Editor—Hepatitis B continues to be a public health problem despite the existence, for the past decade, of a safe and effective vaccine. Particular concern exists for infants at risk of vertical transmission. The Department of Health recommends that all babies born to mothers who are hepatitis B carriers receive hepatitis B immunisation at birth, 1 month, 6 months, and 12 months of age. Universal screening of pregnant mothers for hepatitis B has been in place in Cardiff since 1995. We were concerned that, although babies received immunisation at birth, second and third doses were being missed. An audit was therefore undertaken to assess the coverage of hepatitis B immunisation in infants at risk born between 1 January 1994 and 31 December 1996.1

All hepatitis B carriers identified by antenatal screening at Llandough Hospital were included. Data on the hepatitis B status were obtained from the virology laboratory records. The mother's antenatal notes and the baby's neonatal notes were reviewed. Immunisation details on the infants were obtained from hospital notes, general practitioner records, and the computerised child health system.

Seventeen women were identified by antenatal screening as hepatitis B carriers. One woman moved out of the area antenatally, two postnatally, and one woman had an intrauterine death. Thirteen mothers and infants were included in the study. Twelve of the 13 women (92%) belonged to ethnic minorities and six (46%) had poor English comprehension, as reported by their general practitioner and health visitor. In only two cases was there evidence in the antenatal notes that the implications of the hepatitis B carrier state had been discussed. In none of the neonatal notes was there documentation of parental counselling on the need for follow up of the baby and further hepatitis B immunisation.

All 13 babies were immunised within 48 hours of birth and received immunoglobulin. Eleven (85%) received a second dose, including five babies who received their second dose from one to six months late. Only five (38%) babies received their third dose, and three of them received it later than scheduled.

Our study highlights the difficulties of achieving adequate hepatitis B immunisation coverage in high risk infants. Most women belong to ethnic minorities, with a considerable number having poor English comprehension. Also, communication between health professionals and patients, and between the various health professionals is poor. The Department of Health recently issued a directive to all health authorities to ensure that arrangements for universal antenatal screening are in place by April 2000, and that all babies born to infected mothers receive a complete course of immunisation.2 Our study shows that even when universal antenatal screening is established, full protection of babies at risk does not necessarily follow. Since this audit, a public health nurse with specific responsibility for these families has been appointed. The consultant in communicable disease control now oversees the follow up and hepatitis B immunisation of these babies. Unless health authorities ensure that there is an effective system in place for vaccine delivery, low prevalence countries like the United Kingdom may have to consider universal immunisation.3