Screening in pregnancy allows arrangements to be made for vaccinating the newborn if the mother is found to have hepatitis B.
8.2.1 BackgroundHepatitis B virus is a global acute and chronic communicable disease that causes major hepatic disease (Beasley & Hwang 1984). The virus has an incubation period of 6 weeks to 6 months and is excreted in various body fluids including blood, saliva, vaginal fluid and breast milk. These fluids may be highly infectious. Adults who have hepatitis B may have no symptoms. After infection, some people do not clear the virus; they become carriers and may infect other people.
Hepatitis B in Australia
- Rates of diagnosis of hepatitis B — Of 238 diagnoses of newly acquired hepatitis B in 2009, 6% were among Aboriginal and Torres Strait Islander people, 83% among non-Indigenous people and Indigenous status was not recorded for 11% (NCHECR 2010). The population rates of diagnosis for the non-Indigenous and Aboriginal and Torres Strait Islander populations were 1 and 3 per 100,000, respectively (NCHECR 2010).
- Geographical distribution — In 2005–09, the rate of diagnosis of newly acquired hepatitis B infection remained low in all States and Territories. In NSW, Victoria, Queensland and WA, newly acquired hepatitis B infection was diagnosed among Aboriginal and Torres Strait Islander people at between one and seven times the rate in the non-Indigenous population; the rate of diagnosis was highest in outer regional areas (4 per 100,000) compared to remote areas (1 per 100,000)(NCHECR 2010).
- Country of origin — The prevalence of hepatitis B carriage varies between and within countries (NHMRC 2009). Carrier rates vary from 0.1–0.2% among Caucasians in the United States, northern Europe and Australia, 1–5% in the Mediterranean countries, parts of eastern Europe, China, Africa, Central and South America, and greater than 10% in many sub-Saharan African, south-east Asian and Pacific island populations (Mast et al 2004; Wood et al 2005; Clements et al 2006). First-generation immigrants usually retain the carrier rate of their country of origin, but subsequent generations show a declining carrier rate irrespective of vaccination (Mast et al 2004).
- Risk factors — Routes of transmission of hepatitis B virus include sharing injecting equipment (such as occurs in injecting drug use), needle-stick injury and sexual contact (NHMRC 2009). Based on reported cases, hepatitis B transmission in Australia in 2009 continued to occur predominantly among people with a recent history of injecting drug use (NCHECR 2010).
- Hepatitis B in pregnancy — A retrospective cohort study (n=14,857) found around 2% of women to HbsAg positive (Guirgis et al 2009). A prevalence study in the NT found 3.7% of Aboriginal and Torres Strait Islander women and 0.98% of non-Indigenous women to be HbsAg positive (Schultz et al 2008).
Risks associated with hepatitis B in pregnancyMother-to-child transmission occurs frequently either in the uterus, through placental leakage, or through exposure to blood or blood-contaminated fluids at or around the time of birth (Lee et al 2006). Perinatal transmission is believed to account for 35–50% of hepatitis B carriers (Yao 1996).
The risk of perinatal transmission is associated with the hepatitis B envelope antigen (HbeAg) status of the mother. If a woman is both hepatitis surface antigen (HbsAg) and HbeAg positive, 70–90% of her children will develop hepatitis B (Stevens et al 1975; Akhter et al 1992). If the mother is HbsAg positive but HbeAg negative, the risk is reduced (Okada et al 1976; Beasley et al 1977; Beasley et al 1983; Nayak et al 1987; Aggarwal & Ranjan 2004). In a cohort study of HbsAg-positive, hepatitis B DNA-positive women in Sydney (n=313) (Wiseman et al 2009), transmission rates were 3% among hepatitis B DNA-positive women overall, 7% among HbeAg-positive mothers and 9% among women with very high hepatitis B DNA levels.
It has been estimated that people who are chronic carriers of HbsAg are 22 times more likely to die from hepatocellular carcinoma or cirrhosis than noncarriers (95% CI 11.5–43.2) (Beasley & Hwang 1984).
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8.2.2 Screening for hepatitis B infection in pregnancy
Summary of the evidenceScreening of all pregnant women for hepatitis B is recommended in the United Kingdom (NICE 2008) and the United States (Mast et al 2005; Lin & Vickery 2009; USPSTF 2009). The Australian Immunisation Handbook, while making recommendations on vaccination rather than screening, notes that routine antenatal screening for hepatitis B (ATAGI 2009):
- is essential for preventing babies from becoming carriers of hepatitis B; and
- enables appropriate follow-up and management of the woman, identification of the immune status of other household members, and protection of those who are susceptible.
- screening using risk factors to identify ‘high-risk’ women for HbsAg would miss about half of all pregnant women with HbsAg infection (Summers et al 1987);
- of women offered examination for hepatitis B at 18 weeks pregnancy (n=4,098), one third of women at risk of hepatitis B were not identified by selective screening (Jensen et al 2003); and
- universal screening resulted in an estimated detection of 50 additional pregnant women carrying hepatitis B each year who would not have been detected through selective screening (Cowan et al 2006).
Recommendation - Grade A12. Routinely offer and recommend hepatitis B virus testing at the first antenatal visit as effective postnatal intervention can reduce the risk of mother-to-child transmission.
Testing methodTesting of blood samples is the accepted standard for antenatal detection of hepatitis B virus (NICE 2008) and consists of stages (Balmer et al 2000) – testing for HbsAg and confirmatory testing with a new sample upon a positive result.
Considerations beyond the first trimester
- Mother-to-child transmission of the hepatitis B virus is approximately 95% preventable by administering vaccine and hepatitis B immunoglobulin to the baby at birth (Beasley et al 1983; Nair et al 1984; Wong et al 1984; Lo et al 1985; Xu et al 1985; Sehgal et al et al 1992; Zhu 1997; Lee et al 2006).
- While a meta-analysis (n=5,900) found that multiple hepatitis B immunisation injections in women with a high degree of infectiousness in late pregnancy reduced rates of intrauterine transmission (Shi et al 2010), all studies included were carried out in China and the findings may not be applicable in the Australian context.
- For women with high viral loads (>log 7 IU/ml), discussion with a hepatologist and maternal antiviral treatment in the third trimester are considerations.
8.2.3 Practice summary — hepatitis B screeningWhen — Early in antenatal care
Who — Midwife; GP; obstetrician; Aboriginal and Torres Strait Islander health worker; multicultural health worker
- Discuss hepatitis B screening — Explain that it is important to find out whether a woman has or is carrying hepatitis B because of the risk to the baby.
- Document and follow-up — Note the results of hepatitis B screening in the woman’s record and have a follow up system in place so that the babies of women who are found to have hepatitis B are vaccinated on the day of birth.
- Take a holistic approach — If a woman is found to have or be a carrier of hepatitis B, other considerations include counselling, contact tracing, partner testing, testing for other sexually transmitted infections and continuing follow-up. Consider screening other children, depending on circumstances.
8.2.4. ResourcesATAGI (2009) Australian Immunisation Handbook. 9th edition. Australian Technical Advisory Group on Immunisation. Canberra: Department of Health and Ageing. For more information please visit the Department of Health and Ageing website.
8.2.5 ReferencesAggarwal R & Ranjan P (2004) Preventing and treating hepatitis B infection. Brit Med J 329(7474): 1080–86.
Akhter S, Talukder MQ, Bhuiyan N et al (1992) Hepatitis B virus infection in pregnant mothers and its transmission to infants. Indian J Pediatr 59(4): 411–15.
Balmer S, Bowens A, Bruce E et al (2000) Quality Management for Screening: Report to the National Screening Committee. Leeds: Nuffield Institute for Health.
Beasley RP & Hwang L-Y (1984) Epidemiology of hepatocellular carcinoma. In: Vyas GN et al (eds) Viral Hepatitis and Liver Disease. Orlando, FL: Grune and Stratton, pp209–24.
Beasley RP, Hwang LY, Lee GC et al (1983) Prevention of perinatally transmitted hepatitis B virus infections with hepatitis B virus infections with hepatitis B immune globulin and hepatitis B vaccine. Lancet 2: 1099–102.
Beasley RP, Trepo C, Stevens CE et al (1977) The e antigen and vertical transmission of hepatitis B surface antigen. Am J Epidemiol 105: 94–98.
Clements CJ, Baoping Y, Crouch A et al (2006) Progress in the control of hepatitis B infection in the Western Pacific Region. Vaccine 24: 1975–82.
Cowan SA, Bagdonaite J, Qureshi K (2006) Universal hepatitis B screening of pregnant women in Denmark ascertains substantial additional infections: results from the first five month. Eur Comm Dis Bull 11(6): E0606–08.
Guirgis M, Zekry A, Yan K et al (2009) Chronic hepatitis B infection in an Australian antenatal population: Seroprevalence and opportunities for better outcomes. J Gastroenterol Hepatol 24(6): 998–1001.
Jensen L, Heilmann C, Smith E et al (2003) Efficacy of selective antenatal screening for hepatitis B among pregnant women in Denmark: is selective screening still an acceptable strategy in a low-endemicity country? Scand J Infect Dis 35(6-7): 378–82.
Lee C, Gong Y, Brok J et al (2006) Hepatitis B immunisation for newborn infants of hepatitis B surface antigenpositive mothers. Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.: CD004790. DOI: 10.1002/14651858. CD004790.pub.
Lin K & Vickery J (2009) Screening for hepatitis B virus infection in pregnant women: evidence for the U.S. Preventive Services Task Force reaffirmation recommendation statement. Annals Int Med 150(12): 874–76.
Lo K, Tsai Y, Lee S, Yeh C et al (1985) Combined passive and active immunization for interruption of perinatal transmission of hepatitis B virus in Taiwan. Hepato-gastroenterol 32: 65–68.
Mast E, Mahoney F, Kane MA et al (2004) Hepatitis B vaccine. In: Plotkin SA & Orenstein WA (eds) Vaccines. 4th ed. Philadelphia, PA: Saunders.
Mast EE, Margolis HS, Fiore AE et al (2005) A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices (ACIP) part 1: immunization of infants, children, and adolescents. MMWR 54(RR-16): 1–31.
Nair PV, Weissman JY, Tong MJ et al (1984) Efficacy of hepatitis B immune globulin in prevention of perinatal transmission of the hepatitis B virus. Gastroenterol 87: 293–98.
Nayak NC, Panda SK, Zuckerman AJ et al (1987) Dynamics and impact of perinatal transmission of hepatitis B virus in north India. J Med Virol 21(2): 137–45.
NCHECR (2010) Bloodborne Viral and Sexually Transmitted Infections in Aboriginal and Torres Strait Islander People: Surveillance and Evaluation Report 2010. Sydney: National Centre in HIV Epidemiology and Clinical Research, The University of New South Wales.
ATAGI (2009) Australian Immunisation Handbook. 9th edition. Australian Technical Advisory Group on Immunisation. Canberra: Department of Health and Ageing. For more information please visit Department of Health and Ageing website.
NICE (2008) Antenatal Care. Routine Care for the Healthy Pregnant Woman. National Collaborating Centre for Women’s and Children’s Health. Commissioned by the National Institute for Health and Clinical Excellence. London: RCOG Press.
Okada K, Kamiyama I, Inomata M et al (1976) 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. New Engl J Med 294(14): 746–49.
Schultz R, Romanes F, Krause V (2008) Hepatitis B prevalence and prevention: Antenatal screening and protection of infants at risk in the Northern Territory. Aust NZ J Public Health 32(6): 575–76.
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Sehgal A, Sehgal R, Gupta I et al (1992) Use of hepatitis B vaccine alone or in combination with hepatitis B immunoglobulin for immunoprophylaxis of perinatal hepatitis B infection. J Trop Paediatr 38: 247–51.
Shi Z, Li X, Ma L et al (2010) Hepatitis B immunoglobulin injection in pregnancy to interrupt hepatitis B virus mother-to-child transmission-a meta-analysis. Int J Infect Dis 14(7): e622–34.
Stevens CE, Beasley RP, Tsui J et al (1975) Vertical transmission of hepatitis B antigen in Taiwan. New Engl J Med 292(15): 771–74.
Summers PR, Biswas MK, Pastorek JG et al (1987) The pregnant hepatitis B carrier: evidence favoring comprehensive antepartum screening. Obstet Gynecol 69:701–04.
USPSTF (2009) Screening for hepatitis B virus infection in pregnancy: United States Preventive Services Task Force reaffirmation recommendation statement. Annals Int Med 150(12): 869–73.
Wiseman E, Fraser MA, Holden S et al (2009) Perinatal transmission of hepatitis B virus: an Australian experience. Med J Aust 190(9): 489–92.
Wong VC, Ip HM, Reesink HW et al (1984) Prevention of the HbsAg carrier state in newborn infants of mothers who are chronic carriers of HbsAg and HbeAg by administration of hepatitis-B vaccine and hepatitis-B immunoglobulin. Double-blind randomised placebo – controlled study. Lancet 1: 921–26.
Wood N, Backhouse J, Gidding HF et al (2005) Estimates of chronic hepatitis B virus infection in the Northern Territory. Comm Dis Intell 29: 289–90.
Xu Z-Y, Liu C-B, Francis DP (1985) Prevention of perinatal acquisition of hepatitis B virus carriage using vaccine: preliminary report of a randomized, double-blind placebo-controlled and comparative trial. Pediatr 76: 713–18.
Yao JL (1996) Perinatal transmission of hepatitis B virus infection and vaccination in China. Gut 38(Suppl 2): S37–S38.
Zhu Q (1997) A preliminary study on interruption of HBV transmission in uterus. Chinese Med J 110: 145–47.