New Recommendations Calls For Universal Hepatitis B Screenings

Douglas Owen, MD

A new set of hepatitis B (HBV) recommendations calls for universal screenings and vaccines in an effort to limit the potentially deadly disease from infecting newborns or mothers.

Previously, the US Preventive Services Task Force (USPSTF) presented HBV infection screening recommendations for pregnant women. However, new evidence reaffirms the 2009 recommendations should be updated to include serologic testing for the hepatitis B surface antigen (HBsAg), which accurately identifies the potential infection.

The investigators, led by Douglas K. Owens, MD, also said interventions and case management are effective to prevent perinatal transmission and the 2009 recommendation for HBV screening effectively curtails potential infections.

“Screening for HBV infection during pregnancy identifies women whose infants are at risk of perinatal transmission,” the authors wrote. “The USPSTF found convincing evidence that universal prenatal screening for HBV infection substantially reduces perinatal transmission of HBV and the subsequent development of chronic HBV infection.”

The USPSTF also recommends HBV vaccinations for all infants, while providing post-exposure prophylaxis with hepatitis B immune globulin (HBIG) at birth to infants with HBV infected mothers.

They did not find evidence that HBV screenings harms pregnant women, concluding that the net benefit of HBV screenings is substantial with high certainty.

The overall recommendations include screenings performed during each pregnancy, ordered at the first prenatal visit, regardless of previous vaccination history or previous negative HBsAg test results, while women with unknown HBsAg status or with new or continuing risk factors should be screened during admission to the hospital or other delivery setting.

Treatment includes screening all pregnant women and vaccinating infants born to HBV-negative mothers within 24 hours of birth, completing the vaccination series within 18 months.

In HBV-positive mothers, case management would include HBV DNA viral load testing and the referral to specialty care for counseling and medical management of HBV infection.

The current guidelines call for HBV vaccination and HBIG prophylaxis within 12 hours of birth, while completing the vaccine series within 8 months and undergoing serologic testing for infection and immunity from 9-12 months.

In a research letter accompanying the recommendations, investigators from Kaiser Permanente Center for Health Research in Oregon, led by Jillian Henderson, PhD, MPH, conducted a literature search of common databases with 5688 titles and abstracts and 499 full-text articles dating back to 1986 in an effort to find evidence of the effectiveness of HBV screening programs and case management.

In 1 study, the team found 155,081 infants born to HBV-positive earmarked for case management through the US Centers for Disease Control’s (CDC) Perinatal Hepatitis B Prevention Program, which ran from 1994-2008.

The investigators discovered the outcome of case management for 4446 infants born to HBV-positive women in the US from 1997-2010 in a second study.

In both studies, the investigators observed low rates (.5% to 1.9%) of perinatal transmissions, with reductions over time.

It has been common practice for the last 3 decades to screen pregnant women for HBV to identify women at risk of transmitting the infection to their infant and ensure timely deliveries of effective prophylactic interventions, usually through case management programs using evidence-based protocols.

Neonatal vaccines and hepatitis B immune globulin can effectively prevent perinatal transmissions.

A nationally representative sample found 85.8 cases of maternal HBV infection per 100,000 deliveries in the US between 1998 - 2011. Maternal HBV infections have increased annually by 5.5% since 1998. Currently, 26 states require prenatal screenings by law.

HBV causes chronic infections in 80% to 90% of infants with the virus, resulting in long-term and possibly fatal health complications including cirrhosis, liver failure, hepatocellular carcinoma.

One of the reasons for the push of universal screenings is because known risk factors are only present in 35-65% of HBV-positive pregnant women.