Pregnancy - a Key Moment for Engaging Women with Hepatitis B in Care.

In 2017, only 17% of Australians living with hepatitis B received appropriate monitoring, and half of those who required hepatitis B treatment received it.1 Using current projections, Australia will not reach the 2030 World Health Organization (WHO) goal of a 65% reduction in hepatitis B mortality until 2051 – a delay of 21 years.2, 3 Key to achieving the WHO target is linkage to hepatitis B care. In 2013, a Victorian study demonstrated suboptimal management of hepatitis B in pregnancy.4 A review at our institution found similar results, prompting the development of a collaborative referral pathway.5 A working party from obstetrics, gastroenterology and infectious diseases departments agreed to the following intervention for women with hepatitis B: antenatal medical review, if hepatitis B virus (HBV) viral load >200,000 IU/ml care through the high-risk obstetrician-led antenatal service, referral to Liver Clinic, and education at the high-risk antenatal clinic from hepatology nurses. A Liver Clinic referral pack, containing hepatitis B patient information, pre-printed pathology slips and a referral proforma, was provided in the antenatal clinic. In 2013, the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) also recommended antenatal HBV viral load testing.6 The aim of this study was to compare hepatitis B management in pregnancy and engagement in care post-partum, pre- and post-implementation of a collaborative referral pathway at University Hospital Geelong (UHG), a regional, tertiary maternity hospital in Victoria. Pregnant women receiving care at UHG with hepatitis B (surface antigen detected) were identified via antenatal screening results or delivery records. The pre-intervention group received pregnancy care from 2008 to 2013; the post-intervention group from 2014 to 2018. The following data were collected to assess hepatitis B management during pregnancy: referral to and attendance at Liver Clinic; completion of liver function tests; HBV e antigen (eAg); HBV viral load; indication for and exposure to antiviral therapy and neonate birth dose HBV vaccine and immunoglobulin. HBV replicative status was assessed according to the contemporary RANZCOG guidelines for each group: eAg or HBV viral load pre-intervention, and HBV viral load post-intervention. Antenatal antiviral therapy was indicated at HBV viral load >200,000 IU/ml. Engagement in care post-partum was defined as attendance at Liver Clinic appointments at least annually. Pearson's chi-squared or Fisher's exact tests were used as appropriate. Analysis was undertaken using STATA/MP 16.1 (StataCorp LLC, Tx, USA). This study was approved by the Barwon Health Research Ethics Committee (19/11). Twenty-nine women had 35 pregnancies resulting in 34 live births pre-intervention; 31 women had 36 pregnancies all resulting in live births post-intervention. The median age at delivery was 30 years (interquartile range [IQR] 25–34) pre-intervention and 30.5 years (IQR 26–32) post-intervention. The proportion of women born overseas was 19/29 (66%) pre-intervention and 28/31 (90%) post-intervention. Data and analysis for hepatitis B management during pregnancy is presented in Table 1. HBV viral load testing was performed more frequently post-intervention 33/36 (91%) compared to pre-intervention 11/35 (31%; p<0.001). Variable Pre-intervention n (%) N = 35 Post-intervention n (%) N = 36 Pearson's chi squared Referred to Liver Clinic 13 (37%) 33 (92%) p<0.001 Attended Liver Clinic if referred 8/13 (62%) 31/33 (94%) p=0.006 LFT performed 29 (83%) 34 (94%) p=0.081 HBV e Ag performed 27 (77%) 30 (83%) p=0.512 HBV e Ag detected if test performed 2/27 (7%) 6/30 (20%) N/A HBV viral load performed 11 (31%) 33 (91%) p<0.001 HBV replicative status assessed per current guidelines 28 (80%) 33 (92%) p=0.158 HBV VL >200,000 IU/ml if test performed 1/11 (9%) 6/33 (18%) N/A Antiviral treatment taken if indicated 1/1 (100%) 5/6 (83%) N/A Number of live births 34 (97%) 36 (100%) N/A Birth dose HBV vaccine administered if live birth 33/34 (97%) 36 (100%) p=0.300 HBIg administered if live birth 32/34 (94%) 36 (100%) p=0.336 Pre-intervention, four of 29 women (14%) attended Liver Clinic annually post-partum: one remains engaged seven years post-partum, one attended for five years and then moved out of the area, one attended for two years and then became lost to follow-up, and one attended for two years and was discharged from the clinic. Post-intervention, 21 of 31 women (68%) attended Liver Clinic annually post-partum: 16 remain engaged in care (median duration 4 years, range 2–7), three are lost to follow-up and two moved out of the area. Women in the post-intervention group were significantly more likely to be engaged in Liver Clinic care post-partum (16/31 [52%] vs. 1/29 [3%], p<0.001). A collaborative referral pathway has improved care for pregnant women with hepatitis B at our health service and successfully linked more than half to ongoing hepatitis B care. Previous Australian studies have assessed hepatitis B management in pregnancy and infant immunoprophylaxis, but to our knowledge, none have addressed the role antenatal care could play in linking women to ongoing hepatitis B care.7, 8 Most women in the study were born overseas and therefore face additional language, social and economic barriers to healthcare. Addressing these barriers by creating novel pathways to care is a step towards health service equity for this important patient group. Of note, this study did not capture data of women who may have sought hepatitis B care privately, at other institutions or with their general practitioner. The serologic status of infants born to women with hepatitis B was not assessed in this study. The introduction of a collaborative referral pathway for pregnant women with hepatitis B significantly improved the assessment of viral load during pregnancy and provided an opportunity to link women into ongoing care. The optimisation of hepatitis B prevention, monitoring and treatment is required to achieve the WHO elimination targets by 2030.