The role of the United States in global efforts to eliminate hepatitis B virus (HBV) infection cannot be overstated when HBV together with hepatitis C virus infection accounts for 96% of the 1.34 million viral hepatitis deaths annually.1 Most HBV infections occur perinatally and in early childhood and thus are preventable by early and widespread HBV vaccination.1,2 In this month’s issue of Pediatrics, Koneru et al3 describe programmatic outcomes among 103 825 infants born to hepatitis B surface antigen (HBsAg)–positive women, case managed by the Centers for Disease Control and Prevention’s national Perinatal Hepatitis B Prevention Program (PHBPP).
Starting in 1990, PHBPP has been instrumental in identifying and tracking infants exposed to HBV. Among the estimated number of infants born to HBsAg-positive women, PHBPP has increasingly succeeded in identifying exposed infants, with identified infant rates rising from 42.1% in 1994 to 52.6% in 2017.3,4 From 2014 to 2017, the infant hepatitis B postexposure prophylaxis (PEP) rose from 94.7% to 97%, vaccine completion from 83.1% to 84.7%, and postvaccination serological testing (PVST) significantly increased from 58.8% to 66.8%.3 High rates of PEP are indeed a testament to the dedicated maternal and newborn health care professionals and the American Academy of Pediatrics policy statement on perinatal hepatitis B elimination.5
Steady progress in reducing HBV infection is a major achievement, but we are far from the mark for certain international and national targets. The World Health Organization set targets by 2030 that 90% of infants receive HBV vaccination at ≤12 hours after birth, and 90% complete the 3-dose HBV vaccine series.2 The Centers for Disease Control and Prevention set the following four PHBPP targets for 2019–2024: 80% of births to HBsAg-positive mothers be identified, 98% receive PEP, 90% receive PEP and complete the vaccine series, and 85% receive PVST.3 This calls for dramatic improvements over the next 4 years in case identification and PVST, which would require rates to rise by 27 and 18 percentage points, respectively. Identifying only 52.6% of the estimated cases suggests that HBV-related outcomes for an estimated 13 046 births to HBsAg-positive mothers remain unknown.3 This is particularly concerning given that HBsAg-positivity disproportionately affects disadvantaged populations, specifically pregnant women who identify as Asian and/or Pacific Islander or Black, are born outside of the United States, and whose primary language is non-English.6 Rates of maternal screening for HBV infection range from 84% to 88%; however, recommended screening rates during the first trimester remain low at 60% for those commercially insured, and even lower at 39% for those enrolled in Medicaid.7
Tackling health inequities related to race and ethnicity, access to care, and insurance requires collective efforts beyond the realm of PHBPP, ranging from culturally informed, community-based campaigns to health insurance tracking programs to expansion of perinatal hepatitis B prevention laws.8–10 An exemplary state-based effort is the Alaska universal HBV vaccination program coupled with a catch-up vaccination program that resulted in a 90% reduction in new cases.2,11 In 1988, Kaiser Permanente implemented a tracking and follow-up program for perinatal hepatitis B and demonstrated a PEP rate of 99.8% among exposed infants and a vaccine completion rate of 94% by age 6 to 8 months.9 Clinicians can overcome barriers for those who speak a language other than English by consistently using certified interpreters and providing parents with hepatitis B Vaccine Information Statements, which are available in >30 different languages.12
Closing the loop by ensuring completion of the HBV vaccine series and PVST for exposed infants is essential. Approximately 1 in 6 infants case managed by PHBPP did not complete the HBV vaccine series, and 1 in 3 did not receive PVST. As a community, we have a responsibility to ensure that these children at risk for chronic HBV infection and hepatocellular carcinoma are protected and disease free. PHBPP funding includes follow-up to age 24 months, allowing for 12 months of follow-up beyond the Advisory Committee on Immunization Practices’ recommendation to complete PVST by 12 months.5 Koneru et al3 note that as many as 1070 to 1536 (10.9%) case-managed infants are lost to follow-up, attributing this to a number of barriers, including the fact that some families move out of the country. In today’s world, easily accessible text messaging and e-mail are modes of communication that could optimize follow-up with families and health care providers.13 Health care systems and professionals should have targeted conversations with HBsAg-positive mothers about the life-saving implications of vaccine completion and the importance of PVST.
Extra efforts to protect children from vaccine-preventable HBV infection are required during the current coronavirus disease 2019 pandemic. A recent study revealed declines in vaccination coverage for all vaccines except for the birth dose of HBV vaccine, attributable to pandemic-associated measures and declines in access to health care services.14 As 1 of 20 countries accounting for >75% of the global burden of viral hepatitis,1 the United States must sustain a widespread effort to eliminate perinatal hepatitis B and its disproportionate impact on disadvantaged communities now more than ever.
Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.
FUNDING: No external funding.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2020-1823.
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Competing Interests
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
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