The importance of a preschool booster for children born to hepatitis B-positive mothers

Shamez N Ladhani; Mary E Ramsay

doi:10.1136/archdischild-2013-303652

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The importance of a preschool booster for children born to hepatitis B-positive mothers

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Re: The importance of a preschool booster for children born to hepatitis B-positive mothers
Dayan Vijeratnam
Published on: 22 March 2016
Re: The importance of a preschool booster for children born to hepatitis B-positive mothers
Tom A. Yates 1
Published on: 22 March 2016

Published on: 22 March 2016
Re: The importance of a preschool booster for children born to hepatitis B-positive mothers
- Dayan Vijeratnam, Specialist Registrar Genitourinary Medicine
- Other Contributors:
  Selvarajan Vijeratnam
We read Ladhani and Ramsay's editorial with great interest. Whilst we agree on the need for the delivery of a completed course of Hepatitis B vaccinations in infants of high-risk mothers where the fourth vaccination is administration by their first birthday, in order to improve uptake of vaccines it is essential to recognise factors preventing this occurring.
Firstly, Hepatitis B positive mothers diagnosed in an...
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We read Ladhani and Ramsay's editorial with great interest. Whilst we agree on the need for the delivery of a completed course of Hepatitis B vaccinations in infants of high-risk mothers where the fourth vaccination is administration by their first birthday, in order to improve uptake of vaccines it is essential to recognise factors preventing this occurring.
Firstly, Hepatitis B positive mothers diagnosed in antenatal services may give birth in a labour unit outside of their local area due to bed pressures and newborns may not receive their first vaccination. This should, however, be limited by the use of patient-held maternity records.
The initial Hepatitis B vaccination is often administered by maternity or neonatal paediatric staff under a hospital doctor prescription. Subsequent vaccines are currently offered by a variety of healthcare professionals such as general practitioners (GP) or community paediatricians. Yates et al[1] showed a high level of participation at the first vaccination but large numbers of infants did not have follow-up vaccines. Reasons for this may include poor transfer of information and clinical records between providers. Also, the administration of infant Hepatitis B vaccinations does not result in item of service payments for GPs and as such GP may be less likely to offer follow up vaccinations. Similarly, acquisition of vaccines, blood test sampling, sample handling practices and pathology systems may vary among GP practices, thus posing additional barriers to the completion of vaccination schedules and serological testing.
In the North London Borough of Enfield, a number of children under the age of 2 years old move in and out of area making follow-up more challenging. However, in 2004 in this borough, 80% of all high-risk neonates of Hepatitis B positive mothers registered at Chase Farm Hospital during antenatal testing received the full vaccination course and serology[2]. This success has been attributed to the use of a named clinical lead conducting an integrated immunisation clinic with a clinic nurse. The team would recall and follow up patients to offer immunisation and serological testing while considering migration, language and access barriers. In a resource-limited health system such immunisation clinics may not be feasible. Universal vaccination of children with Hepatitis B vaccines is not practical or more effective than a targeted approach[3]. Therefore, we would recommend that follow-up Hepatitis B vaccinations and serology are performed by incentivised GPs as a new 'item of service' payment.
1. Yates TA, Paranthaman K, Yu L-M, et al. UK vaccination schedule: persistence of immunity to hepatitis B in children vaccinated after perinatal exposure. Arch Dis Child 2013;98:429-33. 2. Giroudon I. Immunization Coverage in Infants at Risk of Perinatal Transmission of Hepatitis B: A London Study (LANSSG). HPA London Regional Epidemiology Unit. 2008. 3. Balogum MA, Parry JV, Mutton K, et al. Hepatitis B virus transmission in pre-adolescent schoolchildren in four multi-ethnic areas of England. Epidemiol Infect 2013; 141(5):916-25
Conflict of Interest:
None declared
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Conflict of Interest:
None declared.
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Published on: 22 March 2016
Re: The importance of a preschool booster for children born to hepatitis B-positive mothers
- Tom A. Yates 1
- Other Contributors:
  Karthikeyan Paranthaman 1, Elizabeth Davis 1, Sarah Lang 2, Scott J Hackett 3, Steven B Welch 3, Andrew J Pollard 1 4, Matthew D Snape 1 4.
We are grateful to Dr Ladhani and Dr Ramsay [1] for their thoughtful editorial that accompanied the publication of our paper [2]. We would agree that, despite discrepant observational data in the UK regarding the waning of antibody titres [2, 3], there is now a large body of evidence [4] demonstrating that, even where antibody titres have waned, booster doses are not required if an adequate primary schedule has been comp...
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We are grateful to Dr Ladhani and Dr Ramsay [1] for their thoughtful editorial that accompanied the publication of our paper [2]. We would agree that, despite discrepant observational data in the UK regarding the waning of antibody titres [2, 3], there is now a large body of evidence [4] demonstrating that, even where antibody titres have waned, booster doses are not required if an adequate primary schedule has been completed.
As discussed in the editorial, the pragmatic priority is to ensure that all children complete the course and receive at least one further dose after their initial (accelerated) schedule at 0, 1, 2 months.
Routine immunisation visits are a convenient time to do this, and the pre-school booster presents one such opportunity. However, as Dr Ladhani and Dr Ramsay have noted elsewhere, almost all UK children diagnosed with chronic hepatitis B infection acquire this through vertical transmission [5]. Having a named clinician responsible for delivery of the 0, 1, 2 month schedule can improve its delivery , and the 12 month routine vaccine visit is more timely than the pre-school booster for ensuring its completion.
1. Ladhani SN, Ramsay ME. The importance of a preschool booster for children born to hepatitis B-positive mothers. Arch Dis Child. 2013; 98: 395-396. 2. Yates TA, Paranthaman K, Yu LM, et al. UK vaccination schedule: persistence of immunity to hepatitis B in children vaccinated after perinatal exposure. Arch Dis Child. 2013; 98: 429-433. 3. Boxall EH, A Sira J, El-Shuhkri N, et al. Long-term persistence of immunity to hepatitis B after vaccination during infancy in a country where endemicity is low. J Infect Dis. 2004; 190(7): 1264-9. 4. Leuridan E, Van Damme P. Hepatitis B and the need for a booster dose. Clin Infect Dis. 2011; 53(1): 68-75. 5. Flood J, Amirthalingam G, Ramsay ME, et al. The diagnosis of chronic Hepatitis B infection among children born in England after introduction of universal antenatal HBV screening programme. Poster presented at the European Society of Paediatric Infectious Disease Meeting, The Hague, June 2011. http://www.kenes.com/ espid2011/cd/pdf/P774.pdf.
Conflict of Interest:
Our study was supported by the NIHR Oxford Biomedical Research Centre and GlaxoSmithKline Biologicals. SL has undertaken paid work for vaccine manufacturers for provision of travel health training and attendance at advisory group meetings. AJP and MDS have conducted clinical trials on behalf of Oxford University sponsored by manufacturers of vaccines. AJP and MDS do not accept any personal payments from vaccine manufacturers: grants for support of educational activities are paid to an educational/administrative fund held by the Department of Paediatrics, Oxford University. MDS has received support from vaccine manufacturers to attend academic conferences. ED, SBW, SJH, KP and TAY declare no conflicts of interest besides funding received for the study.
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Conflict of Interest:
None declared.
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