Indications for hepatitis B immunoglobulin for neonates of HBsAg carrier mothers

Role of hepatitis B immunoglobulin in infants born to hepatitis B e antigen-negative carrier mothers in Taiwan

BACKGROUND

The efficacy of hepatitis B immunoglobulin (HBIG) in infants of hepatitis B e antigen (HBeAg)-negative hepatitis B surface antigen (HBsAg) carrier mothers in Taiwan is not clear.

OBJECTIVE

To describe the responses of infants born to HBeAg-negative carrier mothers receiving HBIG combined with hepatitis B vaccine.

METHODS

Term babies born to HBeAg-negative carrier mothers were assigned based on chart number to 1 of the 2 treatment groups. Group A infants (n = 94) received 0.5 ml (145 IU) of HBIG within 24 h of birth and 3 subsequent doses of recombinant hepatitis B virus (HBV) vaccine at 3 to 5 days, 1 month and 6 months of age. Group B infants (n = 122) received 3 doses of vaccines only. Infants (n = 19) born to HBeAg-positive carrier mothers were treated like those in Group A and are referred to as Group C. Sera obtained from infants at 2 and 7 months of age were tested for hepatitis B virus (HBV) markers.

RESULTS

There were 2 (1%; one in Group A and one in Group B) subclinical breakthrough hepatitis B infections among studied infants. One (5%) child of Group C had asymptomatic HBV infection at the age of 7 months and became a chronic carrier. The rate of protective anti-hepatitis B surface antibody (anti-HBs) titers achieved (>10 mIU/ml) by 2 months of age was significantly higher in Group A than that in Group B (98% vs. 57%, P < 0.001). However, it was not different by 7 months of age. Infants (Group A) immunized with HBIG and vaccine had a significantly higher geometric mean titer (GMT, milli-International Units/ml) of anti-HBs than those (Group B) with vaccines only at 2 months of age (P < 0.001). Conversely at 7 months of age, the GMT of anti-HBs was significantly higher in infants who received vaccine only (P = 0.001).

CONCLUSIONS

A protective level of antibodies was achieved earlier in those infants receiving both passive and active immunizations. However, infants receiving active immunizations alone achieved a higher GMT at 7 months of age. There was no clear benefit of passive-active vs.active immunization alone for chronic HBV infection in infants of HBsAg-positive, HBeAg-negative mothers.

An appraisal of the efficacy and cost effectiveness of antenatal screening for hepatitis B

In this review published data are used to determine the benefits and costs of antenatal screening for hepatitis B carriers to prevent the later occurrence of hepatoma and chronic liver disease in their offspring. In Britain, babies born to carrier mothers have a 25% risk of perinatal infection and of becoming carriers themselves (the risk is 82% if their mothers are positive for the e antigen and 10% if negative). The carrier state increases the risk of hepatoma an estimated 86 times and the risk of chronic liver disease 20 times. Life table analysis showed that there is an 11% lifetime risk in carriers in Britain of dying from hepatoma (which results in seven years of life lost on average) and a 7% risk of chronic liver disease (14 years of life lost). Neonatal vaccination reduces the risk of the infant becoming a carrier by about 90%. Perinatal transmission occurs in 38 of every 100,000 neonates in Britain. Antenatal screening of all women and vaccinating babies of carrier mothers would prevent perinatal transmission in 34 of the 38 children (90%), or 255 per year in Britain. Of these 34, 8.4 children would be Chinese in ethnic origin, 4.2 African, 11.5 South Asian (from the Indian subcontinent), 2.0 Caribbean, and 7.3 would be white. Six deaths in the 34 from hepatoma or chronic liver disease caused by hepatitis B would then be prevented. The direct cost in Britain of screening all women, irrespective of ethnicity, at their first pregnancy only, would be 1300 pounds for each year of life saved (undiscounted) or 2500 pounds if screening at every pregnancy. Screening just Chinese, Africans, and South Asians, at first pregnancy only, would cost 330 pounds for each year of life saved but would prevent only 64% of these deaths. Vaccinating the infants of carrier mothers is likely also to prevent horizontal transmission of hepatitis B in early childhood and prevent the carrier state developing in an estimated three extra children for each child protected from vertical transmission. When this is taken into account the number of deaths prevented increases fourfold, reducing the cost for each year of life saved by 75%. Screening all women at first pregnancy only is an acceptably cost effective policy in Britain (1300 pounds for each year of life saved), actually preventing 45 deaths a year from hepatoma and chronic liver disease (or about 180 deaths if those horizontally infected are included), at a total cost of 540,000 pounds a year. It has the advantage of being comprehensive, equitable, and easier to implement than a policy based on screening of high risk ethnic groups.

Prevention of hepatitis B by immunization of the newborn infant--a long-term follow-up study in Stockholm, Sweden

In order to assess the present hepatitis B immunization program in Stockholm, Sweden, 212 children of HBsAg carrier mothers were followed up 2-9 years after birth. In babies of HBeAg-positive mothers a combined passive and active immunization schedule with hepatitis B immunoglobulin (HBIG) and hepatitis B vaccine was used. Among 25 children to such mothers, 1 HBsAg carrier and 5 children with asymptomatic seroconversion were found. To newborns of HBeAg-negative/anti-HBe-negative mothers, only vaccine was given. Among 15 such children, no HBsAg carrier (but 1 child with an asymptomatic seroconversion) was found. In babies of HBeAg-negative/anti-HBe-positive mothers, immunization was withheld between 1983 and 1987. Among 90 such children, 1 HBsAg carrier and 8 asymptomatic seroconversions were detected. After 1987, newborns in this group were vaccinated whereafter 3 asymptomatic seroconversions were found among 82 children. We conclude that in low prevalence areas a screening program for HBsAg should be offered to pregnant women originating from hepatitis B endemic regions, since immunoprophylaxis gave long-term protection to most children at risk. Children born to HBeAg-positive mothers should receive vaccine in combination with HBIg, whereas for children of mothers lacking HBeAg, vaccination only seems sufficient, at least if a rapid vaccination schedule is used.

Cost-benefit analysis of a nationwide neonatal inoculation programme against hepatitis B in an area of intermediate endemicity

STUDY OBJECTIVE

The aim was to estimate the costs and benefits of a nationwide neonatal vaccination campaign against hepatitis B in Israel for the 1990-2034 period.

DESIGN

Using morbidity, mortality, utilisation, and cost data from Israeli and international sources, a spreadsheet model was constructed to carry out the cost-benefit analysis.

SETTING

The entire State of Israel, an area of intermediate endemicity.

PARTICIPANTS

The population of Israel from 1990-2034.

MAIN RESULTS

A policy of immunising all Israeli neonates would, for a cost of $13.8 million, reduce the number of cases of hepatitis B during the 1990-2035 period in the cohort from 359,000 to 166,000 and save the nation around $21.5 million in health resources alone, $16.6 million in averted work absences, and a further $0.6 million in averted premature mortality costs. Even when the savings to the health services ($0.6 million) arising from the reduction in hepatocellular carcinoma are excluded, the direct benefit to cost ratio is 1.51/1, still in excess of unity.

CONCLUSIONS

The decision to adopt a nationwide neonatal inoculation policy, starting in January 1992, appears to be not only medically but also economically justifiable.

Cost-benefit analysis of a nationwide inoculation programme against viral hepatitis B in an area of intermediate endemicity

The large decrease in the cost of vaccines against hepatitis virus B prompts a re-examination of nationwide vaccination campaign strategies. The present study estimates the costs and benefits that would result from a viral hepatitis B prevention programme (with no prior screening) targeted at all under-16-year-olds in Israel in 1990 and only neonates in the period 1991-2034. Israel is situated in an area of intermediate endemicity, where the majority of HBsAg carriers are anti-HBe positive. Such a policy would reduce the number of cases of viral hepatitis B in the vaccinated cohort from 654,000 to 270,000 over the period 1990-2059, yielding a benefit-to-cost ratio of 1.88: 1 for the health services only. Inclusion also of the indirect benefits of reduced work absences and mortality would increase the benefit-to-cost ratio to 2.77:1. Even when the benefits arising from the reduction in hepatocellular carcinoma and liver transplants were excluded, the benefit-to-cost ratio for the health services alone would still be 1.41:1. The adoption of such a nationwide inoculation policy appears therefore to be not only medically but also economically justifiable.

A nationwide vaccination programme in Italy against hepatitis B virus infection in infants of hepatitis B surface antigen-carrier mothers

In order to prevent hepatitis B virus (HBV) infection of infants of hepatitis B surface antigen (HBsAg)-positive mothers, a nation-wide immunization programme was initiated in Italy in January 1984. During the first 3 years (1984-86), 651,667 out of 1726,000 pregnant women (37.8%) were screened for HBsAg; the percentage of mothers screened increased from 32% in 1984 to 51% in 1986 in 15 of the 21 Italian regions, where data by year were available. HBsAg was present in 15,640 mothers (2.4% of those screened); range by region 0.3-6.4%. All newborns of HBsAg-positive women, regardless of the mother's status of hepatitis Be antigen (HBeAg), were given a single dose (0.5 ml Kg-1) of a hepatitis B immune globulin within 24 h after birth and the first dose of plasma-derived hepatitis B vaccine within 7 days after birth. The immunization coverage rate was 80% in the 3-year period. Protective antibodies were found in greater than 97% of a sample of 1071 infants, immunized from different regions. No serious reactions were observed. On the basis of this field experience, it may be concluded that a nation-wide hepatitis B vaccination programme for infants of HBsAg-carrier mothers would be highly immunogenic and safe. Its implementation, however, requires continuous public education and cooperation from physicians.

The effects of hepatitis B vaccination on infants born to carriers without HBe antigenemia

A retrospective study on fifty-three patients born to hepatitis B surface antigen (HBs antigen) positive mothers was carried out. Among 17 patients born to hepatitis B e antigen (HBe antigen) negative mothers, six patients received hepatitis B(HB) vaccination and eleven did not. None of the six patients who had received HB vaccination showed seroconversion, while six of the 11 patients (54.5%) without HB vaccination did show seroconversion. There was no definite correlation between the frequency of seroconversion and the administration of HB immune globulin (HBIG). HB vaccination alone may be sufficient to protect infants born to HBe antigen negative mothers from HB viral infection.

Immunoprophylaxis of perinatal transmission of the hepatitis B virus: efficacy of hepatitis B immune globulin and hepatitis B vaccine in a low-prevalence area

One hundred eleven newborn infants born of Spanish hepatitis B surface antigen (HBsAg) carrier mothers were consecutively assigned to one of three treatment groups. Group A was treated with three or four doses of hepatitis B immune globulin (HBIG) in one of three different schedules. Group B received one dose of hepatitis B vaccine (Hevac-B, Pasteur) at birth and at 1, 2 and 12 months. Group C was treated with the same vaccination schedule as group B and in addition received a single dose of HBIG at birth. Comparisons were made in the 85 babies who had strictly completed the immunization schedule and had been followed for at least 12 months. The three immunization protocols were equally effective, since none of the children became a chronic HBsAg carrier or developed acute symptomatic infection. There were five transient and subclinical infections among children who received only HBIG (group A), one transient infection in group B, and one in group C. There seems to be some correlation between anti-HBs levels and degree of protection, since all transient infections in group A occurred in the subgroups who did not maintain protective antibodies during the first 6 months. Although the percentage of responders in the two vaccinated groups did not differ significantly, children who received only vaccine reached higher antibody levels than those who also received HBIG. Our results suggest that any immunization schedule able to maintain anti-HBs levels during the first 6 months of life would be useful to prevent mother-to-infant transmission of the hepatitis B virus in areas where most of the carrier women are expected to be anti-HBe positive and hence relatively less infectious.