Hepatitis B and pregnancy: an underestimated issue

Liver function tests in viremic and nonviremic chronic hepatitis B virus-infected pregnant women: importance of alanine aminotransferase/sodium ratio

The major risk factor of perinatal transmission of Hepatitis B virus (HBV) infection is the level of maternal HBV-deoxyribonucleic acid (DNA) during the third trimester of pregnancy. The primary aim of this study was to evaluate the hematological and biochemical status in Hepatitis B e-antigen (HBeAg)-negative chronic HBV-infected pregnant women and to correlate the findings with the presence or absence of viremia. Ninety-five consecutive chronic HBV-infected pregnant women were evaluated between the 28th and 32nd week of gestation. Viral load was determined by using the COBAS TaqMan HBV test. Sixty-nine women were evaluated and 14 of them exhibited HBV-DNA levels higher than 2000 IU·ml. In this study, viremic women exhibited significantly higher alanine aminotransferase (ALT), creatinine, and uric acid values as well as significantly lower white blood cell count compared with nonviremic women. There was also a significant statistical difference concerning ALT/sodium ratio between viremic and nonviremic women (0.20 ± 0.22 vs. 0.10 ± 0.09, respectively, p= .024). The optimal cutoff points discriminating those women with a high probability to have detectable serum HBV-DNA were 0.092 for ALT/sodium ratio (sensitivity = 73.0%, specificity = 61.5%, area under the receiver operating characteristic curve [AUC] = 71.05%) and 12.8 IU/L for ALT (sensitivity = 73.0%, specificity = 63.0%, AUC = 72.2%). Chronic HBV-infected pregnant women with ALT/sodium ratio ≥ 0.11 had the higher probability of having serum HBV-DNA levels higher than 2000 IU/ml (sensitivity = 76.92%, specificity = 58%, AUC = 62.38%). Presence of HBV-DNA in maternal blood during the third trimester of pregnancy is significantly associated with maternal serum ALT levels in HBeAg-negative chronic HBV-infected pregnant women. Women with an ALT/sodium ratio greater than 0.092 have the higher probability of HBV-DNA presence in maternal blood whereas an ALT/sodium ratio greater than 0.11 could discriminate those women with HBV-DNA levels higher than 2000 IU/ml.

Immunization interventions to interrupt hepatitis B virus mother-to-child transmission: a meta-analysis of randomized controlled trials

BACKGROUND

This study aimed to determine the clinical efficacy of various immune interventions on mother-to-child transmission (MTCT) of hepatitis B virus (HBV).

METHODS

We retrieved different immune strategies on how to prevent MTCT reported in the literature from Chinese and English electronic databases from the viewpoint of intrauterine and extrauterine prevention. Relative risk (RR) and 95% confidence interval (CI) methods were used.

RESULTS

Twenty-five articles on intrauterine prevention and 16 on extrauterine prevention were included in the analysis. Intrauterine prevention could reduce infants' HBV infection rate (RR = 0.36, 95% CI: 0.28-0.45) and increase their anti-hepatitis B surface-positive rate (RR = 2.42, 95% CI: 1.46-4.01) at birth. Compared with passive immunization, passive-active immunization could reduce infants' HBV infection rate (RR = 0.66, 95% CI: 0.52-0.84) at birth, even at more than 12 months of age (RR = 0.54, 95% CI: 0.42-0.69). Subgroup analysis demonstrated similar results except for pregnant women who were hepatitis B surface antigen-positive. Funnel plots and Egger's tests showed publication bias mainly in intrauterine prevention not in extrauterine one.

CONCLUSIONS

The long-term protective effect of pregnant women injected with hepatitis B immunoglobulin during pregnancy should be further validated by large-scale randomized trials. Newborns of pregnant women who carried HBV should undergo a passive-active immunization strategy.

Perinatal hepatitis B prevention program in Shandong Province, China. Evaluation and progress

Post-exposure prophylaxis with hepatitis B vaccine (HepB) alone is highly effective in preventing perinatal hepatitis B virus (HBV) transmission and the World Health Organization recommends administering HepB to all infants within 24 h after delivery. Maternal screening for HBsAg and administration of hepatitis B immune globulin (HBIG) in addition to HepB for infants born to HBsAg-positive pregnant women can increase the effectiveness of post-exposure prophylaxis for perinatal HBV transmission. In Shangdong Province, China which has a high prevalence of chronic HBV infection, HepB birth dose and HBIG were integrated into the routine childhood immunization program in 2002 and July 2011 respectively. We assessed progress toward implementation of these measures. Hospital-based reporting demonstrated an increase in maternal screening from 70.7% to 96.9% from 2004-2012; HepB birth dose coverage (within 24 h) remained high (96.3-97.1%) during this period. For infants with known HBsAg-positive mothers, the coverage of HBIG increased from 85.0% (before July 2011) to 92.1% (after July 2011). However, HBIG coverage in western areas of Shandong Province remained at 81.1% among infants with known HBsAg-positive mothers. Preterm/low-birth-weight and illness after birth were the most commonly reported reasons for delay in the first dose of HepB to >24 h of birth. Additional education on the safety and immune protection from HepB and HBIG might help to correct delays in administering the HepB birth dose and low HBIG coverage in the western areas of the Shandong Province.

Maternal hepatitis B and hepatitis C infection and neonatal neurological outcomes

To examine the associations between maternal hepatitis B (HBV) and hepatitis C (HCV) infection status and selected infant neurological outcomes diagnosed at birth, we conducted a population-based, retrospective cohort study on singleton live births in Florida from 1998 to 2009. Primary exposures included maternal HBV and HCV monoinfection. The neurological outcomes included brachial plexus injury, cephalhematoma, foetal distress, feeding difficulties, intraventricular h aemorrhage and neonatal seizures. Multivariable logistic regression models were used to generate odds ratios (OR) and 95% confidence intervals (CI) that were adjusted for socio-demographic characteristics, risky behaviours, pregnancy complications and pre-existing medical conditions, and timing of delivery. The risk of an adverse neurological outcome was higher in infants born to mothers with hepatitis viral infection (7.2% for HCV, 5.0% for HBV), compared with infants of hepatitis virus-free mothers (4.2%). After adjusting for potential confounders, women with HBV were twice as likely to have infants who suffered from brachial plexus injury (OR = 2.04, 95% CI = 1.15-3.60), while those with HCV had an elevated odds of having an infant with feeding difficulties (OR: 1.32, 95% CI = 1.06-1.64) and a borderline increased likelihood for neonatal seizures (OR = 1.74, 95% CI = 0.98-3.10). Additionally, HCV+ mothers had a 22% increased odds of having an infant with some type of adverse neurological outcome (OR: 1.22, 95% CI = 1.03-1.44). Our findings add to current understanding of the association between maternal HBV/HCV infections and infant neurological outcomes. Further research evaluating the role of maternal HBV and HCV infections (including viraemia, treatment) on pregnancy outcomes is warranted.

Growth and development of children prenatally exposed to telbivudine administered for the treatment of chronic hepatitis B in their mothers

OBJECTIVES

We studied the growth and development of children prenatally exposed to telbivudine used to treat chronic hepatitis B virus (HBV) infection in their mothers.

METHODS

Maternal abnormalities during pregnancy and delivery and infant congenital anomalies, physical development status, developmental quotient (DQ), HBV vertical transmission status, and HBV vaccination outcomes of 54 infants were evaluated (2010-2013).

RESULTS

No fetal abnormalities were observed during pregnancy or delivery. Postpartum, three infants (5.56%) had abnormalities: ankyloglossia, cutaneous hemangioma, and vaginal canal leak. Height and weight were within the normal range at birth and at 6 weeks, but were higher than the reference at 12 months (p<0.05). Body mass index increased gradually with age (p<0.05). DQ scores were normal (84.81%, 229/270) in 37 children (68.52%), abnormal or suspicious for a developmental delay (15.19%, 41/270) in 17 children (31.48%), and indicated a developmental delay (4.07%, 11/270) in seven children (12.96%). There were no significant differences in developmental delay between children prenatally exposed to telbivudine and controls (p>0.05). HBV vertical transmission was successfully blocked in all infants. The effective HBV vaccination rate was 98.15% (53/54).

CONCLUSIONS

The growth and development of children prenatally exposed to telbivudine was normal, indicating that telbivudine treatment during pregnancy is safe and effective.

Current developments in nucleoside/nucleotide analogues for hepatitis B

There had been remarkable development in nucleos(t)ide analogues (NAs) and evolution in treatment strategies in last 15 years. Currently, there are five NAs available for chronic hepatitis B treatment, namely lamivudine, telbivudine and entecavir (nucleoside analogues), adefovir dipivoxil and tenofovir disoproxil fumarate (nucleotide analogues). The advantages of relatively infrequent side effects and easy administration per oral make NAs popular treatment options. The major drawback of earlier generation NAs is the risk of emergence of drug resistance. Current international guidelines recommend the use of more potent agents with high genetic barriers to resistance including entecavir and tenofovir as first line chronic hepatitis B treatment. However, there is no consensus regarding the subsequent treatment regimens in patients with suboptimal responses to NAs. De novo combination therapy of two NAs, response-guided therapy and roadmap concept in NAs with subsequent switch or add-on therapy can also potentially improve treatment efficacy and avoid resistance.

Clinical features and outcome of acute hepatitis B in pregnancy

Background

The impact of pregnancy on the clinical course of acute hepatitis B (AHB) is still largely unclear, mainly because most studies have not included matched controls. This study was conducted to investigate the clinical features and outcome of AHB in pregnancy using matched controls.

Methods

Consecutive AHB inpatients who were admitted to Jinan Infectious Disease Hospital, Jinan, between January 2006 and December 2010 were evaluated and followed. Demographic data, clinical manifestations, and results of laboratory tests were compared between pregnant patients and age and sex matched non-pregnant patients at admission, discharge, and final follow-up.

Results

A total of 618 AHB inpatients were identified during the study period. 22 pregnant patients and 87 age and sex matched non-pregnant patients were enrolled in this study. Prodromal fever was less common (0% vs. 20.7%, P = 0.02), serum alanine aminotransferase levels were significantly lower, and HBsAg > 250 IU/mL rate and serum bilirubin levels were significantly higher in pregnant patients than in non-pregnant patients. After a mean (range) of 7(5.2-8.3) months follow-up, 18.2% pregnant patients and 4.6% non-pregnant patients were still HBsAg positive (P = 0.03). For pregnant patients, the relative risk (95% confidence interval) of HBsAg positive at the end of follow-up was 4.6 (1.1-20.2). The median (95% confidence interval) days of HBsAg seroclearance form disease onset in pregnant and non-pregnant patients were 145.0 (110.5-179.5) and 80.0 (62.6-97.4), respectively.

Conclusions

The HBsAg loss and seroconversion were delayed and lower in pregnant patients. Pregnancy might be a possible risk of chronicity following acute HBV infection.

Incomplete hepatitis B immunization, maternal carrier status, and increased risk of liver diseases: a 20-year cohort study of 3.8 million vaccinees

Hepatitis B immunization has been documented to prevent fulminant hepatic failure (FHF) and hepatocellular carcinoma (HCC) by historical comparison studies in Taiwan. This study aimed to assess long-term risks and predictors of various liver diseases associated with incomplete immunization in 3.8 million vaccinees. Profiles of the National Hepatitis B Immunization Registry, National Cancer Registry, and National Death Certification Registry were linked to ascertain newly diagnosed cases of HCC and deaths from FHF and chronic liver diseases (CLDs) from infancy to early adulthood of 3,836,988 newborn vaccinees. Cox's proportional hazards models were used to estimate hazard ratios (HRs) for various risk predictors. There were 49 newly developed cases of HCC, 73 deaths from FHF, and 74 deaths from CLDs during the follow-up of 41,854,715 person-years. There were striking differences between unvaccinated and vaccinated newborns after the launch of a national immunization program for HCC incidence (0.293 vs. 0.117 per 100,000 person-years), FHF mortality (0.733 vs. 0.174 per 100,000 person-years), and CLD mortality (2.206 vs. 0.177 per 100,000 person-years). Among vaccinees, incomplete immunization was the most important risk predictor of HCC, FHF, and CLDs, showing an HR (95% confidence interval, P value) of 2.52 (1.25-5.05; P = 0.0094), 4.97 (3.05-8.11; P < 0.0001), and 6.27 (3.62-10.84; P < 0.0001), respectively, after adjustment for maternal hepatitis B serostatus.

CONCLUSION

Hepatitis B immunization can significantly prevent the long-term risk of HCC, FHF, and CLDs from infancy to early adulthood. Incomplete immunization with hepatitis B immunoglobulin or vaccines was the most important risk predictor of the liver disease among vaccinees.

Comparison of telbivudine versus lamivudine in interrupting perinatal transmission of hepatitis B virus

BACKGROUND

Infection with hepatitis B virus (HBV) during pregnancy may lead to perinatal transmission.

OBJECTIVES

To compare the efficacy and safety of telbivudine versus lamivudine in interrupting perinatal transmission of hepatitis B virus.

STUDY DESIGN

All pregnant women enrolled in this study were positive for hepatitis B surface antigen (HBsAg) and hepatitis B e antigen (HBeAg). Test patients underwent antiviral therapy with telbivudine or lamivudine while control patients received hepatitis B immune globulin (HBIG) injection.

RESULTS

Patients in the telbivudine group had significantly lower HBV DNA and HBeAg levels and higher HBV DNA negative conversion rates compared to those in the lamivudine group before delivery. HBV DNA negative conversion rates in patients with abnormal alanine aminotransferase (ALT) levels were significantly higher than those in patients with normal ALT levels in the telbivudine and lamivudine groups before delivery. The intrauterine HBV infection rate and the percentage of immunization failure were both 0% in the telbivudine and lamivudine groups (χ(2)=0, 0; P=1, 1 respectively), compared to both 5% in the HBIG group (χ(2)=11.83, 7.86; P=0.002, 0.009 respectively). The side effects of three groups in mother and child were all unobvious.

CONCLUSIONS

Telbivudine and lamivudine can reduce HBV DNA levels in pregnant women, interrupt the vertical transmission of HBV and be used safely in mothers and children.

Vertical transmission of hepatitis B virus: challenges and solutions

More than 240 million people worldwide are chronically infected with hepatitis B virus (HBV). Mother-to-child transmission remains the most important mechanism of infection in countries with a high prevalence of HBV. Universal screening of all pregnant women, at-birth prophylaxis with specific anti-HBV immune globulin, as well as HBV vaccination for newborns of infected mothers are effective in reducing the risk of vertical transmission. However, in cases of a high viral load and hepatitis B e antigen positivity, there is a residual risk of HBV transmission to the newborn despite prophylaxis. This review focuses on the above-indicated strategies and on the efficacy and safety of antiviral drugs administered during the third trimester of pregnancy.

Prevention of mother-to-child transmission of hepatitis B virus and hepatitis C virus

About 240 million people worldwide are chronically infected with hepatitis B virus (HBV). Vertical transmission is the most important mechanism of infection persistence in endemic areas. About 150 million people worldwide are chronically infected with hepatitis C virus (HCV). Mother-to-child transmission of HCV, which occurs in 3-10% of cases, is the leading route of infection in childhood. This review focuses on strategies to reduce the vertical transmission of HBV and HCV. The at-birth prophylaxis of newborns of HBV-infected mothers with specific immunoglobulin and vaccine plus administration of antivirals (tenofovir or telbivudine) in the third trimester of pregnancy (in case of high maternal viral load) greatly reduces the risk of transmission. In contrast, currently there is no drug able to reduce the vertical transmission of HCV infection. We discuss the possibility of reducing mother-to-child HCV transmission using newly available antivirals or antivirals in the pipeline for the treatment of hepatitis C.

Knowledge of hepatitis B virus infection, access to screening and vaccination among pregnant women in Ibadan, Nigeria

The knowledge of pregnant women about Hepatitis B virus infection at three different levels of healthcare and their access to screening and vaccination was evaluated by a questionnaire-based cross-sectional study. There were 643 respondents with a mean age of 30.2 ± 5.2 years and mean gestational age of 26.1 ± 8.4 weeks. The distribution of respondents was 55 (8.6%, primary), 204 (31.7%, secondary) and 383 (59.6%, tertiary) women. The majority of respondents were traders (36%) or civil servants/professionals (28.6%). Overall, 76% of all women had inadequate knowledge about hepatitis B infection; 19.5% had been screened, while 9.7% had been vaccinated. There was an increased likelihood of adequate knowledge, previous screening and vaccination among health workers (p = 0.00). Other positive predictors of knowledge and vaccination were tertiary education (p = 0.04) and tertiary care (p = 0.00). There is inadequate knowledge among pregnant women in Ibadan about Hepatitis B infection, with significant differences at the various levels of care, particularly in non-tertiary settings where screening and vaccination is also sub-optimal. Information dissemination, universal screening and vaccination services for pregnant women in Nigeria require urgent consideration.

Efficacy and safety of tenofovir disoproxil fumarate in pregnancy for the prevention of vertical transmission of HBV infection

AIM: To evaluate the effects of tenofovir disoproxil fumarate (TDF) use during late pregnancy to reduce hepatitis B virus (HBV) transmission in highly viremic mothers.

METHODS: This retrospective study included 45 pregnant patients with hepatitis B e antigen (+) chronic hepatitis B and HBV DNA levels > 10⁷ copies/mL who received TDF 300 mg/d from week 18 to 27 of gestation (n = 21). Untreated pregnant patients served as controls (n = 24). All infants received 200 IU of hepatitis B immune globulin (HBIG) within 24 h postpartum and 20 μg of recombinant HBV vaccine at 4, 8, and 24 wk. Perinatal transmission rate was determined by hepatitis B surface antigen and HBV DNA results in infants at week 28.

RESULTS: At week 28, none of the infants of TDF-treated mothers had immunoprophylaxis failure, whereas 2 (8.3 %) of the infants of control mothers had immunoprophylaxis failure (P = 0.022). There were no differences between the groups in terms of adverse events in mothers or congenital deformities, gestational age, height, or weight in infants. At postpartum week 28, significantly more TDF-treated mothers had levels of HBV DNA < 250 copies/mL and normalized alanine aminotransferase compared with controls (62% vs none, P < 0.001; 82% vs 61%, P = 0.012, respectively).

CONCLUSION: TDF therapy during the second or third trimester reduced perinatal transmission rates of HBV and no adverse events were observed in mothers or infants.

Prevalence, correlates and pattern of Hepatitis B among antenatal clinic attenders in Yaounde-Cameroon: is perinatal transmission of HBV neglected in Cameroon?

BACKGROUND

Few studies have evaluated the prevalence of HBV in the general Cameroonian population or among antenatal attendants. The aim of this study was to determine the prevalence, correlates and patterns of Hepatitis B surface antigen among pregnant women attending antenatal care in Yaounde-Cameroon.

METHODS

This was a cross-sectional multicenter study carried out in a referral hospital and two secondary hospitals in Yaounde, the capital of Cameroon. The study lasted 15 months (March 2011 to June 2012), and recruited 959 pregnant women. Patient recruitment was consecutive. The HBsAg was tested using the Monalisa HBsAg Ultra ELISA kit. Other hepatitis B markers were equally tested.

RESULTS

The prevalence of hepatitis B infection (HBsAg) among antenatal clinic attenders in our setting was 7.7%. Amongst these women, just 5.4% were previously aware of their HBsAg status. The rate of HBV infectivity was high, with 28% of HBsAg positive women having evidence of HBeAg in their plasma, and up to 45.8% of these women lacking antibodies against hepatitis B e antigen (anti-HBe). About 41% of the pregnant women had had previous contact with HBV as evidenced by the positive status for anti-HBc.

CONCLUSION

The prevalence of hepatitis B among pregnant women in Cameroon is high, and the pattern tends towards high infectivity and therefore increased risk of perinatal HBV transmission. These highlight the need to step up preventive efforts against hepatitis B infection and perinatal HBV transmission in our community.

Regional and ethnic aspects of viral hepatitis B among pregnant women

OBJECTIVES

The aim of this study was to determine the prevalence of HBV infection among pregnant women in districts of Eastern Slovakia with a diverse prevalence of Roma population.

METHODS

Overall 59,279 serum samples from 9 regional departments of clinical microbiology from Eastern Slovakia were collected in the period from January 2008 till December 2009 and analysed.

RESULTS

The number of HBsAg positive samples overall and during pregnancy was 1.74% and 2.12%, respectively. Comparing districts with higher (> 5%) and lower (< 5%) Roma population, there was no significant difference in the prevalence of HBsAg positive samples overall (1.95% vs.1.62%). However, in the subgroup of pregnant women the prevalence of HBsAg positive samples (2.72% vs. 0.95%) differs significantly (p < 0.01).

CONCLUSIONS

The prevalence of HBV infection among pregnant women in Eastern Slovakia did not rapidly exceed the estimated nationwide prevalence. However, in districts with higher Roma population the expected higher prevalence of HBV infection was confirmed. This indicates the need to pay special attention to the prevention of hepatitis B in these districts.

Safety of telbivudine treatment for chronic hepatitis B for the entire pregnancy

Orally administered nucleus(t)ide analogues (NA) have brought about a simple, safe and effective therapeutic approach for chronic hepatitis B (CHB). However, treatment duration is long and some female patients become pregnant during treatment. In recent years, there have been gradually increasing reports on the safety of telbivudine (LdT) treatment for chronic hepatitis B virus (HBV) infection in the third trimester of pregnancy to block mother-to-infant transmission (MTIT) of HBV; however, the safety of LdT treatment for chronic HBV infection for the entire pregnancy has not been reported. The aim of the present study was to evaluate the safety of LdT treatment for chronic HBV infection for the entire pregnancy and provide a reference for HBV-infected fertile women on how to block MTIT of HBV. Eighty-six pregnant women who received LdT treatment either before or in early pregnancy were enrolled in the study. Adverse events were prospectively observed for the entire pregnancy and perinatal period, and short-term and long-term follow-up of infants was conducted, monitoring the abnormalities of infants and blocking rate of MTIT with LdT treatment. Eighty-six pregnant women treated with LdT had a total of 89 pregnancies: 6 (6.7%) had early embryonic death or spontaneous abortion, 1 (1.1%) had ectopic pregnancy and three had a second pregnancy after initial abortion. Fifty-one mothers completed pregnancy: one had induction of labour at 24 weeks of pregnancy for cleft lip and palate of the foetus and 50 delivered 52 full-term live infants. One infant had right ear accessories, and the total occurrence of congenital abnormality was 3.8%. Thirty-nine infants were followed up for more than 6 months and completed all examinations for MTIT. None of the infants were HBsAg positive, resulting in a 100% success rate of blocking MTIT. All mothers maintained good liver function during the third trimester of pregnancy; 86% maintained complete virological response (HBV DNA <500 copies/mL) prior to delivery, and none developed progression of liver disease. Factors leading to increased adverse effects and drug resistance were not found. LdT treatment is safe and effective in chronic HBV-infected pregnant mothers for the entire pregnancy.

Efficacy of telbivudine on interruption of hepatitis B virus vertical transmission: a meta-analysis

BACKGROUND AND OBJECTIVES

Hepatitis B virus (HBV) infection is one of the most common infections in the world. Vertical transmission is the main reason for the continued endemic infection rates, at least in Asia. This study aimed to investigate the efficacy of telbivudine on mother-to-child transmission (MTCT) interruption.

METHODS

Studies up to April 2012 were collected by searching Pubmed, EMBASE, the Cochrane Library, EBM Review, WangFang Database and China National Knowledge Infrastructure. Serum hepatitis B surface antigen (HBsAg) and HBV DNA in newborns and infants, maternal HBV DNA negative conversion and alanine trans.aminase (ALT) normalization and adverse events were analyzed.

RESULTS

Seven clinical trials involving 644 pregnant women were included in this meta-analysis. Telbivudine resulted in lower HBsAg and HBV DNA seroprevalence in newborns and infants. When maternal viral load prior to delivery was higher than 103copies/mL, HBsAg or HBV DNA positivity had no statistical difference.

CONCLUSIONS

Telbivudine treatment has efficacy and safety on MTCT interruption during late pregnancy. In addition, we demonstrated benefit of telbivudine for mothers in terms of HBV DNA negative conversion and ALT normalization. Telbivudine treatment at the end of pregnancy should be considered in women with high viral load.

Optimal management of HBV infection during pregnancy

Chronic hepatitis B virus (HBV) infection in pregnancy presents a unique and important challenge. Over 50% of chronic HBV carriers in endemic areas acquire infection vertically from their mothers. More importantly, over 90% of perinatally acquired infections progress to chronic HBV infection. Thus, management of chronic HBV during pregnancy and strategies to prevent mother-to-child transmission is an important step in eradicating or reducing the global burden of chronic hepatitis B. In addition, chronic HBV infection in pregnancy presents a unique clinical challenge because of the complex relationship between the physiological changes of pregnancy and the pathophysiological response to HBV. This review will present the current knowledge and a practical approach to management of HBV in pregnancy.

An update after 16 years of hepatitis B vaccination in South Africa

Hepatitis B (HB) virus (HBV) infection is highly endemic with at least 65 million chronic HB surface antigen (HBsAg) carriers in Africa, 25% of whom are expected to die from liver disease. Before the introduction of the HB vaccine, the prevalence of chronic carriage of HBV in black South Africans was 9.6%, with 76% having been previously exposed to HBV. The major transmission route in South Africa is unexplained horizontal transmission between toddlers, with most transmission occurring before the age of 5 years. During adolescence and early adulthood, sexual transmission becomes the dominant route, while healthcare workers (HCWs) are also at risk for parenteral/percutaneous transmission during occupational exposures. In 1995 the South African Department of Health (SADoH) incorporated the HB vaccine, administered as a monovalent, into the Expanded Programme on Immunisation (EPI) at 6, 10, and 14 weeks of age, and studies conducted thereafter have found it to be safe and highly effective. Catch-up vaccination for adolescents was not introduced and there is no schools-based vaccination programme. The SADoH recommends HB vaccination of HCWs, but this is not mandatory and there is no national policy, thus HB vaccination uptake in HCWs is sub-optimal. Since 1995, studies on children have found that the prevalence of chronic HBsAg carriage has decreased, as has the incidence of paediatric hepatocellular carcinoma and HBV-related membranous nephropathy. The SADoH should focus their efforts on attaining a high infant HB vaccine coverage, prepare for introducing a HB birth dose, and consider using a hexavalent vaccine (DTaP-IPV-Hib-HepB). The department may also want to consider including targeted HB vaccination for 12 year-olds, if their Road to Health Cards show they were not vaccinated as infants. A national policy is needed for HCWs to ensure that they are fully vaccinated and protected against HBV infection.

HBV perinatal transmission

Hepatitis B is a serious public health problem all around the world. It is a blood-borne and sexually transmitted DNA virus in adults, but mother to child transmission of hepatitis B virus also occurs in infants born to hepatitis B surface antigen positive mothers.

Safety of lamivudine treatment for chronic hepatitis B in early pregnancy

AIM: To evaluate the safety of lamivudine (LAM) treatment for chronic hepatitis B in early pregnancy.

METHODS: A total of 92 pregnant women who received LAM treatment either before pregnancy or in early pregnancy were enrolled in this study. All of the pregnant women volunteered to take lamivudine during pregnancy and were not co-infected with hepatitis C virus, human immunodeficiency virus, cytomegalovirus, or other viruses. All infants received passive-active immunoprophylaxis with 200 IU hepatitis B immunoglobulin and three doses of 10 μg hepatitis B vaccines (0-1-6 mo) according to the guidelines for the prevention and treatment of chronic hepatitis B. Adverse events were observed throughout the entire pregnancy and perinatal period, and the effectiveness of lamivudine treatment for blocking mother-to-infant transmission of hepatitis B virus (HBV) was evaluated. All adverse events in mothers and infants during pregnancy and the perinatal period and the HBV mother-to-infant transmission blocking rate were compared with the literature.

RESULTS: Among the 92 pregnant women, spontaneous abortions occurred in 11 cases, while 3 mothers had a second pregnancy after the initial abortion; 72 mothers delivered 73 live infants, of whom 68 infants were followed up for no less than 6 mo, and 12 mothers were still pregnant. During pregnancy, the main maternal adverse events were vaginitis (12/72, 16.7%), spontaneous abortion (11/95, 11.6%), and gestational diabetes (6/72, 8.3%); only one case had 1-2 degree elevation of the creatine kinase level (195 U/L). During the perinatal period, the main maternal adverse events were premature rupture of the membranes (8/72, 11.1%), preterm delivery (5/72, 6.9%), and meconium staining of the amniotic fluid (4/72, 5.6%). In addition, 2 infants were found to have congenital abnormalities; 1 had a scalp hemangioma that did not change in size until 7 mo, and the other had early cerebral palsy, but with rehabilitation training, the infant’s motor functions became totally normal at 2 years of age. The incidence of adverse events among the mothers or abnormalities in the infants was not higher than that of normal mothers or HBV-infected mothers who did not receive lamivudine treatment. In only 2 cases, mother-to-infant transmission blocking failed; the blocking rate was 97.1% (66/68), which was higher than has been previously reported.

CONCLUSION: Lamivudine treatment is safe for chronic HBV-infected pregnant mothers and their fetuses with a gestational age of less than 12 wk or throughout the entire pregnancy.

Hepatitis B: Treatment to prevent perinatal transmission

Hepatitis B remains a significant health issue and a leading cause of cirrhosis and hepatocellular carcinoma worldwide. Transmission of the hepatitis B virus, despite the availability of the vaccine, still occurs, particularly in the perinatal setting. Studies have shown that mothers with active viremia especially those with very high viral levels (>10⁸ copies/mL or >10⁷ IU/mL) are at increased risk of hepatitis B virus transmission, even with appropriate immunoprophylaxis at birth. With the development of new and relatively safe oral antiviral therapies, assessment with the mother about the risks and benefits of antiviral therapy should be discussed in those with highest transmission risk.

Hepatitis B in pregnancy

Chronic hepatitis B virus (HBV) infection affects about 350 million individuals worldwide. Management of HBV infection in pregnancy is difficult because of several peculiar and somewhat controversial aspects. The aim of the present review is to provide a tool that may help physicians to correctly manage HBV infection in pregnancy. This review focuses on (1) the effect of pregnancy on HBV infection and of HBV infection on pregnancy; (2) the potential viral transmission from mother to newborn despite at-birth prophylaxis with immunoglobulin and vaccine; (3) possible prevention of mother-to-child transmission through antiviral drugs, the type of antiviral drug to use considering their efficacy and potential teratogenic effect, and the timing of their administration and discontinuation; and (4) the evidence for the use of elective caesarean section vs vaginal delivery and the possibility of breastfeeding.

Management of chronic hepatitis B in pregnancy

Pregnancy associated with chronic hepatitis B (CHB) is a common and important problem with unique challenges. Pregnant women infected with CHB are different from the general population, and their special problems need to be considered: such as the effect of hepatitis B virus (HBV) infection on the mother and fetus, the effect of pregnancy on replication of the HBV, whether mothers should take HBV antiviral therapy during pregnancy, the effect of these treatments on the mother and fetus, how to carry out immunization of neonates, whether it can induce hepatitis activity after delivery and other serious issues. At present, there are about 350 million individuals with HBV infection worldwide, of which 50% were infected during the perinatal or neonatal period, especially in HBV-endemic countries. Currently, the rate of HBV infection in the child-bearing age group is still at a high level, and the infection rate is as high as 8.16%. Effective prevention of mother-to-child transmission is an important means of reducing the global burden of chronic HBV infection. Even after adopting the combined immunization measures, there are still 5%-10% of babies born with HBV infection in hepatitis B e antigen positive pregnant women. As HBV perinatal transmission is the main cause of chronic HBV infection, we must consider how to prevent this transmission to reduce the burden of HBV infection. In this population of chronic HBV infected women of childbearing age, specific detection, intervention and follow-up measures are particularly worthy of attention and discussion.

The effects of telbivudine in late pregnancy to prevent intrauterine transmission of the hepatitis B virus: a systematic review and meta-analysis

Chronic hepatitis B virus (HBV) infection poses a serious public health problem in many parts of the world. Presently, even with proper joint immunoprophylaxis, approximately 10-15% of newborns from HBV carrier mothers suffer from HBV infection through intrauterine transmission. One of the risk factors is the level of maternal viraemia. Telbivudine is a synthetic thymidine nucleoside analogue with activity against HBV. A few studies have evaluated the efficacy of telbivudine in preventing intrauterine HBV infection during late pregnancy. So we conducted this meta-analysis to arrive at an evidence-based conclusion. We searched Medline/PubMed, EMBASE, Cochrane Library, Web of Knowledge and China Biological Medicine Database from January 1990 to December 2011. Relative risks (RR) of the seropositivity rates for hepatitis B surface antigen (HBsAg) and HBV DNA in newborns and infants were studied. Mean differences (MD) in maternal HBV DNA levels were reviewed. Finally two randomised controlled trials (RCTs) and four non-randomised controlled trials (NRCTs) were left for analysis which included 576 mothers in total, of whom 306 received telbivudine treatment and 270 did not receive any drug. All newborns received hepatitis B vaccine (HBVac) and hepatitis B immunoglobulin (HBIG) after birth. The seropositivity rate for HBsAg or HBV DNA was significantly lower in the telbivudine group, both at birth and at 6–12 months follow up. Meanwhile, maternal HBV DNA levels prior to delivery were significantly lower in the telbivudine group. In addition, the frequency of serum creatine kinase (CK) elevation was similar in the two groups. Our meta-analysis provides preliminary evidence that telbivudine application in late pregnancy is effective in the interruption of intrauterine HBV infection, with no significant adverse effects or complications. More high quality, well-designed, double-blinded, randomised controlled and large size clinical trials are needed for further investigation and more convincing results in the future.

[Blood-borne infections and the pregnant health care worker. Risks and preventive measures]

Due to the increasing proportion of women in health care, as well as changes in working conditions (implementation of safety devices, minimally invasive/endoscopic procedures) the question arises whether the applicable laws and regulations for the protection of working mothers are outdated and should be updated.Individual risk analysis, as well as the inclusion of the pregnant health care worker in the decision-making process with regard to continuation or modification of the work practice serves as a protection of the expectant mother and unborn child and allows a continuation of the occupational activities.

Tenofovir in the management of chronic hepatitis B infection during pregnancy

Chronic hepatitis B infection has a worldwide distribution, with approximately 350 million infected persons. While become more of an issue during pregnancy concerning maternal and fetal well-being and the influence of pregnancy itself on the course of the disease; the natural history of chronic hepatitis B infection during pregnancy has not been clearly established. This paper reports the outcome of pregnancy in a patient with chronic hepatitis B infection who discontinued double antiviral treatment since she wanted to get pregnant but then was administered tenofovir disoproxil fumarate (TDF; 245 mg/day) monotherapy at the 32(nd) gestational week.

Telbivudine prevents vertical transmission from HBeAg-positive women with chronic hepatitis B

BACKGROUND & AIMS

Telbivudine reduces hepatitis B virus (HBV) DNA and normalizes levels of alanine aminotransferase (ALT) in patients with chronic hepatitis B (CHB). We investigated its use in preventing vertical transmission.

METHODS

We performed an open-label, prospective study of 88 hepatitis B (HB) e antigen (HBeAg)-positive pregnant women with CHB, levels of HBV DNA >6 log(10) copies/mL, and increased levels of ALT. Women were given telbivudine (n = 53) starting in the 2nd or 3rd trimester, or no treatment (controls, n = 35) and followed until postpartum week (PPW) 28. All infants received standard immunoprophylaxis after birth.

RESULTS

At 28 weeks, none of the infants whose mothers received telbivudine had immunoprophylaxis failure, whereas 8.6% of the infants of control mothers did (P = .029). There were no differences between groups in mothers' adverse events or infants' congenital deformities, gestational age, height, and weight, or Apgar scores. At postpartum week 28, significantly more telbivudine-treated mothers had levels of HBV DNA <500 copies/mL, normalized levels of ALT, and hepatitis B e antigen seroconversion compared with controls (58% vs none, P < .001; 92% vs 71%; P = .008; and 15% vs none; P < .001, respectively) but none had loss of hepatitis B surface antigen. Telbivudine-treated mothers had no virologic breakthrough (HBV DNA >1 log(10) increase from <500 copies/mL) or discontinuations from adverse events. After delivery, 13/52 patients discontinued telbivudine due to preference. There were no episodes of severe hepatitis (levels of ALT >10 times the upper limit of normal) in either group during 28 weeks of postpartum observation.

CONCLUSIONS

Women with CHB given telbivudine during the second or third trimester of pregnancy have reduced rates of perinatal transmission. Telbivudine produced no adverse events in mothers or infants by 28 weeks.

Hepatitis B virus infection and pregnancy: a practical approach

Hepatitis B virus (HBV) infection is a global problem and the world has 350 million carriers of chronic hepatitis B. Over 50 % of these have acquired their infection vertically from their mothers (mother-to-child transmission [MTCT]). Majority (>90 %) of vertically-acquired infection results into chronic infection, due to induction of an immune-tolerant state. Hence, management of chronic HBV during pregnancy and strategies to prevent MTCT would go a long way in global control of HBV infection and the morbidity and mortality associated with it. However, chronic HBV infection in pregnancy presents a unique challenge, because of existence of a complex relationship between the physiological changes of pregnancy and the pathophysiological response of body to HBV. This relationship may lead to a varied presentation of the patient to the doctor depending on the period of her pregnancy and stage of her liver disease. Each of these modes of presentation raises issues that need to be addressed for successful maternal and fetal outcome, including prevention of MTCT of HBV. This review will try to give a practical approach in addressing these issues.

Effects of maternal screening and universal immunization to prevent mother-to-infant transmission of HBV

BACKGROUND & AIMS

Mother-to-infant transmission is the major cause of hepatitis B virus (HBV) infection among immunized children. There has been much debate about screening pregnant women and administering hepatitis B immunoglobulin (HBIG) to newborns. We analyzed the rate of HBV infection among children born to hepatitis B surface antigen (HBsAg)-positive mothers and whether HBIG administration reduces transmission.

METHODS

We analyzed data from 2356 children born to HBsAg-positive mothers, identified through prenatal maternal screens. In addition to HBV vaccines, HBIG was given to all 583 children with hepatitis B e antigen (HBeAg)-positive mothers and to 723 of 1773 children with HBeAg-negative mothers. Serology tests for HBV were performed from 2007 to 2009, when children were 0.5-10 years old.

RESULTS

A significantly greater percentage of children with HBeAg-positive mothers tested positive for antibodies against the hepatitis B core protein (16.76%) and HBsAg (9.26%) than children with HBeAg-negative mothers (1.58% and 0.29%, respectively; P < .0001 and <.001). Among the HBV-infected children, the rate of chronicity also was higher among children with HBeAg-positive mothers than children with HBeAg-negative mothers (54% vs 17%; P = .002). Similar rates of antibodies against the hepatitis B core protein (0.99% and 1.88%; P = .19) and HBsAg (0.14% and 0.29%; P = .65) were noted in children born to HBeAg-negative mothers who were or were not given HBIG. Infantile fulminant hepatitis developed in 1 of 1050 children who did not receive HBIG (.095%).

CONCLUSIONS

Children born to HBeAg-positive mothers are at greatest risk for chronic HBV infection (9.26%), despite immunization. Administration of HBIG to infants born to HBeAg-negative mothers did not appear to reduce the rate of chronic HBV infection, but might prevent infantile fulminant hepatitis. Screening pregnant women for HBsAg and HBeAg might control mother-to-infant transmission of HBV.

Management of severe acute to fulminant hepatitis B: to treat or not to treat or when to treat?

Despite a decline in cases of acute hepatitis B and the low hepatitis B virus (HBV) chronicity rates in adults, still some patients progress to HBV-related fulminant liver failure. In this review, we discuss treatment options that may prevent the progression of severe acute hepatitis B to fulminant liver failure and death. In severe acute HBV with prolonged prothrombin time and increased bilirubin, interferon failed to be effective while antiviral treatment, particularly with lamivudine, appears to improve survival (mean survival almost 80%). Outcome without antiviral therapy has remained considerably poor, whereas there is no convincing evidence of amelioration of HBV-targeted immunity. Of note, most patients who died or required transplantation despite lamivudine therapy, were started on lamivudine at advanced stages compared with those survived. This suggests that prompt and timely antiviral therapy is crucial. Owing to the abovementioned results the design of randomized placebo-control trials in the setting of severe acute hepatitis B seems unethical. On the contrary, the design of multicentre double-blind randomized trials to compare the efficacy between lamivudine and entecavir or even tenofovir in acute severe HBV cases is ideally needed, but these studies appear to be very difficult to perform considering that these cases are not frequent and therefore, it is almost impossible to have two arms adequately numerous and homogenous for statistical evaluation. Thus, in the absence of solid evidence based data, the hepatologists could treat their patients with severe acute hepatitis B with lamivudine or the most potent antivirals entecavir or tenofovir.

Hepatitis B surface gene 145 mutant as a minor population in hepatitis B virus carriers

BACKGROUND

Hepatitis B virus (HBV) can have mutations that include the a determinant, which causes breakthrough infection. In particular, a single mutation at amino acid 145 of the surface protein (G145) is frequently reported in the failure of prophylactic treatment. The aim of this study was to evaluate the frequency of the a determinant mutants, especially the G145 variant, in Japan, where universal vaccination has not been adopted.

METHODS

The present study was a retrospective study. The study cohorts were defined as follows: group 1, children with failure to prevent mother-to-child transmission despite immunoprophylaxis (n = 18, male/female = 8/10, age 1-14 years; median 6 years); group 2, HBV carriers who had not received vaccination or hepatitis B immunoglobulin (n = 107, male/female = 107, age 1-52 years; median 16 years). To detect the G145R and G145A mutants in patients, we designed 3 probes for real-time PCR. We also performed direct sequencing and cloning of PCR products.

RESULTS

By mutant-specific real-time PCR, one subject (5.6%) was positive for the G145R mutant in group 1, while the G145 mutant was undetectable in group 2. The a determinant mutants were detected in one (5.6%) of the group 1 subjects and 10 (9.3%) of the group 2 subjects using direct sequencing, but direct sequencing did not reveal the G145 mutant as a predominant strain in the two groups. However, the subject who was positive according to the mutant-specific real-time PCR in group 1 had overlapped peaks at nt 587 in the electropherogram. In group 2, 11 patients had overlapped peaks at nt 587 in the electropherogram. Cloning of PCR products allowed detection of the G145R mutant as a minor strain in 7 (group 1: 1 subject, group 2: 6 subjects) of 12 subjects who had overlapped peaks at nt 587 in the electropherogram.

CONCLUSIONS

The frequency of the a determinant mutants was not high in Japan. However, the G145R mutant was often present as a minor population in children and adults. HBV carriers might have the a determinant mutants as a minor form.

A prospective and open-label study for the efficacy and safety of telbivudine in pregnancy for the prevention of perinatal transmission of hepatitis B virus infection

BACKGROUND & AIMS

In the Asia-Pacific region, perinatal transmission of the hepatitis B virus (HBV) is the primary cause of chronic hepatitis B infection. Despite the use of HBIG and HBV vaccination, HBV perinatal transmission (PT) occurs in 10-30% of infants born to highly viremic mothers. We evaluated the efficacy and safety of LTD use during late pregnancy in reducing HBV transmission in highly viremic HBeAg+mothers.

METHODS

Two hundred and twenty-nine HBeAg+HBV DNA levels>1.0×10(7) copies/ml mothers received telbivudine 600 mg/day from week 20 to 32 of gestation (n=135) or served as untreated controls (n=94). All infants in both arms received 200 IU of HBIg within 12 h postpartum and recombinant HBV vaccine of 20 μg at 0, 1, and 6 months. HBsAg and HBV DNA results of infants at week 28 were used to determine perinatal transmission rate. All telbivudine treated subjects were registered in the Antiretroviral Pregnancy Registry.

RESULTS

Telbivudine treatment was associated with a marked reduction in serum HBV DNA and hepatitis B e antigen (HBeAg) levels and normalization of elevated ALT levels before delivery. A striking decline of HBV DNA levels started from treatment onset to week 4, and sustained in a low level since week 12. Forty-four (33%) of the 135 telbivudine-treated mothers and none (0%) of the untreated controls had polymerase chain reaction-undetectable viremia (DNA<500 copies/ml) at delivery. Seven months after delivery, the incidence of perinatal transmission was lower in the infants that completed follow-up born to the telbivudine-treated mothers than to the controls (0% vs. 8%; p=0.002). HBV DNA levels were only detectable in HBsAg+infants. No significant differences in anti-HBs levels were observed during postnatal follow-up. No serious adverse events were noted in the telbivudine-treated mothers or their infants.

CONCLUSIONS

Telbivudine used during pregnancy in CHB HBeAg+highly viremic mothers can safely reduce perinatal HBV transmission. Telbivudine was well-tolerated with no safety concerns in the telbivudine-treated mothers or their infants on short term follow up. These data support the use of telbivudine in this special population.

Effectiveness of the targeted hepatitis B vaccination program in Greenland

OBJECTIVES

To evaluate the effectiveness of the hepatitis B virus (HBV) vaccination program in Greenland, which targets children born to mothers who are positive for HBV surface antigen (HBsAg), we determined vaccination coverage, levels of postvaccination antibodies, and frequency of breakthrough infections in at-risk children.

METHODS

We conducted a population-based retrospective cohort study with data from nationwide registries. We identified all children born to HBsAg-positive mothers from 1992 to 2007 and collected data on their HBV vaccination status. In 2008 to 2010, we tested the children for HBV core antibody, HBsAg, and anti-HBsAg antibody (HBsAb).

RESULTS

Of 4050 pregnant women, 3.2% were HBsAg positive. Of 207 children born to these women, 20% received no vaccinations, and only 58% received at least 3 vaccinations. At follow-up, HBsAb levels in vaccinated children were much lower than expected, and 8 (6%) of 140 at-risk children had breakthrough infections, with 4 chronically infected (persistently HBsAg positive).

CONCLUSIONS

The prevention program targeting children at risk for HBV in Greenland is ineffective. HBV vaccination should be included in the universal childhood vaccination program, and postvaccination HBsAb levels should be monitored.

A meta-analysis of lamivudine for interruption of mother-to-child transmission of hepatitis B virus

AIM: To determine the therapeutic effect of lamivudine in late pregnancy for the interruption of mother-to-child transmission (MTCT) of hepatitis B virus (HBV).

METHODS: Studies were identified by searching available databases up to January 2011. Inclusive criteria were HBV-carrier mothers who had been involved in randomized controlled clinical trials (RCTs) with lamivudine treatment in late pregnancy, and newborns or infants whose serum hepatitis B surface antigen (HBsAg), hepatitis B e antigen (HBeAg) or HBV DNA had been documented. The relative risks (RRs) for interruption of MTCT as indicated by HBsAg, HBV DNA or HBeAg of newborns or infants were calculated with 95% confidence interval (CI) to estimate the efficacy of lamivudine treatment.

RESULTS: Fifteen RCTs including 1693 HBV-carrier mothers were included in this meta-analysis. The overall RR was 0.43 (95% CI, 0.25-0.76; 8 RCTs; P_{heterogeneity} = 0.04) and 0.33 (95% CI, 0.23-0.47; 6 RCTs; P_{heterogeneity} = 0.93) indicated by newborn HBsAg or HBV DNA. The RR was 0.33 (95% CI, 0.21-0.50; 6 RCTs; P_{heterogeneity} = 0.46) and 0.32 (95% CI, 0.20-0.50; 4 RCTs; P_{heterogeneity} = 0.33) indicated by serum HBsAg or HBV DNA of infants 6-12 mo after birth. The RR (lamivudine vs hepatitis B immunoglobulin) was 0.27 (95% CI, 0.16-0.46; 5 RCTs; P_{heterogeneity} = 0.94) and 0.24 (95% CI, 0.07-0.79; 3 RCTs; P_{heterogeneity} = 0.60) indicated by newborn HBsAg or HBV DNA, respectively. In the mothers with viral load < 10⁶ copies/mL after lamivudine treatment, the efficacy (RR, 95% CI) was 0.33, 0.21-0.53 (5 RCTs; P_{heterogeneity} = 0.82) for the interruption of MTCT, however, this value was not significant if maternal viral load was > 10⁶ copies/mL after lamivudine treatment (P = 0.45, 2 RCTs), as indicated by newborn serum HBsAg. The RR (lamivudine initiated from 28 wk of gestation vs control) was 0.34 (95% CI, 0.22-0.52; 7 RCTs; P_{heterogeneity} = 0.92) and 0.33 (95% CI, 0.22-0.50; 5 RCTs; P_{heterogeneity} = 0.86) indicated by newborn HBsAg or HBV DNA. The incidence of adverse effects of lamivudine was not higher in the mothers than in controls (P = 0.97). Only one study reported side effects of lamivudine in newborns.

CONCLUSION: Lamivudine treatment in HBV carrier-mothers from 28 wk of gestation may interrupt MTCT of HBV efficiently. Lamivudine is safe and more efficient than hepatitis B immunoglobulin in interrupting MTCT. HBV MTCT might be interrupted efficiently if maternal viral load is reduced to < 10⁶ copies/mL by lamivudine treatment.

Chronic hepatitis B in pregnancy: unique challenges and opportunities

Chronic hepatitis B (CHB) affects 350 million individuals worldwide. Perinatal transmission leads to high rates of chronic infection and complications, including cirrhosis and hepatocellular carcinoma. It is important to recognize and appropriately treat CHB in pregnancy, thereby reducing the risk of neonatal transmission and HBV-associated morbidity and mortality. Screening for CHB is recommended in all pregnant mothers as is universal vaccination of infants with hepatitis B virus (HBV) vaccine with or without hepatitis B immunoglobulin (HBIG). This has resulted in a lower incidence of HBsAg seropositivity and HCC in regions where universal infant vaccination has been endorsed. Mode of delivery and breastfeeding do not appear to affect HBV transmission rates based on available data. Overall, CHB does not increase perinatal maternal-fetal mortality. Administration of oral antiviral therapy during the third trimester to HBsAg-positive mothers with HBV DNA≥7 log IU/mL may be useful in preventing breakthrough infection. Treatment may be considered earlier in pregnancy for persistently active liver disease shown by high ALT, HBV DNA levels and/or significant hepatic fibrosis. Lamivudine, tenofovir and telbivudine are safe and effective and are the agents of choice in pregnancy. However, further clinical studies are necessary to elucidate the role of antiviral therapy in the pregnant HBV carrier.

Evaluation of perinatal and intrafamilial hepatitis B prevention programmes in a well child clinic: 9-year follow-up study in Turkey

Evaluating the performance of well child clinics on adherence to recommended perinatal hepatitis B prevention programmes as well as assessing the outcome of infants living with hepatitis B surface antigen (HBsAg)-positive parents is important. A retrospective study was performed of 336 babies who had at least one HBsAg-positive parent and were followed-up in the well child clinic of Gazi University Hospital (Ankara, Turkey) between 2001 and 2009. Rates of passive immunisation in 109 babies with HBsAg-positive mothers and initiation of hepatitis B vaccination of all 336 babies with HBsAg-positive parents were 98.8% and 100% respectively. Ninety-two babies (27.4%) were lost to follow-up before completing primary immunisation. The recommended perinatal hepatitis B prevention programme was performed successfully in 194 of the 306 infants who were old enough for post-vaccination serotesting (63.4%). One baby became HBsAg-positive, and 88.1% of babies were seroprotected. Hepatitis B surface antibody (anti-HBs) levels were found to be increased if the HBsAg-positive parent was the father. There was a negative correlation between serotesting time and anti-HBs titres. The study infants had a total of 187 siblings and 123 (65.8%) were serotested after completing primary immunisation with 108 found to be seropositive. Although the vaccination rate in the perinatal hepatitis B prevention programme is satisfactory, post-vaccination serotesting and evaluation of infants and their siblings are still deficient.

Evaluation of the compliance with the protocol for preventing perinatal hepatitis B infection in Italy

OBJECTIVE

To evaluate the compliance with the protocol for preventing perinatal hepatitis B infection in Italy, including HBsAg screening of pregnant women and immunization of newborns to infected mothers.

METHODS

Women consecutively delivering, over 6 months in 2008-2009, in public and private hospitals of 13 Italian regions were recruited. Data on socio-demographic characteristics, HBsAg prenatal screening and newborns immunization were collected.

RESULTS

17,260 pregnant women were enrolled. Of them 16,858 (97.7%) attended prenatal screening. Delivering in a public hospital and in hospitals located in South Italy were both independent predictors of non-adherence to HBsAg screening. Foreign pregnant women were also less likely to be screened. Overall, HBsAg prevalence was 0.86%; it was 0.4% for Italian women and 2.5% for foreign women. Differences in prevalence by country of origin and education were statistically significant. Of 138 newborns from HBsAg positive mothers 131 received passive/active immunization; 7 newborns received just vaccine.

CONCLUSION

In this study compliance with the protocol for preventing perinatal hepatitis B was very good. Further efforts are needed to improve adherence to prenatal screening in public hospitals, in hospital located in southern Italy and among foreign women. HBV spread in Italy is progressively declining, also involving immigrant population.

Treatment of children with chronic hepatitis B virus infection in the United States: patient selection and therapeutic options

Chronic hepatitis B virus (HBV) infection in children presents a therapeutic challenge for the practitioner. Decisions regarding selection of patients who may benefit from treatment, appropriate timing of treatment, and the choice of antiviral therapy are complex and are compounded by the limited number of drugs that have been studied in children. An expert panel of nationally recognized pediatric liver specialists was convened by the Hepatitis B Foundation on August 11, 2009, to consider clinical practice relative to the therapeutic options available for children. A detailed account of these discussions is provided, and the opinions expressed are based on consensus of the experts, as well as on published evidence when available. The panel concludes that, at this time, there is no established benefit of treatment of children in the immune tolerant phase, and there is a very high risk of development of drug resistance. In addition, there is no indication for treatment of children in the inactive carrier state. For children in the immune active or reactivation phases, liver histology can help guide treatment decisions, and family history of liver disease, especially hepatocellular carcinoma, may argue for early treatment in some cases. Outside of clinical trials, interferon is the agent of choice in most cases. Nucleos(t)ide analogues are secondary therapies, and children who receive these agents require careful monitoring for development of resistance. There are a few situations when treatment is indicated regardless of HBV DNA or alanine aminotransferase levels. There is still much to be elucidated about the appropriate use of HBV therapy in children. Until more clinical data and therapeutic options are available, a conservative approach is warranted.

Breastfeeding and chronic HBV infection: Clinical and social implications

Mother-to-child transmission of hepatitis B virus (HBV) is among the most important causes of chronic HBV infection and is the commonest mode of transmission worldwide. Currently, the presence of HBsAg, HBeAg and HBV DNA in breast milk is confirmed. Several studies have reported that breastfeeding carries no additional risk that might lead to vertical transmission. Beyond some limitations, the surveys have not demonstrated any differences in HBV transmission rate regarding feeding practices in early childhood. Promotion of breastfeeding is substantial, especially for low-income individuals and regions with uncertain, unfeasible, and unsafe water supplies. Lactoferrin, minimal inflammation or activation within the infant gut during exclusive breastfeeding, and nonspecific biological molecules in the milk are identified as major factors of breast-milk defense. This review discusses preemptive antiviral therapy during pregnancy and lactation. Long-term follow up of breast-milk HBV concentrations and correlation with serum viral load; nucleos(t)ide analogue concentrations in breast milk in HBV-positive mothers in the setting of chronic HBV infection; safety of antiviral therapy during pregnancy and lactation; and the difference in viral load in the milk in exclusive or non-exclusive breastfeeding are still open questions. The paper reviews the current data and outlines the course of further investigation into this often underestimated issue.

Development of occult hepatitis B viral infection in pregnancy: implications for antenatal screening in women from endemic areas

Occult hepatitis B virus (HBV) infection, manifest clinically by the presence of HBV deoxyribonucleic acid (HBV DNA) in peripheral blood in individuals who test negative for the HBV surface antigen (HBsAg), may occur in various clinical contexts, including under the influence of pharmacological immunosuppression in patients from areas endemic for HBV and, hence, at risk of previous exposure. Pregnancy is a condition associated with immune suppression, but whether virus-specific immunity may be suppressed to an extent sufficient to allow occult HBV infection to develop is currently unknown. This is potentially relevant not only to the mother's health but also because vertical transmission has been reported in the occult HBV infection setting. We report a 30-year-old woman from a country endemic for HBV who, prior to pregnancy, was persistently HBsAg-negative with undetectable HBV DNA in peripheral blood, in whom HBV DNA became increasingly detectable during pregnancy, peaking in the third trimester, before returning to undetectable levels postpartum. HBsAg remained negative and liver function tests were normal throughout. Immunoglobulin M hepatitis B core antibody, a marker of the possibility of acquisition of a new HBV infection, was also negative. The baby received immunization against HBV infection from birth and has remained HBV negative at six months. This report documents for the first time that occult HBV infection may develop during pregnancy. Further data are required regarding the prevalence of this phenomenon, predisposing factors, impact on maternal health and risk of vertical transmission so that implications for current antenatal screening strategies that do not include measurement of HBV DNA in peripheral blood can be properly determined.

Management of chronic hepatitis B in pregnancy

Providing appropriate treatment and follow-up to hepatitis B virus (HBV)-infected mothers and their newborns is critical in preventing HBV mother-to-child transmission (MTCT) and eradicating HBV infection. Although highly effective in preventing MTCT, standard passive-active immunoprophylaxis with hepatitis B immunoglobulin and the hepatitis B vaccine may have a failure rate as high as 10% to 15%. Antiviral treatment has been used during pregnancy and may decrease MTCT. Several issues must be addressed in future clinical studies before universal recommendations for antiviral therapy for pregnant women can be made.

Pregnant women with chronic hepatitis B: an analysis of 55 cases

AIM: To analyze the clinical and pathological characteristics of chronic hepatitis B in pregnancy and to explore the relationship between pregnancy and hepatitis B virus (HBV) infection.

METHODS: The clinical data of 55 pregnant women with chronic hepatitis B were retrospectively analyzed and compared with those of pregnant HBV carriers and normal pregnant women. The clinical and pathological characteristics of chronic hepatitis B in pregnancy were then analyzed.

RESULTS: The morbility of hepatitis increased gradually with the increase in pregnancy duration. Compared with pregnant HBV carriers, ALT, AST, TBIL and DBIL significantly increased (210.2 U/L ± 144.7 U/L vs 22.7 U/L ± 11.6 U/L, 197.3 U/L ± 113.8 U/L vs 19.1 U/L ± 14.9 U/L, 64.9 μmol/L ± 37.8 μmol/L vs 6.8 μmol/L ± 5.8 μmol/L, and 44.2 μmol/L ± 23.8 μmol/L vs 4.8 μmol/L ± 2.2 μmol/L, respectively; all P < 0.05), and albumin and PTA decreased significantly (31.3 G/L ± 7.3 G/L vs 35.8 G/L ± 4.7 G/L; 66.4% ± 8.6% vs 82.1% ± 8.7%, both P < 0.05) in pregnant women with chronic hepatitis B. The rates of HBeAg positivity and high HBV DNA load were especially higher in pregnant women with chronic hepatitis B than in other groups of subjects.

CONCLUSION: HBV infection in pregnant women occurs mainly during the middle to late stages of pregnancy. Many cases of chronic hepatitis B in pregnancy are serious. HBeAg positivity and high HBV DNA load could be used as parameters for predicting the occurrence of HBV infection.