Parental Refusal of Immunoprophylaxis for Infants of Hepatitis B Virus-Infected Mothers

Background:
Infants of hepatitis B virus (HBV)-infected mothers are at risk for HBV infection; untreated infants of HBeAg-positive mothers have a 70%-90% risk of infection. Treatment with hepatitis B immune globulin (HBIG) and HBV vaccine <12-24 hours of birth, followed by completion of the vaccine series is 85%-95% effective in preventing infection. Susceptible children not infected at birth remain at risk from contact with their infected mothers; in one study 38% became infected by age four years.

Setting:
California.

Population:
Infants of HBV-infected mothers; approximately 3000 HBV-infected pregnant women identified each year.

Project Description:
In 2008, the California Department of Public Health (CDPH) was notified of three infants of HBV-infected mothers whose parents refused HBV immunoprophylaxis. CDPH worked with local health departments (LHDs) and county child protective services (CPS) in an attempt to obtain treatment for these infants.

Results/Lessons Learned:
Delays occurred in reporting untreated infants to LHDs; HBIG was no longer indicated when notification occurred. LHDs counseled parents about rationale for treatment; refusals were based on rejection of vaccines. One infant received vaccine after CPS informed the parents that a court order would be sought. CPS in two other counties determined that the infants were not at risk of “imminent harm” and declined to take action. CDPH sought legal assistance from CDC and Children's Healthcare Is a Legal Duty. No state appellate or federal court has addressed legal custody of infants whose parents refuse consent for HBV prophylaxis. Under California law, an untreated infant born to an HBV-infected mother is a neglected child; “imminent risk of harm” is not specified in the definition of neglect. Healthcare providers should report untreated infants to LHDs immediately. When other interventions fail, CPS should seek court orders for untreated infants. CPS agencies may need education about the risk of harm to untreated infants.