Improving referral of women with chronic hepatitis B from antenatal services to a specialist hepatitis clinic – the Northern Ireland experience 2004-2014
Leanne Stratton1, Annelies McCurley2, Ruth Campbell2, Neil McDougall1
1Regional Liver Unit, Royal Victoria Hospital, Belfast. 2The Northern Ireland Regional Hepatitis B&C Managed Clinical Network, Belfast.
Antenatal screening for hepatitis B virus (HBV) has been recommended for all pregnancies in the UK since 1998. NICE guidelines published in 2013 now recommend the use of oral tenofovir in the third trimester of pregnancy to women with viral loads >107 in order to reduce the rate of vertical transmission.
Previous work in Northern Ireland (NI) showed a poor rate of follow-up at a specialist hepatitis clinic1 and in 2011 a new referral form and pathway were introduced to improve detection of cases and management of HBV in pregnancy. The aim was to re-audit this group to see whether the rate of review had improved, with the ultimate aim of providing timely and appropriate treatment to women in pregnancy, dependent on viral loads.
Data from NI maternity services, the Regional Virology Laboratory, and the NI Hepatitis B&C Clinical Network, were reviewed from 2004-2014 to identify all hepatitis B surface antigen (HBsAg) positive pregnant women. Data to 2010 were analysed retrospectively, and gathered prospectively from 2011 with the introduction of the new pathway. A record was kept of all clinic appointments offered to this group, and where possible, reason for non-attendance listed. Data were gathered on stage of pregnancy at first review, HBV DNA levels and ethnicity. All patients with HBV DNA >107 were considered for treatment with oral tenofovir.
Table 1 shows the number of HBsAg positive women detected and referred during pregnancy each year. Until 2010, the rate of referral to a specialist hepatology clinic was less than 60%. Following the introduction of the pathway this soon increased to greater than 90%. Review of ethnicity data for 2014 showed patients to be predominantly South-East Asian (41%) and Eastern European (50%). This is similar to previous years.
Detection and follow-up of HBsAg positive pregnant women has improved dramatically with the introduction of a new referral pathway in 2010. Major challenges include timely referral, to allow for consideration of oral tenofovir, and also language and cultural barriers, given that the majority of these patients do not speak English as their first language.