Bagus Setyoboedi

Departemen/SMF Ilmu Kesehatan Anak

FK UNAIR / RSUD Dr. Soetomo – Surabaya
 2,000 million have markers of current or past
infection
 350 million have chronic infection
• 15%-25% will die from chronic liver
disease (liver cancer and cirrhosis)
• about 750,000 deaths per year
Geographic Distribution of Chronic HBV

HBsAg Prevalence
8% - High
2-7% - Intermediate
<2% - Low
 HBsAg HBeAg(+)
STATE N STUDY
% %
Jakarta 200 4 62,5 Noer 1981
Jakarta 736 5,2 38,8 Wihata 1985
Jogykarta 524 2,1 18,2 Soebodo 1984
Bandung 300 4,7 35,7 Ali Usman 1985
Surabaya 100 3 33,3 Hendra R 1981
Surabaya 1016 4,6 66,6 Edison 1989
Surabaya 100 3 - Sjamsul Arief 2007
Denpasar 569 2,46 - Montessori 1991
Denpasar 1552 2,58 47,5 Surya 1991
Mataram 3078 3,8 50,9 soewignyo 1993
Solo 1800 3,4 - suparyanto 1993
 Outcome of Hepatitis B Virus Infection
by Age at Infection
100 100

Symptomatic Infection (%)

Chronic Infection (%)

80 80

60 60
Chronic Infection

40 40

20 20

Symptomatic Infection
0 0
Birth 1-6 months 7-12 months 1-4 years Older Children
and Adults
Age at Infection
 Hepatitis B immunization
 Universal infant immunization
 Catch-up immunization
 Prevent Perinatal Transmission
 Prevent nosocomial HBV transmission
Assure identification Assure all exposed
of all HBsAg positive infants receive HBIG
women and their and 1st dose of hep.
infants Prevention B vaccine w/in 12
of hours of birth
Perinatal
Hepatitis B
Transmission
Assure that all Assure
susceptible completion of 3
household and doses of hepatitis B
sexual contacts vaccine and post
are vaccinated vaccination testing
of exposed infants

Conduct active surveillance,

quality assurance, and outreach to
improve program
 Caused by a double-stranded DNA virus
Incubation period of 45-160 days
 Can survive 30 days on surfaces
 Causes acute and chronic HBV infection
 Humans are the only host
There are three well defined antigens associated
with Hep B:
 HBcAg
 HBeAg
 HBsAg – viral antigen measured most routinely in
blood. It is the earliest serologic marker to appear
before onset of infection
Young children
• <10% get sick when first infected
• chronic infection:
▪ 80-90% at age < 1 year
▪ 30-50% at age 1-4 years
• 25% die from liver cancer/cirrhosis
Adults
o 30-50% get sick when first infected
o 2-6% develop chronic infection
o 15% die from liver cancer/cirrhosis
Hepatitis B (chronically evolving)
• Vertical transmission from mother to infant
• Horizontal transmission from infected
household contact to child

 Both modes of transmission can be

prevented by vaccination of newborns!
 If the mother is positive for hepatitis B surface
antigen (HBsAg) and HbeAg, the risk of
perinatal transmission is 70-90%.
 Up to 25% of infants infected during the
perinatal period will die in adulthood of chronic
liver disease
 Identify HBsAg-positive pregnant women
through serologic screening
 Provide prophylaxis for infant born to HBsAg-
positive women
 Provide the birth dose of hepatitis B vaccine to
all infants
 Screen all pregnant women for HBsAg at
delivery for each pregnancy
 Report all HBsAg-positive women
 Administer the hepatitis B vaccine at birth all
newborns
Administer the Hep B vaccine birth dose and
HBIG within 12 hours of birth to infants born to:
 HBsAg-positive mothers (confirm with HBeAg)
 Mothers of unknown HBsAg status

Administer the Hep B vaccine birth dose to all

newborns before hospital discharge
 HBsAg positive women or unknown HBV status:
Initiate prophylaxis at birth If birth weight <2,000 grams,
then first dose of vaccine is not counted
 Infant will need 4 doses of Hep B vaccine
 Initiate second dose of hepatitis B vaccine at 1
month of age (chronological)
 HBsAg-negative women
Delay first dose of Hep B vaccine
until one month of age (chronological)
• Without immunoprophylaxis, ~40% of infants of
Hepatitis B Surface Antigen (HBsAg) positive
mothers develop chronic HBV infection
• Immunoprophylaxis includes:
• hepatitis B vaccine & Hepatitis B Immune
Globulin (HBIG) at birth
• This is 85%-95% effective in preventing vertical
HBV transmission; hepatitis B vaccine alone at
birth prevents transmission in 70-95% of infants
 The overall goal of program is twofold:
Identify the pregnant women who are hepatitis
B surface antigen positive; and to prophylax
their infants appropriately
From Murray et. al., Medical Microbiology 5th edition, 2005, Chapter 62, published by Mosby Philadelphia,,
HBsAg Prevalence
8% - High
2-7% - Intermediate
<2% - Low
 Routes of HBV Transmission
Endemicity
Age Group Route(s) of Infection Low Int High

Newborn •mother to infant ++ ++ ++

Childhood •child to child ++ +++ ++++

•unsafe injections - + ++
Adolescent/ •sexual contact ++++ ++ +
Adult •injecting drug use +++ ++ +
•unsafe injections - +/- +
Low Intermediate High

Perinatal Childhood Adolescent/Adult

Global Patterns of Chronic HBV Infection

 High (³8%): 45% of global population

• lifetime risk of infection >60%
• early childhood infections common
 Intermediate (2%-7%): 43% of global population
• lifetime risk of infection 20%-60%
• infections occur in all age groups
 Low (<2%): 12% of global population
• lifetime risk of infection <20%
• most infections occur in adult risk groups
Pathogenesis of the Immune Response in Acute and Chronic
Hepatitis B, and the Relation between the Binding of HBcAg Peptides
by MHC Molecules and T-Cell Responses
Lee WM. N Engl M J. 1997:337(24)
• Before implementation of perinatal hepatitis B
prevention programs, studies show:
• 61%-66% of children with chronic HBV infection were
born to HBsAg-negative mothers
• Children likely were infected by household contacts*
• Birth dose of hepatitis B vaccine will prevent
these early childhood infections

*Pediatrics 1995; 96:1113-6;

Pediatrics, 2001, 108:5, 1123-28
 All pregnant women should be screened for
HBsAg during an early prenatal visit and at the
time of delivery for each pregnancy
Once HBsAg positive lab results are reported we
provide:
 Educational and consultative services
 Provide completion of the hepatitis B vaccine
series
 Provides post-vaccination testing
 Provides vaccination of household and sexual
contacts of HBsAg-positive women
 Document maternal HBsAg in both maternal
and infant records
 Establish a specific written policy for perinatal
hepatitis B prevention
 Establish universal hepatitis B vaccine birth
dose policy
 Increase life expectancy

 Increases quality of life

 Reduced health care cost

• Hepatitis B vaccine series cost $27.00
• New liver costs$1,000,000