Hepatitis B Virus Infection in Pregnant Women: Screening --Pregnant women


General

Grade: A The USPSTF recommends the service. There is high certainty that the net benefit is substantial. Offer or provide this service.

Specific Recommendations

The USPSTF recommends screening for hepatitis B virus (HBV) infection in pregnant women at their first prenatal visit

Frequency of Service

A test for HBsAg should be ordered at the first prenatal visit. Women with unknown HBsAg status or with new or continuing risk factors for HBV infection (eg, injection drug use or a sexually transmitted infection) should be screened at the time of admission to a hospital or other delivery setting.

Risk Factor Information

In the United States, new cases of HBV among adults are largely transmitted through injection drug use or sexual intercourse, but most prevalent cases of HBV infection are chronic infections from exposure occurring in infancy or childhood. Another major risk factor for HBV infection is country of origin. In the United States, adults with HBV born in high-prevalence countries were commonly infected during childhood. In children, the primary source of infection is perinatal transmission at birth.


Clinical

Patient Population Under Consideration

This recommendation applies to all pregnant persons.

Screening Tests

The principal screening test for detecting maternal HBV infection is the serologic identification of HBsAg. Screening should be performed in each pregnancy, regardless of previous HBV vaccination or previous negative HBsAg test results.1

Screening Interval

A test for HBsAg should be ordered at the first prenatal visit. Women with unknown HBsAg status or with new or continuing risk factors for HBV infection (eg, injection drug use or a sexually transmitted infection) should be screened at the time of admission to a hospital or other delivery setting.

Treatment

Interventions to prevent perinatal transmission of HBV infection include screening all pregnant women for HBV, vaccinating infants born to HBV-negative mothers within 24 hours of birth, and completing the HBV vaccination series in infants by age 18 months. For HBV-positive mothers, case management during pregnancy includes HBV DNA viral load testing and referral to specialty care for counseling and medical management of HBV infection. For infants born to mothers who test positive for HBsAg, current guidelines for case management include HBV vaccination and hepatitis B immune globulin (HBIG) prophylaxis within 12 hours of birth, completing the vaccine series, and serologic testing for infection and immunity at age 9 to 12 months. For infants born to mothers with unknown HBsAg status, current guidelines for case management include HBV vaccination within 12 hours of birth, followed by HBIG prophylaxis.5

Emerging evidence has demonstrated that administering tenofovir to HBV-positive women with acute infection significantly reduces the risk of HBsAg seropositivity in infants when combined with HBIG prophylaxis at birth and HBV vaccination.67 As a result, recent guidelines recommend testing for viral load, antiviral treatment, and HBV vaccination and HBIG prophylaxis.5

Useful Resources

The USPSTF has made recommendations on screening for other infections, including chlamydia and gonorrhea,8 HBV in nonpregnant adults and adolescents,9 genital herpes,10 HIV,11 and syphilis in pregnant women.12

The Centers for Disease Control and Prevention (CDC) provides more information about HBV infection, including perinatal transmission.13,14

 

Other Considerations

Implementation

Universal screening for HBV infection in women during pregnancy is standard clinical practice in the United States. Presently, 26 states have laws mandating prenatal HBV screening.15 Although rates of maternal screening for HBV infection range from 84% to 88%, screening rates during the first trimester are lower, with 60% of commercially insured and 39% of Medicaid-enrolled women screened during the first trimester.16 Seventy-one percent of infants receive HBV vaccination within 3 days of birth.117 Primary care clinicians and delivery settings must establish effective systems for the accurate and timely transfer of maternal HBsAg test results to labor, delivery, and newborn medical records to maximize benefit.1

Research Needs and Gaps

 

The USPSTF has identified areas of needed research. Continued research on effective implementation of case management in vulnerable populations most at risk for perinatal transmission of HBV infection is needed. Additional studies on the effectiveness of prenatal antiviral medication to reduce perinatal transmission are needed. Analyses of recent data from existing case management programs, such as the Perinatal Hepatitis B Prevention Program (PHBPP), would be helpful in understanding program performance and research needs.1 There is emerging evidence on the use of antiviral therapy during pregnancy.167 Further research is needed to examine the prevention of perinatal transmission.


Rationale

Importance

Screening for HBV infection during pregnancy identifies women whose infants are at risk of perinatal transmission. Data from a nationally representative sample showed a prevalence of maternal HBV infection of 85.8 cases per 100,000 deliveries from 1998 to 2011 (0.09% of live-born singleton deliveries in the United States).12 Although there are guidelines for universal infant HBV vaccination, rates of maternal HBV infection have increased annually by 5.5% since 1998.12 Persons infected with HBV during infancy or childhood are more likely to develop chronic infection. Chronic HBV infection increases long-term morbidity and mortality by predisposing infected persons to cirrhosis of the liver and liver cancer.

Reaffirmation

In 2009, the USPSTF reviewed the evidence for screening for HBV infection in pregnant women and issued an A recommendation.3 The USPSTF has decided to use a reaffirmation deliberation process to update this recommendation. The USPSTF uses the reaffirmation process for well-established, evidence-based standards of practice in current primary care practice for which only a very high level of evidence would justify a change in the grade of the recommendation.4 In its deliberation of the evidence, the USPSTF considers whether the new evidence is of sufficient strength and quality to change its previous conclusions about the evidence.

Detection

The USPSTF previously reviewed the evidence on serologic testing for HBV (hepatitis B surface antigen [HBsAg]) in pregnancy and found adequate evidence of its accuracy (sensitivity and specificity both >98%).

Benefits of Early Detection and Interventions

The USPSTF found convincing evidence that universal prenatal screening for HBV infection substantially reduces perinatal transmission of HBV and the subsequent development of chronic HBV infection. The USPSTF found adequate evidence that vaccination of all infants against HBV infection and providing postexposure prophylaxis with hepatitis B immune globulin (HBIG) at birth to infants of mothers infected with HBV substantially reduce the risk for acquisition of HBV infection in infants.

Harms of Screening and Interventions

The USPSTF found limited evidence on the harms of screening for HBV infection in pregnant women but bounded the potential harms of screening as no greater than small based on the high accuracy of screening and the low likelihood of harms from preventive interventions.

USPSTF Assessment

Using a reaffirmation process, the USPSTF concludes with high certainty that the net benefit of screening for HBV infection in pregnant women is substantial.


Others

Reaffirmation of Previous USPSTF Recommendations   This recommendation is a reaffirmation of the USPSTF 2009 recommendation statement. In 2009, the USPSTF reviewed the evidence for screening for HBV infection in pregnant women and found that the benefits of screening substantially outweighed the harms.3 For the current recommendation, the USPSTF commissioned a targeted review to look for new and substantial evidence on the benefits and harms of screening and determined that the net benefit of screening for HBV infection in pregnant women continues to be well established. The USPSTF found no new substantial evidence that would change its recommendation and, therefore, reaffirms its recommendation to screen for HBV infection in pregnant women.   Recommendations of Others The American College of Obstetricians and Gynecologists recommends screening for HBV with serologic testing for HBsAg in every pregnant patient at the earliest prenatal visit. These tests should be designated as “prenatal.” Pregnant women who test positive for HBsAg should then be tested for HBV DNA.29 The CDC Advisory Committee on Immunization Practices similarly recommends testing for HBsAg in all pregnant women during an early prenatal visit (e.g., in the first trimester) and HBV DNA testing for pregnant women who test positive for HBsAg.5 The American Academy of Family Physicians recommends screening for HBV infection in pregnant women at their first prenatal visit.30 The American Association for the Study of Liver Diseases recommends screening in all pregnant women by testing for HBsAg and the hepatitis B surface antibody (anti-HBs).24


Tools

To get started, log in or create your free account Create Account