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Immunisation - Hepatitis B

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Introduction

Hepatitis B is a DNA virus with estimated 240 million chronically infected individuals worldwide.1  It is spread through close physical contact with body fluids of an infected person. The most infectious period is from several weeks before symptoms appear until several weeks or months later. Carriers have the virus in their blood and can remain infectious for many years.

The younger a person is when Hep B infection occurs the more likely they are to become a chronic carrier.

In New Zealand, it is estimated that overall 5.7% of the population is HepBsAg positive.2   The prevalence in antenatal population is not well characterized; there is a suggestion that antenatal prevalence is about 1%.3

Hepatitis B Immunoglobulin (HBIg) is prepared from plasmas that contain high levels of antibody to the surface antigen of the Hepatitis B virus. It is given to all babies (including premature infants) whose mothers are Hepatitis B antigen positive. The vaccine should be stored according to the cold chain management policy.

Risk of vertical transmission

For a newborn born to HepBsAg positive mother, there is a risk of vertical transmission as high as 90% if no prophylaxis given.4 The risk of vertical transmission is associated with the following:

  • Hepatitis B DNA viral load5 
  • Hepatitis B e antigen status: 90% in HepBeAg positive vs 30% in HepBeAg negative6

Other considerations

  • Mode of delivery: No trials to support a difference between vaginal or c-section in hepatitis B vertical transmission rates7 
  • Breast-feeding: There is no evidence that breast-feeding increase the risk of HepB transmission.8 HepB DNA can be detected in breast milk 

Prevention

For Known HepBsAg positive mother

There is an evidence to suggest that hepatitis B immunoglobulin alone, hepatitis B vaccine alone and hepatitis B vaccine plus hepatitis B immunoglobulin given at birth prevents hepatitis B occurrence in the newborn. For these newborns please use the following management information:

Screen all women in early pregnancy for Hepatitis B carriage
If the woman is NOT HBsAg positive then see 'Infants' in section 8.5.2 of the immunisation schedule
If the woman IS HBsAg positive, then:

  1.  All HBsAg-positive pregnant women should also be tested for HBeAg and should have HBV DNA measured. The results should be discussed with a specialist or, early in her pregnancy, the woman should be referred to a specialist for ongoing care. Give the baby hepatitis B protection as follows.

     At age  Action to be taken
     Birth Give hepatitis B immunoglobulin 100-110 IU neonatal and hepatitis B vaccine 5 µg
     6 weeks DTaP-IPV-HepB/Hib
     3 months DTaP-IPV-HepB/Hib
     5 months DTaP-IPV-HepB/Hib
    Take a blood test to check for hepatitis B infection (HBsAg) and for vaccine-induced immunity (anti-HBs).
     9 months  If HBsAg is negative and anti-HBs level is >10 IU/L at age 9 months, immunity is proven.
    If HBsAg is positive, the baby has become infected despite prophylaxis: refer to an appropriate specialist.
    ​If HBsAg is negative and anti-HBs level is ≤10 IU/L at age 9 months, give 1 to 3 further doses of hepatitis B vaccine at least 4 weeks apart. Recheck serology 4 weeks after each dose to determine if further doses are necessary (ie, if anti-HBs is still ≤10 IU/L). If there is no seroconversion after the third further dose of hepatitis B vaccine, discuss with a specialist.


All other vaccines should be administered as per the Schedule. Source: New Zealand immunisation handbook 2017

For unknown HepBsAg status mother

  1. Newborn should receive hepatitis B vaccine at birth. Mother should be tested for hepatitis B serology and if HepBsAg positive the infant should also receive hepatitis B immunoglobulin within 48 hrs
  2. Follow routine vaccine schedule from 6 weeks
  3. If mother was determined to be HepBsAg positive then infant should have HepB serology tests at 9 months of age.10

For HepBsAg negative mother

Follow routine vaccine schedule from 6 weeks.10

For further information regarding hepatitis B immunization please check New Zealand immunisation handbook

Hepatitis B - Mothers Antigen Positive and Status Unknown

Babies born to carrier mothers are at greater risk of catching Hep B virus during birth. Baby can be protected from Hepatitis B by having extra injections of Hep B vaccine and Immunoglobulin (HBIG) at birth. If the recommended immunisations are completed the baby's risk of becoming infected is reduced by about 95%.

Parental consent/ prescribing of Hep B vaccine

See flow chart below for parental consent and vaccinations to give

HepB consent flow chart

Mothers Hepatitis B antigen (HBsAg) status unknown

See flow chart above for process - consent vaccinations and Hep B Immunoglobulin (HBIG)

Efficacy

  • 85-95% and virtually complete protection in those who develop antibody levels of greater than or equal to 10mlU/ml (the protection level). At least 95% in children after 3 doses.
  • The red form HNN2 then goes into the multidisciplinary notes. Later one copy goes to the Medical Officer of Health, Community Health.

Ordering of Hep B Immunoglobulin

On the request form for Human Plasma Protein Products (S405). Send to Blood Bank by chute plus a phone call.

Hepatitis B - Nursing Care of Baby whose Mother is Hep B Antigen Positive or Status Unknown

The Nurse will ensure the following steps are carried out in the nursing care for baby whose mother is Hepatitis B antigen positive or status unknown.:

  1. Strict handwashing
  2. Gloves for all cares, where contact with body fluid is anticipated
  3. Baby may have breast milk
  4. Babies greater than 32 weeks gestation bath as soon as possible, if condition stable, using chlorhexidine surgical scrub 4%:
    Have bath water and towels on hand.
    Nurse wears long sleeve gown and gloves.
    Nurse wets hands, pours some chlorhexidine surgical scrub 4% into hands, lathers up solution. Then using hands cover all of baby's skin-hair (avoiding eyes and ears)
    Place baby in bath water and rinse off the chlorhexidine.
    Dry baby.

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Document Control

  • Date last published: 01 September 2015
  • Document type: Clinical Guideline
  • Services responsible: Neonatology
  • Owner: Newborn Services Clinical Practice Committee
  • Editor: Sarah Bellhouse
  • Review frequency: 2 years