Andrey Nailor, M.D.·Published 29 March 2012·8 min read
Key points
A program to prevent chronic hepatitis B infection in newborns seems to be working, according to a new study from researchers at the Centers for Disease Control and Prevention.
Perinatal exposure to HBsAg positive mothers is a continuing problem with acute and long term adverse effects for infants.
About 7 out of 10 adults with acute hepatitis B have signs or symptoms when infected with HBV.
Though HBV has been found in saliva, there are no data to suggest that saliva alone transmits HBV infection.
A program to prevent chronic hepatitis B infection in newborns seems to be working, according to a new study from researchers at the Centers for Disease Control and Prevention.
They found that more babies exposed to hepatitis B through their moms have gotten vaccinated right away, and fewer have ended up with chronic infections, since the program started in 1990.
That's important because the virus can be passed between mother and child during birth, and over the long run chronic infection increases the risk of liver failure and cancer.
"The findings were very encouraging - they showed that most infants completed the (vaccination) series," said Emily Smith, the lead researcher on the study.
"For the infants that were followed... they had great results and outcomes," she told Reuters Health.
Still, Smith emphasized that there's work to be done in making sure all new moms with hepatitis B are reported to the CDC's program so that babies can receive the proper care to prevent infection.
40,000 NEW INFECTIONS PER YEAR
About one million people living in the United States have chronic hepatitis B infection, and an additional 40,000 are infected every year though bodily fluids such as blood and semen - as well as during birth.
Perinatal Hepatitis B Program
Perinatal exposure to HBsAg positive mothers is a continuing problem with acute and long term adverse effects for infants. The primary objectives of the perinatal program are: - Test all pregnant women for the hepatitis B virus. - Identify pregnant women who are positive (+) for hepatitis B. - Ensure the newborn receives appropriate prophalaxis as well as sexual/household contacts.
The Perinatal Hepatitis B Prevention Program collaborates with laboratories, hospitals and local health departments to ensure all positive lab reports are reported to the Arizona Department of Health Services. Positive expectant mothers are identified, offered services and tracked by the perinatal program to ensure that exposed infants are appropriately treated with hepatitis B Immune Globulin (HBIG) and hepatitis B vaccine within 12 hours of birth and complete the hep B series in the appropriate time frame.
Additionally, the program offers free services to the sexual and household contacts of the positive mothers, to ensure that they are tested for the hepatitis B virus and if found susceptible, receive the hepatitis B vaccine series.
The CDC's vaccine program calls for screening all pregnant women for hepatitis B and giving exposed babies antibodies and a vaccine against the virus within 12 hours of birth, followed by an additional two or three vaccine doses over the next year or so. Individual cities and states submit reports to the CDC on the number of hepatitis B cases identified in women and how their infants were managed, and those numbers are used to make nationwide estimates.
Written and revised by
Andrey Nailor, M.D.
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About 7 out of 10 adults with acute hepatitis B have signs or symptoms when infected with HBV. Children under age 5 years who become infected rarely show any symptoms. Signs and symptoms of hepatitis B might include nausea, lack of appetite, tiredness, muscle, joint, or stomach pain, fever, diarrhea or vomiting, headache, dark urine, light-colored stools, and yellowing of the skin and whites of the eyes (jaundice). People who have such signs or symptoms generally feel quite ill and might need to be hospitalized. The case fatality rate among persons with reported cases of acute hepatitis B is approximately 1.5%, with the highest rates occurring in adults who are over 60 years of age.
How long does it take to show signs of illness after a person becomes infected with hepatitis B virus (HBV)?
The incubation period ranges from 45 to 160 days (average 120).
Can HBV be transmitted in daycare via saliva, e.g., drooling infants?
Though HBV has been found in saliva, there are no data to suggest that saliva alone transmits HBV infection. There have been reports of HBV transmission when an HBV-infected person bites another person. In these reports, bloody saliva was usually present in the infected person's mouth and the blood was more likely the vehicle of transmission. HBV is not spread by kissing, hugging, sneezing, coughing, food or water, sharing eating utensils or drinking glasses, or casual contact.
Based on those reports, the researchers calculated that from 1994 to 2008, the number of women who screened positive for hepatitis B each year increased from about 19,000 to close to 26,000. And health care workers seemed to get better at making sure their babies were protect against the virus.
Over the study period, the number of exposed babies who got both hepatitis B antibodies and a vaccine within a day of birth increased from 92 percent to almost 97 percent.
What is the risk for transmitting HBV by oral sex?
There are no specific data on transmission of bloodborne viruses through oral-genital sex. Saliva has not been associated with HBV transmission unless biting has taken place. HBV is not spread by kissing, hugging, sneezing, coughing, food or water, sharing eating utensils or drinking glasses, or casual contact.
Can "French" kissing transmit HBV?
While HBV has been found in saliva, there are no data to suggest that kissing transmits HBV; however, there have not been studies to specifically look at "French" kissing.
Along with that, tracked infants who ended up with chronic hepatitis B infection fell from two percent to less than one percent by 2008, the researchers reported in Pediatrics.
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LONGER FOLLOW-UP NEEDED
Still, they were only able to follow about half of babies out to one year. And the number of infants who'd had all of their hepatitis B vaccines by that point actually decreased during the study period - from 86 percent to 78 percent - with at least some of that due to more families refusing vaccines.
"The program is certainly working - they're vaccinating more infants successfully," said Dr. Maya Gambarin-Gelwan, who has studied hepatitis B at Weill Cornell Medical College in New York but wasn't involved in the new research.
"But half of the infants who are born to those mothers are slipping through the system essentially," she told Reuters Health. "It's also bothersome that there's this growing percentage of infants who are not completing vaccination or that we don't have a follow-up on."
Do women who have been vaccinated previously against HBV infection still need to be screened during pregnancy?
Yes. Women who have received hepatitis B vaccine should still be screened for HBsAg early with each pregnancy. Just because a woman has been vaccinated does not mean she is HBsAg negative. Since postvaccination testing is not performed for most vaccinated persons, she could have been vaccinated even though she was already HBsAg positive.
Is it safe to give hepatitis B vaccine to a pregnant woman?
Yes. Limited data indicate no apparent risk for adverse events to developing fetuses. Current vaccines contain noninfectious HBsAg and should cause no risk to the fetus. If the mother is being vaccinated because she is at risk for HBV infection (e.g., a healthcare worker [HCW], a person with an STD, an IDU, multiple sex partners), vaccination should be initiated as soon as her risk factor is identified during the pregnancy. In contrast, HBV infection affecting a pregnant woman might result in severe disease for the mother and chronic infection for the newborn.
Smith agreed that not being able to follow infants over time is a problem.
"Women need to receive hepatitis B screening and positive results need to be reported to (the program), to make sure that the infants receive vaccination and care and testing," she said.
Gambarin-Gelwan added that it's important to get the message out that hepatitis B programs really do work when babies get all of their recommended vaccines, especially to communities with high virus rates, such as among Asian-Americans.
Is it safe for an HBsAg-positive mother to breastfeed her infant?
Yes! An HBsAg-positive mother who wishes to breastfeed should be encouraged to do so, including immediately following delivery. However, the infant should receive HBIG and hepatitis B vaccine within 12 hours of birth. Although HBsAg can be detected in breast milk, studies done before hepatitis B vaccine was available showed that breastfed infants born to HBsAg-positive mothers did not demonstrate an increased rate of perinatal or early childhood HBV infection. More recent studies have shown that, among infants receiving postexposure prophylaxis to prevent perinatal HBV infection, there is no increased risk of infection among breastfed infants.
What is the possibility of maternal HBV transmission when breastfeeding an infant if the mother is HBsAg positive and has cracked or bleeding nipples?
As stated before, although HBsAg can be detected in breast milk, there is no evidence that HBV is transmitted by breastfeeding. Babies born to HBsAg-positive mothers should be immunized with hepatitis B vaccine and HBIG, which will substantially reduce the risk of perinatal transmission and protect the infant from modes of postnatal HBV transmission, including the theoretical exposure to HBV from cracked or bleeding nipples during breastfeeding. To prevent cracked and bleeding nipples, all mothers that breastfeed should be instructed on proper nipple care.
Dr. Tram Tran from Cedars-Sinai Medical Center in Los Angeles told Reuters Health that while doctors are really good at screening women early in pregnancy when they're already in the health care system, there's still a big gap for other women, such immigrants and illicit drug users.
And even if those women do get screened, she said, they may not have the resources to bring their babies back for the multiple hepatitis B shots necessary for protection.
"It's a completely preventable disease, that's the thing that's frustrating," said Tran, a hepatitis researcher who wasn't part of the study team.
"We have a vaccine that works really well. It's just getting to these high-risk pockets and these high-risk groups where there's still a lot of opportunity."
The National Perinatal Hepatitis B Prevention Program, 1994–2008
CONCLUSIONS: The PHBPP achieved substantial progress in preventing perinatal hepatitis B virus infection in the United States, despite an increasing number of at-risk infants. Significant gaps remain in identifying HBsAg-positive pregnant women, and completing management and assessment of their infants to ensure prevention of perinatal hepatitis B virus transmission.
Emily A. Smith, MPH, Lisa Jacques-Carroll, MSW, Tanja Y. Walker, MPH, Barry Sirotkin, MS, and Trudy V. Murphy, MD
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