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.