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Screening of Pregnant Women for Hepatitis B and Overview of Hepatitis B Virus Serological Markers

Screening of Pregnant Women for Hepatitis B and Overview of Hepatitis B Virus Serological Markers. Rita Espinoza, MPH Emerging and Acute Infectious Disease Branch May 11, 2010. Objectives. Review screening requirements for pregnant women in Texas

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Screening of Pregnant Women for Hepatitis B and Overview of Hepatitis B Virus Serological Markers

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  1. Screening of Pregnant Women for Hepatitis B and Overview of Hepatitis B Virus Serological Markers Rita Espinoza, MPH Emerging and Acute Infectious Disease Branch May 11, 2010

  2. Objectives • Review screening requirements for pregnant women in Texas • Review serological markers for hepatitis B virus infections

  3. Outline • Historical perspective/rationale • Screening requirements in Texas • Serologic markers • Importance of serologic markers • Review serologic markers • Acute infection • Chronic infection • Case Studies

  4. Background Information • 1991 hepatitis B screening of pregnant women recommended by ACOG, AAP, ACIP • Risk of perinatal transmission • HBsAg and HBeAg + at delivery - 70-90% • HBsAg + only 5-20% • 90% of infants infected perinatally will become chronic carriers of hepatitis B • 25% of those infected will die of HBV-related disease

  5. Strategies to Reduce HBV Disease • Continue and enhance vaccination efforts • School and childcare requirements • HCW • Adults (20-44 years) • Birth dose • Surveillance • Early detection • Education • Perinatal hepatitis B prevention program

  6. Texas Rules • Health & Safety Code, Chapter 81, Section §81.090 • Texas Administrative Code, Title 25, Part 1, Chapter 97 • Subchapter A, Rule §97.1 – §97.6 • Subchapter F, Rule §97.135

  7. Screening Requirements in Texas – Health and Safety Code, Chapter 81, Section §81.090 Sec. 81.090.  DIAGNOSTIC TESTING DURING PREGNANCY AND AFTER BIRTH.   (a)  A physician or other person permitted by law to attend a pregnant woman during gestation or at delivery of an infant shall: (1)  take or cause to be taken a sample of the woman's blood or other appropriate specimen at the first examination and visit; (2)  submit the sample to an appropriately certified laboratory for diagnostic testing approved by the United States Food and Drug Administration for: (A)  syphilis; (B)  HIV infection;  and (C)  hepatitis B infection;  and (3)  retain a report of each case for nine months and deliver the report to any successor in the case.

  8. Screening Requirements in Texas – Health and Safety Code, Chapter 81, Section §81.090, (cont’d) (a-1)  A physician or other person permitted by law to attend a pregnant woman during gestation or at delivery of an infant shall: (1)  take or cause to be taken a sample of the woman's blood or other appropriate specimen at an examination in the third trimester of the pregnancy; (2)  submit the sample to an appropriately certified laboratory for a diagnostic test approved by the United States Food and Drug Administration for HIV infection; and (3)  retain a report of each case for nine months and deliver the report to any successor in the case. (b)  A successor is presumed to have complied with this section if the successor in good faith obtains a record that indicates compliance with Subsections (a) and (a-1), if applicable.

  9. Screening Requirements in Texas – Health and Safety Code, Chapter 81, Section §81.090, (cont’d) (c)  A physician or other person in attendance at a delivery shall: (1)  take or cause to be taken a sample of blood or other appropriate specimen from the mother on admission for delivery;  and (2)  submit the sample to an appropriately certified laboratory for diagnostic testing approved by the United States Food and Drug Administration for: (A)  syphilis; and (B)  hepatitis B infection.

  10. Summary of Requirement • Women should be tested • during pregnancy And • At delivery • Women should be educated on • Transmission • Prevention • Treatment

  11. Serological Markers

  12. Possible Outcomes of Hepatitis B Infection

  13. Clinical Manifestations of HBV Infection • S/SX not unique to HBV infection • Only 50% of adult infections are symptomatic • Need diagnostic tests to distinguish • Incubation period - 45 to 180 days (average = 60-90 days) • Communicability – 1 to 2 months before and after onset of symptoms; chronic carrier

  14. Hepatitis B Lab Markers

  15. Typical Serological Markers for Acute Hepatitis B Infection

  16. Acute Hepatitis B Virus Infection with Recovery Typical Serologic Course Titer HBsAg 0 4 8 12 16 24 28 32 52 100 20 36 Weeks after Exposure

  17. Acute Hepatitis B Virus Infection with Recovery Typical Serologic Course Titer HBV DNA HBsAg 0 4 8 12 16 24 28 32 52 100 20 36 Weeks after Exposure

  18. Acute Hepatitis B Virus Infection with Recovery Typical Serologic Course HBeAg Titer HBV DNA HBsAg 0 4 8 12 16 24 28 32 52 100 20 36 Weeks after Exposure

  19. Acute Hepatitis B Virus Infection with Recovery Typical Serologic Course HBeAg anti-HBe Titer HBV DNA HBsAg 0 4 8 12 16 24 28 32 52 100 20 36 Weeks after Exposure

  20. Acute Hepatitis B Virus Infection with Recovery Typical Serologic Course Symptoms HBeAg anti-HBe Titer HBV DNA HBsAg 0 4 8 12 16 24 28 32 52 100 20 36 Weeks after Exposure

  21. IgM anti-HBc Acute Hepatitis B Virus Infection with Recovery Typical Serologic Course Symptoms HBeAg anti-HBe Titer HBV DNA HBsAg 0 4 8 12 16 24 28 32 52 100 20 36 Weeks after Exposure

  22. Total anti-HBc IgM anti-HBc Acute Hepatitis B Virus Infection with Recovery Typical Serologic Course Symptoms HBeAg anti-HBe Titer HBV DNA HBsAg 0 4 8 12 16 24 28 32 52 100 20 36 Weeks after Exposure

  23. Total anti-HBc IgM anti-HBc anti-HBs Acute Hepatitis B Virus Infection with Recovery Typical Serologic Course Symptoms HBeAg anti-HBe Titer HBV DNA HBsAg 0 4 8 12 16 24 28 32 52 100 20 36 Weeks after Exposure

  24. Total anti-HBc IgM anti-HBc anti-HBs Acute Hepatitis B Virus Infection with Recovery Typical Serologic Course Symptoms HBeAg anti-HBe Titer HBV DNA HBsAg Window Period 0 4 8 12 16 24 28 32 52 100 20 36 Weeks after Exposure

  25. Typical Serological Markers for Chronic Hepatitis B Infection

  26. Chronic Hepatitis B Virus InfectionTypical Serologic Course HBsAg

  27. Chronic Hepatitis B Virus InfectionTypical Serologic Course HBsAg Total anti-HBc

  28. Chronic Hepatitis B Virus InfectionTypical Serologic Course HBsAg Total anti-HBc HBV DNA

  29. Chronic Hepatitis B Virus InfectionTypical Serologic Course HBsAg Total anti-HBc IgM, anti-HBc HBV DNA

  30. Chronic Hepatitis B Virus InfectionTypical Serologic Course HBeAg HBsAg Total anti-HBc HBV DNA

  31. Chronic Hepatitis B Virus InfectionTypical Serologic Course HBeAg Anti-HBe HBsAg Total anti-HBc HBV DNA

  32. Acute HBsAg+ < 6 mos. IgM anti-HBc + positive Infection will resolve and person will have lifelong immunity HBsAb+ and HBcAb+ Chronic HBsAg + for at least 6 months Also known as a “carrier” Infection does not resolve and the person remains infectious HBsAb- and HBcAB+ Acute vs. Chronic HBV Infection

  33. Hepatitis B, acute Surveillance Case Definition • Confirmed: • Positive anti-HBc, IgM with or without symptoms or • Meets clinical case definition and is HBsAg-positive and anti-HAV IgM negative, if done

  34. Hepatitis B, perinatal Surveillance Case Definition • Confirmed: • HBsAg-positive • < 24 months of age • Born to an HBsAg-positive woman

  35. Hepatitis B, chronicSurveillance Case Definition • Confirmed: case that is laboratory-confirmed (2 positives 6 months apart or HBsAg+, anti-HBc+, and IgM-) • Probable: case with a single HBsAg or HBeAg or HBV DNA positive lab when no IgM anti-HBc results are available

  36. CASE STUDIES

  37. Case Study A

  38. Patient History: John went to his doctor with jaundice, fatigue and abdominal pain. After reviewing John’s liver panel, the doctor diagnosed him with acute hepatitis B infection.

  39. Question 1 What might his hepatitis B panel look like?

  40. Answer

  41. Case Study B

  42. Sara visits his doctor and has a hepatitis panel done. Her results are as follows: HBsAg Positive anti-HBc Positive IgM anti-HBc Negative anti-HBs 6mIU/mL

  43. Question 1 How would you interpret Sara’s results?

  44. Answer • Chronic hepatitis B infection

  45. Question 2 What significance is the anti-HBs?

  46. Answer • No biological significance

  47. Case Study C

  48. Jada went to her doctor for a routine physical. A hepatitis panel was done and her results were as follows: HBsAg Negative anti-HBs Positive anti-HBc Negative

  49. Question 1 • How would you interpret her results?

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