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Screening for Hepatitis B Virus Infection in Pregnancy: U.S. Preventive Services Task Force Reaffirmation Recommendation Statement FREE

U.S. Preventive Services Task Force
[+] Article and Author Information

For a list of the members of the USPSTF, see the Appendix.


From the U.S. Preventive Services Task Force, Agency for Healthcare Research and Quality, Rockville, Maryland.


Disclaimer: Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.

Financial Support: The USPSTF is an independent, voluntary body. The U.S. Congress mandates that the Agency for Healthcare Research and Quality support the operations of the USPSTF.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Reprints are available from the USPSTF Web site (http://www.preventiveservices.ahrq.gov).


Ann Intern Med. 2009;150(12):869-873. doi:10.7326/0003-4819-150-12-200906160-00011
Text Size: A A A

Description: Reaffirmation of the 2004 U.S. Preventive Services Task Force (USPSTF) recommendation on screening for hepatitis B virus hepatitis B virus infection in pregnancy.

Methods: The USPSTF performed a brief literature update, including a search for new and substantial evidence on the benefits and harms of screening pregnant women for hepatitis B virus infection.

Finding: The net benefit of screening continues to be well established.

Recommendation: Screen for hepatitis B virus infection in pregnant women at their first prenatal visit. (Grade A recommendation.)

The U.S. Preventive Services Task Force (USPSTF) makes recommendations about preventive care services for patients without recognized signs or symptoms of the target condition.

It bases its recommendations on a systematic review of the evidence of the benefits and harms and an assessment of the net benefit of the service.

The USPSTF recognizes that clinical or policy decisions involve more considerations than this body of evidence alone. Clinicians and policymakers should understand the evidence but individualize decision making to the specific patient or situation.

The USPSTF recommends screening for hepatitis B virus (HBV) infection in pregnant women at their first prenatal visit. (This is a grade A recommendation.)

See the Figure for a summary of the recommendation and suggestions for clinical practice.

Grahic Jump Location
Figure.
Screening for hepatitis B virus infection in pregnancy: clinical summary of U.S. Preventive Services Task Force Recommendation.
Grahic Jump Location

Table 1 describes the USPSTF grades, and Table 2 describes the USPSTF classification of levels of certainty about net benefit. Both are also available at http://www.annals.org.

Table Jump PlaceholderTable 1.  What the USPSTF Grades Mean and Suggestions for Practice
Table Jump PlaceholderTable 2.  U.S. Preventive Services Task Force Levels of Certainty Regarding Net Benefit
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% 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 greater than 98%.

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 for 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.

Patient Population Under Consideration

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 test results.

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 HBV-infected mothers 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 7 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 sexual partners and household contacts and reassurance regarding the safety of breastfeeding in infants who receive appropriate prophylaxis.

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 clinicians and delivery settings must establish effective systems for the accurate and timely transfer of maternal HBsAg test results to the labor, delivery, and newborn medical records.

Research is needed to assess the effect of long-standing 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.

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 update (2) and determined that the net benefit of screening pregnant women for hepatitis B 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 hepatitis B at their first prenatal visit. The previous recommendation statement (3) and evidence review, as well as the current summary of the updated literature search, can be found at http://www.preventiveservices.ahrq.gov.

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/online/en/home/clinical/exam.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.

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.

Krishnaraj R.  Screening for hepatitis B virus infection: a brief evidence update for the U.S. Preventive Services Task Force. Rockville, MD: Agency for Healthcare Research and Quality; 2004. Accessed athttp://www.ahrq.gov/clinic/3rduspstf/hepbscr/hepbup.htmon 4 May 2009.
 
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; 150:874-6.
 
U.S. Preventive Services Task Force.  Screening for hepatitis B virus infection: recommendation statement. Rockville, MD: Agency for Healthcare Research and Quality; 2004. Accessed athttp://www.ahrq.gov/clinic/uspstf/uspshepb.htmon 4 May 2009.
 
American Academy of Family Physicians.  Summary of recommendations for clinical preventive services. AAFP Policy Action, revision 6.4. Leawood, KS: American Academy of Family Physicians; 2007.
 
American College of Obstetricians and Gynecologists.  ACOG Practice Bulletin No. 86: Viral hepatitis in pregnancy. Obstet Gynecol. 2007; 110:941-56. PubMed
CrossRef
 
American Academy of Pediatrics Committee on Infectious Diseases.  Red Book. 27th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2006.
 
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. MMWR Recomm Rep. 2005; 54:1-31. PubMed
 
Appendix: U.S. Preventive Services Task Force

Members of the U.S. Preventive Services Task Force† are Ned Calonge, MD, MPH, Chair (Colorado Department of Public Health and Environment, Denver, Colorado); Diana B. Petitti, MD, MPH, Vice-Chair (Arizona State University, Phoenix, Arizona); Thomas G. DeWitt, MD (Children's Hospital Medical Center, Cincinnati, Ohio); Allen J. Dietrich, MD (Dartmouth Medical School, Hanover, New Hampshire); Kimberly D. Gregory, MD, MPH (Cedars-Sinai Medical Center, Los Angeles, California); David Grossman, MD (Group Health Cooperative, Seattle, Washington); George Isham, MD, MS (HealthPartners, Minneapolis, Minnesota); Michael L. LeFevre, MD, MSPH (University of Missouri School of Medicine, Columbia, Missouri); Rosanne M. Leipzig, MD, PhD (Mount Sinai School of Medicine, New York, New York); Lucy N. Marion, PhD, RN (School of Nursing, Medical College of Georgia, Augusta, Georgia); Bernadette Melnyk, PhD, RN (Arizona State University College of Nursing & Healthcare Innovation, Phoenix, Arizona); Virginia A. Moyer, MD, MPH (Baylor College of Medicine, Houston, Texas); Judith K. Ockene, PhD (University of Massachusetts Medical School, Worcester, Massachusetts); George F. Sawaya, MD (University of California, San Francisco, San Francisco, California); J. Sanford Schwartz, MD (University of Pennsylvania Medical School and the Wharton School, Philadelphia, Pennsylvania); and Timothy Wilt, MD, MPH (University of Minnesota Department of Medicine and Minneapolis Veteran Affairs Medical Center, Minneapolis, Minnesota).

† Members of the Task Force at the time this recommendation was finalized. For a list of current Task Force members, go to http://www.ahrq.gov/clinic/uspstfab.htm.

Figures

Grahic Jump Location
Figure.
Screening for hepatitis B virus infection in pregnancy: clinical summary of U.S. Preventive Services Task Force Recommendation.
Grahic Jump Location

Tables

Table Jump PlaceholderTable 1.  What the USPSTF Grades Mean and Suggestions for Practice
Table Jump PlaceholderTable 2.  U.S. Preventive Services Task Force Levels of Certainty Regarding Net Benefit

References

Krishnaraj R.  Screening for hepatitis B virus infection: a brief evidence update for the U.S. Preventive Services Task Force. Rockville, MD: Agency for Healthcare Research and Quality; 2004. Accessed athttp://www.ahrq.gov/clinic/3rduspstf/hepbscr/hepbup.htmon 4 May 2009.
 
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; 150:874-6.
 
U.S. Preventive Services Task Force.  Screening for hepatitis B virus infection: recommendation statement. Rockville, MD: Agency for Healthcare Research and Quality; 2004. Accessed athttp://www.ahrq.gov/clinic/uspstf/uspshepb.htmon 4 May 2009.
 
American Academy of Family Physicians.  Summary of recommendations for clinical preventive services. AAFP Policy Action, revision 6.4. Leawood, KS: American Academy of Family Physicians; 2007.
 
American College of Obstetricians and Gynecologists.  ACOG Practice Bulletin No. 86: Viral hepatitis in pregnancy. Obstet Gynecol. 2007; 110:941-56. PubMed
CrossRef
 
American Academy of Pediatrics Committee on Infectious Diseases.  Red Book. 27th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2006.
 
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. MMWR Recomm Rep. 2005; 54:1-31. PubMed
 

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Comments

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A simple guideline for Clinical Practice Guideline updating.
Posted on June 22, 2009
Alain Braillon
University Hospital. Amiens. France
Conflict of Interest: None Declared

A simple guideline for Clinical Practice Guideline updating.

Clinical Practice Guideline (CPG) are regarded as a solution to get effective health care (1). Their obsolescence is a frequent and serious concern which preclude physicians to adopt evidence based medicine (2). Therefore, updating can be applauded. However a mandatory pre-request is forgotten: the assessment of the CPG's implementation!

The U.S. Preventive Services Task Force update cited four other organizations which issued the same guideline for screening for AgHBs during pregnancy (3). None published data assessing the adherence to this CPG.In France, the 1992 mandatory screening for AgHBs during pregnancy was reaffirmed in 2004. Again, no one has concern for its evaluation. We just published the first data which showed that compliance must be improved (4). Ongoing evaluation of the CPG for the treatment of infants born to HBV- infected mothers too shows poor conformity to the recommended processes and non relevant indications.

When, issuing a GPG one must plan measuring the adherence to it. Accordingly, funding must be foreseen. Recommandation and reaffirmation are not sufficient to obtain quality. Evaluation of practice performance, plus corrective actions when needed, are necessary and essential.

References

1 Haynes B, Haines A. Barriers and bridges to evidence based clinical practice. BMJ. 1998;317:273-6.

2 Braillon A, Gignon M, Dubois G. G-I-N must adopt the WHISKY statement. Qual Saf Health Care. 2005;14:391.

3 U.S. Preventive Services Task Force. Screening for hepatitis B virus Infection in pregnancy: U.S. Preventive Services Task Force reaffirmation recommendation statement. Ann Intern Med. 2009;150:869-73.

4 Braillon A, Nguyen-Khac E. Pregnancy and hepatitis B in Europe. Liver Int. 2009; Jun 6 (In press).

Funding: this study had no explicit funding.

Ethical approval: Not needed.

Conflict of Interest:

None declared

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Supplemental Content
Recommendation Summary

Summary for Patients

Screening Pregnant Women for Hepatitis B Virus Infection: U.S. Preventive Services Task Force Recommendation

The summary below is from the full reports titled “Screening for Hepatitis B Virus Infection in Pregnancy: U.S. Preventive Services Task Force Reaffirmation Recommendation Statement” and “Screening for Hepatitis B Virus Infection in Pregnant Women: Evidence for the U.S. Preventive Services Task Force Reaffirmation Recommendation Statement.” They are in the 16 June 2009 issue of Annals of Internal Medicine (volume 150, pages 869-873 and pages 874-876). The first report was written by the U.S. Preventive Services Task Force; the second report was written by K. Lin and J. Vickery.

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