Clinical Overview of Perinatal Hepatitis B

Overview

When a pregnant person has HBV infection, it can pose a serious risk to their infant at birth. Infants with HBV infection have about a 90% chance of developing a chronic HBV infection.

Testing pregnant people for hepatitis B and providing pregnant people and infants with appropriate treatment and vaccination is the best way to prevent perinatal HBV infection.

Causes

The most common cause of perinatal HBV infection is when a pregnant person with HBV infection gives birth and the infant does not receive postexposure immunoprophylaxis (hepatitis B birth dose and hepatitis B immune globulin [HBIG]) within 12 hours of birth1.

An infant can also develop HBV infection through contact with blood or other bodily fluids from a person with HBV infection.

Types

HBV infection can occur either with or without symptoms. HBV infection can be identified in pregnant people and infants with a confirmed positive hepatitis B surface antigen (HBsAg) test result.

Acute hepatitis B infection that does not resolve progresses to chronic, or long-term, HBV infection. The risk for chronic HBV infection varies according to the age at infection and is greatest among young children. Approximately 90% of infants with HBV infection and 30% of children between ages 1–5 years with HBV infection will develop a chronic HBV infection. By contrast, approximately 95% of adults with HBV infection recover completely and do not become chronically infected.

Infection rates and trends

In 2021, an estimated 17,827 infants were born to HBsAg-positive people in the United States, representing nearly 0.5% of all births. Births to US-born and non-US-born people comprised 79% and 20% of all births, respectively, and 46% and 53% of estimated births to HBsAg-positive people, respectively.2

CDC collects, analyzes, and reports outcome data on infants born to people with HBV infection. This intervention is called the Perinatal Hepatitis B Prevention Program (PHBPP).3

Learn more about PHBPP outcome data.

Clinical features

Infants and children younger than 5 are typically asymptomatic.

If symptoms develop, they usually appear about 90 days after exposure (range: 60–150 days).

When present, signs and symptoms of HBV infection can include:

• Abdominal pain, nausea, and/or vomiting
• Dark urine or clay-colored stools
• Fatigue
• Fever
• Jaundice
• Joint pain
• Loss of appetite

Learn more about signs and symptoms of HBV infection.

Prevention

CDC's Advisory Committee on Immunization Practices (ACIP) recommends that all infants receive hepatitis B vaccine (HepB) at birth, regardless of the HBV infection status of the birthing parent1.

Infants born to HBsAg-positive people require HepB vaccine and HBIG within 12 hours of birth to protect them from infection. However, because errors or delays in testing, reporting, and documenting perinatal HBsAg status can and do occur, administering the first dose of HepB vaccine soon after birth to all infants acts as a safety net, reducing the risk for perinatal transmission when the HBsAg status of the parent is either unknown or incorrectly documented at delivery. Also, initiating the HepB vaccine series at birth has been shown to increase a child's likelihood of completing the vaccine series on schedule.

Testing, screening, and diagnosis

Clinicians should screen all pregnant people for HBsAg during each pregnancy, preferably in the first trimester, regardless of vaccination status, chronic disease, or testing history. A confirmed positive HBsAg test result indicates current HBV infection.

Clinicians should test all infants born to an HBsAg-positive person that have completed the HepB vaccine series. Clinicians should test the infants for HBsAg and antibody to hepatitis B surface antigen (anti-HBs) at 9–12 months of age, or 1–2 months after vaccine series completion if the series is delayed.

To learn more about perinatal screening and testing, see perinatal testing guidelines.

Treatment and recovery

Once a clinician has confirmed test results, they can make treatment and management decisions.

Case management of pregnant persons with HBV infection

• All pregnant people who are HBsAg-positive should be tested for HBV DNA to guide the use of maternal antiviral therapy during pregnancy for the prevention of perinatal HBV transmission.
• The American Association for the Study of Liver Diseases (AASLD) suggests maternal antiviral therapy when the maternal HBV DNA is greater than 200,000 IU/mL.
• All pregnant people who are HBsAg-positive should be referred to their jurisdiction's PHBPP for case management to ensure that their infants receive timely postexposure immunoprophylaxis and follow-up. A copy of the original laboratory report indicating the pregnant person's HBsAg-positive status should be provided to the hospital or birthing facility where the delivery is planned and to the health care provider (HCP) who will care for the newborn infant.

All infants born to people who are HBsAg-positive should receive HepB vaccine and HBIG within 12 hours of birth, administered at different injection sites (e.g., separate limbs). Only single-antigen HepB vaccine should be used for the birth dose.

Management of perinatally HBV-exposed infants with birth weights ≥2,000 grams (≥4.4 lbs)

Management of perinatally HBV-exposed infants with birth weights <2,000 grams (<4.4 lbs)

* Administer the final dose no earlier than 6 months of age (minimum age of 164 days includes 4-day grace period). Complete PVST at 9–12 months of age (or 1–2 months after final dose if series is delayed) by testing for ONLY HBsAg and anti-HBs. Do NOT test for anti-HBc.

The HepB vaccine series should be completed according to the recommended schedule above for infants born to an HBsAg-positive parent. The final dose in the series should not be administered before the age of 24 weeks (164 days). Download a printable version of this vaccination series here.

Other important things to keep in mind:

• After completion of the vaccine series, post-vaccination serologic testing (PVST) for HBsAg and anti-HBs should be performed at age 9–12 months.
• Testing should not be performed before age 9 months to avoid detection of passive anti-HBs from HBIG administered at birth and to maximize the likelihood of detecting late HBV infection.
• Antibody to hepatitis B core antigen (anti-HBc) testing of infants is not recommended because passively acquired maternal anti-HBc might be detected in infants born to a person who is HBsAg-positive up to age 24 months.

For more information on management of infants, see Tip Sheet — Hepatitis B Screening, Testing, and Management of Pregnant Persons for Obstetricians.

Patient counseling

Clinicians should provide all pregnant persons who test HBsAg-positive with:

• Information about the potential use of antiviral therapy for HBV infection.
• Information outlining the importance of timely postexposure immunoprophylaxis for their infant (HepB vaccine and HBIG within 12 hours of birth).
• Information on completing the vaccine series and PVST for their infant.

Long-term effects

HBV infection in a pregnant person poses a serious risk to an infant at birth. Without timely postexposure immunoprophylaxis, approximately 90% of infants born to HBsAg-positive people in the US will acquire chronic HBV infection, approximately one-fourth of whom will eventually die from chronic liver disease.

Case definition

CDC, in collaboration with the Council of State and Territorial Epidemiologists, has developed case definitions to provide uniform clinical and laboratory-testing criteria of identifying and reporting nationally notifiable infections diseases.

To learn more about classification of perinatal hepatitis B cases, visit the: National Notifiable Diseases Surveillance System (NNDSS).

Public health efforts and research

HBV infection in a pregnant person poses a serious risk to an infant at birth. Without timely postexposure immunoprophylaxis, approximately 90% of infants born to HBsAg-positive people in the US will acquire chronic HBV infection, approximately one-fourth of whom will eventually die from chronic liver disease.

Since 1990, CDC has funded public health jurisdictions (regions managed by state or local public health agencies) to identify pregnant people with HBV infection and case manage their infants to prevent parent-to-child transmission of HBV infection. The national PHBPP aims to ensure infants born to people with HBV infection receive timely postexposure immunoprophylaxis, complete a full series of HepB vaccine, and receive PVST after a complete series to confirm immunity, identify infants needing revaccination, and identify infants who are infected. PHBPP-funded jurisdictions follow these infants for up to 24 months to monitor completion of these recommended interventions.3

Learn more about PHBPP outcome data.

Resources

For clinicians seeking more information, CDC has several resources available concerning perinatal HBV.

• Perinatal Hepatitis B Prevention Program: This site contains resources for PHBPP staff at the state, local, and territorial levels.

• Tip Sheet — Hepatitis B Screening, Testing, and Management of Pregnant Persons for Obstetricians: This is a one-page hepatitis B resource for obstetricians managing pregnant people.

• Tip Sheet — Management of Infants Born to People with HBV Infection for Pediatricians: This is a two-page tip sheet for pediatricians managing perinatally HBV-exposed infants.

• Procedures to Prevent Perinatal Hepatitis B Virus Transmission at Delivery When HBsAg Results Are Available: This is an algorithm illustrating procedures to prevent perinatal HBV transmission when maternal HBsAg test results are available.

• Procedures to Prevent Perinatal Hepatitis B Virus Transmission at Delivery When HBsAg Results Are Unavailable: This is an algorithm illustrating procedures to prevent perinatal HBV transmission when maternal HBsAg test results are unavailable.

Other resources

• Sources for HBIG: This page contains information on manufacturers of HBIG.
• Perinatal Hepatitis B Prevention Program: This site contains resources for PHBPP staff at the state, local, and territorial levels.

Patient information

When a Pregnant Woman Has Hepatitis B: These one-page resource covers the preventative measures a parent with hepatitis B can take to protect their baby.

• When a Pregnant Woman Has Hepatitis B (English)
• When a Pregnant Woman Has Hepatitis B (Spanish)
• When a Pregnant Woman Has Hepatitis B (French)
• When a Pregnant Woman Has Hepatitis B (Russian)
• When a Pregnant Woman Has Hepatitis B (Burmese)
• When a Pregnant Woman Has Hepatitis B (Chinese)
• When a Pregnant Woman Has Hepatitis B (Hmong)
• When a Pregnant Woman Has Hepatitis B (Khmer)
• When a Pregnant Woman Has Hepatitis B (Korean)
• When a Pregnant Woman Has Hepatitis B (Laotian)
• When a Pregnant Woman Has Hepatitis B (Tagalog)
• When a Pregnant Woman Has Hepatitis B (Vietnamese)

Hepatitis B and Your Baby: This one-page resource covers the benefits of Hep B vaccine for parents and their infants.

• Hepatitis B and Your Baby (English)
• Hepatitis B and Your Baby (Spanish)