Audio‐computer‐assisted survey interview and patient navigation to increase chronic viral hepatitis diagnosis and linkage to care in urban health clinics

Intravenous drug use and sexual practices account for 60% of hepatitis C (HCV) and B (HBV) infection. Disclosing these activities can be embarrassing and reduce risk reporting, blood testing and diagnosis. In diagnosed patients, linkage to care remains a challenge. Audio‐computer‐assisted survey interview (Audio‐CASI) was used to guide HCV and HBV infection testing in urban clinics. Risk reporting, blood testing and serology results were compared to historical controls. A patient navigator (PN) followed up blood test results and provided patients with positive serology linkage to care (LTC). Of 1932 patients surveyed, 574 (30%) were at risk for chronic viral hepatitis. A total of 254 (44.3%) patients were tested, 34 (13.5%) had serology warranting treatment evaluation, and 64% required HBV vaccination. Of 16 patients with infection, seven HCV and three HBV patients started treatment following patient LTC. Of 146 HBV‐naïve patients, 70 completed vaccination. About 75% and 49% of HCV antibody and HBV surface antigen‐positive patients were born between 1945 and 1965. Subsequently, automated HCV testing of patients born between 1945 and 1965 was built into our hospital electronic medical records. Average monthly HCV antibody testing increased from 245 (January‐June) to 1187 (July‐October). Patient navigator directed LTC for HCV antibody‐positive patients was 61.6%. In conclusion, audio‐CASI can identify patients at risk for HCV or HBV infection and those in need of HBV vaccination in urban medical clinics. Although blood testing once a patient is identified at risk for infection needs to increase, a PN is useful to provide LTC of newly diagnosed patients.     

Increased diagnosis and treatment of hepatitis C in prison by universal offer of testing and use of telemedicine

With recent advances in antiviral therapy, there is an opportunity to eliminate hepatitis C virus (HCV) from the UK population. HCV is common in incarcerated individuals, with previous estimates suggesting ~7% of the UK prison population is anti‐HCV antibody positive. Increasing diagnosis and treatment of HCV in prison is a priority in seeking to eliminate transmission in the general population. Thus the study aimed to assess the impact implementation of: (a) A universal offer of blood borne virus testing (UOBBVT) using dry blood spot testing for prisoners at reception to increase diagnosis; (b) Telemedicine clinics (TC) within North East England (NEE) prisons to increase HCV treatment rates. UOBBVT was initially implemented at Her Majesty's Prison (HMP) Durham, commencing March 2016. From March 2016 to February 2017, 2831 of 4280 (66%) new receptions were offered blood borne virus (BBV) testing. Of these, 1495 (53% of offered) accepted BBV testing, of whom 95 (6.4%) were HCV antibody positive, with 47 of those 95 (49.5%) HCV RNA positive, suggesting a prevalence of active infection in the tested population of 3.1% (95% CI 2.4%‐4.2%). Between August 2015 and October 2017, 80 individuals were seen in the TC and 57 (71%) commenced antiviral therapy. Of those with known outcome (n = 29), 100% achieved sustained virological response. In the year prior to implementation, only four patients received HCV treatment. In conclusion, a universal offer of BBV testing to inmates presenting at HMP reception coupled with linkage into specialist care via TC can substantially increase rates of testing, diagnosis and treatment of HCV in this high‐prevalence population.     

The impact of hepatitis screening on diagnosis and treatment in rheumatoid arthritis

Identification of patients with exposure to viral hepatitis is an important part of the care of patients with inflammatory arthritis. This study was conducted to assess the extent of hepatitis B and C screening, and the prevalence of viral hepatitis in a cohort of patients with established rheumatoid arthritis (RA). The medical records of 100 consecutive RA patients were retrospectively analysed for screening of hepatitis B surface antigen, surface antibody and core antibody and hepatitis C antibody. A teaching session was then conducted with the rheumatology team, emphasising the rationale for viral hepatitis testing. We then prospectively analysed 100 more RA patients to see if hepatitis screening improved. In the initial 100 patients (21 % male, mean age 65 years), 85 % were taking methotrexate and 22 % biologic treatments. A complete hepatitis screen was present in 8 %, while 12 % had hepatitis B core antibody checked and 53 % had been tested for hepatitis C. The second cohort of patients was similar to the first in terms of demographics and treatment. A complete hepatitis screen was available in 63 %, while 65 % had hepatitis B core antibody checked and 81 % had been tested for hepatitis C. In total, we identified 4 new cases of positive hepatitis B core antibody, 11 cases of positive hepatitis B surface antibody and 1 case of positive hepatitis C antibody. Even in populations where hepatitis B or C is non-endemic, screening will reveal new cases. Educational initiatives are helpful in teaching staff to screen patients.     

Maternal hepatitis B and hepatitis C carrier status and perinatal outcomes

Background and aims: To examine the association between maternal hepatitis B and C mono‐ and co‐infections with singleton pregnancy outcomes in the state of Florida. Methods: We analysed all Florida births from 1998 to 2007 using birth certificate records linked to hospital discharge data. The main outcomes of interest were selected pregnancy outcomes including preterm birth, low birth weight (LBW), small for gestational age (SGA), fetal distress, neonatal jaundice and congenital anomaly. Results: The study sample consisted of 1 670 369 records. Human immunodeficiency virus co‐infection and all forms of substance abuse were more frequent in mothers with hepatitis B and C infection. After using multivariable modelling to adjust for important socio‐demographical variables and obstetric complications, women with hepatitis C infection were more likely to have infants born preterm [odds ratio (OR), 1.40; 95% confidence intervals (CI), 1.15–1.72], with LBW (OR, 1.39; 95% CI, 1.11–1.74) and congenital anomaly (OR, 1.55; 95% CI, 1.14–2.11). In addition, women with hepatitis B infection were less likely to have infants born SGA (OR, 0.79; 95% CI, 0.66–0.95). Conclusions: Our findings provide further understanding of the association between maternal hepatitis B or C carrier status and perinatal outcomes. Infants born to women with hepatitis C infection appear to be at risk for poor birth outcomes, including preterm birth, LBW and congenital anomaly.     

Transformation of hepatitis B serologic markers in babies born to hepatitis B surface antigen positive mothers

AIM: To better understand the clinical significance of hepatitis B seroiogic markers in babies born to hepatitis B surface antigen (HBsAg) positive mothers, the incidence of maternal seroiogic markers of hepatitis B via placenta and its transformation in these babies were investigated. METHODS: Mothers with positive HBsAg were selected in the third trimester of pregnancy. Their babies received immunoprophylaxis with hepatitis B immunoglobulin and hepatitis B vaccine after birth, and were consecutively followed up for hepatitis B seroiogic markers and HBV DNA at birth, mo 1, 4, 7, 12, and 24. RESULTS: Forty-two babies entered the study, including 16 born to hepatitis B e antigen (HBeAg)-positive HBsAg carrier mothers and 26 to HBeAg-negative HBsAg carrier mothers. Apart from four babies born to HBeAg-positive carrier mothers and demonstrated persistent positive HBeAg eventually became HBV carriers, all other babies developed anti-HBs before 12 mo of age. Among the other 12 babies born to HBeAg-positive carrier mothers, HBeAg was detected in 7 at birth, in 4 at mo 1, and in none of them thereafter. No antibody response to the transplacental HBeAg was detected. Among the babies born to HBeAg-negative carrier mothers, anti-HBe was detected 100% at birth and mo 1, in 88.5% at mo 4, in 46.2% at mo 7, in 4.2% at mo 12 and none in mo 24. Among all the immunoprophylaxis-protected babies born to either HBeAg-positive or HBeAg-negative carrier mothers, anti-HBc was detected in 100% at birth, mo 1 and mo 4, in 78.9% at mo 7, in 36.1% at mo 12 and in none at mo 24. CONCLUSION: HBeAg can pass through human placenta from mother to fetus and become undetectable before 4 mo of age, but no antibodies response to the transplacental HBeAg can be detected till mo 24 in the immunoprophylaxis-protected babies. The sole existence of anti-HBe before 1 year of age or anti-HBc before 2 years of age in babies born to HBsAg carrier mothers may simply represent the transplacental maternal antibodies, instead of indicators of HBV infection status.     

Occult Hepatitis B Virus Infection in Hemodialysis Patients in Japan

Hepatitis B surface antigen is widely used in hepatitis B virus surveillance; patients who test negative for the antigen are judged to be uninfected. However, occult hepatitis B virus infection has been confirmed with hepatitis B virus DNA at low levels in the liver and peripheral blood in patients positive for hepatitis B core antibody or hepatitis B surface antibody, even if they test negative for hepatitis B surface antigen. To investigate the prevalence of occult hepatitis B virus in hemodialysis patients, we performed cross‐sectional analysis of 161 hemodialysis patients in two related institutions for hepatitis B surface antigen, hepatitis B core antibody, and hepatitis B surface antibody. Hepatitis B surface antigen, hepatitis B core antibody, or hepatitis B surface antibody was present in 45 patients (28.0%). Hepatitis B virus DNA was present in six patients (3.7%), all of whom also tested positive for hepatitis B core antibody. Hepatitis B surface antibody positivity was unrelated in only one of the six patients. Four of the six patients were positive for hepatitis B surface antigen; however, two (1.3%) of these with occult hepatitis B virus infection were found to be hepatitis B surface antigen negative. Occult hepatitis B virus infection may be missed in hepatitis B virus surveillance using hepatitis B surface antigen alone; therefore, routine hepatitis B core antibody screening is necessary. Patients who test positive for hepatitis B core antibody should undergo further hepatitis B virus DNA testing to enable accurate hepatitis B virus screening.     

Reduced prevalence of hepatitis B surface antigen positivity among pregnant women born after the national implementation of immunoprophylaxis for babies born to hepatitis B virus‐carrier mothers in Japan

Aim

We aimed to estimate hepatitis B surface antigen (HBsAg) positivity among birth year‐stratified pregnant women in Hiroshima, Japan, and compare prevalence rates between women born before and after implementation of a national immunoprophylactic vaccination program for babies born to hepatitis B virus (HBV) carrier mothers in Japan.

Methods

Pregnant women who gave birth at all delivery hospitals/clinics in Hiroshima prefecture between 1 April 2010 and 31 March 2011 were eligible. Lists collected from each institution included survey items such as age (pregnant woman's birth year) and HBsAg and hepatitis C virus (HCV) antibody (anti‐HCV) test results, which were posted anonymously and non‐consolidated from medical records. We calculated the HBsAg and anti‐HCV prevalence in our cohort according to the mothers' birth year.

Results

In 41 of 58 hospitals/clinics, 15 233 and 15 035 pregnant women underwent HBsAg and anti‐HCV testing, corresponding to 59.6% and 58.9% of 25 546 births in the 2010 fiscal year, respectively. The overall HBsAg positive rate was 0.51% (95% confidence interval [CI], 0.40–0.63%), and an extremely low prevalence (0.10%; 95% CI, 0.00–0.25%) was observed among pregnant women born after 1986. However, the prevalence in this study was slightly higher than the nationwide value (0.31%) and the Chugoku region‐specific value (0.46%) among first‐time blood donors at Japanese Red Cross blood centers between 2001 and 2006. No significant difference in anti‐HCV positivity was observed.

Conclusion

Only two pregnant women born after the preventive program implementation were HBsAg‐positive. Perinatal HBV transmission is estimated to be almost completely inhibited in the next generation.

     

Failure of immune serum globulin to prevent hepatitis B virus infection in infants born to HBsAg-positive mothers.

Twelve infants, born to mothers with hepatitis B virus infection, were inoculated within 7 days of birth with immune serum globulin containing antibody to hepatitis B surface antigen (HBsAg) titers of 1:32 to 1:64 as measured by passive hemagglutination. Six of nine infants (66.7%) born to HBsAg-positive carrier mothers became HBsAg-positive within 3 mo of age. In addition, two of three treated infants born to mothers with acute hepatitis B during the delivery period also developed HBsAg. The hepatitis e antigen was detected in four of five carrier mothers and in two mothers with acute hepatitis, whose infants subsequently became HBsAg positive. In addition, hepatitis B-specific DNA polymerase activity was detected in the seven HBsAg-positive mothers who transmitted the virus to their infants. All eight infants have remained persistently HBsAg positive. Thus, the immune serum globulin containing low-titer antibody to HBsAg is not protective when given to infants born to HBsAg carrier mothers or to mothers with acute hepatitis B during the delivery period.     

Epidemiological Survey of Patients With Hemodialysis Complicated by Hepatitis C in Japan

Nowadays, interferon‐free direct‐acting antiviral (DAA) treatment is the standard of care for chronic hepatitis C patients. Some DAA regimens are highly effective and safe even for those with renal dysfunction/failure including those receiving HD. However, it remains unclear to what extent HD specialists gain knowledge about advances in anti‐hepatitis C virus (HCV) treatment. To clarify the current situation and identify problems in the treatment of HD patients with chronic hepatitis C, we performed a questionnaire survey at 36 HD facilities between June 2016 and September 2017. In a total of 3418 HD patients, 179 (5.2%) were positive for anti‐HCV antibody, and among these patients, 110/125 (88.0%) were positive for serum HCV RNA. Of the latter, only 42/110 (38.2%) patients received antiviral therapy. Moreover, HCV serotyping or genotyping was performed in 23/110 (20.9%) patients. In 26/49 (53.1%) of the remaining 68 untreated patients, “HD specialists do not know any HCV‐specific treatments” and “HD specialists have no opportunity to consult with a hepatologist” were the reasons cited for the lack of anti‐HCV treatment. This epidemiological study found that some HD patients with chronic hepatitis C had not yet received antiviral treatment despite the emergence of DAAs. To overcome such undesirable circumstances, medical cooperation between HD specialists and hepatologists should be required.     

Immunoprophylaxis of infection with hepatitis B virus in infants born to hepatitis B surface antigen-positive carrier mothers

Infants born to carrier mothers positive for hepatitis B surface antigen (HBsAg) and hepatitis B e antigen (HBeAg) received 5 micrograms of hepatitis B virus (HBV) vaccine on four occasions. Group 1 received vaccine only, group 2 received vaccine plus hepatitis B immune globulin (HBIG) at birth, and group 3 received vaccine plus HBIG at birth and at one month. Infants born to HBeAg-positive mothers (group 4) received a reduced dose of vaccine (2.5 micrograms) on three occasions as well as HBIG at birth. As compared with 78.4% of the control group (infants whose parents refused vaccination) who became chronic HBV carriers at the age of 14 months, the protective efficacy rate of vaccination was 75.3% in group 1,85.5% in group 2,89.7% in group 3, and 87.2% in group 4. HBV vaccine (5 micrograms) was also given to infants born to HBsAg-positive, HBeAg-negative mothers on four on four occasions. The antibody response to HBsAg in vaccine recipients was 12% after the first dose, 44% after the second dose, and 75% and 100% at six months and 1.5 years of age, respectively.     

Community-based screening for hepatocellular carcinoma in elderly residents in a hepatitis B- and C-endemic area

Background and Aim: The aim of the present study was to elucidate a reasonable model and the efficacy of hepatocellular carcinoma (HCC) screening on an elderly population. Methods: Two‐stage HCC screening was conducted in a hepatitis C virus (HCV)‐endemic area. First, participants underwent blood tests for hepatitis B surface antigen (HBsAg), anti‐HCV antibody, serum α‐fetoprotein (AFP), aspartate aminotransferase, alanine aminotransferase, and platelet count. Patients who were abnormal for any of the six markers were enrolled for second‐stage ultrasonography. Suspected cases were referred for confirmation. HCC cases were followed for 4 years. All patients were linked to national mortality and cancer register databases to identify newly‐developed HCC, 30 months after screening. Results: A total of 461 males and 541 females were screened for HCC, with 15.1% testing positive for HBsAg and 44.3% positive for anti‐HCV. Among them, 619 (61.8%) met the criteria of ultrasonographic screening; 527 (85.1%) responded, and 16 confirmed HCC (male/female = 8/8, 68.8 ± 8 years) cases were detected. All tumor diameters were less than 5 cm, and six were less than 2 cm. AFP and thrombocytopenia were two independent predictive factors of HCC. The overall survival rates of detected cases were 93.8% and 56.3% was 1 and 4 years, respectively. The only good prognostic predictor was “underwent curative treatment”. Another seven non‐HCC residents developed HCC after screening, and five of these were with either thrombocytopenia or AFP elevation. Conclusion: Under economical consideration, AFP and platelet count should be feasible screening markers of risk identification. Early detection and prompt treatment results in good prognosis in an aged population.     

Serologic and Molecular Characteristics of Hepatitis B Virus among School Children in East Java,Indonesia

Universal childhood hepatitis B vaccination was introduced in Indonesia in 1997; by 2008, coverage was estimated to be 78%. This study aimed to investigate the serologic status and virologic characteristics of hepatitis B virus (HBV) among the children in East Java. A total of 229 healthy children born during 1994–1999 were enrolled in this study. Overall, 3.1% were positive for hepatitis B surface antigen (HBsAg) and 23.6% were positive for antibody to HBsAg (anti-HBs). HBV DNA was detected in 5 of 222 HBsAg-negative carriers, which were suggested to be cases of occult HBV infection. A single amino substitution (T126I) in the S region was frequently found. HBV infection remains endemic, and the prevalence of anti-HBs remains insufficient among children in East Java, Indonesia.     

2005年康定县雅拉乡乙型病毒性肝炎血清流行病学调查

目的了解康定县雅拉乡1～59岁人群乙型病毒性肝炎病毒(HBV)感染状况,为乙肝防治提供依据。方法采用多阶段分层随机抽样的方法抽取康定县雅拉乡312名1～59岁人群进行问卷调查和血清学检测,利用ELISA方法检测乙肝病毒表面抗原(HBsAg),乙肝病毒表面抗体(Anti-HBs),乙肝病毒e抗原(HBeAg)和乙肝病毒e抗体(Anti-HBe),乙肝病毒核心抗体(Anti-HBc),检测。结果康定县雅拉乡1～59岁人群乙肝病毒表面抗原(HBsAg),乙肝病毒表面抗体(Anti-HBs),乙肝病毒核心抗原(HBcAg)经标化后阳性率分别为2.10%、21.65%和15.65%;男、女性人群HBcAg阳性率分别为4.27%、0;HBsAg阳性人群中,乙肝病毒e抗原阳性率为1.92%。结论康定县雅拉乡1～59岁人群HBsAg阳性率明显下降,提示提高乙肝疫苗的接种率是降低人群HBsAg阳性率的关健措施。     

Interpretation and management of positive anti‐hepatitis B core antibody tests in immunocompromised pediatric patients

Intravenous immunoglobulin (IVIg) therapy is increasingly used in the pediatric population, in particular among children with immune‐compromising conditions. Pooled immunoglobulin products are routinely tested for hepatitis B surface antigen (HBsAg) and nucleic acid; however, screening for hepatitis B core antibody (anti‐HBc) is not commonly performed. Thus, the administration of IVIg containing anti‐HBc to children with immune‐compromising conditions may complicate the interpretation of hepatitis B serologic testing in that a positive anti‐HBc test may represent passive transfer of antibody from IVIg or may indicate resolved or chronic hepatitis B infection. Due to the risk of hepatitis B reactivation in immunocompromised patients, a positive anti‐HBc test must be carefully considered. As part of a quality improvement initiative, we identified and reviewed the records of all pediatric patients at our institution who tested positive for anti‐HBc over an 18‐month period. Of 44 total patients with positive anti‐HBc tests, we found that 22 (50%) had previously received IVIg in the preceding 4 months. All but one of these, 21/22 (95%), went on to receive immunosuppressive therapy (IS). Among the patients who received IS, 19 (86%) had not undergone hepatitis B serologic testing prior to IVIg administration and 16 (73%) did not have subsequent testing to distinguish between passive acquisition of anti‐HBc from IVIg and chronic hepatitis B infection. Our single‐center experience reveals that a high proportion of positive anti‐HBc tests in children are presumed to be because of the passive antibody transfer from IVIg. However, a low proportion of patients undergo confirmatory testing, despite the risk of hepatitis B reactivation during IS. We thus propose a risk‐based algorithm for interpretation and monitoring of hepatitis B testing in immunocompromised children.     

A serological re-evaluation of acute non-A non-B hepatitis from the early 1970s

Background: The epidemiology and natural history of recently discovered viruses, which may be responsible for cases of seronegative infectious hepatitis, are currently being investigated. Retrospective studies of stored sera can provide a historical perspective of these infections. Aims: To re‐evaluate the serological, demographic and clinical characteristics of patients hospitalised in the early 1970s with acute hepatitis. Methods: The stored sera of 57 patients hospitalised between 1971 and 1974 with acute hepatitis, designated at that time as non‐A non‐B (NANB) hepatitis, were re‐tested using commercially available enzyme‐linked immunosorbent assays (ELISAs) for the presence of anti‐hepatitis A virus (HAV) IgM, hepatitis B surface antigen (HBsAg), anti‐hepatitis C virus (HCV) IgG, and anti‐hepatitis E virus (HEV) IgG. Stored sera from a group of 57 patients concurrently hospitalised for other conditions were also tested. Detailed records of the original epidemiological interviews were examined to compare patient demographics, risk factors for infectious hepatitis and clinical data for the NANB hepatitis group and an original control group of 604 hospitalised patients. Results: Serum from 15 of the 57 (26%) previously designated NANB hepatitis cases had elevated anti‐HAV IgM and are likely to represent missed cases of hepatitis A. Thirteen (23%) of cases previously designated as NANB hepatitis had positive hepatitis C antibody tests. These patients were younger and significantly more likely to have used intravenous drugs than control patients. Three NANB hepatitis and two hospital control patients were anti‐HEV IgG antibody positive. All of these individuals were born in, or had travelled to, developing countries. Serum from 27 (47%) of the NANB hepatitis patients were negative on all tests. These hepatitis non‐A‐E cases included children and elderly adults, but as a group were significantly more likely to have used intravenous drugs than hospitalised control patients.     

Changing aetiology of liver dysfunction in the new generation of a hepatitis B and C‐endemic area: cross‐sectional studies on adolescents born in the first 10 years after universal hepatitis B vaccination

Background/Aim: Geographical variation in viral hepatitis infection complicates various levels of liver diseases. This study elucidates the changing aetiology of alanine transaminase elevation (ALT levels >40 IU/L) in a previously hepatitis‐endemic township. Design/Methods: Five cross‐sectional screenings were performed on teenagers born from 1984 to 1993. We examined hepatitis B surface antigen (HBsAg), anti‐hepatitis C virus (anti‐HCV), ALT and body mass index, and additionally checked hepatitis B envelope antigen (HBeAg) for positive HBsAg and HCV RNA for positive anti‐HCV. Teenagers with ALT elevation underwent an ultrasonography examination. Results: This study enrolled 1788 (93.7%) of 1909 students, discovering individual prevalence of HBsAg (6.3%), anti‐hepatitis B core (anti‐HBc) (15.5%), anti‐HCV (2.2%), overweight (22.4%), obesity (12.8%) and ALT >40 IU/L (3.7%). HBsAg and anti‐HBc prevalence declined with trends, while obesity increased with trends (P<0.001). Among 66 ALT‐elevated teenagers, prevalence percentages of risk factors were HBsAg (22.7%), anti‐HCV (1.5%), obesity (45.5%), HBsAg with obesity (7.6%) and anti‐HCV with obesity (3.0%). Additionally, obesity showed predominance (85.7%) among aetiologies of teenagers with fatty livers (60.9%). The independently associated factors of ALT elevation included being male (odds ratio, 2.18; 95% confidence interval, 1.21–3.93), HBsAg (4.25; 1.06–17.13), HBeAg (7.24; 1.64–31.9), HCV RNA (29.03; 5.8–145.29) and obesity (16.5; 8.79–30.98). Conclusion: In place of viral hepatitis, obesity is becoming the major aetiology of abnormal liver function among the young generation in a previously hepatitis‐endemic area.     

Waning-off effect of serum hepatitis B surface antibody amongst Taiwanese university students: 18 years post-implementation of Taiwan's national hepatitis B vaccination programme

Summary. Hepatitis B virus (HBV) infection and its sequelae remain a major health problem for Taiwan. The national hepatitis B (HB) vaccination programme was first launched in 1984 to combat the spread of this infection. This study examined the status of HBV infection amongst students at a Taiwanese university in 2005, 18 years after the implementation of a nation‐wide mass HB vaccination programme. In 2005, 5875 new university entrants, who were born during the period 1 July 1976 to 30 June 1988, were subdivided into one of 12 one‐year‐interval birth‐year cohorts. Each student was individually tested for serum hepatitis B surface antigen (HBsAg), Antibody to hepatitis B surface antigen (anti‐HBs) and antibody to hepatitis B core antigen (anti‐HBc) status. We observed a declining trend of past exposure to HB infection from 48.7% (1976 birth‐year cohort) to 5.2% (1987 birth‐year cohort). The prevalence of chronic HB infection also declined from 14.5% (1976 birth‐year cohort) to 1.9% (1987 birth‐year cohort). The prevalence of persistent HB immunity through (earlier) active vaccination declined from 72% (1984 birth‐year cohort) to 41.6% (1987 birth‐year cohort). The prevalence of HB infection‐naïve individuals increased from 18.2% (1984 birth‐year cohort) to 53.1% (1987 birth‐year cohort). This study demonstrates that as the implementation of the mass HB vaccination programme in 1984, the incidence of HB infection in Taiwan has declined, although a ‘waning‐off’ effect of serum anti‐HBs to low or undetectable levels, which may not provide protection, amongst this student population has arisen, 18 years following the implementation of the nation‐wide HB vaccination programme. Such a situation may mean that these individuals may not be effectively protected against future HB infection. A booster dose of HB vaccine, given 18 years following HB vaccination, perhaps even earlier, should be considered.     

Evaluation of prophylaxis against hepatitis B in a large municipal hospital.

BACKGROUND: Perinatal transmission of hepatitis B can be interrupted by the administration of hepatitis B vaccine and hepatitis B globulin to the infants of carrier mothers. Universal screening of pregnant women makes this strategy possible. METHODS: To evaluate the implementation of universal hepatitis B surface antigen screening of women giving birth at Kings County Hospital Center during 1988, we reviewed laboratory records to find all women with a positive test result who might give birth. We also randomly reviewed records of women who gave birth to live infants to determine the percentage of screening in the population. Infants' charts were reviewed for documentation of maternal hepatitis B surface antigen status and administration of hepatitis B immune globulin and vaccine. RESULTS: Sixty infants who lived long enough to receive antihepatitis B prophylaxis were distinguished out of a total of 5146 births. Screening was done for from 66.8% to 80.4% (95% confidence interval) of the mothers of these infants. Although 44 of 60 infants received hepatitis B immune globulin and 39 of 60 infants received vaccine, only 27 of 60 received vaccine within 12 hours in combination with immune globulin (Centers for Disease Control-recommended therapy). CONCLUSIONS: Documentation of hepatitis B surface antigen in the infant's delivery room record was present in 23 of 60 infants. Those infants all received hepatitis B immune globulin and vaccine; 21 received hepatitis B immune globulin within 12 hours. Hepatitis B immune globulin was given within 12 hours to 8 of 37 infants who lacked documentation of hepatitis B surface antigen status on the delivery room record. These differences were highly significant (p less than 0.001) even when only the 40 patients who had documented prenatal screening at Kings County Hospital Center (21/23 vs 4/17). Prenatal care did not have any effect on outcome.     

Hepatitis B virus vaccination and antenatal transmission of HBV markers to neonates

The high prevalence of hepatitis B surface antigen (HBsAg) and hepatitis B e antigen (HBeAg) in pregnant women is considered to be the most important factor contributing to the high carrier rate of HBsAg in some populations. Several factors, including the age at which infection occurs, predispose to the acquisition and frequency of the carrier state. The proportion of infected people who become chronic carriers ranges from about 80 to 95% for babies born to HBsAg/HBeAg-positive mothers. In this study of Indonesian infants receiving only active immunization against HBV, we measured the HBV markers passively acquired from their HBsAg-positive mothers. The relationship of these markers with vaccination response and with HBV infection status was studied longitudinally in the infants. In the exposed neonates from the HBsAg-positive mothers (n=61), the seroconversion rate to hepatitis B surface antibody (HBsAb) positivity was 95% after the first booster vaccination, with a geometric mean titre (GMT) of 2017 IUl-1. After 60 months, the GMT in this group decreased to 50 IUl-1. Four newborns in this group became HBsAg carriers. Of the four vaccination failures, three newborns were HBsAg/HBeAg positive at birth, suggesting that they had been infected in utero. No vaccination strategy (active alone, or passive/active) can prevent this transmission from occurring. One carrier was HBsAg negative at birth and up to month 4 but was HBsAg positive at month 12 and subsequently, suggesting a postnatal infection. Vaccination early in life can, to a large extent, prevent perinatal transmission and hepatitis B virus (HBV) infection later in infancy and childhood. In this study, the protective efficacy of the vaccination was 85% in the subcohort of neonates from HBeAg-positive mothers and 100% in the subcohort of neonates from HBeAg-negative mothers. Lack of maternal antibodies to hepatitis B core antigen (HBcAb) correlated strongly with transmission of HBV infection.     

HBsAg阳性母亲所生婴儿的母婴阻断及全程接种乙型肝炎疫苗后免疫应答状态

目的 了解HBsAg阳性母亲所生婴儿的母婴阻断及全程接种乙型肝炎疫苗后免疫应答状态及变化规律.方法 对249例HBsAg阳性母亲的新生儿予以联合母婴阻断措施,并全程接种乙型肝炎疫苗,用微粒化学发光法跟踪测定婴儿生后7、12、24、36个月的HBsAg和抗-HBs水平.组间比较采用卡方检验.结果 HBsAg阳性母亲所生婴儿母婴阻断后不同时间免疫应答状态不同,7月龄婴儿无应答率为8.0%(20/249),低应答率为11.7%(29/249),强应答率为80.3%(200/249);12月龄婴儿无应答率为10.8%(13/120),低应答率为26.7%(32/120),强应答率为62.5%(75/120);24月龄婴儿无应答率14.8%(4/27),低应答率为33.3%(9/27),强应答率为51.9%(14/27),36月龄婴儿无应答率为14.3%(1/7),低应答率为28.6%(2/7),强应答率为57.1%(4/7);7月龄组与其他月龄组同等应答状态间比较,差异有统计学意义(x2=21.98,P＜0.01).强应答组婴幼儿抗-HBs效价出生7个月后出现逐渐下降的趋势,效价越高,其下降的例数越少,下降出现的时间越晚.抗-HBs效价＞1000 mIU/mL时,在36个月内下降比率为57.6%(19/33),下降高峰为24个月(57.9%,11/19);抗-HBs效价为100～1000 mIU/mL时,在36个月内下降比率为73.8%(31/42),下降高峰为12个月(54.8%,17/31).HBsAg阳性婴儿7月龄多表现为无应答状态,占全部无应答婴儿的70%(14/20,x2=128.61,P＜0.01),99%(189/191)HBsAg阴性婴儿多为强应答.HBeAg同时阳性母亲的婴儿无应答率有高于HBeAg阴性母亲婴儿的趋势,但差异无统计学意义(9.1%比5.5%,x2=0.24,P＞0.05).结论 HBsAg阳性母亲新生婴儿的母婴阻断及全程接种乙型肝炎疫苗后不同时间免疫应答状态不同,且呈动态变化;无应答状态多见于HBsAg阳性的免疫失败婴儿;HBsAg阴性婴儿大多呈强应答;HBeAg同时阳性的母亲婴儿更易呈低应答.建议完善母婴阻断后管理流程,特别是生后7个月～2年的积极随访监测.