Background

  • Hepatitis B virus is acquired though contact with blood and body
  • Most carriers acquire the virus from their mother perinatally or by exposure in early
  • Some patients may have acquired Hepatitis B though intravenous needle sharing or sexual contact.
  • Following Hepatitis B infection as an adult, 90% of individuals clear the virus, become immune and are not infectious to others.
  • However, with infection acquired at birth, up to 90% will not clear the virus and will become chronically
  • Chronic infection is indicated by a positive surface antigen result (HBsAg). If the hepatitis B e- antigen (HBeAg) is also positive, this means that the patient has viral protein associated with a high level of
  • Perinatal transmission can be prevented by administration of a course of active immunisation (Hep B vaccine) together with Hepatitis B immunoglobulin (HBIg) at birth where indicated (See flow diagram below)

 

There are 3 groups of babies at risk of acquiring Hepatitis B:

  1. Babies born to mothers who have activeHepatitis B infection
  2. Babies born where a household member has Hepatitis B
  3. Babies born to parents who are problem drug users

 

1.       Babies born to mothers who have active Hep B infection

  • Hepatitis vaccine should be given at birth, this has been shown to be effective in 95% of infants at
  • Some babies may also require Hepatitis B immunoglobulin at birth, this will be documented on the neonatal management plan.
  • Refer to flow chart below and Section A - Hepatitis B vaccination for babies born to mothers with Hepatitis B infection

 

2.       Babies born where a household member has Hepatitis B

  • Should be offered the monovalent Immunisation soon after birth as it would reduce transmission through exposure to mucous membranes or minor cuts
  • It is dependent on the mother alerting staff that there is a household member positive for Hepatitis B in order for the vaccine to be given.
  • Refer to Section B - Hepatitis B vaccination for babies born to a household with an infected contact (not the mother)

 

3.  Babies born to parents who are problem drug users

  • Drug users are at ongoing risk of acquiring HBV due to sharing of injecting equipment and through sexual
  • Children of problem drug users are susceptible because they live in a high risk environment, with close household contact between parent and child, and with other
  • .
  • These infants do not need the monovalent immunisation after birth but would be offered the vaccine as part of standard Immunisation schedule where new hexavalent vaccine is given at 2, 3 and 4

Flow diagram to determine if babies require additional monovalent hepatitis B vaccine +/- hepatitis immunoglobulin:

Flow diagram to determine if babies require additional monovalent hepatitis B vaccine +/- hepatitis immunoglobulin

Protocol

  • In Lothian, all women are screened for hepatitis B at booking. Any woman found to be hepatitis B positive at booking will automatically be referred to specialist obstetric clinics by virology. Confirmatory testing including hepatitis e-markers, viral load and liver function will be performed. Women have repeat serology again at 28 weeks
  • All women are also referred to the Hepatology clinic (Dr Andy Bathgate) for follow up off their chronic Hep B in pregnancy.
  • All women will also be asked about problem drug use, both personal and relating to their partner.
  • Pregnant women whose babies are at risk of Hepatitis B will be flagged on TRAK (special features section). Once they have been seen at the high risk obstetric clinic, there will be a Neonatal Management Plan completed by the consultant obstetrician, which provides details of the appropriate postnatal management individualised according to the mother’s serology. Please ensure you refer to the Neonatal Management Plan in the mothers TRAK for all babies at risk of Hep B.

Hepatitis B Immunoglobulin

  • If Immunoglobulin is required this will be documented in the neonatal Management plan. It must be given within 4 hours of delivery (can be given up to 12 hours after delivery) especially if mother HBeAg positive.
  • This must be ordered from pharmacy when open. If required out of pharmacy-hours, it can be obtained from the Hospital at Night bleep holder (via switchboard).
  • A pharmacy order for Hepatitis B immunoglobulin needs to include the following details: name, unit number, dose, route and prescriber.
  • Dose
  • 200units (If 200unit vials are still available) 
  • OR
  • 250 units (approximately1.75ml, or half of a 500 unit vial) by IM injection
  • Discard unused portion

 

Vaccine

  • The vaccine is stored on the postnatal wards and can also be obtained from pharmacy. The dose of HepB vaccine depends on the brand, but the volume given should always be 0.5ml so either 5 or 10 micrograms may be given. Please prescribe as 0.5ml IM injected into the upper anterolateral thigh of the opposite limb to that used for Ig injection. Ensure that the brand and batch number are
  • Give at same time as immunoglobulin if possible, ideally with in 4 hours, and otherwise not later than 24 hours after

Infection control

  • Universal precautions and sample
  • No isolation

NB - very low risk of acquiring infection from baby at birth.

 

Breast feeding

Hepatitis B in the mother is NOT a contraindication to breast feeding. The baby is protected through passive and active immunisation.

Communication and follow-up

  • The midwives will complete a form to inform the Scottish Immunisation Recall System (SIRS) and Public Health (health.protection@nhslothian.scot.nhs.uk) that the baby has had the first dose of vaccine, so that recall for subsequent doses is triggered. Information will also be entered on the TRAK postnatal discharge
  • Further doses of vaccine are given at 1 month (if required) and during standard immunisation protocol. These are organised by the health protection team and given by the local immunisation team.
  • Follow up is by the Health Protection team and child health therefore it is imperative that the Health Protection team is made aware that the baby has had their first dose of Hep B vaccine and the need for follow up. The postnatal notification form for SIRS and Public health MUST be sent to health.protection@nhslothian.scot.nhs.uk or internal post to health protection team, level 2, Waverley gate.  The form is on page 14 of section A.
  • There is a letter contained in the Hep B resource pack if the baby is on the postnatal wards which is sent to the GP for information only. If the baby is admitted to the neonatal unit, this information should be clearly communicated in the discharge letter. Parents should be given an information leaflet
  • Please use the correct resource packs as there are 2 different Hep B resource packs:
    • Section A: Mother with Hepatitis B infection
    • Section B:Household contact

Editorial Information

Last reviewed: 12/10/2017

Next review date: 12/07/2023

Author(s): David Quine, Vix Monnelly, Louise Wellington.