Running head: HEALTH POLICY ANALYSIS: SENATE BILL 114

Health Policy Analysis: Senate Bill 114

Angela Long
Coppin State University
Helen Fuld School of Nursing
Masters in Nursing Family Nurse Practitioner Program
Health Systems Policy, Organizations, and Financing
Nurs 505
Dr. Nayna Philipsen, JD, RN
April 16, 2013
Health Policy Analysis: Senate Bill 114
Policy Problem
The state of Maryland is trying to address many healthcare initiatives for pregnant
women and innocent infants. One of the issues that pregnant women face is that not all medical
providers practice the same way. Do medical providers who practice in the city practice the
same as medical providers in rural areas? Do older medical providers practice the same way as
brand new young medical providers? Do medical providers order the same serological tests for
pregnant women without regards to age, sex, insurance or any insurance and race? The Centers

for Disease Control and the Department of Health and Mental Hygiene have issued guidelines in
2007 for serological testing for women who are pregnant. According to Frischknecht, Are the
guidelines set for serological testing in pregnancy followed and are the results on hand on
admission to the labor ward? (Frischknecht, Sell, Trummer, & Bruhwiler, 2011, p. 1). These
guidelines are not laws and are only recommendation that do not have to be followed.
Background
The CDC recommends that all pregnant women have a HIV screening as early as
possible and serologic syphilis, hepatitis B, chlamydia trachomatis and gonorrhea (Centers for
Disease Control and Prevention [CDC], 2010, p. 1).
Hepatitis B virus is a double stranded DNA virus from the Hepadnavirdae family that can
be found in the blood, saliva, semen, vaginal secretions and wound exudates ("Hepatitis B
Virus," 2013, p. 1). The virus incubation period is ninety days from time of exposure and signs
and symptoms may vary from six weeks to six months ("Hepatitis B Virus," 2013, p. 1). Some
examples of signs and symptoms are loss of appetite, nausea, vomiting, fevers, abdominal pain,
jaundice, dark urine and gray stool ("Hepatitis B Virus," 2013, p. 1). Hepatitis B can cause liver
failure and even death ("Hepatitis B Virus," 2013, p. 1). According to the CDC, hepatitis is the
leading cause of liver transplantation and liver cancer (CDC, 2010, p. 1).
The research that has been published states that neonates whose mother were HBeAg
positive during the perinatal period have a 90% chance of developing chronic HBV infection
(Aspinall, Hawkins, Fraiser, Hutchinson, & Goldberg, 2011, p. 533). Of those infants effected
15% to 25% have higher risk from dying in adulthood of cirrhoris or liver cancer (Vu Lam,
Gotsch, & Langan, 2010, p. 1225).

HEALTH POLICY ANALYSIS: SENATE BILL 114

The Maryland General Assembly 2013 session has induced a bill named Senate Bill 114.
This bill has previously been introduced in 2012 as Senate Bill 611 and had received a hearing in
the House Health and Government Operations Committee but no further actions were taken
(Senate Bill 114, 2013, p. 2). A bill has along legislative process it must go through in order to
become a law. The progress of a bill is that the sponsoring chamber must start with a first
reading then referral to committee and next a second reading and next a third reading. After the
passing of the bill from first chamber the bill moves on to the second chamber. The bill has the
first reading and then it is referred to committee and next has a second reading and then a third
reading for final passage. Next the bill is sent to the governor for signing. In 2013 Senators
Benson and Montgomery presented Senate Bill 114.
Senate Bill 114 is a bill that requires any medical provider attending to a women for
pregnancy to submit to a medical laboratory, a blood sample taken from the women when the
women first presents for examination and if the women has not had prenatal services or there is
no documentation of the womens hepatitis B status (Senate Bill 114, 2013, p. 1). Women may
object to the testing for religious beliefs and practices (Senate Bill 114, 2013, p. 1). The Bill also
states that the laboratory must perform a standard hepatitis B test that is approved by the
Department of Health and Mental Hygiene (Senate Bill 114, 2013, p. 1).

Stakeholders
The US Centers for Disease Control and Prevention has collected research from around
the world that supports the policy guidelines that it has suggested since 2007 for immediate
serological Hepatitis B testing for pregnant women (Senate Bill 114, 2013, p. 1).

HEALTH POLICY ANALYSIS: SENATE BILL 114

The Department of Health and Mental Hygiene supports the guidelines recommended by the
CDC (Senate Bill 114, 2013, p. 1). The U.S. Preventive Services Task Forces supports all
pregnant women being screened on their first visit along with The American Academy of Family
Physicians, The American College of Obstetricians and Gynecologists and the American
Academy of Pediatrics (Vu Lam et al., 2010, p. 1226).

Senator Benson and Montgomery

supported this health care bill (Senate Bill 114, 2013, p. 1).
Stakeholder Interests
No one opposed this bill; it was voted on third reading and received 47 yeas and 0 nays
on March 7 in the senate. Senate Bill 114 had its first and second hearings in the house which
were favorable, on March 13, 2013 hearings at the committee Education, Health and
Environmental Affairs.
Financial Considerations
The DHMH has advised that this testing is already a recommendation of standard of care
and will cause no increase in health care cost, already covered by Medicaid and will not affect
state finances or operations, no local effect, no small business effect (Senate Bill 114, 2013, p. 1)
The only potential harm of screening for HBV is false positives, which can lead to psychological
harms, increase cost of subsequent testing and unnecessary treatments (Lin & Vickery, 2009, p.
876). Currently there are no studies published against HBV testing (Lin & Vickery, 2009, p.
876).

Rationale for being on Agenda

HEALTH POLICY ANALYSIS: SENATE BILL 114

HBV is a major cause of morbidity and mortality worldwide, of which chronic HBV can
cause cirrhosis, hepatic decompensation and hepatocellular carcinoma and even death (Aspinall,
Hawkins, Fraiser, Hutchinson, & Goldberg, 2011, p. 1). The World Health Organization
estimated that two billion people have been infected with HBV and 350 million of those are
chronically infected and 65 million will die from liver disease (Aspinall, Hawkins, Fraiser,
Hutchinson, & Goldberg, 2011, p. 531). It is also noted to be the major cause for liver
transplants worldwide is HBV (Senate Bill 114, 2013, p. 2). The overall prelevance of HBV in
the united states is 4.9% (Vu Lam et al., 2010, p. 1226).
Transmission can occur vertically from mother to child, horizontally from child to child
within a household, sexually, or parenteral such as IV drug use, sharps injury or contaminated
blood products (Aspinall et al., 2011, p. 2). A high proportion of women that are infected with
blood borne infections such as HBV are in their child bearing years (Giles, Sasadeusz, Garland,
Grover, & Hellard, 2004, p. 328). HBV is primarily acquired by sexual contact in areas of low
prevalence by perinatal or in early childhood in areas of high prevalence (Aspinall et al., 2011, p.
532). In China, South East Asia, Africa, parts of South America and Alaska the prevalence for
HBV is high, and low prevalence areas include North America, Australia, Northern Europe and
most of Western Europe (Aspinall et al., 2011, p. 533).
In 2004 US preventive services task force recommended HBV screening for women on
the first prenatal visit that way positive woman could receive treatment and their infants could
receive prophylaxis treatment immediately following birth (Lin & Vickery, 2009, p. 874). Not
all medical providers practice the same way. The literature that is currently published states that
only 60% of medical providers offer testing for HBV and HIV as an option and this differs from
urban to rural areas.

Medical community continues to argue over the transmission of HBV via

HEALTH POLICY ANALYSIS: SENATE BILL 114

the breast milk and is another concern facing HBV positive mothers (Yogeswaran & Fung, 2011,
p. 6)
Proper management of hepatitis in the prenatal phase of pregnancy ensures better
outcomes for the neonate (Vu Lam et al., 2010, p. 1227). Positive pregnant women need to be
managed differently than those that are negative. Women who test positive need to be managed
medically and offered education and counseling on the HBV.

Policy goals/objectives
The goal of Senate Bill is to make sure that all pregnant women are treated the same. The
Senate Bill 114 is a bill that will make sure that all pregnant women get HBV testing early in
pregnancy so that infants can be treated and immunized immediately to prevent them from being
affected and potentially being given a death sentence at birth that is preventable in this day and
age. The research that is supported by the CDC indicates that the early a women can be
diagnosed the early she can begin treatment and the plans can be in place for the neonate.
Effectiveness of treatment depends on the full adherences of every medical provider, and that
protocols and recommendations are not always followed. But if this bill is made a law medical
providers will have no choice but to practice in a way that is most healthy for pregnant women
and society as a whole.

Criteria to meet objectives

All medical providers who treat women who are pregnant will be required to draw blood
for serological HBV testing on their first visit for treatment. The results of the testing will be

HEALTH POLICY ANALYSIS: SENATE BILL 114

made available for the hospital that the pregnant women plan to give birth in. The only women
that are exempt from this law are women who refuse for religious reasons.
If pregnant women are positive for HBV then she would be referred to a hematologist for
treatment while pregnant. Pregnant women that are positive for HBV should receive an antiviral
prophylaxis in their third trimester to preventing a breakthrough infection (Yogeswaran & Fung,
2011, p. 1).

When the infant is born hepatitis b immune globulin and hepatitis b vaccine

immediately after birth. (Hu, Zhang, Luo, & Zhou, 2012, p. 1).
The current recommendation for treatment of infants based on maternal status is simple.
If maternal testing is negative then hepatitis B vaccine should be given before discharge,
preferably within first twelve hours of life with the except that if infant is less than 4.6 lbs
postpone the first dose of vaccine until one month old (Vu Lam et al., 2010, p. 1228). If
maternal status is positive give hepatitis B immune globulin and hepatitis B vaccine within 12
hours of life and complete vaccine series within first six months of life (Vu Lam et al., 2010, p.
1228). Next obtain follow up serological testing at nine and eighteen months of life (Vu Lam et
al., 2010, p. 1228). If maternal status is unknown administer hepatitis b vaccine within twelve
hours of life and immediately test mother for HBV (Vu Lam et al., 2010, p. 1228).
Evaluation of options
The only two options for Senate Bill 114 are to pass this bill and make it a law or to let it
fail and linger around in the bill progress for another year. By not passing this bill, it allows
medical providers to continue to practice as they see fit, ignoring the recommendations of the
CDC. By not passing this bill countless numbers of neonates could fail to be treated properly
and could potentially lose their lives unnecessarily Hepatitis B is a virus that has treatments to

HEALTH POLICY ANALYSIS: SENATE BILL 114

prevent transmissions by vaccination and other medications to treat. Hepatitis B should not be a
death sentence but it can be without proper treatment for innocent neonates.

Solutions
The Senate Bill 114 needs to be passed by Maryland legisalation in 2013 so that
Maryland will continue to move forward with its health iniatives for a health future. All pregnant
women should receive the same treatment no matter race, age, or payment status. All medical
provider who take care of pregnant women should continue with learning all the current
recommendation made by the CDC and medical research. All neonates should be offered HBV
vaccines immediately after birth or as soon as possible.

References
Aspinall, E., Hawkins, G., Fraiser, A., Hutchinson, S., & Goldberg, D. (2011). Hepatitis B
prevention, diagnosis, treatment and care: a review. Occupational Medicine, 61(1), 531540. http://dx.doi.org/10.1093/occmed/kqr136
B Virus (herpes B, monkey B virus, herpes virus simiae, and herpes virus B). (2013). Retrieved
from http://www.cdc.gov/herpesbvirus/index.html

HEALTH POLICY ANALYSIS: SENATE BILL 114

Centers for Disease Control and Prevention. (2010). Sexually transmitted Diseases treatment
guidelines, 2010: special populations. Retrieved from
http://www.cdc.gov/std/treatment/2010/specialpop.htm
Centers for Disease Control and Prevention. (2013). Reported cases of acute, hepatitis b by
state-United States 2006-2010 [Table 3.1]. Retrieved from
http://www.cdc.gov/hepatitis/statistics/2010surveillance/table3.1.htm
Frischknecht, F., Sell, W., Trummer, I., & Bruhwiler, H. (2011, Janurary 6). Serological testing
for infectious diseases in pregnant women: are the guidelines followed? The European
Journal of Medical Science, 1-5. http://dx.doi.org/10.4414/smw.2011.13138
Giles, M., Garland, S., Grover, S., Lewin, S., & Hellard, M. (2006, April 16). Impact of an
education campaign on management in pregnancy of women infected with a blood-borne
virus. MJA, 184(8), 389-392. http://dx.doi.org/
Giles, M., Sasadeusz, J., Garland, S., Grover, S., & Hellard, M. (2004, April 4). An audit of
obstetricians management of women potentially infected with blood-borne virsues. MJA,
180(1), 328-332. http://dx.doi.org/
Global alert and response. (2013). Retrieved from
http://www.who.int/csr/disease/hepatitis/whocdscsrlyo20022/en/index4.html
Healthline Medical Team. (2013). Infections in pregnancy: hepatitis b. Retrieved from
http://www.healthline.com/health/pregnancy/infections-hepatitis-b
Hepatitis B Foundation. (2013). Hepatitis b guidelines for pregnant women. Retrieved from
www.hepb.org
Hu, Y., Zhang, S., Luo, C., & Zhou, Y. (2012). Gaps in the prevention of perinatal transmission
of hepatitis B virus between recommendations and routine practices in a highly endemic

HEALTH POLICY ANALYSIS: SENATE BILL 114

10

region: a provincial population-based study in China. Biomed Central, 1-7.

http://dx.doi.org/10.1186/1471-2334-12-221
Infections during pregnancy. (2013). Retrieved from
http://www.perinatology.com/exposures/infection/hepatitis b.html
Jury, E. (2002, September 13). EASL international consensus conference on hepatitis b. Journal
of Hepatology, 38(1), 533-540. http://dx.doi.org/10.1016/s0168-8278(03)00083-7
Lin, K., & Vickery, J. (2009, June 16). Screening for hepatitis B virus infection in pregnant
women: evidence for the U. S. preventive services task force reaffirmation
recommendation statement. Annals of Internal Medicine, 150(12), 874-876. Retrieved
from www.annals.org
McCance, K., Huether, S., Brashers, V., & Rote, N. (2010). Pathophysiology The Biologic Basis
for Disease in Adults and Children (6th ed.). Missouri: .
Senate Bill 114 [Press release]. (2013, March 22, 2013). Retrieved from
http://mgaleg.maryland.gov
Vu Lam, N., Gotsch, P., & Langan, R. (2010, November 15). Caring for pregnant women and
newborns with hepatitis b or c. American Family Physician, 15(82), 1225-1229.
Retrieved from http://www.aafp.org
Yogeswaran, K., & Fung, S. (2011, February 25). Chronic hepatitis B in pregancy: unique
challeges and opportunties. The Korean Journal of Hepatology, 17(1), 1-8.
http://dx.doi.org/10.3350/kjhep.2011.17.1.1