Cost-effectiveness of active-passive prophylaxis and antiviral prophylaxis during pregnancy to prevent perinatal hepatitis B virus infection

Hepatitis B Vaccine: Four Decades on

Hepatitis B virus is a substantial contributor to cirrhosis and hepatocellular carcinoma (HCC) globally. Vaccination is the most effective method for prevention of hepatitis B and its associated morbidity and mortality, and the only method to prevent infection with hepatitis D virus. The hepatitis B vaccine has been used worldwide for more than four decades; it is available in a single- or triple-antigen form and in combination with vaccines against other infections. Introduction of the vaccine and administration at birth led to sustained decline in mother-to-child transmission, chronic hepatitis B, and HCC, however, global birth dose coverage remains suboptimal. In this review we will discuss different hepatitis B vaccine formulations and schedules, vaccination guidelines, durability of the response, and vaccine escape mutants, as well as the clinical and economic benefits of vaccination.

Effects of hepatitis B virus infection and strategies for preventing mother-to-child transmission on maternal and fetal T-cell immunity

One of the most common routes of chronic hepatitis B virus (HBV) infection is mother-to-child transmission (MTCT). Approximately 6.4 million children under the age of five have chronic HBV infections worldwide. HBV DNA high level, HBeAg positivity, placental barrier failure, and immaturity of the fetal immune are the possible causes of chronic HBV infection. The passive-active immune program for children, which consists of the hepatitis B vaccine and hepatitis B immunoglobulin, and antiviral therapy for pregnant women who have a high HBV DNA load (greater than 2 × 10⁵ IU/ml), are currently two of the most important ways to prevent the transmission of HBV from mother to child. Unfortunately, some infants still have chronic HBV infections. Some studies have also found that some supplementation during pregnancy can increase cytokine levels and then affect the level of HBsAb in infants. For example, IL-4 can mediate the beneficial effect on infants' HBsAb levels when maternal folic acid supplementation. In addition, new research has indicated that HBV infection in the mother may also be linked to unfavorable outcomes such as gestational diabetes mellitus, intrahepatic cholestasis of pregnancy, and premature rupture of membranes. The changes in the immune environment during pregnancy and the hepatotropic nature of HBV may be the main reasons for the adverse maternal outcomes. It is interesting to note that after delivery, the women who had a chronic HBV infection may spontaneously achieve HBeAg seroconversion and HBsAg seroclearance. The maternal and fetal T-cell immunity in HBV infection is important because adaptive immune responses, especially virus-specific CD8 T-cell responses, are largely responsible for viral clearance and disease pathogenesis during HBV infection. Meanwhile, HBV humoral and T-cell responses are important for the durability of protection after fetal vaccination. This article reviews the literature on immunological characteristics of chronic HBV-infected patients during pregnancy and postpartum, blocking mother-to-child transmissions and related immune mechanisms, hoping to provide new insights for the prevention of HBV MTCT and antiviral intervention during pregnancy and postpartum.

The effectiveness of 20 μg hepatitis B vaccine used for the prevention of HBV vertical transmission

To evaluate the efficiency of a 20 μg hepatitis B vaccine(HepB) for disease prevention in two counties in Henan Province, China. A questionnaire was designed to examine the information of hepatitis B surface antigen (HBsAg) positive pregnant women, and their blood samples were collected to test for hepatitis B e antigen (HBeAg), hepatitis B e antibody, and hepatitis B virus (HBV) DNA. Three doses of 20 μg HepB and one dose of hepatitis B immune globulin(HBIG) were administered to newborns. Blood samples were collected from children one month after their complete immunization to test for HBsAg and hepatitis B surface antibody(HBsAb). A total of 419 HBsAg positive-pregnant women and 430 newborns were investigated. The average age of pregnant women was 29.6 ± 4.3 years, with an HBeAg positive rate of 29.1% (122/419). All newborns received their first dose of 20 μg hepatitis B vaccine and 100 IU HBIG within 12 h after birth. Six infants (1.9%, 6/319) tested positive for HBsAg and negative for HBsAb after one month of receiving the three basic doses of HepB. The geometric mean concentration(GMC) of HBsAb-positive infants was 861.6 mIU/mL, and their HBsAb antibody titers decreased with age. Immunization of children born to HBsAg-positive mothers with 20 μg HepB got the satisfactory effect on preventing mother-to-child transmission.

Application of hepatitis B immunoglobulin in prevention of mother-to-child transmission of chronic hepatitis B in HBsAg- and HBeAg-positive mother

The aim of our study was to compare the efficacy of two dosages of hepatitis B immunoglobulin (HBIG) combined with HBV vaccine (HBVac) to prevent mother-to-child transmission (MTCT) of hepatitis B in HBsAg- and HBeAg-positive mother. We enrolled 331 mother-infant pairs with HBsAg- and HBeAg-positive maternal state from the Women's Hospital School of Medicine of Zhejiang University. Newborns were randomly distributed into two groups according to the dosages of HBIG injection: 100 IU and 200 IU. Newborns from both groups were injected with HBVac in the same doses. We compared the immune outcomes between the two groups and explore the influencing factors of immune outcomes through regression analysis. There was no statistically significant relationship between HBsAg serological transmission of newborns and dosages of HBIG in HBsAg- and HBeAg-positive mother (p > .05). The Logistic regression showed that high DNA load is a risk factor for passive-active immunoprophylaxis failure for both 100 IU and 200 IU group, but higher-dosage HBIG is not necessary for higher-viral-load pregnant women with HBsAg- and HBeAg-positive. In conclusion, combined application of HBVac and a single dose of 100 IU HBIG can achieve the ideal MTCT interruption results for HBsAg- and HBeAg-positive pregnant women.IMPACT STATEMENTWhat is already known on this subject? Passive-active immunoprophylaxis is proved to be effective in preventing mother-to-child transmission of hepatitis B. Hepatitis B vaccine combined with 100 IU or 200 IU immunoglobulin is mostly recommended in China.What do the results of this study add? At present, there is still a lack scientific basis for improving existing strategies and measures to prevent mother-to-child transmission of hepatitis B in China.What are the implications of these findings for clinical practice and/or further research? 100 IU and 200 IU immunoglobulin show equivalent blocking effect, and combined use of hepatitis B vaccine and 100 IU immunoglobulin is more cost-effective.

Benefits and Risks of Antiviral Treatment during Pregnancy in Patients with Chronic Hepatitis B

Hepatitis B virus (HBV) is a main cause of chronic liver disease worldwide and can lead to severe liver diseases. The World Health Organization has planned to eliminate viral hepatitis, including hepatitis caused by HBV and hepatitis C virus, by 2030. As mother-to-child transmission (MTCT) of HBV is a main cause of chronic HBV infection, MTCT prevention is the main target to reduce the risk of chronic HBV infection and eliminate the disease. Recent clinical trials and meta-analyses found that antiviral therapy could prevent MTCT effectively in mothers with ≥200,000 IU/mL of HBV DNA, in combination with serial vaccination and hepatitis B immune globulin administration in infants. Despite the preventive role of antivirals for MTCT of HBV, there are several concerns regarding antiviral therapy with respect to the safety of the mother and fetus during pregnancy. This review summarizes the benefits and risks of antiviral treatment during pregnancy in women with chronic HBV infection.

Prevention of hepatitis B mother-to-child transmission in Namibia: A cost-effectiveness analysis

Despite access to a safe and effective vaccine, mother-to-child transmission (MTCT) of hepatitis B virus (HBV) persists in Africa. This is of concern since perinatally-infected infants are at highest risk of developing hepatocellular carcinoma, a life-threatening consequence of chronic HBV infection. While tools to prevent HBV MTCT are available, the cost implications of these interventions need consideration prior to implementation. A Markov model was developed to determine the costs and health outcomes of (1) universal HBV birth dose (BD) vaccination, (2) universal BD vaccination and targeted hepatitis B immunoglobulin (HBIG), (3) maternal antiviral prophylaxis using sequential HBV viral load testing added to HBV BD vaccination and HBIG, and (4) maternal antiviral prophylaxis using sequential HBeAg testing combined with HBV BD vaccination and HBIG. Health outcomes were assessed as the number of paediatric infections averted and disability-adjusted life years (DALYs) averted. Primary cost data included consumables, human resources, and hospital facilities. HBV epidemiology, transitions probabilities, disability weights, and the risks of HBV MTCT were extracted from the literature. Incremental cost-effectiveness ratios (ICERs) were calculated to compare successive more expensive interventions to the previous less expensive one. One-way sensitivity analyses were conducted to test the robustness of the model's outputs. At the Namibian cost/DALY averted threshold of US$3 142, the (1) BD vaccination + targeted HBIG, and (2) maternal antiviral prophylaxis with sequential HBeAg testing interventions were cost-effective. These interventions had ICERs equal to US$1909.03/DALY and US$2598.90/DALY averted, respectively. In terms of effectiveness, the maternal antiviral prophylaxis with sequential HBeAg testing intervention was the intervention of choice. The analysis showed that elimination of HBV MTCT is achievable using maternal antiviral prophylaxis with active and passive immunization. There is an urgent need for low cost diagnostic tests to identify those women who will most benefit from drug therapy to attain this laudable goal.

Maternal infections: revisiting the need for screening in pregnancy

The decision to implement screening for infections during pregnancy depends upon epidemiological, economic, therapeutic and test performance criteria. It therefore varies with public health priorities from country to country. When screening is implemented, the first trimester has become the best time slot to build individual care pathways in this field. This is most relevant for evaluating the risk of embryonic consequences, planning diagnostic testing, initiating primary or secondary prevention and optimising the accuracy of ultrasound follow-up. This article is a critical appraisal of epidemiological data and current international screening recommendations for infections in pregnancy. TWEETABLE ABSTRACT: Screening for infections in pregnancy: a critical review of current epidemiological evidence and international guidelines.

Tenofovir disoproxil fumarate in pregnancy for prevention of mother to child transmission of hepatitis B in a rural setting on the Thailand-Myanmar border: a cost-effectiveness analysis

BACKGROUND

Hepatitis B Virus (HBV) is transmitted from mother to child which can be prevented via birth dose vaccine combined with three follow up hepatitis B vaccines, hepatitis B immunoglobulins (HBIG), and maternal antiviral treatment with Tenofovir Disoproxil Fumarate (TDF). This study evaluates the cost effectiveness of six strategies to prevent perinatal HBV transmission in a resource limited setting (RLS) on the Thailand-Myanmar border.

METHODS

The cost effectiveness of six strategies was tested by a decision tree model in R. All strategies included birth and follow up vaccinations and compared cost per infection averted against two willingness to pay thresholds: one-half and one gross domestic product (GDP) per capita. Strategies were: 1) Vaccine only, 2) HBIG after rapid diagnostic test (RDT): infants born to HBsAg+ are given HBIG, 3) TDF after RDT: HBsAg+ women are given TDF, 4) TDF after HBeAg test: HBeAg+ women are given TDF, 5) TDF after high HBV DNA: women with HBV DNA > 200,000 are given TDF, 6) HBIG & TDF after high HBV DNA: women with HBV DNA > 200,000 are given TDF and their infants are given HBIG. One-way and probabilistic sensitivity analyses were conducted on the cost-effective strategies.

RESULTS

Vaccine only was the least costly option with TDF after HBeAg test strategy as the only cost-effective alternative. TDF after HBeAg test had an incremental cost-effectiveness ratio of US$1062; which would not be considered cost-effective with the lower threshold of one-half GDP per capita. The one-way sensitivity analysis demonstrated that the results were reasonably robust to changes in single parameter values. The PSA showed that TDF after HBeAg test had an 84% likelihood of being cost effective at a willingness to pay threshold of one GDP per capita per infection averted.

CONCLUSIONS

We found that TDF after HBeAg test has the potential to be cost-effective if TDF proves effective locally to prevent perinatal HBV transmission. The cost of TDF treatment and reliability of the RDT could be barriers to implementing this strategy. While TDF after RDT may be a more feasible strategy to implement in RLS, TDF after HBeAg test is a less costly option.

Maternal hepatitis B infection status and adverse pregnancy outcomes: a retrospective cohort analysis

PURPOSE

To investigate the association between maternal HBsAg-positive status and pregnancy outcomes.

METHODS

The study enrolled women with singleton pregnancies who delivered during January-December 2018. Data of maternal demographics and main adverse pregnancy outcomes were collected from the institutional medical records and analyzed by univariate and multivariate logistic regression models to determine the association between maternal HBV markers (HBsAg/HBeAg/HBV-DNA loads status) and adverse pregnancy outcomes.

RESULTS

Total 1146 HBsAg-positive and 18,354 HBsAg-negative pregnant women were included. After adjusting for potential confounding variables, maternal HBsAg-positive status was associated with a high risk of gestational diabetes mellitus (GDM) [adjusted odds ratio (aOR) = 1.24; 95% confidence interval (CI) 1.07-1.43], intrahepatic cholestasis of pregnancy (ICP) (aOR = 3.83; 95% CI 3.14-4.68), preterm birth (aOR = 1.42; 95% CI 1.17-1.72), and neonatal asphyxia (aOR = 2.20; 95% CI 1.34-3.63). Further, higher risks of ICP and neonatal asphyxia remained with either HBeAg-positive status (aOR = 1.64; 95% CI 1.10-2.44; aOR = 3.08; 95% CI 1.17-8.00) or high HBV-DNA load during the second trimester (aOR = 1.52; 95% CI 1.06-2.35; aOR = 4.20; 95% CI 4.20-15.83) among HBsAg-positive pregnant women.

CONCLUSION

Women with maternal HBsAg-positive status may have increased risks of GDM, ICP, preterm birth, and neonatal asphyxia; furthermore, the risks of ICP and neonatal asphyxia were higher in women with HBeAg-positive status and a high HBV-DNA load during the second trimester among the HBsAg-positive pregnant women, implying that careful surveillance for chronic HBV infection during pregnancy is warranted.

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.

Expanding Antiviral Prophylaxis During Pregnancy to Prevent Perinatal Hepatitis B Virus Infection: A Cost-effectiveness Study

Background

Mother-to-child transmission (MTCT) cannot be completely prevented by the administration of active-passive immunoprophylaxis in pregnant women with hepatitis B virus (HBV) DNA levels <10⁶ copies/mL. This study will assess the economic outcomes of expanding antiviral prophylaxis in pregnant women with HBV DNA levels <10⁶ copies/mL.

Methods

A decision model was adopted to measure the economic outcomes of expanded antiviral prophylaxis at different cutoff values of HBV DNA in HBsAg(+) pregnant women in the context of the United States and China. The model inputs, including clinical, cost, and utility data, were extracted from published studies. Sensitivity analyses were carried out to examine the uncertainty of the model outputs. Quality-adjusted life-years (QALYs) and direct medical costs were expressed over a lifetime horizon.

Results

Compared with standard antiviral prophylaxis at HBV DNA ≥10⁶ copies/mL, expanded antiviral prophylaxis improved the health outcomes, and the incremental cost of expanded antiviral prophylaxis varied from $2063 in pregnant women with HBV DNA ≥10⁵ copies/mL to $14925 in all HBsAg(+) pregnant women per QALY gained in the United States, and from $1624 to $12348 in China. The model outcome was considerably influenced by the discount rate, key clinical parameters related to the incidence of MTCT, and efficacy of the prophylaxis strategy.

Conclusions

This study indicates that antiviral prophylaxis using tenofovir among pregnant women with HBV DNA <10⁶ copies/mL may be a cost-effective option, and the cutoff value of the HBV DNA load for antiviral prophylaxis needs to be tailored.

Tenofovir prophylaxis for preventing mother-to-child hepatitis B virus transmission in China: A cost-effectiveness analysis

OBJECTIVES

This study aimed to evaluate whether tenofovir prophylaxis for mothers with high viral loads in late pregnancy is a cost-effective way to prevent mother-to-child hepatitis B virus (HBV) transmission in China.

METHODS

A decision tree Markov model was constructed for a cohort of infants born to HBV surface antigen-positive mothers in China, 2016. The expected cost and effectiveness were compared between the current active-passive immunoprophylaxis strategy and the tenofovir prophylaxis strategy, and the incremental cost-effectiveness ratio was calculated. One-way and multi-way probabilistic sensitivity analyses were performed.

RESULTS

For 100,000 babies born to mothers positive for hepatitis B surface antigen, tenofovir prophylaxis strategy will prevent 2213 perinatal HBV infections and will gain 931 quality-adjusted life years when compared with the current active-passive immunoprophylaxis strategy. The incremental cost-effectiveness ratio was ￥59,973 ($9087) per quality-adjusted life years gained. This result was robust over a wide range of assumptions.

CONCLUSIONS

Tenofovir prophylaxis for mothers with high viral loads in late pregnancy was found to be more cost-effective than the current active-passive immunoprophylaxis alone. Embedding tenofovir prophylaxis for mothers with high virus loads into the present hepatitis B prevention strategies should be considered to further prevent mother-to-child hepatitis B transmission in China.

Hep B Moms: A cross-sectional study of mother-to-child transmission risk among pregnant Asian American women with chronic hepatitis B in New York City, 2007-2017

Mother-to-child transmission (MTCT) is responsible for the majority of chronic hepatitis B virus (HBV) infections worldwide. Despite timely HBV immunoprophylaxis of neonates, MTCT can occur in infants born to mothers with high levels of HBV viremia. We performed a retrospective cross-sectional analysis of Asian American women with chronic HBV evaluated with HBV DNA during prenatal care at two community health sites in New York City from 2007 to 2017. We described patient's demographic and clinical characteristics, categorized their HBV disease phase and analysed for variables associated with high MTCT risk (defined by HBV DNA level >200 000 IU/mL) using multivariable logistic regression. A total of 1298 pregnancies among 1012 mostly China-born (97.6%) women with chronic HBV were included in the study. Of the 1241 pregnancies among women not on antiviral treatment, 22.4% were considered high risk for MTCT and, of these, 255 (91.7%) were HBV e antigen (HBeAg)-positive and 19 (6.8%) were HBeAg-negative. HBeAg-positive status and ALT levels between 26 and 50 U/L were associated with higher likelihood for being high risk for MTCT. Only 0.8% of pregnancies low risk for MTCT were in the immune active phase while the majority (58.4%) were in the inactive chronic HBV phase of infection. Approximately one in five (22.4%) pregnancies among Asian American women with chronic HBV was considered high risk for MTCT and met criteria for antiviral therapy. Full assessment of HBV pregnant women and early coordinated care is needed to deliver interventions to prevent MTCT during critical windows of time.

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.

Cost-effectiveness of augmenting universal hepatitis B vaccination with immunoglobulin treatment: a case study in Zhejiang Province, East China

Objective: To evaluate the cost-effectiveness of the current strategy combining universal vaccination with hepatitis B immunoglobulin (HBIG) treatment for infants of hepatitis B surface antigen (HBsAg) positive mothers compared with universal vaccination with hepatitis B vaccine only.Methods: A decision tree model with a Markov process was constructed and used to simulate the lifetime of the birth cohort in Zhejiang Province during 2016. The current strategy was compared against universal vaccination with respect to costs and health effects. Costs were assessed from the health care system perspective. Health effects were measured by the number of hepatitis B virus (HBV) related diseases and deaths avoided and quality-adjusted life-years (QALYs) gained. The incremental cost‑effectiveness ratio (ICER) is calculated and compared to standard willingness-to-pay thresholds. A one-way sensitivity analysis and a probabilistic sensitivity analysis (PSA) were performed to assess parameter uncertainties.Results: Over the cohort's lifetime, 182 acute symptomatic infections, 2215 chronic infections, 872 cases of cirrhosis, 595 cases of hepatocellular carcinoma (HCC) and 1,350 HBV-related deaths among the cohort of 624,000 infants would be further avoided by the current strategy compared to universal vaccination. Universal vaccination was dominated by the current strategy that produced not only higher total QALYs, but also had lower costs. The results remained robust over a wide range of assumptions.Conclusions: The current strategy was cost saving compared to universal vaccination, and continuing the current strategy is recommended to further decrease the burden of hepatitis B.

Stability of hepatitis B viral load during pregnancy and implications for antepartum prophylaxis: A prospective cohort study

BACKGROUND: We examined changes in hepatitis B virus (HBV) viral loads (VLs) in pregnancy, their association with hepatitis B e antigen (HBeAg), and the associated infant outcomes. METHODS: We prospectively followed 132 mothers positive for hepatitis B surface antigen (HBsAg) and their 135 infants from 2011 to 2015 in Vancouver, British Columbia. Outcome measures included association between maternal HBeAg and high (>200,000 IU/mL) or low (≤200,000 IU/mL) HBV VL, changes in HBV VL through pregnancy, infant HBsAg status, and infant completion of the HBV vaccination series. RESULTS: Of the 91 participants with an available HBV VL, 13 (14.3%) had an HBV VL of more than 200,000 IU/mL. Of 59 participants with paired HBeAg and HBV VL in pregnancy, 6 had an HBV VL of more than 200,000 IU/mL; of interest, 2 of the 6 (33.3%) were HBeAg-negative. Thirty-eight participants had HBV VL results at both mid-trimester and delivery. For these 38 participants, Wilcoxon signed-ranks test for paired data found that an HBV VL remained stable ( p = .58). We observed no perinatal transmissions. However, 20.7% of infants did not have a documented complete HBV vaccination series, 20.0% did not have post-vaccination HBsAg testing completed, and 18% did not have anti-HBs titres measured by age 12 months. CONCLUSIONS: Our study demonstrates that HBeAg and HBV VL are not reliably predictive of each other. This supports the improved predictive value of VL measurement in pregnancy to risk stratify pregnant patients to offer antiviral treatment when indicated and further minimize the risk of perinatal transmission.

First line nucleos(t)ide analog monotherapy is more cost-effective than combination strategies in hepatitis B e antigen-positive chronic hepatitis B patients in China

BACKGROUND

Nucleos(t)ide analog (NA) in combination with peginterferon (PegIFN) therapy in patients with hepatitis B e antigen (HBeAg)-positive chronic hepatitis B (CHB) shows better effectiveness than NA monotherapy in hepatitis B surface antigen loss, termed "functional cure," based on previous published studies. However, it is not known which strategy is more cost-effective on functional cure. The aim of this study was to analyze the cost-effectiveness of first-line monotherapies and combination strategies in HBeAg-positive CHB patients in China from a social perspective.

METHODS

A Markov model was developed with functional cure and other five states including CHB, compensated cirrhosis, decompensated cirrhosis, hepatocellular carcinoma, and death to assess the cost-effectiveness of seven representative treatment strategies. Entecavir (ETV) monotherapy and tenofovir disoproxil fumarate (TDF) monotherapy served as comparators, respectively.

RESULTS

In the two base-case analysis, compared with ETV, ETV generated the highest costs with $44,210 and the highest quality-adjusted life-years (QALYs) with 16.78 years. Compared with TDF, treating CHB patients with ETV and NA - PegIFN strategies increased costs by $7639 and $6129, respectively, gaining incremental QALYs by 2.20 years and 1.66 years, respectively. The incremental cost-effectiveness ratios were $3472/QALY and $3692/QALY, respectively, which were less than one-time gross domestic product per capita. One-way sensitivity analysis and probabilistic sensitivity analyses showed the robustness of the results.

CONCLUSION

Among seven treatment strategies, first-line NA monotherapy may be more cost-effective than combination strategies in HBeAg-positive CHB patients in China.

Modelling cost-effectiveness of tenofovir for prevention of mother to child transmission of hepatitis B virus (HBV) infection in South Africa

BACKGROUND

International sustainable development goals for the elimination of viral hepatitis as a public health problem by 2030 highlight the need to optimize strategies for prevention, diagnosis and treatment of hepatitis B virus (HBV) infection. An important priority for Africa is to have affordable, accessible and sustainable prevention of mother to child transmission (PMTCT) programmes, delivering screening and treatment for antenatal women and implementing timely administration of HBV vaccine for their babies.

METHODS

We developed a decision-analytic model simulating 10,000 singleton pregnancies to assess the cost-effectiveness of three possible strategies for deployment of tenofovir in pregnancy, in combination with routine infant vaccination: S1: no screening nor antiviral therapy; S2: screening and antiviral prophylaxis for all women who test HBsAg-positive; S3: screening for HBsAg, followed by HBeAg testing and antiviral prophylaxis for women who are HBsAg-positive and HBeAg-positive. Our outcome was cost per infant HBV infection avoided and the analysis followed a healthcare perspective.

RESULTS

Based on 10,000 pregnancies, S1 predicts 45 infants would be HBV-infected at six months of age, compared to 21 and 28 infants in S2 and S3, respectively. Relative to S1, S2 had an incremental cost of $3940 per infection avoided. S3 led to more infections and higher costs.

CONCLUSION

Given the long-term health burden for individuals and economic burden for society associated with chronic HBV infection, screening pregnant women and providing tenofovir for all who test HBsAg+ may be a cost-effective strategy for South Africa and other low/middle income settings.

Accelerating the elimination of viral hepatitis: a Lancet Gastroenterology & Hepatology Commission

Viral hepatitis is a major public health threat and a leading cause of death worldwide. Annual mortality from viral hepatitis is similar to that of other major infectious diseases such as HIV and tuberculosis. Highly effective prevention measures and treatments have made the global elimination of viral hepatitis a realistic goal, endorsed by all WHO member states. Ambitious targets call for a global reduction in hepatitis-related mortality of 65% and a 90% reduction in new infections by 2030. This Commission draws together a wide range of expertise to appraise the current global situation and to identify priorities globally, regionally, and nationally needed to accelerate progress. We identify 20 heavily burdened countries that account for over 75% of the global burden of viral hepatitis. Key recommendations include a greater focus on national progress towards elimination with support given, if necessary, through innovative financing measures to ensure elimination programmes are fully funded by 2020. In addition to further measures to improve access to vaccination and treatment, greater attention needs to be paid to access to affordable, high-quality diagnostics if testing is to reach the levels needed to achieve elimination goals. Simplified, decentralised models of care removing requirements for specialised prescribing will be required to reach those in need, together with sustained efforts to tackle stigma and discrimination. We identify key examples of the progress that has already been made in many countries throughout the world, demonstrating that sustained and coordinated efforts can be successful in achieving the WHO elimination goals.

Pattern and predictors of medical care received by hepatitis B carriers during pregnancy and after delivery

OBJECTIVE

The objective of the study is to evaluate the pattern and predictors of medical care received by hepatitis B virus (HBV) carriers during pregnancy and after delivery in Hong Kong.

STUDY DESIGN

The study is a retrospective analysis.

METHODS

Pregnant HBV carriers and their infants were followed up for 9-12 months after delivery. Face-to-face interviews were conducted to investigate what medical care they received for HBV before, during and after pregnancy.

RESULTS

Data were available for 412 HBV carriers. A total of 375 (91.0%) women were known HBV carriers before pregnancy. Routine antenatal screening picked out the remaining 37 (9.0%) HBV carriers; these women were younger, more likely to be smokers and had a lower level of education (P < 0.05) than known HBV carriers. In total, 356 of 412 (86.4%) HBV carriers did not receive any medical care for HBV during pregnancy. Known HBV carrier status, history of medical check-up and the use of antiviral treatment before pregnancy were significant predictors for HBV medical care during pregnancy (P < 0.05). The results show that 217 of 412 (52.6%) HBV carriers did not receive medical care for HBV after delivery. HBV medical care before pregnancy, use of antiviral treatment before pregnancy and a higher level of education were significant predictors for postpartum HBV medical care (P < 0.05). Multivariate analysis showed that HBV medical care before pregnancy (odds ratio [OR], 7.73; 95% confidence interval [CI], 3.21-18.65; P < 0.001) and the use of antiviral treatment (OR, 5.02; 95% CI, 1.41-17.81; P = 0.013) were associated with medical care during pregnancy. Medical care before pregnancy was also associated with postpartum HBV medical care (OR, 5.05; 95% CI, 3.29-7.51; P < 0.001).

CONCLUSIONS

A significant proportion of HBV carriers did not receive HBV-related medical check-ups during and after pregnancy in Hong Kong despite the majority being aware of their carrier status. Medical care before pregnancy predicted antenatal and postpartum HBV medical care.

Incidence and Risk Factors of Intrauterine Transmission Among Pregnant Women With Chronic Hepatitis B Virus Infection

GOALS

To identify the potential risk factors of hepatitis B virus (HBV) intrauterine transmission and predict the incidence of HBV intrauterine transmission among hepatitis B surface antigen-positive pregnant women with diverse viral load.

BACKGROUND

The intrauterine transmission of HBV significantly contributes to the persistence of a high number of patients infected with HBV. However, its risk factors remain unclear.

MATERIALS AND METHODS

A prospective study was performed on hepatitis B surface antigen-positive pregnant women who delivered from June 2012 to December 2016 at Wuhan Medical Care Center for Women and Children, Wuhan, China.

RESULTS

In total, 1200 women paired with 1219 infants were enrolled. In total, 11 (0.9%) infants were identified with intrauterine transmission. We observed that all infants with intrauterine transmission were born to hepatitis B e antigen-positive mothers who had serum HBV DNA levels >7 log10 copies/mL. Our study suggested that the HBV DNA levels (for each log10 copies/mL increase, odds ratio=5.43; 95% confidence interval, 1.31-22.43; P=0.019) had independent effects on HBV intrauterine transmission in a multivariate logistic regression model. Moreover, cesarean section (odds ratio=0.18; 95% confidence interval, 0.04-0.74; P=0.018) was associated with a reduced risk of HBV intrauterine transmission. The predictive rates of intrauterine transmission were 0.06%, 0.50%, 2.81%, 8.89% in infants with maternal HBV DNA levels of 10, 10, 10, 10 copies/mL, respectively.

CONCLUSIONS

Our data confirmed that increasing maternal viral load has the ability to predict intrauterine HBV transmission. Vaginal delivery increased risk of HBV transmission in infants compared with cesarean section. Further studies are warranted to clarify the possible mechanism underlying these associations.

Prenatal Screening for and Prevalence of Hepatitis B Surface Antigen in Pregnant Women and Prevention of Transmission to Infants Born to Infected Mothers-Guam, 2014

BACKGROUND

Perinatal transmission is the major mode of hepatitis B virus (HBV) transmission and drives HBV endemicity in the US territory of Guam. We assessed correlates of prenatal hepatitis B surface antigen (HBsAg) screening and HBsAg positivity among pregnant women and evaluated the care of infants of HBsAg-positive women.

METHODS

Demographic and clinical data were abstracted from the maternal medical records of 966 randomly selected live infants born in 2014. Frequencies were calculated, and prevalence ratios (PRs) and 95% confidence intervals (CIs) were estimated using Poisson regression.

RESULTS

Among the mothers of the 966 infants, 78.2% were Pacific Islanders, 56.9% were >25 years old (born before universal infant hepatitis B vaccination in Guam), 89.0% received prenatal care (PNC), 96.7% underwent prenatal HBsAg screening, and 2.0% were HBsAg positive. Approximately 15% of the women who did not have PNC were not screened for HBsAg. Receipt of PNC was associated with HBsAg screening (adjusted PR, 1.13 [95% CI, 1.04-1.23]), and HBsAg positivity was associated with a maternal age of >25 years (adjusted PR, 6.80 [95% CI, 1.32-35.08]). All 18 infants of the HBsAg-positive mothers received hepatitis B vaccine, and 17 (94.4%) received hepatitis B immunoglobulin.

CONCLUSION

Although the prenatal HBsAg screening prevalence in this sample was high, the maternal HBsAg prevalence among women in this sample was more than 14 times and 2 times the prevalence among US-born Pacific Islander/Asian women and all women in the continental United States, respectively. Improving access to PNC, ensuring that all pregnant women in Guam (especially those born before universal hepatitis B vaccination) are screened for HBsAg, and adopting postexposure prophylaxis for infants of HBsAg-positive mothers as standard clinical practice are important for preventing perinatal HBV transmission and reducing HBV endemicity.

Novel insights in the prevention of perinatal transmission of hepatitis B

Perinatal transmission of hepatitis B virus (HBV) infection is major contributor to the growing burden of chronic hepatitis B worldwide. Administration of HBV immunoglobulin and HBV vaccination as soon after pregnancy as possible are the mainstay of prevention of perinatal transmission of HBV infection. In women with high viral loads, antiviral prophylaxis also appears to be useful. Lamivudine, telbivudine and tenofovir have been shown to be both safe and effective in this setting but tenofovir is the first-line option due to its low potential for resistance and more favorable safety profile.

Chronic hepatitis B virus infection

Chronic hepatitis B virus infection is a global public health threat that causes considerable liver-related morbidity and mortality. It is acquired at birth or later via person-to-person transmission. Vaccination effectively prevents infection and chronic hepatitis B virus carriage. In chronically infected patients, an elevated serum hepatitis B virus DNA concentration is the main risk factor for disease progression, although there are other clinical and viral parameters that influence disease outcomes. In addition to liver biochemistry, virological markers, and abdominal ultrasonography, non-invasive assessment of liver fibrosis is emerging as an important assessment modality. Long-term nucleos(t)ide-analogue therapy is safe and well tolerated, achieves potent viral suppression, and reduces the incidence of liver-related complications. However, a need to optimise management remains. Promising novel therapies are at the developmental stage. With current vaccines, therapies, and an emphasis on improving linkage to care, WHO's goal of eliminating hepatitis B virus as a global health threat by 2030 is achievable.

Cesarean section reduces the risk of early mother-to-child transmission of hepatitis B virus

AIMS

To evaluate the effects of cesarean section (CS) on the prevention of mother-to-child transmission (MTCT) of hepatitis B virus (HBV) among hepatitis B surface antigen (HBsAg) positive pregnant women.

METHODS

A prospective cohort study was performed on HBsAg-positive pregnant women who delivered from June 2012 to March 2017 at Wuhan Medical Care Center for Women and Children in Wuhan, China. Logistic regression models were used to examine the associations between mode of delivery and the presence of HBV MTCT.

RESULTS

A total of 1384 women paired with 1407 infants were enrolled. Our study showed that the incidence of HBV MTCT was 1.0% (14/1407) in infants born to HBsAg-positive pregnant women. We observed that the infants born by CS had a smaller percentage of HBV infection than those born by vaginal delivery (VD) (0.5% vs 1.7%, P = 0.043). In the fully adjusted model, CS was significantly associated with a decreased risk of HBV MTCT (OR = 0.26; 95% CI: 0.07-0.95; P = 0.042).

CONCLUSION

Our data confirmed that CS has a protective effect on early MTCT of HBV. CS for HBeAg-positive mothers with high viral load could reduce risk of MTCT and may become a new preventive measure of HBV MTCT through research on its risk-benefit assessment.

Elimination of Vertical Transmission of Hepatitis B in Africa: A Review of Available Tools and New Opportunities

PURPOSE

This review article focuses on preventing vertical transmission of hepatitis B virus (HBV) among pregnant women living in sub-Saharan Africa (SSA), where disease is endemic and the estimated maternal HBV seroprevalence is >8%. Available interventions that have been studied in low- and middle-income countries are compared in terms of efficacy and effectiveness in clinical practice. Global disease-elimination targets, barriers to HBV-prevention efforts, and critical research gaps are discussed.

METHODS

A PubMed literature search in February 2018 identified relevant studies of interventions to reduce or prevent the transmission of HBV during pregnancy or in the peripartum period. Studies that focused on interventions that are currently available or could be made available in SSA were included. Trials conducted in SSA and other low-income countries were prioritized, although studies of interventions in middle- and high-income countries were included.

FINDINGS

Among 127 studies and reports included in the review, 60 included data from SSA. The most cost-effective intervention to reduce HBV infection rates in SSA is timely birth-dose vaccination followed by completion of the 3-dose infant-vaccination series. The identification and treatment of pregnant women with elevated HBV viral load to further reduce the risk for vertical transmission in SSA show promise, but efficacy and tolerability trials in Africa are lacking.

IMPLICATIONS

Scale-up of currently available tools is required to reach HBV disease-elimination goals in SSA. Many countries in SSA are in the process of rolling out national birth-dose vaccination campaigns; this roll out provides an opportunity to evaluate and improve processes in order to expand coverage. Early antenatal care, promotion of facility deliveries, and increased awareness of HBV prevention are also key components of prevention success. Future studies in SSA should identity an HBV-prevention package that is effective, well tolerated, and feasible and can be administered in the antenatal clinic and tailored to vertical-transmission risk.

Cost-effectiveness of antiviral prophylaxis during pregnancy for the prevention of perinatal hepatitis B infection in South Korea

BACKGROUND

In Korea, hepatitis B virus (HBV) infection accounts for approximately 65-75% of HBV-related diseases, such as chronic hepatitis and liver cancer, and mother-to-child transmission is presumed to be a major source of the infection. To tackle this issue, the Korean government launched the national Perinatal Hepatitis B Prevention Program (PHBPP) in 2002. This study analyzed the cost-effectiveness of the PHBPP with antiviral prophylaxis compared with the current PHBPP and/or universal vaccination, as well as identified the optimal strategy to eliminate mother-to-child transmission of HBV in Korea.

METHODS

A decision tree model with the Markov process was developed and simulated over the lifetime of a birth cohort in Korea during the year 2014. The current PHBPP providing HBV vaccine and hepatitis B immune globulin to neonates born to HBV positive mothers was compared against two other strategies, universal vaccination of HBV and PHBPP with antiviral prophylaxis, with respect to their costs and health outcomes. The Korean National Health Insurance database was investigated to estimate the costs of HBV-related diseases and utilization of health resources. Costs were assessed from the health care system perspective and converted to 2014 US dollars. Health outcome measures were quality-adjusted life years (QALYs) and number of HBV-related diseases and deaths. Both costs and QALYs were discounted at 5%, following the recommendation of the Health Insurance Review & Assessment Service in Korea. The incremental cost-effectiveness ratio (ICER) obtained from the analysis was evaluated using the willingness-to-pay (WTP) in the Korean society.

RESULTS

PHBPP with antiviral prophylaxis in Korea was cost-effective compared with the current PHBPP. An introduction of antiviral prophylaxis to pregnant women with a high viral load of HBV averted 13 HBV-related deaths per 100,000 people and saved 82 QALYs in total (ICER: $16,159/QALY).

CONCLUSIONS

Considering that WTP in Korea is $29,000, PHBPP with antiviral prophylaxis appears to be a cost-effective strategy. To further decrease the burden of perinatal hepatitis B in Korea, adding antiviral prophylaxis to PHBPP is recommended.

Prevention of Hepatitis B Virus Infection in the United States: Recommendations of the Advisory Committee on Immunization Practices

HEPATITIS B VIRUS (HBV) IS TRANSMITTED VIA BLOOD OR SEXUAL CONTACT. PERSONS WITH CHRONIC HBV INFECTION ARE AT INCREASED RISK FOR CIRRHOSIS AND LIVER CANCER AND REQUIRE MEDICAL CARE. THIS REPORT UPDATES AND SUMMARIZES PREVIOUSLY PUBLISHED RECOMMENDATIONS FROM THE ADVISORY COMMITTEE ON IMMUNIZATION PRACTICES (ACIP) AND CDC REGARDING THE PREVENTION OF HBV INFECTION IN THE UNITED STATES. ACIP RECOMMENDS TESTING ALL PREGNANT WOMEN FOR HEPATITIS B SURFACE ANTIGEN (HBSAG), AND TESTING HBSAG-POSITIVE PREGNANT WOMEN FOR HEPATITIS B VIRUS DEOXYRIBONUCLEIC ACID (HBV DNA); ADMINISTRATION OF HEPB VACCINE AND HEPATITIS B IMMUNE GLOBULIN (HBIG) FOR INFANTS BORN TO HBV-INFECTED WOMEN WITHIN 12 HOURS OF BIRTH, FOLLOWED BY COMPLETION OF THE VACCINE SERIES AND POSTVACCINATION SEROLOGIC TESTING; UNIVERSAL HEPATITIS B VACCINATION WITHIN 24 HOURS OF BIRTH, FOLLOWED BY COMPLETION OF THE VACCINE SERIES; AND VACCINATION OF CHILDREN AND ADOLESCENTS AGED <19 YEARS WHO HAVE NOT BEEN VACCINATED PREVIOUSLY. ACIP RECOMMENDS VACCINATION OF ADULTS AT RISK FOR HBV INFECTION, INCLUDING UNIVERSAL VACCINATION OF ADULTS IN SETTINGS IN WHICH A HIGH PROPORTION HAVE RISK FACTORS FOR HBV INFECTION AND VACCINATION OF ADULTS REQUESTING PROTECTION FROM HBV WITHOUT ACKNOWLEDGMENT OF A SPECIFIC RISK FACTOR. THESE RECOMMENDATIONS ALSO PROVIDE CDC GUIDANCE FOR POSTEXPOSURE PROPHYLAXIS FOLLOWING OCCUPATIONAL AND OTHER EXPOSURES. THIS REPORT ALSO BRIEFLY SUMMARIZES PREVIOUSLY PUBLISHED AMERICAN ASSOCIATION FOR THE STUDY OF LIVER DISEASEST GUIDELINES FOR MATERNAL ANTIVIRAL THERAPY TO REDUCE PERINATAL HBV TRANSMISSION.

Maternal Hepatitis B Virus Infection and Pregnancy Outcomes: A Hospital-based Case-control Study in Wuhan, China

GOALS

To examine the impact of maternal hepatitis B virus infection on pregnancy outcomes.

BACKGROUND

Studies regarding hepatitis B virus infection and pregnancy outcomes are limited with inconsistent results, and none of them have evaluated the effect of maternal viral load in pregnancy on pregnancy outcomes.

STUDY

A hospital-based case-control study was conducted. In total, 1728 hepatitis B surface antigen (HBsAg)-positive women who delivered consecutively at Wuhan Women and Children Medical and Healthcare Center, Wuhan, China, from June 2008 to May 2015, were compared with 1497 HBsAg-negative women giving birth in the same hospital during the same period who were randomly identified and selected from the computerized medical record database in parallel. Univariate and multivariate logistic regression models were constructed.

RESULTS

After adjusting for confounding variables, maternal HBsAg carriage was associated with increased risk of pregnancy-induced hypertension [adjusted odds ratio (aOR)=2.20; 95% confidence interval (CI), 1.30-3.73], fetal distress (aOR=1.40; 95% CI, 1.09-1.78), cesarean delivery (aOR=1.70; 95% CI, 1.45-1.99), and macrosomia (aOR=1.68; 95% CI, 1.19-2.37). Moreover, maternal viral load in the second trimester was significantly associated with risk of preterm birth (aOR for each log10 copy/mL increase, 1.18; 95% CI, 1.01-1.39) among HBsAg carriers after adjustment for maternal age, employment, parity, history of abortion, and prenatal body mass index.

CONCLUSIONS

Maternal HBsAg carriage was associated with several adverse pregnancy outcomes. Furthermore, hepatitis B viral activity in pregnancy might have certain effects on pregnancy outcomes. Careful surveillance of maternal HBsAg status as well as viral activity in the second trimester among HBsAg carriers is warranted.

Management of hepatitis B in special populations

Special populations infected with chronic HBV include those with decompensated cirrhosis, coinfections (HIV, HCV, HDV), hemodialysis and renal failure, immunosuppressed including transplant patients, children and women in pregnancy. These populations differ in their natural history and risk for liver-related complications, the indications for anti-HBV therapy as well as the recommendations regarding the HBV drugs used, duration of therapy and anticipated endpoints. Reflecting the special populations with substantive changes in management in recent years, this review focuses on HBV-HIV coinfected patients, immunosuppressed patients at risk for reactivation, liver transplant recipients and pregnant women. Management of women in the context of pregnancy and post-partum requires consideration of risks to mother and fetus/infant, including the risk of mother-to-child transmission. HBV-HIV coinfected patients require initiation of treatment concurrent with their HIV therapy and the HBV drugs used must by selected to minimize HIV and HBV resistance long-term. Increasing recognition of the risk for HBV reactivation with immunosuppressive therapy has led to recommendations to use prophylactic HBV therapy in patients with moderate to high risk of reactivation. Liver transplant recipients with HBV require life-long therapy to prevent or treat HBV infection but with current therapies, graft and patient survival are excellent.