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Hepatitis B Prevention

  • Practice Advisory PA
  • January 2018

(Last updated May 22, 2020; Reaffirmed September 2020)


In 2018, the Centers for Disease Control and Prevention (CDC) and the Advisory Committee on Immunization Practices (ACIP) released updated guidance on preventing the transmission of hepatitis B virus (HBV) infection 1. A critical element of the strategy to eliminate HBV in the United States is the prevention of perinatal transmission. The CDC and ACIP’s updated guidance reflects the best currently available evidence, and select recommendations include the following:

 

  • Pregnant individuals who test positive for hepatitis B surface antigen (HBsAg) also should be tested for hepatitis B virus deoxyribonucleic acid (HBV DNA) to guide the use of antiviral medication to prevent perinatal transmission.
  • Persons with chronic liver disease* should be vaccinated against HBV.
  • The American Association for the Study of Liver Diseases suggests antiviral therapy for pregnant individuals with HBV DNA greater than 200,000 IU/mL (7.6 log10 IU/mL). Published evidence indicates that maternal antiviral therapy during pregnancy further reduces perinatal HBV transmission 2 3 4 5.
  • The American Association for the Study of Liver Diseases suggests all HBsAg-positive pregnant individuals should be referred to their jurisdiction’s Perinatal Hepatitis B Prevention Program (PHBPP) for case management to ensure that their infants receive timely prophylaxis and follow-up.

In addition to those highlighted above, there also are new recommendations regarding postvaccination serologic testing of infants born to HBsAg-positive patients and revaccination for those not responding to initial vaccination (see CDC’s MMWR for details).

Hepatitis B Vaccination

Hepatitis B vaccination is recommended for patients who are identified as being at risk of hepatitis B infection during pregnancy. This includes but is not limited to patients who: have household contacts or sex partners who are hepatitis B surface antigen–positive; have had more than one sex partner during the previous 6 months; have been evaluated or treated for a sexually transmitted infection; are current or recent injection-drug users; have chronic liver disease; have HIV infection; or have traveled to certain countries. Any patient who wants to be protected from hepatitis B or has an indication for use may receive the vaccine during pregnancy and the postpartum period assuming they do not have any contraindications to vaccination 6.

In 2018, the CDC published recommendations on the use of a new hepatitis B vaccine containing a novel adjuvant. Although CDC allows the use of HEPLISAV-B in adults over age 18 years who are recommended for vaccination against hepatitis B, available human data on HepB-CpG administered to pregnant patients are insufficient to inform assessment of vaccine-associated risks in pregnancy. Thus, until safety data are available for HepB-CpG, health care professionals should continue to vaccinate pregnant patients needing HepB vaccination with a vaccine from a different manufacturer 7. For pregnant patients who inadvertently receive HEPLISAV-B, health care professionals should report this administration to the manufacturer’s pregnancy registry by calling 1-844-443-7734 or emailing heplisavbpregnancyregistry@ppdi.com 8.

The CDC recommends universal hepatitis B vaccination within 24 hours of birth for medically stable infants greater than 2000 grams, has removed permissive language that allowed the vaccine to be delayed until after hospital discharge, and continues to recommend hepatitis B vaccination and hepatitis immune globulin regardless of birth weight within 12 hours of birth for infants born to hepatitis B-infected patients. Both of these recommendations are consistent with ACOG and the American Academy of Pediatrics (AAP)’s Guidelines for Perinatal Care, 8th edition.

ACOG agrees with the recommendations outlined by CDC and encourages members to adopt these strategies into practice. Additional information and recommendations related to hepatitis B and pregnancy can be found in ACOG Practice Bulletin 86: Viral Hepatitis in Pregnancy, and any additional updates to hepatitis B guidance will be incorporated into a future revision of this Practice Bulletin.

*Persons with chronic liver disease include, but are not limited to, those with hepatitis C virus infection, cirrhosis, fatty liver disease, alcoholic liver disease, autoimmune hepatitis, and an alanine aminotransferase or aspartate aminotransferase level greater than twice the upper limit of normal.

This Practice Advisory was developed by the American College of Obstetricians and Gynecologists’ Immunization and Emerging Infections Expert Work Group in collaboration with Brenna L. Hughes, MD and Kevin A. Ault, MD.


References

  1. Schillie S, Vellozzi C, Reingold A, Harris A, Haber P, Ward JW, et al. Prevention of hepatitis B virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices. MMWR Recomm Rep 2018;67(RR-1):1-31. Available at: https://www.cdc.gov/mmwr/volumes/67/rr/rr6701a1.htm?s_cid=rr6701a1_w. Retrieved January 23, 2018.
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  2. Terrault NA, Bzowej NH, Chang KM, Hwang JP, Jonas MM, Murad MH. AASLD guidelines for treatment of chronic hepatitis B. American Association for the Study of Liver Diseases. Hepatology 2016;63:261-83. Available at: http://onlinelibrary.wiley.com/doi/10.1002/hep.28156/abstract. Retrieved January 23, 2018.
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  3. Pan CQ, Duan ZP, Bhamidimarri KR, Zou HB, Liang XF, Li J, et al. An algorithm for risk assessment and intervention of mother to child transmission of hepatitis B virus. Clin Gastroenterol Hepatol 2012;10:452-9. Available at: https://www.sciencedirect.com/science/article/pii/S1542356511011736. Retrieved January 23, 2018.
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  4. Pan CQ, Duan Z, Dai E, Zhang S, Han G, Wang Y, et al. Tenofovir to prevent hepatitis B transmission in mothers with high viral load. China Study Group for the Mother-to-Child Transmission of Hepatitis B. N Engl J Med 2016;374:2324-34. Available at: http://www.nejm.org/doi/full/10.1056/NEJMoa1508660. Retrieved January 23, 2018.
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  5. Dionne-Odom J, Tita AT, Silverman NS. #38: hepatitis B in pregnancy screening, treatment, and prevention of vertical transmission. Society for Maternal-Fetal Medicine (SMFM). Am J Obstet Gynecol 2016;214:6-14. Available at: http://www.ajog.org/article/S0002-9378(15)01214-4/fulltext. Retrieved January 23, 2018.
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  6. Maternal immunization. ACOG Committee Opinion No. 741. American College of Obstetricians and Gynecologists. Obstet Gynecol 2018;131:e214-7. Available at: https://journals.lww.com/greenjournal/FullText/2018/06000/Maternal_Immunization__ACOG_Committee_Opinion,.60.aspx. Retrieved May 19, 2020.
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  7. Schillie S, Harris A, Link-Gelles R, Romero J, Ward J, Nelson N. Recommendations of the Advisory Committee on Immunization Practices for use of a hepatitis B vaccine with a novel adjuvant. MMWR Morb Mortal Wkly Rep 2018;67:455-8. Available at: https://www.cdc.gov/mmwr/volumes/67/wr/mm6715a5.htm?s_cid=mm6715a5_w. Retrieved May 19, 2020.
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  8. HEPLISAV-B [hepatitis b vaccine (recombinant), adjuvanted] solution for intramuscular injection. Highlights of prescribing information. Emeryville, CA: Dynavax Technologies Corporation; 2020. Available at: https://www.heplisavb.com/images/pdf/HEPLISAV-B-Prescribing-Information.pdf. Retrieved May 19, 2020.
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A Practice Advisory is issued when information on an emergent clinical issue (e.g. clinical study, scientific report, draft regulation) is released that requires an immediate or rapid response, particularly if it is anticipated that it will generate a multitude of inquiries. A Practice Advisory is a brief, focused statement issued within 24-48 hours of the release of this evolving information and constitutes ACOG clinical guidance. A Practice Advisory is issued only on-line for Fellows but may also be used by patients and the media. Practice Advisories are reviewed periodically for reaffirmation, revision, withdrawal or incorporation into other ACOG guidelines.

This information is designed as an educational resource to aid clinicians in providing obstetric and gynecologic care, and use of this information is voluntary. This information should not be considered as inclusive of all proper treatments or methods of care or as a statement of the standard of care. It is not intended to substitute for the independent professional judgment of the treating clinician. Variations in practice may be warranted when, in the reasonable judgment of the treating clinician, such course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or technology. The American College of Obstetricians and Gynecologists reviews its publications regularly; however, its publications may not reflect the most recent evidence. Any updates to this document can be found on www.acog.org or by calling the ACOG Resource Center.

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The American College of Obstetricians and Gynecologists (ACOG), is the nation's leading group of physicians providing health care for women. As a private, voluntary, nonprofit membership organization of more than 58,000 members, ACOG strongly advocates for quality health care for women, maintains the highest standards of clinical practice and continuing education of its members, promotes patient education, and increases awareness among its members and the public of the changing issues facing women's health care. www.acog.org