Adherence to Pregnancy Hepatitis B Care Guidelines in Women and Infants in the United States and Evaluation of Two Interventions to Improve Care

A Multicentre Hospital-based Study

Tatyana Kushner; Elianna Kaplowitz; Rena Mei; Chelsea Xu; Alex Acker; Emma Rosenbluth; Igbagbosanmi Oredein; Monika Sarkar; Norah Terrault; Meena Bansal; Kimberly A. Forde

Disclosures

J Viral Hepat. 2021;28(4):582-591. 

In This Article

Abstract and Introduction

Abstract

There has been an increase in hepatitis B (HBV) detection during pregnancy in the United States and an emphasis on measures to decrease mother-to-child transmission of HBV. We performed a multicentre retrospective study (2015–2018) evaluating care among all women with HBV during pregnancy. We determined rates and predictors of adherence to key maternal care measures including: (1) referral to HBV specialty care, (2) assessment of HBV DNA, and (3) initiation of antiviral therapy, and (4) rates of HBIG and HBV vaccine completion in infants. We evaluated two interventions to improve HBV care: (1) clinical decision support with best practice alert and (2) co-location of HBV care in obstetrics department. We identified 372 women with HBV during pregnancy. Patients had a median age of 33 (IQR 29, 36), were mostly of Asian (49%) or Black (36%) race, HBeAg-negative (83%) with HBV DNA ≤2000 IU/mL (65%) and maximum ALT ≤25 (66%). Regarding care measures, 62% were referred to an HBV specialist, 85% had HBV DNA checked during pregnancy and 68% with HBV DNA ≥200,000 were initiated on antiviral therapy. Co-located obstetric-liver diseases clinics appeared to improve adherence to maternal care measures. All infants received HBIG and the first HBV vaccine dose, 106 (81%) received the second, 94 (74%) received the 3rd dose, but fewer at the recommended time intervals. We identified clear gaps in adherence to HBV care measures for both mothers and infants. Co-location of HBV care in the obstetrics department shows promise in improving adherence to maternal care measures.

Introduction

In the United States (US), as many as 2.2 million individuals live with chronic hepatitis B (HBV) with the majority of infections observed among immigrant populations.[1] Mother-to-infant transmission is the most common mode of HBV transmission globally, with 90% of perinatal infections progressing to chronic hepatitis, which can lead to cirrhosis and/or hepatocellular carcinoma.[2] In July 2019, the US Preventive Services Task Force (USPSTF) reaffirmed its 2009 grade 'A' recommendation for screening for HBV in pregnant women at their first prenatal visit, citing evidence that this substantially decreases perinatal transmission of HBV and subsequent development of chronic HBV,[3] with recommendation for universal birth dose HBV vaccination and postexposure prophylaxis with hepatitis B immune globulin (HBIG) at birth to infants of HBsAg-positive mothers. Due to these efforts, rates of perinatal HBV transmission in the US have significantly declined.[4] However, the prevalence of maternal HBV infections has increased in part due to increased detection.[5] Furthermore, recent evidence suggests that there may be an increase in HBV exposure among women of childbearing age potentially related to the opioid epidemic.[6,7]

Pregnancy is a key time to intervene to decrease HBV transmission and improve HBV disease outcomes, as it is the only time during contact with the health system for universal (ie not risk-based) HBV screening among women and is an important opportunity to link HBV-positive women to follow-up care. The USPSTF has identified a need for further research on effective implementation of care management in vulnerable populations most at risk for perinatal transmission of HBV.[3] The American Association for the Study of Liver Diseases (AASLD) recommends testing of viral load at end of second trimester, initiation of antiviral therapy if HBV DNA is greater than 200,000 IU/mL, as well as linkage to HBV care.[8] However, prior United States-based studies have found inadequate adherence to HBV management guidelines during pregnancy for laboratory testing, antiviral therapy initiation, and specialist referral.[9–14] Thus, despite national efforts for increased surveillance and detection of HBV, women are not adequately being treated and integrated into long-term care. These represent important missed opportunities, especially in the setting of heightened emphasis on HBV elimination in recent years in the setting of the World Health Organization goals for viral hepatitis elimination by 2030.[15]

We aimed to evaluate the current status of HBV care in pregnancy at three large inner-city hospital-based obstetric care settings located in different geographical regions in the US - New York, San Francisco and Philadelphia, and factors associated with gaps in care. We further describe impact of two strategies implemented to enhance adherence to HBV care measures.

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