Providing right care to mothers and newborn important in eliminating Hepatitis B transmission through birth

Every year, 25,000 women with chronic hepatitis B infection give birth, according to the Centers for Disease Control and Prevention (CDC). They are a subset of the estimated 700,000 to 1.4 million people chronically infected with hepatitis B virus in the U.S., but merit our special attention because of the risk of perinatal hepatitis B infection, which occurs when the virus is transmitted from a mother to her infant. Although such transmission is completely preventable, an estimated 952 infants in the U.S. were infected perinatally in 2009, the most recent year for which estimates are available.

Given the relatively small, yet stubbornly persistent number of perinatal hepatitis B infections in the U.S., the national Viral Hepatitis Action Plan (Action Plan) set as one of its overarching goals the elimination of perinatal hepatitis B transmission in the U.S. by 2020. The steady annual number of perinatal hepatitis B cases is particularly concerning because approximately 90% of HBV-infected newborns develop chronic infection; up to 25% of these children will die of cirrhosis, liver failure, or liver cancer later in life.

A key to achieving that goal is ensuring that all pregnant women are tested for hepatitis B so that appropriate interventions can be taken upon the birth of the infant to a mother who tests positive for chronic hepatitis B infection–specifically, the provision of post-exposure prophylaxis (i.e., hepatitis B immune globulin and hepatitis B vaccine) to all infants born to HBV-infected women.

Fortunately, according to a 2014 CDC analysis, over 96% of all pregnant women in the U.S. are tested for hepatitis B infection as a standard part of their prenatal care. So a high percentage of mothers who could potentially transmit the virus to their newborns are detected. An estimated 70 percent of women chronically infected with hepatitis B were born in Asia, the Pacific Islands, or Africa, regions with the highest prevalence of hepatitis B infection worldwide. Access to this important screening may now be enhanced since it is among the Preventive Services that health plans are required to cover without charging a co-pay under the Affordable Care Act.

But that screening test is only the first step in preventing perinatal transmission of hepatitis B. Mothers who test positive need to be provided with case management services to ensure that they and their newborns receive the proper monitoring and services to prevent transmission. These services are available in all states through the CDC-supported Perinatal Hepatitis B Prevention Program. However, these programs only see fewer than half of the expected number of births to mothers who are infected with HBV. Given this gap in identification of births despite high rates of maternal testing, if we are to achieve the goal of eliminating transmission of hepatitis B from mother to child in the U.S., it is vital that we sharpen the focus of our efforts on expectant mothers who test positive for HBV.

Healthcare providers are critical to this effort. So, during this week that we celebrate both Mother’s Day and National Women’s Health Week as well as May’s observance of Hepatitis Awareness Month, it seems timely to call on all stakeholders with an interest in achieving this international goal of eliminating perinatal hepatitis B transmission to raise awareness among healthcare providers and others who provide services to pregnant women about important steps they can take to help us realize this life-saving goal:

Ensure all expectant mothers receive hepatitis B screening,
Refer women who screen positive for chronic hepatitis B to: The Perinatal Hepatitis B Prevention Program for infant case management services and
A liver or infectious disease specialist to ensure appropriate management and consideration for treatment.

By sharpening our focus on these actions that can prevent perinatal hepatitis B transmission, we can improve the overall quality of health care for women with chronic hepatitis B and move closer toward the goal of eliminating perinatal hepatitis B transmission.

Testing for chronic hepatitis B

An infectious inflammatory illness of the liver caused by the hepatitis B virus, HBV can be either acute or chronic.

Transmission is usually the result of contact with infectious blood or body fluids containing blood and in Asia, where the prevalence of HBV is high, it is often passed from person to person through sexual contact, re-use of contaminated needles and syringes in drugs users as well as through blood transfusions.

Vaccination against hepatitis B is now part of the overall immunisation programme for children and while the number of cases has dropped, the disease is still prevalent among those who have not been immunised. Acute HBV often resolves itself but the chronic disease in many cases leads to cirrhosis or hepatocellular carcinoma.

Screening the blood for the HBsAg surface antigen is the most common approach for diagnosing chronic HBV and yields prompt results. If a patient's blood tests are positive for hepatitis B, and the HBsAg is persistently positive for over six months, the patient has chronic hepatitis B. If such a case, the patient needs to undergo an additional test to determine whether the virus B has split and mutated, as well as to ascertain how much of the virus is in the body. The measurements for assessing hepatitis B viral activity are HBeAg, HBeAb, and HBV DNA.

If it is found that the hepatitis B virus has active viral replication, the doctor will perform a blood test to see if there is any inflammation in the liver by checking the level of enzymes in the blood (AST, ALT). If the AST and ATL are unusually high with no known causes, the patient is suffering from chronic hepatitis B. In this case, a test also needs to be conducted to evaluate the function of the liver by checking the levels of albumin and bilirubin in the blood - the Prothrombin time (PT) test.

An ultrasound examination can be conducted to see whether a patient with Hepatitis B has developed cirrhosis. The ultrasound examination can also detect tumours in the liver or liver cancer. Patients with high risk of liver cancer such as men aged over 40, women aged above 50 years old, patients with cirrhosis or with history of liver cancer in their family will have an ultrasound examination of the liver and a blood test to check the level of alpha tetoprotein (AFP) every six months in order to monitor occurrence of liver cancer.

In some patients, liver tissues can confirm the presence of hepatitis B and evaluate the severity of the inflammation of the liver and fibrosis in the liver. A tissue test is not an operation. It can be conducted by using a needle to penetrate into the skin to remove tissues from the liver for examination. The side effects from this method are very minor.

The possibility of significant bleeding or the need for an operation occurs in just 3 out of every 1,000 cases. Recently, many additional ways have been developed for assessing fibrosis stage in the liver, including Fibroscan, which can reduce the need for a tissue test by 60 per cent.

After evaluating the severity and stage of liver disease, the doctor will consider every indicator to decide on the best treatment approach and treatment strategy. Most importantly, the patient needs to be examined every 3-6 months because there is a possibility that the disease will develop in the future. The next step will be the treatment and care of the hepatitis B patient.

Vaccination can give birth to the end of hepatitis B

People may not realize that an infected mother can pass on the hepatitis B virus to her newborn. This is a serious disease caused by a virus that attacks the liver. According to the Centers for Disease Control and Prevention (CDC), the hepatitis B virus can cause lifelong infection, cirrhosis (scarring) of the liver, liver cancer, liver failure, and death. 

Fortunately, there’s a way to prevent transmission of the virus to newborns - vaccination at birth to prevent the perinatal transmission. Experts agree that the disease could even be eliminated by vaccinating all newborns. 

Recently, a small nonprofit called the Immunization Action Coalition (IAC) has been urging the nation’s birthing institutions to “Give birth to the end of hepatitis B,” asking them to get involved in promoting this standard of care and assuring administration of the hepatitis B vaccine shortly after birth. One way to assure the vaccine is given to newborns is for the hospital to make the vaccine birth dose part of a standard order set so it is universally administered before hospital discharge. Then, follow up in the doctor’s office or clinic with a total of 3 or 4 doses at properly spaced intervals would help more than 95% of infants, children, and adolescents develop lifelong immunity to the hepatitis B virus. It’s important for mothers to know about this and insist that their babies receive hepatitis B vaccine before they leave the hospital. If the mother is known to have the disease or her status is unknown, the vaccine should be given within 12 hours.

Despite the expert consensus, nearly one in three US newborns leaves the hospital un-vaccinated against hepatitis B, and approximately 800 US newborns become chronically infected each year because of perinatal exposure. Some doctors may decide not to give the baby the vaccine if the mother has a negative screening test, electing instead to give the vaccine after discharge. But this is risky. There can be situations where a medical error occurs, like ordering the wrong hepatitis B screening test or misinterpreting or mistranscribing hepatitis B test results. Failure to properly communicate test results to or within the hospital is also a possibility. There are also doctors who don’t notice that the mother was never tested and let it go, never getting the screening test for mom. So there is room for error - all reasons to give the vaccine at birth and the sooner the better. The hepatitis B vaccine for newborns is recommended by many professional organizations and health care agencies including the American Academy of Pediatrics and the CDC.

Hepatitis B Vaccination in Taiwan Cuts Deaths From Liver Disease, Cancer

Hepatitis B virus (HBV) infection causes infant fulminant hepatitis (IFH), and chronic HBV infection may progress to chronic liver disease (CLD) and hepatocellular carcinoma (HCC) or liver cancer. Taiwan launched a nationwide HBV immunization program for newborns in July 1984, which has successfully lowered the prevalence of chronic HBV carriers, incidence of HCC, and mortality of IFH in vaccinated birth cohorts.

From July 1984 to June 1986, the immunization program covered only newborns with high-risk mothers who were seropositive for HBV surface antigen. Coverage was extended to all newborns in July 1986, preschool children in July 1987, and primary school children in 1988-1990. Recombinant HBV vaccines replaced plasma-derived vaccines in 1992. The immunization coverage rates for birth cohorts from 1984 to 2010 was 88.8 percent to 96.9 percent. The mortality of IFH, CLD, and HCC and the incidence of HCC were compared among birth cohorts born before and after the launch of the program.

The researchers found that from 1977-1980 to 2001-2004, the age- and sex-adjusted rate ratios for individuals 5 to 29 years of age decreased by more than 90 percent for CLD and HCC mortality and by more than 80 percent for HCC incidence, which were higher than the previously reported reduction (70 percent) in HCC incidence for youth 6 to 19 years of age.

The mortality of IFH in vaccinated birth cohorts decreased by more than 90 percent from 1977-1980 to 2009-2011, which was greater than the previously reported reduction (approximately 70 percent) from 1975-1984 to 1985-1998. This long-term, high-coverage immunization program was associated with lower IFH mortality through increasing individual and herd immunity of vaccinated cohorts.

Catching and stopping the silent killer Hepatitis B's slow moves

Despite of the fact that there is a vaccine to prevent Hepatitis B, approximately 2,40,000 people die in India because of the disease. A silent killer, Hepatitis B is more infectious than HIV and is the cause for liver cirrhosis, liver failure and has been linked to the development of hepatocellular carcinoma (liver cancer). The general perception is that HIV virus is very infectious and contagious. However Hepatitis B Virus is much more infectious than HIV. In fact, HBV is about 10 times more prevalent than HIV infection worldwide!

Hepatitis B is an infectious inflammatory condition of the liver caused due to Hepatitis B virus that spreads through exposure to infectious blood, vaginal fluid, and semen. Thus the possible modes of transmission are sexual contact, transfusion of infected blood/ blood products, use of contaminated needles or syringes, and from a mother to her child during child birth.

In order to understand the disease's intensity in various cities of India, a study was conducted on 24,225 samples in 2012. The samples were from the cities of Bangalore, Chennai, Delhi and Mumbai. Of these tested samples, 3373 (14%) samples were found positive for Hepatitis B. Maximum positive samples for Hepatitis B belonged to the age group of 20 to 40 years [13,884 (48%) positive samples].

Hepatitis is a silent killer, and may go undiagnosed for years together. Most of the people who are infected (almost two-thirds) are unaware of their infection and this has resulted in the silent HBV infection becoming one of the biggest threat to the health of the world.

Since the younger age group is a sexually active group, and given the fact that Hepatitis B is a silent disease, chances of the infection spreading are high. The disease can remain undiagnosed for years together, until the associated symptoms get pronounced.

Vaccination against Hepatitis B is extremely safe and the most effective way to prevent it. Prevention measures for this disease are the same as that of HIV/AIDS.

If not properly monitored or treated HBV infection can kill 25% of the infected people due to liver cancer or liver failure from cirrhosis. HBV along with HCV is a dangerous condition and this combined infection has infected 530 million of the 6 billion people worldwide.

Though there are surgeries to deal with it, early diagnosis and treatment with alternative medicine is the only way to prevent further damage caused by Hepatitis B to the liver, or development of complications like liver cancer.