Please see the MDPH Recommendations and Resources for the Control of Influenza and Pneumococcal Disease, 2017-2018.  Like previous years, the advisory has a section added which includes the latest recommendations for use of PCV13 followed by PPSV23 in those >65 years of age. 

This year there are no major changes to the Advisory Committee on Immunization Practices (ACIP) Recommendations for Influenza Vaccine for the 2017-2018 season. You may find the Summary of the ACIP Influenza Recommendationshelpful as well.  Guidelines related to management of those with egg allergy are unchanged from last year.  In addition, live attenuated influenza vaccine (LAIV) is not recommended for the 2017-2018 season.

We have received a number of questions from providers concerning the correct dose volume of FluLaval Quadrivalent (IIV4), which is approved for use in children aged 6 months through 35 months as a 0.5 mL intramuscular dose.  This is the correct dose volume for this age group for this product.  See the table below for more information.

Take Care to Use Correct Volume for Dose in Children

·         For any dose needed, children aged 6 through 35 months may receive either:

o   0.5 mL FluLaval Quadrivalent (IIV4) intramuscularly, or

o   0.25 mL Fluzone Quadrivalent (IIV4) intramuscularly.

o   Note that dose volume differs for these two brands. Care should be taken to administer the correct dose.

·         Children aged 3 through 17 years may receive 0.5 mL intramuscularly of an age-appropriate IIV formulation.

Please note:  Children 6 months through 8 years who are receiving influenza vaccine for the 1st time or who have had a total of only 1 dose of influenza vaccine in any previous seasons will need 2 doses separated by >4 weeks.  For those children who need 2 doses this season, the 2 doses do not need to be the same product.

The MDPH Flu website at www.mass.gov/flu has information for providers and the general public. Click on 'Information for Healthcare Professionals' for provider resources such as clinical advisories and control guidance, model standing orders, screening forms and planning clinics and campaigns. Pneumococcal vaccine guidance is also located here.

We hope you find these resources helpful.

The influenza VIS is no longer updated each year, unless needed. The current flu VIS posted on the CDC website is the one you can use for this upcoming flu season. If you need VISs in other languages, please visit the http://www.immunize.org/vis/vis_flu_inactive.asp

For questions about state supplied flu vaccine availability and ordering, please contact the Vaccine Management Unit at 617-983-6828. For questions about flu vaccine recommendations, please call the Immunization Program at 617-983-6800 and ask to speak to an immunization epidemiologist.

Here is the Immunization Program Newsletter Spring-Summer 2017.


If you have any questions about the contents of the newsletter, please contact the following numbers:

  • Vaccine availability, ordering or storage and handling: Vaccine Management Unit - 617-983-6828
  • MIIS related information: MIIS Help Desk - 617-983-4335
  • Immunization schedules and recommendations, VPD disease morbidity, or other immunization related information:Immunization Program Main Number- 617-983-6800

This year the Advisory Committee on Immunization Practices (ACIP) is publishing its recommendations regarding influenza vaccine in 3 separate documents.  Below you will find the respective links:

·         2017-2018 ACIP influenza recommendations:  CDC. Prevention and Control of Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP) - United States, 2017-18 Season. MMWR 2017; 66(RR-2):1-20. https://www.cdc.gov/mmwr/volumes/66/rr/pdfs/rr6602.pdf

  • See pages 5 and 6 for the primary changes and updates, which are not extensive this year.  Please note that live attenuated influenza vaccine (LAIV) should not be used during the 2017-2018 influenza season.

·         A summary of this year’s recommendations:  CDC. Prevention and Control of Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization (ACIP) – United States, 2017-2018, Summary of Recommendations.  Available at: https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/downloads/ACIP-recs-2017-18-summary.pdf

  • This 4 page ‘Job Aid’ is a new document that contains all the critical recommendations, tables and flow charts.

·         And a background document for this year’s recommendations: Background Document for “Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices—United States, 2017-18 Influenza Season.”  Available at https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/downloads/ACIP-recs-2017-18-bkgd.pdf

  • This is also a new document that contains all of the background information, data and studies which informed the ACIP deliberations when making their recommendations about the use of influenza vaccine.

We have received a number of questions from providers concerning the correct dose volume of FluLaval Quadrivalent (IIV4), which is approved for use in children aged 6 months through 35 months as a 0.5mL intramuscular dose.  This is the correct dose volume for this age group for this product.  See the table below for more information.
 

Take Care to Use Correct Volume for Dose in Children

·         For any dose needed, children aged 6 through 35 months may receive either:

  • 0.5mL FluLaval Quadrivalent (IIV4) intramuscularly, or
  • 0.25mL Fluzone Quadrivalent (IIV4) intramuscularly.
  • Note that dose volume differs for these two brands. Care should be taken to administer the correct dose.

·         Children aged 3 through 17 years may receive 0.5 mL intramuscularly of an age-appropriate IIV formulation.

Please note:  Children 6 months through 8 years who are receiving influenza vaccine for the 1st time or who have had a total of only 1 dose of influenza vaccine in any previous seasons will need 2 doses separated by >4 weeks.  For those children who need 2 doses this season, the 2 doses do not need to be the same product.

We will circulate our updated guidance for healthcare providers, guidance for long-term care, and model standing orders soon. 

The influenza VIS is no longer updated each year, unless needed.  The current flu VIS posted on the CDC website is the one you can use for this upcoming flu season.  If you need VISs in other languages, please visit the http://www.immunize.org/vis/vis_flu_inactive.asp.

 

For questions about state supplied flu vaccine availability and ordering, please contact the Vaccine Management Unit at 617-983-6828.

For questions about flu vaccine recommendations, please call the Immunization Program at 617-983-6800 and ask to speak to an immunization epidemiologist. 

 

The Centers for Disease Control and Prevention (CDC) and U.S. Food & Drug Administration (FDA) recently announced VAERS 2.0 (Vaccine Adverse Event Reporting System 2.0), the national adverse event reporting system for monitoring the safety of U.S.-licensed vaccines (https://vaers.hhs.gov/). VAERS 2.0 includes a new reporting form and a new website that allows users to:

  • Easily submit a VAERS report electronically
  • Access VAERS data
  • Learn more about how CDC and FDA monitor the safety of vaccines

Additionally, there are now two ways to report an adverse event following vaccination to VAERS:

  1. Use the online reporting tool
  2. Complete a writable VAERS PDF form and upload it onto the new VAERS website

By the end of 2017, CDC and FDA will phase out the old VAERS-1 paper form and fully transition to the new VAERS 2.0 electronic submission process. Accommodations will be made for persons unable to submit reports electronically. Additional assistance is available via email at info@vaers.org or by phone at 1-800-822-7967.

If you have any questions or concerns, please feel free to contact the Immunization Program at 617-983-6800.

Monthly Update – July 2017

The National HPV Vaccination Roundtable has created a social media campaign to promote HPV vaccination during August 2017, National Immunization Awareness Month (NIAM). We are hosting a brief Communicators Showcase on Tuesday, July 25th at 12 p.m. ET to unveil these resources. Attendees will be able to ask questions, request technical assistance, and immediately have access to all the resources. Registration is required.

Click Here to Register

**Hot Shots** 

HPV Vaccine Champions Award

The Centers for Disease Control and Prevention, Association of American Cancer Institutes, and American Cancer Society—leaders in HPV cancer prevention—have partnered to establish an HPV Vaccination Champion Award to reinforce that HPV Vaccine is Cancer Prevention and recognize HPV vaccination champions. Nominate clinicians, clinics, practices, groups, or health systems effectively working to protect their adolescent patients against HPV cancers by achieving high HPV vaccination rates among their young adolescent patients.

Nomination packets must be sent to PreteenVaccines@cdc.gov on or before September 1, 2017.

You can submit your nominations directly to CDC, by visiting https://www.cdc.gov/hpv/champions/submit-nominee.html

HPV Roundtable Resources

The HPV Vaccination Roundtable has developed a “We’re In!”  Facebook profile picture frame. Facebook picture frames are a way people can show support for a cause they believe in, in this case – HPV vaccination as cancer prevention! Visit https://www.facebook.com/profilepicframes and search for ‘HPV’ to find it and use it.  

 In Case You Missed It

Area Health Education Center Network offers archived webinars on HPV vaccination, including one on HPV hesitancy and myths; free CE/CEU credit available

The Scenic Rivers Area Health Education Center Network has several webinars about HPV archived on its website, including a June offering titled "Addressing HPV Vaccine Hesitancy and Myths." Free continuing education credit (CE/CME) is available for completing archived events. 

Access the archived webinar page on the Scenic Rivers Area Health Education Center Network website.
 

HPV Vaccination Partner Resources and Shareables

August is National Immunization Awareness Month; 2017 communications toolkit available

Every year in August, National Immunization Awareness Month (NIAM) provides an opportunity to raise awareness of the importance of immunization and the need for improving national vaccination coverage levels. NIAM is sponsored by the National Public Health Information Coalition (NPHIC). The 2017 edition of the communications toolkit, put out by NPHIC in collaboration with CDC, contains key messages, vaccine information, sample news releases and articles, sample social media messages, links to web resources from CDC and other organizations, and logos, web banners, posters, and graphics to use with social media. The website also includes a place for you to share your NIAM activities and view what others are doing for NIAM, using the hashtag #NIAM17.

The observance features a different group each week of August: 

  • July 31–August 6—Babies and Young Children: A healthy start begins with on-time vaccinations
  • August 7–13—Pregnant Women: Protect yourself and pass protection on to your baby
  • August 14–20—Adults: Vaccines are not just for kids
  • August 21–27—Preteens/teens: Ensure a healthy future with vaccines

You can access the toolkit here: National Immunization Awareness Month Communication Toolkits

 2017 American Academy of Pediatrics HPV Vaccination Update: Free CME/CNE Available 

The 2017 HPV Vaccination Update one-hour webinar features a panel of experts in pediatric primary care, infectious diseases, obstetrics and gynecology and ear, nose and throat who cover the latest trends in HPV disease prevalence and prevention, tools to help office staff with questions about HPV vaccine timing and scheduling, vaccine safety and effectiveness, evidence-based techniques for increasing HPV vaccination rates and answers to commonly asked questions from parents. The webinar informs providers on how to word a strong recommendation, frame the HPV vaccine as cancer-preventing and frame the vaccine as part of the routine adolescent vaccination schedule. Free continuing education credit is available through the Boston University School of Medicine.

You can access the webinar here: http://bucme.org/node/1018

A report in MMWR on 7-7-17, High Risk for Invasive Meningococcal Disease Among Patients Receiving Eculizumab (Soliris) Despite Receipt of Meningococcal Vaccine, suggests that patients receiving eculizumab (Soliris®) are at high risk for meningococcal disease despite vaccination. Please share this information with partners.

Healthcare providers:

  • Could consider antimicrobial prophylaxis for the duration of eculizumab therapy to potentially reduce the risk of meningococcal disease
  • Should continue immunizing patients with meningococcal vaccines who receive eculizumab
  • Should maintain a high index of suspicion for meningococcal disease in patients taking eculizumab who present with any symptoms consistent with either meningitis or meningococcemia, even if the patient’s symptoms initially appear mild, and irrespective of the patient’s meningococcal vaccine or antimicrobial prophylaxis status

Eculizumab, a terminal complement inhibitor, is most commonly prescribed for treatment of two rare blood disorders: atypical hemolytic uremic syndrome (aHUS) and paroxysmal nocturnal hemoglobinuria (PNH). It is associated with a 1000 to 2000 fold increased incidence of meningococcal disease. Sixteen cases of meningococcal disease in eculizumab recipients were identified in the United States from 2008 through 2016; eleven (69%) were caused by nongroupable Neisseria meningitidis. Nongroupable N. meningitidis typically does not cause invasive meningococcal disease.  

Meningococcal conjugate vaccine targets serogroups A, C, W, and Y, and provides no protection against nongroupable N. meningitidis. Serogroup B meningococcal vaccines are licensed specifically for protection against serogroup B meningococcal disease. Researchers have not assessed the extent of any potential cross protection for nongroupable N. meningitidis strains.
 

For More Information:

For Clinicians: Managing the Risk of Meningococcal Disease among Patients Who Receive Eculizumab Therapy

For Patients: Taking Eculizumab (Soliris®) Increases Your Risk for Meningococcal Disease

CDC Health Advisory: Patients Receiving Eculizumab (Soliris®) at High Risk for Invasive Meningococcal Disease Despite Vaccination

Signs and Symptoms of Meningococcal Disease

Soliris® (Eculizumab) Product Label

Atypical Hemolytic Uremic Syndrome (aHUS)

Paroxysmal Nocturnal Hemoglobinuria (PNH)

Child and Adolescent Indications Schedule: Vaccines That Might Be Indicated for Persons Aged 0 through 18 Years Based On Medical Indications

Adult Immunization Schedule by Medical and Other Indications: Recommended Immunization Schedule for Adults Aged 19 Years or Older by Medical Conditions and Other Indications, United States, 2017

CDC has released a new on-line Vaccine Administration course at https://www2.cdc.gov/vaccines/ed/vaxadmin/va/ce.asp.

It is also available on the Continuing Education web page at https://www.cdc.gov/vaccines/ed/courses.html#elearn-vaccadmin. The e-Learn is a free, interactive, online educational program that serves as a useful introductory course or a great refresher on vaccine administration.  

Proper vaccine administration is critical for ensuring that vaccines are both safe and effective. Vaccine administration errors happen more often than you might think. Of the average 36,000 reports received annually by the Vaccine Adverse Event Reporting System (VAERS), about 1,500 are directly related to administration error. 

Some of the most common vaccination administration errors include:

·         Not following the recommended immunization schedule

·         Administering improperly stored or expired vaccine and/or diluent

·         Administering the wrong vaccine—confusing look-alike or sound-alike vaccines such as DTaP/Tdap or administering products outside age indications

The self-paced e-Learn provides comprehensive training, usingvideos, job aids, and other resources to accommodate a variety of learning styles, and offers a certificate of completion and/or Continuing Education (CE) for those that complete the training.

We encourage you to share information on the Vaccine Administration e-Learn with your members and health care professional community.

If you have any questions or would like more information, please contact nipinfo@cdc.gov. You can also address questions about immunization to the MDPH Immunization Program at 617-983-6800 and ask to speak to an immunization epidemiologist or nurse.

CDC has released the General Best Practice Guidelines for Immunization as an online report, and it is available on the Advisory Committee on Immunization Practices (ACIP) web page (https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/index.html). The General Best Practice Guidelines for Immunization replace the General Recommendations on Immunization, last published in the Morbidity and Mortality Weekly Report (MMWR) in 2011.

The General Best Practice Guidelines for Immunization goes beyond vaccination recommendations to give providers guidelines on vaccination practice. The document will help vaccination providers to assess vaccine benefits and risks, use recommended administration practices, understand the most effective strategies for ensuring that vaccination coverage in the population remains high, and communicate the importance of vaccination to reduce the effects of vaccine-preventable disease.

By releasing the General Best Practice Guidelines for Immunization as an online report, ACIP will be able to update the document more quickly, giving vaccination providers the most up-to-date guidance on vaccination practice. 

We encourage you to share General Best Practice Guidelines for Immunization with your partners and health care professionals. Attached is a sample announcement you can modify to post online or share through a newsletter, as well as sample tweets.

The updated guidelines include:

1.       Confirmation that if a patient is not acutely, moderately, or severely ill, vaccination during hospitalization is a best practice;

2.       New information on simultaneous vaccination and febrile seizures;

3.       Enhancement of the definition of “precaution” to include any condition that might confuse diagnostic accuracy;

4.        More descriptive characterization of anaphylactic allergy;

5.       Incorporation of protocols for management of anaphylactic allergy;

6.        Allowances for alternate route (subcutaneous instead of intramuscular) for hepatitis A vaccination;

7.        An age cutoff of 12 years through 17 years for validating a dose of intradermal influenza vaccine;

8.       Deletion of much of the storage and handling content, including information on storage units, temperature monitoring, and expiration dates (this content is now contained and continually updated in CDC’s Vaccine Storage and Handling Toolkit, available at https://www.cdc.gov/vaccines/hcp/admin/storage/toolkit/index.html);

9.        Incorporation of the Infectious Diseases Society of America guidance on vaccination of persons with altered immunocompetence;

10.    Timing of intramuscular administration in patients with bleeding disorders;

11.   Updated data on vaccination record policy;

12.   Additional impacts of the Affordable Care Act on adult vaccination; and

13.    Updated programmatic contact information on source material for vaccine information.

Continuing education (CE) credit is available for the General Best Practice Guidelines for Immunization.

To receive updates on this and other ACIP recommendations and guidelines, sign up at https://www.cdc.gov/vaccines/hcp/acip-recs/index.html.


If you have questions regarding immunization practice, please send them to NIPinfo@cdc.gov. As always, if you have questions about immunizations please call the MDPH Immunization Program at 617-983-6800 and ask to speak to an immunization epidemiologist.

The quarterly reports are intended to facilitate collaboration between awardees and partners to help increase HPV vaccination coverage. This quarter’s report focuses on establishing partnerships to increase rates and highlights CDC’s HPV Partner Vaccination Toolkit.

You are receiving a copy of your city or state report.  The report has been distributed to you, yourstate or city health official, and executive directors or presidents of your local AAP and AAFP chapters. 

If you have any questions regarding this report, please contact your project officer. If you would like more information on HPV resources and materials, feel free to contact us at preteenvaccines@cdc.gov and CC your project officer.

We hope this report can serve as a tool for engaging stakeholders and continue conversations about raising HPV vaccination coverage rates. We appreciate your ongoing commitment to increasing HPV vaccination coverage. 


Massachusetts HPV Report

The 2017 Immunization Schedule for those 19 years and older has been published.  The changes in the schedule are discussed in the MMWR from February 10, 2017 (attachment 1) and are outlined below.  The MMWR can be found at: https://www.cdc.gov/mmwr/volumes/66/wr/pdfs/mm6605e2.pdf

The figures, footnotes, and tables of the schedule (attachment 2) are published on the CDC immunization schedule website at:  http://www.cdc.gov/vaccines/schedules/index.html. This provides readers electronic access to the most current version of the schedules and footnotes on the CDC website.

 Changes to the 2017 immunization schedule for adults 19 years of age and older are outlined below (significant ones are highlighted):

Influenza

·         Live Attenuated Intranasal Influenza Vaccine (LAIV) should not be used during the 2016–2017 influenza season. 

·         Adults with a history of egg allergy who have only hives after exposure to egg should receive age-appropriate inactivated influenza vaccine (IIV) or recombinant influenza vaccine (RIV).

·         Adults with a history of egg allergy with symptoms other than hives (e.g., angioedema, respiratory distress, lightheadedness, or recurrent emesis, or who required epinephrine or another emergency medical intervention) may receive age-appropriate IIV or RIV. The selected vaccine should be administered in an inpatient or outpatient medical setting and supervised by a health care provider who is able to recognize and manage severe allergic conditions.

 Hepatitis B (Hep B) Vaccine

·         Adults with chronic liver disease, including, but not limited to, hepatitis C virus infection, cirrhosis, fatty liver disease, alcoholic liver disease, autoimmune hepatitis, and an alanine aminotransferase (ALT) or aspartate aminotransferase (AST) level greater than twice the upper limit of normal should receive a HepB series.

Human papillomavirus (HPV) Vaccine

·         Adult females through age 26 years and adult males through age 21 years who have not received any HPV vaccine should receive a 3-dose series of HPV vaccine at 0, 1–2, and 6 months. Males aged 22 through 26 years may be vaccinated with a 3-dose series of HPV vaccine at 0, 1–2, and 6 months.

·         The number of doses of HPV vaccine a person needs is determined by their age when they initiated the series and whether they have certain high risk conditions.

o  Adult females through age 26 years and adult males through age 21 years (and males aged 22 through 26 years who may receive HPV vaccine) who initiated HPV vaccination series before their 15th birthday and received 2 doses at least 5 months apart are considered adequately vaccinated and do not need an additional dose of HPV vaccine.

o  Adult females through age 26 years and adult males through age 21 years (and males aged 22 through 26 years who may receive HPV vaccine) who initiated HPV vaccination series before their 15th birthday and received only 1 dose, or 2 doses less than 5 months apart, are not considered adequately vaccinated and should receive 1 additional dose of HPV vaccine.

o  Certain immunocompromising conditions might reduce cell-mediated or humoral immunity and immune response to vaccine might be attenuated.  A 3-dose HPV series is indicated for individuals in these groups (regardless of age).   Such conditions include: B lymphocyte antibody deficiencies, complete or partial T lymphocyte defects, HIV infection, malignant neoplasm, transplantation, autoimmune disease or immunosuppressive therapy.

Meningococcal Vaccines

High Risk Adults

·         Adults with anatomical or functional asplenia or persistent complement component deficiencies should receive a 2-dose primary series of MenACWY, with doses administered at least 2 months apart, and revaccinate every 5 years. They should also receive a series of MenB with either Bexsero (MenB-4C) (2 doses administered at least 1 month apart) or Trumenba (MenB-FHbp) (3 doses administered at 0, 1–2, and 6 months). 

o    Please note: high risk adults, including those exposed during outbreaks, who will be receiving Trumenba should be vaccinated with the 3-dose series.  Healthy adults not at increased risk for risk for serogroup B meningococcal disease may receive a 2-dose series of either Trumenba or Bexsero.  See, the first bullet in the section below under ‘Healthy Young Adults’ for more guidance.

·         Adults withHIV infection who have not been previously vaccinated should receive a 2-dose primary MenACWY vaccination series, with doses administered at least 2 months apart, and be revaccinated every 5 years. Those who previously received 1 dose of MenACWY should receive a second dose at least 2 months after the first dose. MenB is not routinely recommended for adults with HIV infection, because meningococcal disease in this population is caused primarily by serogroups C, W, and Y.

·         Microbiologists who are routinely exposed to isolates of Neisseria meningitidis should receive 1 dose of MenACWY and be revaccinated every 5 years if the risk for infection remains, as well as either MenB-4C (2 doses administered at least 1 month apart) or MenB-FHbp (3 doses administered at 0, 1–2, and 6 months).

·         Adults at risk because of a meningococcal disease outbreak should receive 1 dose of MenACWY if the outbreak is attributable to serogroup A, C, W, or Y; or, if the outbreak is attributable to serogroup B, either MenB-4C (2 doses administered at least 1 month apart) or MenB-FHbp (3 doses administered at 0, 1–2, and 6 months).

·         Meningococcal Polysaccharide Quadrivalent Vaccine(MPSV4), Menomune, will no longer be available in the US.  The last doses of this vaccine to will expire between June and September.  Adults >56 years at increased risk for meningococcal disease should be vaccinated with MenACWY conjugate vaccine (MCV4).

Healthy Young Adults

·         Healthy young adults aged 16 through 23 years (preferred age range is 16 through 18 years) who are not at increased risk for serogroup B meningococcal disease may receive either a 2-dose series of MenB-4C at least 1 month apart or a 2-dose series of MenB-FHbp at 0 and 6 months for short-term protection against most strains of serogroup B meningococcal disease.  Please note: high risk adults, including those exposed during outbreaks, receiving Trumenba should be vaccinated with the 3 dose series. See the first bullet and sub-bullet in the section above under ‘High Risk Adults' for more guidance about the series in these groups.

The 2017 Adult Immunization Schedule was also published on February 7, 2017 in the Annals of Internal Medicine and can be found at:

http://annals.org/aim/article/2601209/recommended-immunization-schedule-adults-aged-19-years-older-united-states

 Immunization coverage rates among adults remain unacceptably low.  The latest data can be found on the CDC website:  www.cdc.gov/vaccines/imz-managers/coverage/adultvaxview/.

Please make sure you are assessing adults at every clinical encounter and making a strong recommendation for immunization!  More information about evidence-based strategies to improve adult immunization rates can be found at:

https://www.cdc.gov/vaccines/hcp/adults/for-practice/standards/

 Join us at the 22nd Annual Massachusetts Adult Immunization Conference on Tuesday, April 25, 2017 if you are interested in learning more about adult immunizations, including recent changes to the immunization schedule, evidence-based strategies to improve adult immunization rates, and networking opportunities to build and maintain partnerships. Find out more by visiting the conference website.   

If you have questions about the immunization schedule, please call the MDPH Immunization Program at 617-983-6800 and ask to speak to an immunization epidemiologist or nurse.

2017 US Adult Combined Schedule CDC

Thank you.

Perinatal hepatitis B virus (HBV) transmission from mother to child has been dramatically reduced in Massachusetts, as a result of your efforts. However, despite timely post-exposure prophylaxis, mother-to-child HBV transmission still occurs in approximately 1% of infants born to hepatitis B surface antigen (HBsAg)-positive mothers.

Emerging evidence suggests that HBV treatment of pregnant women in the 3rd trimester is safe and reduces rates of transmission. In partnership with the American College of Obstetricians and Gynecologists (ACOG), CDC developed a Screening and Referral Algorithm for Hepatitis B Virus Infection among Pregnant Women (attachment). It is now recommended that all women who are found to be HBsAg-positive during pregnancy should have the following additional testing performed:
· HBeAg (hepatitis B e antigen)
· HBV DNA (viral load)
· ALT (alanine aminotransferase)

If any of the following results are obtained, pregnant women should be referred to a specialist immediately for further evaluation and consideration for possibleantiviral treatment:
HBeAg postive; or
HBV DNA >20,000 IU/mL (approximately 112,000 viral copies per mL); or
ALT > 19 IU/L

Providers of prenatal care should ensure that certain positive laboratory reports of hepatitis B infection (HBsAg, HBeAg, IgM anti-HBc and HBV DNA testing) in pregnant women are reported to the local board of health and the Massachusetts Department of Public Health (MDPH). In addition, providers should work with their laboratories to ensure that these postive results indicating hepatitis B infection in this group are also reported to the Massachusetts Department of Health within 24 hours.

In an effort to aid in the early identification of pregnant women with hepatitis B virus infection, four major commercial laboratories (ARUP Laboratories, LabCorp, Mayo Medical Laboratories and Quest Diagnostics) are now reporting pregnancy status as part of electronic laboratory reporting. Additional commercial and clinical laboratories are encouraged to participate in this initiative. To support this effort, it is recommended that providers order prenatal testing panels or prenatal HBsAg testing when available. Providers should also consult with their laboratory to determine the best method to indicate pregnancy status when ordering hepatitis B testing (e.g., "OB", "PRENATAL", ICD-10 code, etc.).

Thank you for your continued efforts to reduce the spread of HBV infection. We will be incorporating these new considerations into our MDPH perinatal hepatitis B prevention program. If you have any questions, please call the MDPH Immunization Program at 617-983-6800 and ask to speak to an immunization nurse or epidemiologist.

Resources for managing HBV infection in pregnant women can be found on the ACOG and CDC websites. For the latest recommendations for treatment of chronic HBV infection in pregnant women, see pages 276 and 277 in the American Association for the Study of Liver Diseases Guidelines for Treatment of Chronic Hepatitis (attachment).

References
Terrault, NA, et.al. AASLD guidelines for treatment of chronic hepatitis B. Hepatology 2016.
http://onlinelibrary.wiley.com/doi/10.1002/hep.28156/epdf
Brown, RS et.al. Antiviral therapy in chronic HBV infection: a systematic review and meta-analysis. Hepatology 2016.
http://onlinelibrary.wiley.com/doi/10.1002/hep.28302/epdf
Fan L., et al. Antiviral treatment among pregnant women with chronic hepatitis B. Infect Dis Obstet Gynecol 2014.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4274824/
Kubo A., et al. Prevention of vertical transmission of hepatitis B: an observational study. Ann Intern Med 2014.
http://annals.org/article.aspx?articleid=1876817&resultClick=1
Schille S., et al. Outcomes of infants born to women infected with hepatitis B. Pediatrics 2015.
http://pediatrics.aappublications.org/content/pediatrics/135/5/e1141.full.pdf
Wang L., et al. Safety of tenofovir during pregnancy for the mother and fetus: a systematic review. Clin Infect Dis 2013
http://cid.oxfordjournals.org/content/57/12/1773.full.pdf+html
Zhang H., et al. Telbivudine or lamivudine use in late pregnancy safely reduces perinatal transmission of hepatitis B virus in real-life practice. Hepatology 2014.
http://onlinelibrary.wiley.com/doi/10.1002/hep.27034/pdf