Discussion
It is very important to screen pregnant females for Hepatitis B infection on the first perinatal visit 12. In any healthcare system, priorities, screening requirements and medical procedures are governed by a clear, published protocol by the health governing official bodies, mainly the Ministry of Health. Although (97.2%) of practitioners in Jordan agreed on the importance of counseling and screening the pregnant females on HBV, knowledge among them was limited.
More than half of the surveyed practitioners were not aware of the presence of the obligatory protocol for Hepatitis B screening in Jordan. Only 55% offered screening for Hepatitis B on the first perinatal visit during their daily practice. This is most likely due to lack of awareness and knowledge of the practitioners on the importance of Hepatitis B screening. Also, the unclear policies of practice that are followed in the healthcare facilities may contribute to such result.
It has been reported that healthcare workers at the Jordanian hospitals do not have enough trainings, nor a clear protocol on how to deal with infectious diseases including Hepatitis B 13. In Jordan the vaccination against Hepatitis B has been mandatory for all newborns since 1995 3. This fact may also have allowed the practitioners to ignore the screening of females who were born before 1995, assuming that there is no need to do the tests. However, a large proportion of those females are still in the childbearing age. Another reason could be the lack of practitioners adherence to the protocols and safety precautions, although they would have known about them 14.
This study identified a clear association between the specialty of the practitioner and offering the screening for Hepatitis B (p=0.002). In addition, there was a clear association between the years of practice of the practitioner and the screening rates of pregnant females on Hepatitis B in daily practice (p=.044). Most of the surveyed specialists screen pregnant females for Hepatitis B on their first perinatal visit in contrary to practicing residents. This result may be attributed to the fact that practicing specialists have more years in practice and experience compared to practicing residents, resulting in higher screening rates. As well as the association between the type of health facility and the level of specialty (p=0.007) adds to this result; most of the practicing specialists work in private hospitals, where most of their patients are in a better educational and financial state compared to public hospitals’ patients. Most of these patients are willing to have the HBV test performed regardless of the cost barrier. All of the above contributes to have higher screening rates in private hospitals compared to public hospitals. Interestingly an earlier study in Italy observed similar results; it was reported that the risk of not screening the pregnant women for Hepatitis B was also found to be higher in public hospitals compared to private hospitals 15.
The maternal viral load plays a crucial role in determining the vertical transmission rate to infants 16,17. High viral loads of >108 IU/mL were associated with higher risk of transmission, as well as with higher probability of failure to prophylactic immunization 16,18,19. Thus, the 2018 American Association for the Study of Liver Diseases (AASLD) guidelines recommends antiviral therapy for pregnant women with HBV DNA level >200,000 IU/mL. The AASLD guidelines recommends tenofovir as one of the preferred antiviral medications due to its safety and lack of resistance concerns 20. It is reported that receiving antiviral therapy on the third trimester of pregnancy reduces the risk of mother-to-child transmission (MTCT) massively21. According to the results there was a significant difference between the type of healthcare facility and the recommendation of antiviral therapy to third trimester pregnant females with high viral loads (>1 million copies/mL or 200,000 IU/mL). More than half of the public hospitals’ practitioners (58.3%) agreed on giving antiviral agents when needed in contrary to private hospitals practitioners (34%). This may be due to the fact that practitioners in public hospitals are mostly residents who are still training and continuously being reminded and updated on the protocols of treatment, in contrary to specialists who mostly practice in their private gynecological clinics in private hospitals.
Data regarding the safety of taking antiviral therapies during pregnancy or breastfeeding has not been reported yet, as there are insufficient long term safety studies on infants 20. The AASLD (2018) guidelines reported that breastfeeding is not contraindicated during therapy because the excreted levels of antiviral agents in breast milk are insignificant 20. Adding on, numerous studies have been reporting the same findings on low levels of antiviral agents in breast milk 22. As long as there is immunization and vaccination programs followed, it is reported to have no risk of Hepatitis B transmission to breast fed infants 23. According to our results, this has been confirmed by most of the surveyed practitioners, as 71% of them approved breast feeding for carrier mothers and 70% recommended Hepatitis B immunoglobulin (HBIG) injection at the birth for newborns of HBsAg carrier mothers.
The mode of delivery has not been proved to affect the risk of Hepatitis B transmission to the infant 20. The AASLD (2018) guidelines do not recommend a C-section to be performed to the pregnant females as there is no clear benefit found compared to other modes of delivery 20. A previous research study reported that there is no significant effect for rupture of membranes and labor on vertical transmission of Hepatitis B 24. In agreement, 62.6% of our surveyed participants did not recommend a C-section for HBV pregnant females.