Maternal hepatitis B e antigen can be an indicator for antiviral prophylaxis of perinatal transmission of hepatitis B virus

As a high-risk factor of perinatal HBV transmission, the potential role of maternal hepatitis B e antigen (HBeAg) to guide antiviral prophylaxis has not yet been fully reported. This large prospective cohort study enrolled 1177 hepatitis B surface antigen (HBsAg)-positive pregnant women without antiviral treatment and their newborns. HBeAg, HBsAg, and viral load in maternal serum collected before delivery were measured. All the newborns were given standard passive-active immunoprophylaxis within 12 h after birth, and post-vaccination serologic testing was performed at 7 (±7d) months of age. The results revealed that 20 of the 1177 infants (1.70%) were immunoprophylaxis failure, and all their mothers were HBeAg positive. Maternal quantitative HBeAg was positively correlated with viral load (r = 0.83; P < .0001) and quantitative HBsAg (r = 0.68; P < .0001). The area under the receiver operating characteristic curve (AUC) for predicting immunoprophylaxis failure by maternal HBeAg was comparable to that by maternal viral load (0.871 vs 0.893; P = .441) and HBsAg (0.871 vs 0.871; P = .965). The optimal cutoff value of maternal quantitative HBeAg to predict perinatal infection was 2.21 log₁₀ PEI U/mL, and the sensitivity and specificity was 100.0% and 74.5%, respectively. According to maternal viral load >2 × 10⁵ IU/mL, the sensitivity and specificity of maternal qualitative HBeAg to identify the risk of HBV MTCT for pregnant women and determine the necessity for antiviral prophylaxis was 95.5% and 92.6%, respectively. This study showed that maternal HBeAg can be a surrogate marker of HBV DNA for monitoring and evaluating whether antiviral prophylaxis is necessary for preventing perinatal HBV transmission.

[Toxoplasmosis in pregnancy: Practical Management]

The burden of congenital toxoplasmosis has become small in France today, in particular as a result of timely therapy for pregnant women, fetuses and newborns. Thus, the French screening and prevention program has been evaluated and recently confirmed despite a decline over time in the incidence of toxoplasmosis. Serological diagnosis of maternal seroconversion is usually simple but can be difficult when the first trimester test shows the presence of IgM, requiring referral to an expert laboratory. Woman with confirmed seroconversion should be referred quickly to an expert center, which will decide with her on treatment and antenatal diagnosis. Although the level of proof is moderate, there is a body of evidence in favor of active prophylactic prenatal treatment started as early as possible (ideally within 3 weeks of seroconversion) to reduce the risk of maternal-fetal transmission, as well as symptoms in children. The recommended therapies to prevent maternal-fetal transmission are: (1) spiramycin in case of maternal infection before 14 gestational weeks; (2) pyrimethamine and sulfadiazine (P-S) with folinic acid in case of maternal infection at 14 WG or more. Amniocentesis is recommended to guide prenatal and neonatal care. If fetal infection is diagnosed by PCR on amniotic fluid, therapy with P-S should be initiated as early as possible or continued in order reduce the risk of damage to the brain or eyes. Further research is required to validate new approaches to preventing congenital toxoplasmosis.

Evaluation of prevention of mother-to-child transmission national health information system for HIV/AIDS, in southern region of Mozambique, April to November 2016

Introduction

Mozambique has a generalized HIV epidemic, among pregnant women, HIV prevalence is estimated at 15.8% with a vertical transmission rate of 14%, more than double global targets. We evaluate electronic national health information system (SIS-MA) performance to verify if the data flow procedures met its objectives and evaluated the prevention of mother-to-child transmission (PMTCT) surveillance system to access its attributes and usefulness.

Methods

we conducted a descriptive, cross-sectional evaluation of the PMTCT surveillance system in eight facilities in Gaza and Inhambane provinces using the centers for disease control and prevention guidelines (2001). For data quality, we cross-referenced patient registries from health facilities against the SIS-MA. We also interviewed 34 health technicians, using a Likert scale, to assess the following attributes of the PMTCT surveillance system: simplicity, stability, flexibility, acceptability, timeliness and data quality, usefulness of the system and knowledge of PMTCT.

Results

regarding the simplicity measure, we verified that the registry books contain more than 30 variables. The system was 83% flexible in maintaining functionality with the introduction of new health facilities in the system. The completeness of the data was 50% and concordance of data from the register book and monthly reports was 89%.

Conclusion

the PMTCT SIS-MA is useful in supporting the collection, analysis, interpretation and continuous and systematic dissemination of health data that are used to define and monitor public health policies in Mozambique. However, continued efforts are needed to improve data quality to ensure that the SIS-MA can adequately monitor the PMTCT program and contribute to reduced vertical transmission.

2019 Chinese Clinical Practice Guidelines for the Prevention of Mother-to-child Transmission of Hepatitis B Virus

To develop the evidence-based guidelines for managing mother-to-child transmission of hepatitis B virus in China, a multidisciplinary guideline development group was established. Clinical questions were identified from two rounds of surveys on the concerns of first-line clinicians. We conducted a comprehensive search and review of the literature. A grading of recommendations' assessment, development, and evaluation system was adopted to rate the quality of evidence and the strength of recommendations. Recommendations were formulated based on the evidence, overall balance of benefits and harms (at individual and population levels), patient/health worker values and preferences, resources available, cost-effectiveness, and feasibility. Eventually, recommendations related to 13 main clinical concerns were developed, covering diagnostic criteria, treatment indications, antiviral therapy choice, timing to initiate and discontinue treatment, immunoprophylaxis strategy at birth, and how to deal with special situations, such as unintended pregnancy, assisted reproduction, and breastfeeding. The guidelines are intended to serve as guidance for clinicians and patients, to optimize the management of majority of pregnant women who are positive for hepatitis B surface antigen. Guideline registration: International Practice Guide Registration Platform (IPGRP-2018CN040).

Preventing mother to child transmission of HIV: lessons learned from China

Background

The program for the prevention of mother-to-child transmission (PMTCT) of human immunodeficiency virus (HIV) was launched in 2003 in China, but few studies have been conducted to describe the panorama of PMTCT. We investigated the rate and associated factors of mother-to-child transmission (MTCT) in China from 2004 to 2018.

Methods

HIV-infected pregnant women from two areas in China between 2004 and 2018 were enrolled. Antiretrovirals (ARVs) were provided to the mothers and their babies, and the children were followed and tested for HIV.

Results

In total, 857 mothers and their 899 children were enrolled, and the overall MTCT rate was 6.6% (95% CI 5.0–8.2). The MTCT rates of nonintervention, only formula feeding (FF), infant prophylaxis (IP) + FF, single dosage antiretrovirals (sdARVs) + IP + FF, zidovudine (AZT) alone+IP + FF and prenatal combination antiretroviral therapy (cART) + IP + FF were 36.4, 9.4, 10.0, 5.7, 3.8 and 0.3%, respectively. The MTCT rate declined over time. No ARVs, CD4 count < 200/μL, low birth weight, and breastfeeding were associated with MTCT of HIV. For different ARVs, a higher MTCT rate was observed for AZT alone, sdARVs, and no ARVs compared to cART for pregnant women.

Conclusions

Although the overall MTCT rate remains relatively high, the real-world effect of prenatal cART+IP + FF in China has exerted the same protective effects in high-income countries. With the extension of prenatal cART for pregnant women with HIV, the MTCT rate of HIV has gradually declined in China. However, the coverage of prenatal cART for pregnant women should be further improved. The effect of only post-exposure prophylaxis for infants was limited.

Toxoplasmosis in pregnancy

Toxoplasmosis is one of the common chronic infections caused by the parasite Toxoplasma gondii. Even though its infection in healthy non-pregnant women is self-limited and largely asymptomatic, the main concern is the risk to the fetus by vertical transmission in pregnancy. Congenital toxoplasmosis can result in permanent neurological damage and even serious morbidity such as blindness. Screening programs are implemented in various countries depending on the prevalence and virulence of the parasite in the respective regions. Upon diagnosis of infection, appropriate antibiotic therapy should be initiated as it has been proven to reduce the risk of fetal transmission. Primary prevention remains the key intervention to avoid the infection and hence patient education is an important aspect of the management.

Maternal Envelope gp41 Ectodomain-Specific Antibodies Are Associated With Increased Mother-to-Child Transmission of Human Immunodeficiency Virus-1

Mother-to-child transmission of human immunodeficiency virus (HIV) occurs in the setting of maternal and passively acquired antibodies, providing a unique window into immune correlates of HIV risk. We compared plasma antibody binding to HIV antigens between 51 nontransmitting mother-infant pairs and 21 transmitting mother-infant pairs. Plasma antibody binding to a variety of gp41 ectodomain-containing antigens was associated with increased odds of transmission. Understanding the reasons why gp41 ectodomain-targeting antibodies are associated with transmission risk will be important in determining whether they can directly enhance infection or whether their presence reflects a redirecting of the humoral response away from targeting more protective epitopes.

Efficacy and Safety of Tenofovir in the Prevention of Perinatal Transmission of Hepatitis B, a Meta-Analysis

BACKGROUND

Tenofovir disoproxil fumarate (TDF) is recommended for the prevention of perinatal transmission of the hepatitis B virus (HBV). This study aimed to systematically assess the efficacy and safety of TDF in pregnant women with chronic HBV and their infants.

MATERIAL AND METHODS

Database searches were performed to identify studies blocking the mother-to-child transmission of the hepatitis B virus with tenofovir. The search included pregnant women with chronic HBV infection administered with TDF compared to the no treatment controls, and data from individual studies were pooled using RevMan v5.3 for meta-analysis.

RESULTS

Seven studies with a total of 911 patients met the inclusion criteria: 433 patients in the TDF group and 478 patients in the non-TDF group. The HBV mother-to-child transmission rate in the tenofovir group was effectively reduced compared to the control group (RR: 0.18, 95% CI: 0.08-0.40). HBV-DNA positivity was also significantly low in infants from TDF group (RR: 0.17, 95% CI: 0.10-0.30) and the TDF treatment resulted in significantly higher anti-HBs production (RR: 1.11, 95% CI: 1.04-1.18). Similarly, maternal HBV-DNA was suppression was significantly high in the TDF group (RR: 34.16, 95% CI: 16.40-71.13). Women treated with TDF and their infants did not result in serious adverse events that are statistically different as compared to the women who did not receive any treatment.

CONCLUSION

Treatment of HBV infected pregnant women with TDF can effectively and safely prevent the perinatal transmission of chronic hepatitis B.

Seroprevalence of Hepatitis B Virus Infection, Mother-To-Child Transmission, and Associated Risk Factors Among Delivering Mothers in Tigray Region, Northern Ethiopia: a Cross-Sectional Study

Introduction

High prevalence of hepatitis B virus (HBV) infection among pregnant women is the primary source of infection for their children and the general population. Mother-to-child transmission (MTCT) is the primary mode of transmission in endemic areas like Ethiopia. The aim of this study was to determine the prevalence of HBV infection, rate of MTCT, and associated risk factors among delivering mothers.

Methods

This health facility-based cross-sectional study was conducted in four public hospitals of the Eastern zone of Tigray among 473 delivering mothers. Structured questionnaires and laboratory results were used to collect the data. The data were checked for completeness and entered into EpiData manager version 4.6.0.0. Then the data were exported to Statistical Package for Social Sciences (SPSS) version 23. The odds ratio, along with a 95% confidence interval, was estimated to identify predictors of HBV infection using multivariable logistic regression analysis. Significant association was considered at p < 0.05.

Results

A total of 473 mothers were enrolled, and the response rate was 100%. The prevalence of HBV infection among the mothers and the rate of MTCT of the infection were 11.6% and 30.9%, respectively. History of home delivery [adjusted odds ratio (AOR) = 4.5, 95% confidence interval (CI) (2, 10.6)], history of hospital admission [AOR = 5, 95% CI (2.2, 11.5)], working at health facility [AOR = 5.4, 95% CI (1.4, 20.7)], body tattoos [AOR = 5.8, 95% CI (2.4, 13.6)], sharing personal care materials [AOR = 3.8, 95% CI (1.4, 9.9)], insufficient knowledge [AOR = 5.6, 95% CI (1.6, 19)], and having human immunodeficiency virus (HIV) [AOR = 5.1, 95% CI (1, 26.2)] were significantly associated with HBV infection.

Conclusion

HBV infection among delivering women is becoming highly endemic, and the rate of MTCT was high. Therefore, administering hepatitis B vaccine to all neonates within 24 h of birth is mandatory to prevent MTCT of HBV infection and related complications. Furthermore, health education and dissemination of information about HBV for the pregnant mothers are needed to reduce HBV infection and vertical transmission in Ethiopia.

Factors associated with HIV and syphilis screenings among pregnant women at first antenatal visit in Lusaka, Zambia

OBJECTIVES

To identify characteristics associated with obtaining HIV and syphilis screenings of pregnant women attending a first antenatal visit in Lusaka, Zambia.

RESULTS

Among 18,231 participants from April 2015 to January 2016, 95% obtained HIV screening, 29% obtained syphilis screening, and 4% did not obtain antenatal HIV or syphilis screenings. Divorced/separated women were associated with a moderate decrease in prevalence of obtaining HIV (adjusted prevalence ratio (aPR) 0.88, 95% confidence interval (95% CI) 0.82, 0.95) and syphilis (aPR 0.51, 95% CI 0.27, 0.96) screenings compared to married women. Women with previous pregnancies were associated with a slight decrease in prevalence of obtaining HIV screening (aPR 0.97, 95% CI 0.95, 0.99) compared to women without previous pregnancy. Older women ≥ 35 years were associated with a slight decrease in prevalence of obtaining HIV screening (aPR 0.96, 95% CI 0.92, 0.99) compared to younger women. The statistically significant differences were not of clinical relevance as defined by a proportional difference of 10 percent. Findings of this study show that a vast majority of pregnant women are obtaining HIV screenings but not syphilis screenings during first antenatal visit. Provision of antenatal HIV and syphilis screening at first visit is only weakly related to patient level factors.

Introduction of birth dose of hepatitis B virus vaccine to the immunization program in Ethiopia: an economic evaluation

BACKGROUND

Hepatitis B virus (HBV) infection is an important cause of morbidity and mortality with a very high burden in Africa. The risk of developing chronic infection is marked if the infection is acquired perinatally, which is largely preventable through a birth dose of HBV vaccine. We examined the cost-effectiveness of a birth dose of HBV vaccine in a medical setting in Ethiopia.

METHODS

We constructed a decision analytic model with a Markov process to estimate the costs and effects of a birth dose of HBV vaccine (the intervention), compared with current practices in Ethiopia. Current practice is pentavalent vaccination (DPT-HiB-HepB) administered at 6, 10 and 14 weeks after birth. We used disability-adjusted life years (DALYs) averted to quantify the health benefits while the costs of the intervention were expressed in 2018 USD. Analyses were based on Ethiopian epidemiological, demographic and cost data when available; otherwise we used a thorough literature review, in particular for assigning transition probabilities.

RESULTS

In Ethiopia, where the prevalence of HBV among pregnant women is 5%, adding a birth dose of HBV vaccine would present an incremental cost-effectiveness ratio (ICER) of USD 110 per DALY averted. The estimated ICER compares very favorably with a willingness-to-pay level of 0.31 times gross domestic product per capita (about USD 240 in 2018) in Ethiopia. Our ICER estimates were robust over a wide range of epidemiologic, vaccine effectiveness, vaccine coverage and cost parameter inputs.

CONCLUSIONS

Based on our cost-effectiveness findings, introducing a birth dose of HBV vaccine in Ethiopia would likely be highly cost-effective. Such evidence could help guide policymakers in considering including HBV vaccine into Ethiopia's essential health services package.

Frequent horizontal and mother-to-child transmission may contribute to high prevalence of STLV-1 infection in Japanese macaques

Background

Simian T-cell leukemia virus type 1 (STLV-1) is disseminated among various non-human primate species and is closely related to human T-cell leukemia virus type 1 (HTLV-1), the causative agent of adult T-cell leukemia and HTLV-1-associated myelopathy/tropical spastic paraparesis. Notably, the prevalence of STLV-1 infection in Japanese macaques (JMs) is estimated to be > 60%, much greater than that in other non-human primates; however, the mechanism and mode of STLV-1 transmission remain unknown. The aim of this study is to examine the epidemiological background by which STLV-1 infection is highly prevalent in JMs.

Results

The prevalence of STLV-1 in the JMs rearing in our free-range facility reached up to 64% (180/280 JMs) with variation from 55 to 77% among five independent troops. Anti-STLV-1 antibody titers (ABTs) and STLV-1 proviral loads (PVLs) were normally distributed with mean values of 4076 and 0.62%, respectively, which were mostly comparable to those of HTLV-1-infected humans. Our initial hypothesis that some of the macaques might contribute to frequent horizontal STLV-1 transmission as viral super-spreaders was unlikely because of the absence of the macaques exhibiting abnormally high PVLs but poor ABTs. Rather, ABTs and PVLs were statistically correlated (p < 0.0001), indicating that the increasing PVLs led to the greater humoral immune response. Further analyses demonstrated that the STLV-1 prevalence as determined by detection of the proviral DNA was dramatically increased with age; 11%, 31%, and 58% at 0, 1, and 2 years of age, respectively, which was generally consistent with the result of seroprevalence and suggested the frequent incidence of mother-to-child transmission. Moreover, our longitudinal follow-up study indicated that 24 of 28 seronegative JMs during the periods from 2011 to 2012 converted to seropositive (86%) 4 years later; among them, the seroconversion rates of sexually matured (4 years of age and older) macaques and immature macaques (3 years of age and younger) at the beginning of study were comparably high (80% and 89%, respectively), suggesting the frequent incidence of horizontal transmission.

Conclusions

Together with the fact that almost all of the full-adult JMs older than 9 years old were infected with STLV-1, our results of this study demonstrated for the first time that frequent horizontal and mother-to-child transmission may contribute to high prevalence of STLV-1 infection in JMs.

Impact of the National Perinatal Hepatitis B Prevention Programme in the Republic of Korea: A retrospective registry-based cohort study

INTRODUCTION

Hepatitis B is a major preventable cause of morbidity and mortality from chronic hepatitis, liver cirrhosis, and hepatocellular carcinoma. We aimed to evaluate the performance and outcomes of the Korean Perinatal Hepatitis B Prevention Programme (PHBPP) and to investigate the impact of the current post-exposure immunoprophylaxis protocol.

METHODS

A retrospective cohort study was performed based on electronic data registry of infants born to hepatitis B virus (HBV)-infected mothers between July 2002 and 2013.

RESULTS

During the study period, 159,983 Korean infants were registered with the PHBPP, with an overall programme coverage of 92.8%. Despite receiving timely post-exposure immunoprophylaxis, 8.6% of infants born to mothers aged <25 years and hepatitis B e antigen (HBeAg)-positive, and 0.7% of infants born to mothers aged ≥25 years and HBeAg-negative were infected. An estimated 14,123 infants were directly protected from perinatal HBV transmission by the PHBPP during the 11.5-year period, at a cost of 1157 US dollars per case averted. The incidence of paediatric hepatocellular carcinoma declined dramatically during the period.

CONCLUSIONS

A substantial number of infants have been prevented from hepatitis B since the PHBPP was launched in the Republic of Korea. Continued efforts to promote the programme, an integrated approach to maximising its coverage, a risk-stratified strategy, and innovations in logistics could further reduce perinatal HBV transmission.

[Status on maternal testing and detection of HIV infection among pregnant women in Liangshan Yi Autonomous Prefecture, Sichuan province, 2008-2016]

Objective: To understand the status of maternal testing, detection and trends of HIV infection among pregnant women in Liangshan Yi Autonomous Prefecture (Liangshan) of Sichuan province during 2008-2016. Methods: Data were collected from the monthly work report on maternal HIV testings and the case-reporting records of HIV-positive pregnant women, from the National Management Information System of China's Prevention of Mother-to-child transmission of HIV, syphilis, and HBV Program. Descriptive method was applied to show both the maternal HIV and predelivery HIV testing rates and maternal HIV positive rates as well as the distribution in different counties, between 2008 and 2016. Results: During 2008-2016, both maternal HIV test rates and predelivery maternal HIV testing increased from 40.7% (8 191/20 125) and 8.0% (1 607/20 125) to 95.7% (88 000/91 946) and 70.1% (64 421/91 946), respectively (trend χ(2)=94 497.28, P<0.001; trend χ(2)=90 655.03, P<0.001). A total of 3 271 HIV-positives were detected from 436 519 pregnant women, with the HIV positive rate as 0.75% (95%CI: 0.72%-0.77%). Among 3 271 HIV-positive pregnant women, 1 527 (46.7%) of them were tested at labor. The maternal HIV-positive rates at labor increased yearly (trend χ(2)=9.21, P=0.002). In 2016, the maternal HIV-positive rate at labor was 1.32% (95%CI: 1.18%-1.47%), which was higher than that (0.67%, 95%CI: 0.61%-0.73%) in the pregnant women who received HIV test predelivery (χ(2)=88.23, P<0.001). The maternal HIV- positive rates in Butuo, Zhaojue, Jinyang, Meigu, and Yuexi counties all appeared ≥1%, in 2016,respectively. Conclusions: The maternal HIV test rates increased in Liangshan during 2008-2016, but the maternal HIV test rates at labor were relatively high. The HIV prevalence among pregnant women in Liangshan was severe and late for pregnant women to receive testing.

The changing profile of paediatric HIV infection: An experience from the Middle East

OBJECTIVE

To describe the clinical and epidemiological profiles of HIV-infected Omani children before and after the implementation of the prevention of mother-to-child transmission of HIV (PMTCT) programme.

METHODS

A retrospective review of HIV-infected children seen at a national paediatric HIV unit between 1992 and 2015 was performed.

RESULTS

Ninety-one HIV-infected children were identified; 59 (65%) were ≤5 years of age at diagnosis, with 28 (47.5%) of these being <1 year old. The average annual incidence of infection per million children (≤14 years old) was 5.7, and the highest (11.6) was in 2010. At diagnosis, 48 (60%) patients had a CD4 count of ˂200cells/mm³. The median HIV viral load was 81600copies/ml at diagnosis and 5911copies/ml at 12 months after HIV treatment (p=0.015). The median CD4 count was 586cells/mm³ at diagnosis and 800cells/mm³ at 12 months after therapy (p=0.004). Compared to those diagnosed before 2009 (n=68), HIV-infected children diagnosed after 2009 (n=22) were more likely to be asymptomatic at the time of HIV diagnosis (23.5% (16/68) vs. 59.1% (13/22); p=0.002) and to have a favourable clinical outcome (42.6% (29/68) vs. 86.4% (19/22); p<0001).

CONCLUSIONS

The number of HIV-infected children in Oman has decreased substantially since the introduction of the PMTCT programme. Furthermore, the HIV-infected children diagnosed after 2009 had higher proportions of asymptomatic HIV infections at diagnosis and favourable clinical outcomes, in comparison to those diagnosed before 2009.

HIGH-FREQUENCY failure of combination antiretroviral therapy in paediatric HIV infection is associated with unmet maternal needs causing maternal NON-ADHERENCE

BACKGROUND

Early combination antiretroviral therapy (cART) reduces the size of the viral reservoir in paediatric and adult HIV infection. Very early-treated children may have higher cure/remission potential.

METHODS

In an observational study of 151 in utero (IU)-infected infants in KwaZulu-Natal, South Africa, whose treatment adhered strictly to national guidelines, 76 infants diagnosed via point-of-care (PoC) testing initiated cART at a median of 26 h (IQR 18-38) and 75 infants diagnosed via standard-of-care (SoC) laboratory-based testing initiated cART at 10 days (IQR 8-13). We analysed mortality, time to suppression of viraemia, and maintenance of aviraemia over the first 2 years of life.

FINDINGS

Baseline plasma viral loads were low (median 8000 copies per mL), with 12% of infants having undetectable viraemia pre-cART initiation. However, barely one-third (37%) of children achieved suppression of viraemia by 6 months that was maintained to >12 months. 24% had died or were lost to follow up by 6 months. Infant mortality was 9.3%. The high-frequency virological failure in IU-infected infants was associated not with transmitted or acquired drug-resistant mutations but with cART non-adherence (plasma cART undetectable/subtherapeutic, p<0.0001) and with concurrent maternal cART failure (OR 15.0, 95%CI 5.6-39.6; p<0.0001). High-frequency virological failure was observed in PoC- and SoC-tested groups of children.

INTERPRETATION

The success of early infant testing and cART initiation strategies is severely limited by subsequent cART non-adherence in HIV-infected children. Although there are practical challenges to administering paediatric cART formulations, these are overcome by mothers who themselves are cART-adherent. These findings point to the ongoing obligation to address the unmet needs of the mothers. Eliminating the particular barriers preventing adequate treatment for these vulnerable women and infants need to be prioritised in order to achieve durable suppression of viraemia on cART, let alone HIV cure/remission, in HIV-infected children.

FUNDING

Wellcome Trust, National Institutes of Health.

Hepatitis B-management of acute infection and active inflammation in pregnancy-a hepatologist's perspective

Women at childbearing age and pregnant ladies living in the areas of high or intermediate prevalence of hepatitis B virus (HBV) remain at risk of getting the infection and passing the infections to their offspring via mother-to-child transmission (MTCT) of HBV. HBV infection may affect the mothers by active hepatitis, very occasionally liver cirrhosis and rarely fulminant hepatitis and liver failure. The virus may be transmitted to the babies despite immunoprophylaxis in the setting of very high maternal viral load. Tenofovir disoproxil fumarate (TDF) has been shown to be efficacious to reduce MTCT of HBV, which contributes to the elimination of chronic HBV infection by 2030, the goal set by World Health Organization.

The effect of maternal use of telbivudine on neonatal CD4+CD25+ regulatory T cells for the prevention of mother-to-child transmission of hepatitis B virus

Antiviral treatment could block mother-to-child transmission (MTCT) of hepatitis B virus (HBV) effectively. We examined whether maternal use of telbivudine (LdT) could decrease the proportion of CD4⁺CD25⁺ regulatory T cells and explored the immunological mechanism. A total of 89 pregnant women with HBsAg positive were enrolled, where 30 pregnant women with HBeAg negative (viral load<10⁶ IU/ml) and the other 59 pregnant women with HBeAg positive (viral load≥10⁶ IU/ml) were followed in the study. The women with high viral load were divided to the LdT-treated group where they were prescribed with 600mg LdT daily (29 cases) during the third trimester of pregnancy or to the non-treated group (30 cases) on a voluntary basis. Samples of neonates were taken for analyzing CD4⁺CD25⁺ Tregs with flow cytometric techniques. A more significant decrease in the proportion of CD4⁺CD25⁺Tregs in neonatal peripheral blood had been observed with maternal use of telbivudine (2.8%±1.1%) than those without any treatment (7.0%±1.6%, P< 0.01). None of the infants in the LdT-treated group were HBsAg positive at 7 months of age. In addition, neonates whose mothers received telbivudine had a significant improvement in cellular immune function, as indicated by the proportion of CD8⁺ T cells. For HBV carriers with high viral load, maternal use of LdT may be useful in regulating neonatal immune function involved in mother-to-child transmission of hepatitis B virus.

A Real-world Prospective Study of Mother-to-child Transmission of HBV in China Using a Mobile Health Application (Shield 01)

Background and Aims: The World Health Organization (WHO) Western Pacific Region set a target of eliminating mother-to-child transmission (MTCT) of hepatitis B virus (HBV) by 2030. To assess the feasibility of this target in China, we carried out an epidemiological study to investigate the status quo of MTCT in the real-world setting. Methods: One thousand and eight hepatitis B surface antigen-positive pregnant women were enrolled at 10 hospitals. Immunoprophylaxis was administered to infants. In addition, mothers with HBV DNA level >2,000,000 IU/mL were advised to initiate antiviral therapy during late pregnancy. A health application called SHIELD was used to manage the study. Results: Nine hundred and five of the enrolled mothers, with 924 infants, completed the follow-up. Birth-dose hepatitis B vaccine and hepatitis B immunoglobulin were received by 99.7% and 99.7% of infants, respectively, within 24 h after birth. There were 446 mothers who received antiviral therapy, including 72.3% of the mothers with HBV DNA level >2,000,000 IU/mL and 21.0% of the mothers with HBV DNA level <2,000,000 IU/mL. Eight infants were infected with HBV. The overall rate of MTCT was 0.9%. Birth defects were rare (0.5% among infants with maternal antiviral exposure versus 0.7% among infants without exposure; p=1.00). Conclusions: The MTCT rate was lower than the WHO Western Pacific Region elimination MTCT target in this real-world study, indicating that a comprehensive management composed of immunoprophylaxis to infants and antiviral prophylaxis to mothers may be a feasible strategy to achieve the 2030 WHO elimination goal.

Efficacy and safety of antiviral therapy for HBV in different trimesters of pregnancy: systematic review and network meta-analysis

BACKGROUND

Several antiviral agents licenced for blocking mother-to-child transmission (MTCT) of HBV, but their relative efficacy beginning from different trimesters has scarce been evaluated. We aimed to conduct a network meta-analysis to statistically differ the efficacy and safety of each antiviral agents initiating on different timings in preventing mother-to-infant transmission of HBV.

METHODS

Studies were included from PubMed, EMBASE, Web of Science, and Cochrane databases through July 1, 2019. Eligible studies recruited randomized controlled trials and nonrandomized studies reporting about infant or/and maternal efficacy and safety outcomes and were screened by two investigators independently. Extracted data were analyzed by pair-wised and network meta-analysis, respectively.

RESULTS

3 Randomized and 32 nonrandomized studies enrolling 6738 pregnant female were included. Using network analysis, any antiviral agent interrupted HBV vertical transmission much more effectively than placebo. No agent showed significant efficacy different from others, but a strong trend toward significance was found in telbivudine and tenofovir, of which had the highest probability of being ranked the first- or second-best treatment for reducing MTCT of HBV. The treatment applied in the first and second trimester had a similar efficacy in preventing MTCT. Compared with the initiation during the third trimester, lower rate of MTCT was revealed when antiviral therapy was administrated before third trimester, (RR = 0.045, 95% CI 0.0053 to 0.20); a similar effect at delivery on suppressing maternal HBV DNA level and converting serum HBeAg were achieved if the timing of antiviral treatment started prior, but an obvious improvement of normalizing ALT flare was calculated out; no statistically differences among maternal and fetal safety outcomes were found if mothers received antiviral agents before pregnant 28 weeks.

CONCLUSION

This network meta-analysis recommended the earlier use of telbivudine or tenofovir, tends to be better to prevent MTCT of HBV in pregnancy with no increased adverse maternal or fetal outcomes.

Efficacy of oral antiviral drugs to prevent mother-to-child transmission of hepatitis B virus: a network meta-analysis

BACKGROUND

Hepatitis B is a serious global health problem. Mother-to-child transmission (MTCT) of hepatitis B virus (HBV) is a major risk factor in the endemicity of HBV infection. Oral antiviral drugs are recommended to highly viremic mothers to decrease MTCT of HBV. The present network analysis compared the efficacy of available treatments to prevent the MTCT of HBV.

METHODS

The electronic databases of PubMed, Embase, Web of Science, Scopus, and Wanfang data were searched for eligible studies. Pair-wise meta-analysis and Bayesian network analysis were applied to compare the efficacy of antiviral drugs.

RESULTS

Seventy-five studies involving 12,740 pregnant females were eligible for analysis. On pair-wise analysis, lamivudine (OR 0.15, 95% CI 0.09-0.25, I-squared = 0%), telbivudine (OR 0.07, 95% CI 0.05-0.10, I-squared = 0%) and tenofovir (OR 0.07, 95% CI 0.04-0.13, I-squared = 0%) significantly decreased the MTCT rate. Results of multiple comparisons with ranking probability based on Bayesian analysis showed that tenofovir (SUCRA = 96.83%) appeared more effective than the two other drugs.

CONCLUSION

In addition to active and passive immunoprophylaxis, lamivudine, telbivudine and tenofovir in highly viremic mothers can further decrease MTCT of HBV. Based on direct and indirect evidence, tenofovir appears to be more effective than the two other drugs in the prevention of HBV MTCT.

Antibody-dependent cellular cytotoxicity targeting CD4-inducible epitopes predicts mortality in HIV-infected infants

BACKGROUND

Antibody-dependent cellular cytotoxicity (ADCC) has been associated with improved infant outcome in mother-to-child transmission (MTCT) of HIV-1. Epitopes of these ADCC-mediating antibodies remain unidentified. CD4-inducible (CD4i) epitopes on gp120 are common ADCC targets in natural infection and vaccination. We tested whether CD4i epitope-specific ADCC mediated by maternal antibodies or passively-acquired antibodies in infants is associated with reduced MTCT and improved infant survival.

METHODS

We used variants of CD4i cluster A-specific antibodies, A32 and C11, and a cluster C-specific antibody, 17b, with mutations abolishing Fc-Fc receptor interactions as inhibitors in a competition rapid and fluorometric ADCC assay using gp120-coated CEM-nkr target cells with plasma from 51 non-transmitting and 21 transmitting breastfeeding mother-infant pairs.

FINDINGS

Cluster A-specific ADCC was common. Individually, neither A32-like nor C11-like ADCC was statistically significantly associated with risk of MTCT or infected infant survival. In combination, total maternal cluster A-specific ADCC was statistically significantly associated with decreased infected infant survival in a log-rank test (p = 0·017). There was a non-significant association for infant passively-acquired total cluster A-specific ADCC and decreased infected infant survival (p = 0·14). Surprisingly, plasma ADCC was enhanced in the presence of the defective Fc 17b competitor. Defective Fc 17b competitor-mediated maternal ADCC enhancement was statistically significantly associated with reduced infected infant survival (p = 0·011). A non-significant association was observed for passively-acquired infant ADCC enhancement and decreased survival (p = 0·19).

INTERPRETATIONS

These data suggest that ADCC targeting CD4i epitopes is not associated with protection against breast milk HIV transmission but is associated with decreased survival of infected infants. FUND: This study was funded by NIH grant R01AI076105 and NIH fellowship F30AI136636.

Prevention and treatment of neonatal herpes simplex virus infection

Herpes simplex virus (HSV), a member of the Herpesviridae family, is a well-known cause of infections including genital herpes and herpes labialis in the adolescent and adult population. Transmission of HSV infection to an infant during the first 4-6 weeks of life can lead to devastating disease with the potential for poor outcomes. Early diagnosis is imperative when evaluating neonatal HSV infection in order to prevent further disease progression, neurological complications, and even death. In the past 4 decades, significant advancements have been made in the diagnosis, treatment, and prevention of neonatal HSV infection, but there remains room for improvement as efforts continue to reduce the burden of disease caused by this infection.

Cost-effectiveness of couple-based immunization strategy to prevent mother-to-child transmission of hepatitis B virus in China: A decision-analytic Markov model

BACKGROUND

Mother-to-child transmission (MTCT) is the major route of HBV transmission in many parts of the world. We designed couple-based immunization strategy and aimed to assess the cost-effectiveness of this strategy in China.

METHODS

We constructed a decision-analytic Markov model to compared current immunization strategy consisting of hepatitis B vaccination (HepB) for all infants and extra hepatitis B immunoglobulin for infants with HBsAg-positive mothers versus couple-based immunization strategy including additional HBV screening for pre-pregnant couples and HepB for high-risk wives. Costs were assessed from a healthcare system perspective. Number of infants with perinatal HBV infection, life-years (LYs), quality-adjusted life-years (QALYs), and disability-adjusted life-years (DALYs) were used to access effects. We calculated incremental cost-effectiveness ratios (ICERs) and performed sensitivity analysis.

FINDINGS

Based on the birth cohort of 17,578,815 livebirths in China in 2017, couple-based immunization strategy reduced perinatal HBV infection by 18% (9194/51,365) with cost increase of ¥ 41 million, saved 49,986 LYs (ICER: ¥819 per LY saved), gained 48,879 QALYs (ICER: ¥837 per QALY gained) and averted 63,362 DALYs (¥646 per DALY averted) compared with current immunization strategy. These ICERs were below willingness-to-pay levels of China's once GDP per capita (¥59,660), remaining robust in sensitivity analysis.

INTERPRETATION

Under the intermediate endemic of HBV infection in China, implementation of couple-based immunization strategy can improve the efficiency of preventing MTCT of HBV, and is highly cost-effective. This strategy can be a new immunization strategy choice to achieve the target of eliminating hepatitis B by 2030.

FUNDING

National Natural Science Foundation of China.

Incidence and predictors of lost to follow-up among women under Option B+ PMTCT program in western Ethiopia: a retrospective follow-up study

Objective

Although Ethiopia has been implementing Option B+ program, LTFU of women from the Option B+ program is one of the challenges that minimizes its implementation. Thus, this study assessed the incidence and predictors of LTFU among women under Option B+ PMTCT program in western Ethiopia. An institution-based retrospective follow-up study was conducted. A cox proportional hazards regression model was fitted to identify predictors of LTFU. A Hazard ratios with 95% confidence CI was computed and all predictors that were associated with the outcome variable at p-value ≤ 0.05 in the multivariable cox proportional hazards were declared as a significance predictor of the outcome.

Results

A total of 330 women were followed for a mean follow up time of 16.9 (± 7.6) months. An overall incidence rate of LTFU was 9/1000 person-months. Women’s educational status, residence, HIV-disclosure status, the status of women at enrollment, previous history of HIV and ART adherence were significant predictors of LTFU. The incidence of LTFU from Option B+ PMTCT is lower as compared to evidence from sub-Saharan African and strengthening linkage and referral system between clinics as well as establishing appropriates tracing mechanisms would retain pregnant women in the program.