ReviewFactors associated with incomplete vaccination of babies at risk of perinatal hepatitis B transmission: A London study in 2006
Introduction
The risk of neonatal hepatitis B virus (HBV) infection acquired through mother to child transmission is between 70 and 90% when a mother is of high infectivity (HBsAg positive and anti HBe negative). Babies born to HBsAg positive mothers in the absence of HBeAg can also be infected [1], [2]. About 85% of infections in newborns become chronic [3], [4]. Among infected babies, the risk of cirrhosis or primary hepatocellular carcinoma is around15–25% [1], [5].
Since 1998 in the UK, the antenatal screening programme has included universal offer of HBsAg testing in order to ensure that women receive appropriate treatment; their babies receive a full course of vaccination to prevent perinatal or early childhood infection; and their family contacts are screened and vaccinated to prevent horizontal transmission [6], [7]. The accelerated schedule comprises four doses, given at birth, 1, 2 and 12 months; babies born to high-risk women are also given 200 i.u. of HB Immunoglobulin (HBIg) at birth; infants are tested at around 1 year to identify those with chronic infection [8].
In London an estimated 98% of pregnant women are tested for HBsAg and there are an estimated 1200 infants per year at risk [9], [10]. There are various mechanisms in maternity units and Primary Care Trusts (PCTs) for the provision and recording of vaccination [11]. Local audits have shown that vaccination uptake ranged from less than 20 to 90% [12], [13]. The HPA Cover of Vaccination Evaluated Rapidly (COVER) scheme monitors the coverage of HB vaccination through data submissions from the PCTs [14] but the completeness and quality of this information is unclear. No detailed London wide study of the characteristics of those at risk, completeness of vaccine coverage and factors associated with completion of vaccination has been carried out. This paper describes a cohort of HBsAg positive mothers and their babies, uptake of HB vaccination by 1 year of age and factors associated with incomplete uptake. Implications for policy and practice in London are discussed.
Section snippets
Materials and methods
We conducted a retrospective cohort study of London resident HBsAg positive mothers, who delivered a live baby in a London NHS Trust maternity unit in the fourth quarter of 2004, and their babies. Cases were identified through maternity units’ and laboratories’ records.
A questionnaire was filled in for each mother by the Antenatal Screening Coordinators (ASC) which included age, ethnicity, place of birth, occupation, residence, command of English; history of drug use, imprisonment and
Results
Of 269 women initially identified at 29 NHS maternity units, 20 were excluded: four had a stillbirth; one delivered in September 2004; five were out of London residents; three were identified by the name of the baby only but no other data could be reported; four were duplicate reports, three were not HBsAg+ but were initially included because their baby received vaccination due to family circumstances (e.g. partner of the mother was HBsAg+, child in fostering, mother declining the HB antenatal
Discussion
There were 249 mothers with hepatitis B in one quarter of 2004, suggesting more than 1000 babies per year at risk in London. The majority of mothers were born outside of the UK and more than half were born in Africa, unlike in previous regional and national studies where the majority of mothers were from Asia, South East Asia and India [16], [17], [18]. This most likely highlights demographic differences in London compared to elsewhere [19] and is possibly due to the identification of patients
Acknowledgments
The authors wish to acknowledge the London maternity units’ Midwives, Heads of Midwifery, Antenatal Screening Coordinators; Laboratories virologists and other staff. At each HPUs: hepatitis leads and their colleagues who helped in the data collection, at HPA CfI, Joanne White for her contribution on COVER system, at HPA London Kathryn Harris, Elizabeth Jaffa who helped with the collection of the data, Josh Forde for his help in liaising with the Antenatal Screening Coordinators and the
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- 1
On behalf of the Infectious Disease Working Group of the London Antenatal and Newborn Screening Steering Group (LANSSG).