement (VIS) before vaccine administration. 

     

    Resources for Laboratories

    Laboratories are required to report all HBsAg-positive test results to the Public Health Department.

     


    Perinatal Hepatitis B Prevention Program
    976 Lenzen Avenue, 1st Floor, Suite 1200
    San Jose, CA 95126
    Tel: (408) 885-4214
    Fax: (408) 792-1304

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