ATLANTA — The birth dose of hepatitis B vaccine is now the standard of care, the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention voted at its meeting.
Although giving newborns their first dose of hepatitis B vaccine prior to discharge has already been deemed the “preferred” practice by the CDC, the American Academy of Family Physicians, and the American Academy of Pediatrics, the groups have allowed providers the alternative of administering during the first 2 months of age if the mother is hepatitis B surface antigen (HBsAg) negative.
Now ACIP has updated its recommendation—pending approval by the CDC—to say that withholding of the birth dose in a medically stable infant weighing 2,000 g or more at birth should be “rare” and must be documented in the infant's medical chart, along with the laboratory report confirming the mother's antigen-negative status. Both AAFP and AAP will consider endorsing the new policy, their ACIP liaisons told FAMILY PRACTICE NEWS.
“Core to the ACIP recommendations is having standing orders, which the [AAP's Committee on Infectious Diseases] supports as long as there is some physician discretion,” said Margaret Rennels, M.D., AAP's co-liaison to ACIP.
Eric E. Mast, M.D., chief of the prevention branch in the CDC's Division of Viral Hepatitis, said that implementation of the infant immunization series beginning in 1991 has resulted in a 93% reduction in hepatitis B incidence in persons younger than 20 years. “We've been very successful in preventing infections in children and adolescents, but there are still gaps in the perinatal hepatitis B-prevention program,” he said.
In particular, only about 50% of expected infants born to HBsAg-positive mothers are identified for case management, which has been shown to increase successful completion of postexposure immunization. In addition, there have been numerous documented incidences of failure to test women with unknown HBsAg status at the time of delivery and failure to administer appropriate immunoprophylaxis to infants.
Giving the first dose of hepatitis B vaccine soon after birth to all infants weighing 2,000 g or more should minimize the risk for infection because of errors in maternal HBsAg testing or reporting or from exposure to persons with chronic HBV infection in the household and can increase the likelihood of completing the vaccine series, he explained.
Still, some panel members expressed discomfort with the idea of removing a degree of provider autonomy, while others wanted to remove the “opt out” clause altogether. In the end, the committee opted for the compromise language to require documentation for “rare” deferrals.
“This sets a high bar of things to consider. The chart record is critical. … It emphasizes that the birth dose is the standard of care,” said panel member Guthrie S. Birkhead, M.D., director of the Center for Community Health, New York State Department of Health, Albany.
Fellow ACIP member Janet R. Gilsdorf, director of pediatric infectious diseases at the University of Michigan, Ann Arbor, agreed. “What I want is for every child in America to get that birth dose.”
Also included in the recommendation is a call for delivery hospitals to implement standing orders for review of maternal HBsAg test results for all pregnant women at the time of delivery and for women to be tested if the result was not documented. Immunoprophylaxis should be administered to all infants born to women who are HbsAg positive and to those with unknown status, and both the maternal test results and the infant hepatitis B vaccination status should be documented in the infant's medical record.
Standing orders should also address the management of infants weighing less than 2,000 g at birth, including ensuring initiation of postexposure immunization of infants born to HBsAg-positive mothers and to mothers who were not screened, and documenting the maternal HBsAg test results on the infant's medical record.
In other votes pertaining to hepatitis B vaccination, ACIP said providers should review immunization records for all children aged 11–12 years and those born in hepatitis B-endemic countries, including all of Asia, the Pacific Islands, and Africa. Hepatitis B vaccine should be offered to all such individuals not previously vaccinated.
Foreign-born HBsAg-positive persons are expected to be an increasing source of transmission—in 2001–2002, 42% of verified hepatitis B cases among children born after 1991 were born outside the United States (MMWR 2004;53:1015–8). The number of people coming into the United States with HBV infection is 10 times greater than the number currently becoming infected here, Dr. Mast noted.