U.S. Preventive Services Task Force

Screening for Hepatitis B Virus Infection in Pregnancy: Reaffirmation Recommendation Statement



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Summary of Recommendation and Evidence

The U.S. Preventive Services Task Force (USPSTF) recommends screening for hepatitis B virus (HBV) infection in pregnant women at their first prenatal visit (Table 1). A recommendation.

Table 1.

Screening for HBV Infection in Pregnancy: Clinical Summary of the USPSTF Recommendation

Population

All pregnant women

Recommendation

Screen at the first prenatal visit

Grade: A

Screening tests

Serologic identification of HBsAg

Reported sensitivity and specificity are greater than 98 percent.

Timing of screening

Order HBsAg testing at the first prenatal visit.

Rescreen women with unknown HBsAg status or new or continuing risk factors at admission to hospital, birth center, or other delivery setting.

Interventions

Administer hepatitis B vaccine and hepatitis B immune globulin to HBV-exposed infants within 12 hours of birth.

Refer women with positive test results for counseling and medical management.

Counseling should include information about how to prevent transmission to sex partners and household contacts.

Reassure patients that breastfeeding is safe for infants who receive appropriate prophylaxis.

Implementation

Establish systems for timely transfer of maternal HBsAg test results to the labor and delivery and newborn medical records.

Relevant USPSTF recommendations

USPSTF recommendations on the screening of pregnant women for other infections, including asymptomatic bacteriuria, bacterial vaginosis, chlamydia, human immunodeficiency virus, and syphilis, can be found at http://www.preventiveservices.ahrq.gov.


NOTE: For the full USPSTF recommendation statement and supporting documents, visit http://www.uspreventiveservicestaskforce.org/recommendations.htm.

HBsAg = hepatitis B surface antigen; HBV = hepatitis B virus; USPSTF = U.S. Preventive Services Task Force.

Table 1.   Screening for HBV Infection in Pregnancy: Clinical Summary of the USPSTF Recommendation

View Table

Table 1.

Screening for HBV Infection in Pregnancy: Clinical Summary of the USPSTF Recommendation

Population

All pregnant women

Recommendation

Screen at the first prenatal visit

Grade: A

Screening tests

Serologic identification of HBsAg

Reported sensitivity and specificity are greater than 98 percent.

Timing of screening

Order HBsAg testing at the first prenatal visit.

Rescreen women with unknown HBsAg status or new or continuing risk factors at admission to hospital, birth center, or other delivery setting.

Interventions

Administer hepatitis B vaccine and hepatitis B immune globulin to HBV-exposed infants within 12 hours of birth.

Refer women with positive test results for counseling and medical management.

Counseling should include information about how to prevent transmission to sex partners and household contacts.

Reassure patients that breastfeeding is safe for infants who receive appropriate prophylaxis.

Implementation

Establish systems for timely transfer of maternal HBsAg test results to the labor and delivery and newborn medical records.

Relevant USPSTF recommendations

USPSTF recommendations on the screening of pregnant women for other infections, including asymptomatic bacteriuria, bacterial vaginosis, chlamydia, human immunodeficiency virus, and syphilis, can be found at http://www.preventiveservices.ahrq.gov.


NOTE: For the full USPSTF recommendation statement and supporting documents, visit http://www.uspreventiveservicestaskforce.org/recommendations.htm.

HBsAg = hepatitis B surface antigen; HBV = hepatitis B virus; USPSTF = U.S. Preventive Services Task Force.

Rationale

Importance. An estimated 24,000 infants are born each year to women in the United States who are infected with HBV. Between 30 and 40 percent of all chronic HBV infections result from perinatal transmission. Chronic HBV infections increase long-term morbidity and mortality by predisposing infected persons to cirrhosis of the liver and liver cancer.

Detection. The principal screening test for detecting maternal HBV infection is the serologic identification of hepatitis B surface antigen (HBsAg). Immunoassays for detecting HBsAg have a reported sensitivity and specificity of greater than 98 percent.

Benefits of detection and early intervention. 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 current practice of vaccinating all infants against HBV infection and providing postexposure prophylaxis with hepatitis B immune globulin administered at birth to infants of mothers infected with HBV substantially reduces the risk of acquiring HBV infection.

Harms of detection and early intervention. The USPSTF found no published studies that describe harms of screening for HBV infection in pregnant women. The USPSTF concluded that the potential harms of screening are no greater than small.

USPSTF assessment. The USPSTF concludes that there is high certainty that the net benefit of screening pregnant women for HBV infection is substantial.

Clinical Considerations

  • Patient population. This recommendation applies to all pregnant women.

  • Screening tests. Screening for HBV infection by testing for HBsAg should be performed in each pregnancy, regardless of previous hepatitis B vaccination or previous negative HBsAg tests.

  • Timing of screening. A test for HBsAg should be ordered at the first prenatal visit with other recommended screening tests. At the time of admission to a hospital, birth center, or other delivery setting, women with unknown HBsAg status or with new or continuing risk factors for HBV infection (such as injection drug use, or evaluation or treatment for a sexually transmitted disease) should receive screening.

  • Treatment. Infants born to mothers with HBV infection should receive hepatitis B vaccine and hepatitis B immune globulin within 12 hours of birth. Infants born to mothers with unknown HBsAg status should receive hepatitis B vaccine within 12 hours of birth, followed by hepatitis B immune globulin as soon as possible (but not later than seven days after birth) if the mother tests positive for HBsAg.

    Pregnant women who test positive for HBsAg should be referred to an appropriate case-management program and should be provided with or referred for counseling and medical management of HBV infection. Counseling should include information about prevention of HBV transmission to sex partners and household contacts, and reassurance regarding the safety of breast-feeding in infants who receive appropriate prophylaxis.

Other Considerations

Implementation. Screening for HBV infection in pregnant women is necessary but not sufficient to prevent disease transmission to newborns. To realize the maximum benefit from screening, primary care physicians and delivery settings must establish effective systems for the accurate and timely transfer of maternal HBsAg test results to the labor and delivery and newborn medical records.

Research needs/gaps. Research is needed to assess the effect of longstanding universal childhood hepatitis B vaccination on the magnitude of benefit of screening for HBV infection in U.S.-born pregnant women. Research is also needed to determine the net health benefit to the mother and infant of treating pregnant women whose chronic HBV infections are identified by prenatal screening.

Discussion

In 2004, the USPSTF reviewed the evidence for screening for HBV infection in pregnant women and found that the benefits of screening substantially outweighed the harms.1 In 2008, the USPSTF performed a brief literature update2 and determined that the net benefit of screening pregnant women for HBV infection continues to be well established. This update included a search for new and substantial evidence on the benefits and harms of screening. The USPSTF found no new substantial evidence that could change its recommendation and, therefore, reaffirms its recommendation to screen pregnant women for HBV infection at their first prenatal visit. The previous recommendation statement3 and evidence review, as well as the current summary of the updated literature search, can be found at http://www.uspreventiveservicestaskforce.org/recommendations.htm.

Recommendations from Other Groups

The American Academy of Family Physicians strongly recommends screening for HBV infection in pregnant women at their first prenatal visit.4 This recommendation is available at http://www.aafp.org/patient-care/clinical-recommendations/a-z.html.

The American College of Obstetricians and Gynecologists recommends routine screening of all pregnant women with HBsAg.5

The American Academy of Pediatrics recommends HBsAg testing for all pregnant adolescents “at the time a pregnancy is discovered, regardless of hepatitis B immunization history and previous results of tests for HBsAg and antibody to HBsAg.”6 This recommendation is available at http://aapredbook.aappublications.org/cgi/content/full/2006/1/2.9.2 (subscription required).

The Centers for Disease Control and Prevention recommends that all pregnant women be tested routinely for HBsAg during an early prenatal visit (for example, first trimester) in each pregnancy, even if they have been previously vaccinated or tested.7 This recommendation is available at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5416a1.htm?s_cid=rr5416a1_e.


This recommendation statement was first published in Ann Intern Med. 2009;150(12):869–873.

The U.S. Preventive Services Task Force Recommendations are independent of the U.S. government. They do not represent the views of the Agency for Healthcare Research and Quality, the U.S. Department of Health and Human Services, or the U.S. Public Health Service.

REFERENCES

1. Krishnaraj R. Screening for hepatitis B virus infection: brief evidence update for the US Preventive Services Task Force. Rockville, Md: Agency for Healthcare Research and Quality; 2004. http://www.ahrq.gov/clinic/3rduspstf/hepbscr/hepbup.htm. Accessed May 4, 2009.

2. Lin K, Vickery J. Screening for hepatitis B virus infection in pregnant women: evidence for the U.S. Preventive Services Task Force reaffirmation recommendation statement. Ann Intern Med. 2009;150(12):874–876.

3. US Preventive Services Task Force. Screening for hepatitis B virus infection: recommendation statement Rockville, Md: Agency for Healthcare Research and Quality; 2004. http://www.ahrq.gov/clinic/uspstf/uspshepb.htm. Accessed May 4, 2009.

4. American Academy of Family Physicians. Clinical preventive services. AAFP Policy Action. Revision 6.4. Leawood, Kan.: American Academy of Family Physicians; 2007.

5. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 86: viral hepatitis in pregnancy. Obstet Gynecol. 2007;110(4):941–956.

6. American Academy of Pediatrics Committee on Infectious Diseases. Red Book. 27th ed. Elk Grove Village, Ill.: American Academy of Pediatrics; 2006.

7. Mast EE, Margolis HS, Fiore AE, et al., for the Advisory Committee on Immunization Practices (ACIP). A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices (ACIP) part 1: immunization of infants, children, and adolescents [published corrections appear in MMWR Morb Mortal Wkly Rep. 2006;55(6):158–159, and MMWR Morb Mortal Wkly Rep. 2007;56(48):1267]. MMWR Recomm Rep. 2005;54(RR-16):1–31.

This summary is one in a series excerpted from the Recommendation Statements released by the U.S. Preventive Services Task Force (USPSTF). These statements address preventive health services for use in primary care clinical settings, including screening tests, counseling, and preventive medications.

A collection of USPSTF recommendation statements reprinted in AFP is available at http://www.aafp.org/afp/uspstf.

The complete version of this statement, including supporting scientific evidence, evidence tables, grading system, members of the USPSTF at the time this recommendation was finalized, and references, is available on the USPSTF Web site at http://www.ahrq.gov/clinic/uspstf/uspshepbpg.htm.



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