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:
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
- Review the hepatitis B surface antigen (HBsAg) status of all pregnant women.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- Advise HBsAg positive women that their infants who receive post exposure prophylaxis may be breastfed beginning immediately after birth.
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.