Hepatitis B During Pregnancy in Endemic Areas: Screening, Treatment, and Prevention of Mother-to-Child Transmission

Hepatitis B and C in Immigrants and Refugees in Central Brazil: Prevalence, Associated Factors, and Immunization

Introduction: Eliminating hepatitis B and C in immigrant and refugee populations is a significant challenge worldwide. Given the lack of information in Brazil, this study aimed to estimate the prevalence of infections caused by hepatitis B and C viruses and factors associated with hepatitis B in immigrants and refugees residing in central Brazil. Methods: An observational, cross-sectional, and analytical study was conducted from July 2019 to January 2020 with 365 immigrants and refugees. Hepatitis B was detected by a rapid immunochromatographic test, enzyme immunoassay, and chemiluminescence, and hepatitis C by rapid immunochromatographic test. Multiple analysis was used to assess factors associated with hepatitis B infection. Results: Of the participants, 57.8% were from Haiti and 35.6% were from Venezuela. Most had been in Brazil for less than 2 years (71.2%). The prevalence of HBV infection and exposure was 6.6% (95% CI: 4.5–9.6%) and 27.9% (95% CI: 23.6–2.8%), respectively, and 34% had isolated anti-HBs positivity. Reporting a sexually transmitted infection was statistically associated with HBV infection (OR: 7.8; 95% CI: 2.3–26.4). No participant with positive anti-HCV serology was found. Conclusions: The study showed that participants were outside the reach of prevention and control actions for hepatitis B. Therefore, public health strategies must be designed to reach, inform, and vaccinate this group.

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.

Hepatitis B virus genotype is an independent prognostic factor of telbivudine and tenofovir treatment in hepatitis B surface antigen-positive pregnant women

To investigate whether HBV genotype influences the effect of tenofovir and telbivudine on HBV DNA and RNA levels in HBsAg-positive pregnant women. This was a retrospective study of 74 HBsAg-positive pregnant women in Guizhou of China. All patients were treated with telbivudine or tenofovir from 12 weeks of pregnancy and HBV infection to the date of delivery. Blood samples were collected at 12-24, 28-32, and 36-40 weeks of pregnancy for the measurement of genotype, HBsAg, hepatitis B e antigen (HBeAg), HBV DNA, HBV RNA, and liver function, including alanine transaminase, aspartate transaminase, total bilirubin, total bile acids, cholinesterase, alkaline phosphatase (ALP), and gamma-glutamyl transferase. All women with HBsAg were followed up. The HBV genotype was B in 64.9% and C in 35.1%. There were 37 patients of telbivudine and tenofovir group respectively. The telbivudine and tenofovir groups showed no differences in demographic and clinical characteristics, including liver function tests, HBsAg, HBeAg, log10(HBV DNA), and log10(HBV RNA). Compared with baseline (12-24 weeks), telbivudine group showed a significant increase in ALP and significant reductions in HBsAg, HBeAg, log10(HBV DNA), and log10(HBV RNA) at 36-40 weeks (p < .05). Tenofovir group exhibited a significant increase in ALP and significant reductions in HBeAg, log10(HBV DNA), and log10(HBV RNA) at 36-40 weeks, compared with baseline (p < .05). HBV genotype (B vs. C) was independently associated with HBV DNA change after therapy (p = .005). In telbivudine group, log10 (HBV DNA) increased from 3.38 (2.00-7.30) to 7.43 (4.68-8.70). In tenofovir group, log10 (HBV DNA) decreased from 7.52 (3.32-8.70) to 2.98 (2.00-5.01). HBV genotype was independently associated with HBV DNA change response to telbivudine or tenofovir in pregnant women with hepatitis B. These findings might be helpful for risk assessment regarding vertical transmission of HBV in HBeAg-positive mothers treated with nucleos(t)ide analogues.

Challenges in the discontinuation of chronic hepatitis B antiviral agents

Long-term antiviral treatment of chronic hepatitis B patients has been proven to be beneficial in reducing liver-related complications. However, lengthy periods of daily administration of medication have some inevitable drawbacks, including decreased medication adherence, increased cost of treatment, and possible long-term side effects. Currently, discontinuation of antiviral agent has become the strategy of interest to many hepatologists, as it might alleviate the aforementioned drawbacks and increase the probability of achieving functional cure. This review focuses on the current evidence of the outcomes following stopping antiviral treatment and the factors associated with subsequent hepatitis B virus relapse, hepatitis B surface antigen clearance, and unmet needs.

Hepatitis B in Pregnant Women and their Infants

Chronic hepatitis B is a global health problem affecting approximately 350 million to 400 million individuals worldwide, and mother to child transmission remains the major mode of transmission. Approximately 50% of chronically infected individuals acquire infection, either perinatally or early in childhood, predominantly in areas where hepatitis B virus (HBV) is endemic. Management of HBV in pregnancy presents a unique set of challenges. All infants born of hepatitis B surface antigen-positive mothers should receive postexposure immune prophylaxis with hepatitis B immunoglobulin and HBV vaccination within 24 hours of birth and need close follow-up for the first few years of life.

Prenatal hepatitis B screening and associated factors in a high prevalence district of Lira, northern Uganda: a community based cross sectional study

BACKGROUND

Chronic hepatitis B Virus (HBV) infection affects 80-100 million people in sub-Saharan Africa and accounts for an estimated 650,000 deaths annually. The prevalence of active hepatitis B virus infection among women aged 15-64 in mid-Northern Uganda is about 5%. Lira district is among the high prevalence areas where government embarked on mass HBV screening since 2015 as a gateway for access to prevention, treatment services, and an effective response to the hepatitis B epidemic. The current proportion of pregnant women screened and the factors associated with prenatal HBVscreening in Lira are not known despite the fact that women contribute largely to both vertical and horizontal transmission of HBV. This study aimed at determining the proportion of pregnant women screened for HBV and factors associated with prenatal HBV screening in Lira district.

METHODS

This was a community based cross sectional study conducted among 423 pregnant women in the sub counties of Aromo and Agweng in Lira district. Data were collected using open data kit and analysed using STATA version 14. The outcome variable was prenatal HBV screening while predictor variables were community, individual and health facility factors associated with HBV screening. Multivariable logistic regression was used to determine factors associated with prenatal HBV screening.

RESULTS

Thirty five women (8.3%) had been screened for HBV during the current pregnancy. Factors associated with prenatal HBV screening in Lira included perceived risk (Adjusted Odds Ratio (AOR) 3.78, 95% CI 1.01-6.14), respondent's age (AOR = 3.98, 95% CI 1.39-5.09), husband/partner's education (AOR = 3.34, 95% CI 1.10-5.12) and past failure to access to HBV screening services at government health facilities (AOR = 6.44, 95% CI 2.10-8.02).

CONCLUSION

The level of HBV screening among pregnant women in Lira was low and is mainly associated with perceived risk, age, access to HBV screening services and spousal education level. More effort is needed in creating mass awareness on the need and importance of HBV screening most especially among pregnant women.

Interferon alpha treatment leads to a high rate of hepatitis B surface antigen seroconversion in Chinese children with chronic hepatitis B

Chronic hepatitis B virus (HBV) infection (CHB) in children remains a public health challenge despite significant success in programme is established to prevent mother-to-child transmission. In particular, CHB in Chinese children are mostly acquired through vertical transmission, which differs from the common infection route reported in other countries and regions. This situation has resulted in a high endemic prevalence of CHB in Chinese adults. Thus, successful treatment of children with CHB will prevent the development of advanced liver diseases in late adulthood. However, there is still no consensus on the clinical guideline to treat paediatric CHB. In this study, we evaluated the potential of interferon alpha (IFNa) treatment for Chinese children with CHB. A total of 41 patients with CHB aged 3-17 years were enrolled in this retrospective study: 21 patients were treated with pegylated (PEG)-IFNa and 20 patients without treatment served as the control group. The rates of HBV DNA suppression, hepatitis B e antigen (HBeAg) clearance and hepatitis B surface antigen (HBsAg) clearance were significantly higher in the PEG-IFNa treatment group than in the control group (P < 0.05 at 48 weeks). Unexpectedly, PEG-IFNa treatment achieved a high rate of HBsAb production, far exceeding the clinical outcome in documented PEG-IFNa-treated CHB adults. Further analysis revealed that younger children (3-6 years old) were more responsive to PEG-IFNa treatment with respect to achieving a protective level of HBsAb in a short treatment cycle than adolescents (10-17 years old). Overall, these results indicate that the immune system of children might have a preserved PEG-IFNa-mediated mechanism to completely control HBV, which can help to design new strategies to treat CHB patients.

A case of chronic hepatitis B merged with acute fatty liver of pregnancy with severe coagulopathy

Background

Acute fatty liver of pregnancy (AFLP) is a life-threatening disorder, and its relevance to viral hepatitis B (HB) remains unknown. This case presents an initial experience of treating a patient with HB progressing to AFLP throughout pregnancy; anesthesiologists should also recognize its clinical feature for perioperative management.

Case presentation

A 28-year-old parturient was diagnosed as chronic HB (CHB) at 21 weeks gestation. Liver and kidney dysfunction appeared rapidly at 34 weeks gestation, suspected as acute exacerbation of either CHB or AFLP. Emergency cesarean section was carried out, after which maternal disseminated intravascular coagulation and hypothermia persisted. With multidisciplinary management, the patient and infant were discharged on postpartum days 64 and 12, respectively.

Conclusions

Active CHB develops into AFLP. Antiviral therapy should be considered for parturient patients with CHB, particularly for those with high viral load. The most favorable outcome is prompt and accurate diagnosis to establish suitable termination method.

Efficacy and safety of tenofovir in preventing mother-to-infant transmission of hepatitis B virus: a meta-analysis based on 6 studies from China and 3 studies from other countries

BACKGROUND

The vertical transmission of HBV from mothers to their infants at birth or in early infancy has a significant role in the endemicity of HBV infection. Tenofovir is one of the most potent anti-HBV agents with a high genetic barrier to resistance. The study is to evaluate the efficacy of tenofovir in preventing perinatal HBV transmission, as well as monitoring safety for mothers and infants.

METHODS

PubMed, Embase, Web of Science, and CNKI (National Knowledge Infrastructure, China) database were systematically reviewed for studies that compared the efficacy and safety of tenofovir with other treatments. Pooled estimates were expressed with weight mean difference (WMD) with 95% confidence intervals (95% CIs) and risk ratio (RR) with 95% CIs.

RESULTS

Nine studies involving 1046 pregnant patients met the inclusion criteria and were included in this meta-analysis. Compared with other treatments, tenofovir significantly reduced maternal HBV DNA levels (WMD = 2.33 log10 IU/mL, 95% CI: 1.01, 3.64; P < 0.001), infant HBsAg positivity rate (RR = 0.25, 95% CI: 0.16, 0.38; P < 0.001), infant HBeAg positivity rate (RR = 0.26, 95% CI: 0.14, 0.48; P < 0.001), infant HBV DNA positivity rate (RR = 0.15, 95% CI: 0.07, 0.31; P < 0.001), and immunoprophylaxis failure rate (RR = 0.31, 95% CI: 0.13, 0.73; P = 0.008). Moreover, maternal and infant safety profiles, including ALT, CK, and Cr were comparable between tenofovir and other treatment groups.

CONCLUSION

Based on the current evidence, our study suggested that tenofovir significantly reduced the rate of vertical transmission of HBV, as well as the HBV DNA levels in HBV-infected mothers. Moreover, tenofovir was safe and tolerable for both mothers and their infants.

Development of a fibrosis index including hepatitis B virus basal core promoter A1762T mutation for pretherapeutic evaluation

BACKGROUND AND AIM

Commonly used non-invasive fibrosis scores usually included serum transaminase levels in the equations, including Aspartate transaminase to Platelet Ratio Index (APRI) and fibrosis-4 (FIB-4). Transaminases fluctuated significantly in chronic hepatitis B patients with exacerbations, leading to unsteady score values. As such, here, we aim to develop a transaminase-free score suitable for pretherapeutic evaluation of fibrosis stages.

METHODS

Firstly, 1082 treatment-naïve chronic hepatitis B patients were enrolled and divided into modeling (n = 541) and verification (n = 541) cohorts. Secondly, 265 patients having received liver biopsy, with known Ishak fibrosis stages, were included for independent correlation.

RESULTS

Cross-sectional analysis of 1082 patients revealed age-dependent variation of association between virological factors and cirrhosis. A fibrosis score including Anti-hepatitis B e antibody, Basal core promoter (BCP) A1762T mutation, and Platelet count Index (named ABPI) was derived from the modeling cohort. ABPI performed better than APRI and FIB-4 in the verification cohort for identifying cirrhotic patients (comparison of area under the receiver operating characteristic curves: ABPI vs APRI and FIB-4 = 0.785 vs 0.563 [P < 0.001] and 0.700 [P = 0.026], respectively). The performance of ABPI was even better in young (< 40 years old) hepatitis B patients (area under the receiver operating characteristic curves: 0.856 vs 0.402 [P < 0.001] and 0.599 [P = 0.009], respectively). Finally, in the independent cohort of 265 patients with known Ishak fibrosis stages, it was found that ABPI effectively distinguished between Ishak fibrosis stages 3 and > 3 and between 4 and > 4 (P < 0.001 for each).

CONCLUSIONS

We developed a transaminase-free fibrosis score (ABPI) utilizing basal core promoter A1762T data, which outperformed APRI and FIB-4.

Nucleoside/nucleotide analogues in the treatment of chronic hepatitis B infection during pregnancy: a systematic review

BACKGROUND

Women of childbearing age who have developed chronic hepatitis B (CHB) infection, especially HBeAg-positive highly viraemic pregnant women, are largely responsible for the familial transmission of the infection. Therefore, choosing the most effective and safest antiviral medications to manage pregnant CHB patients is of crucial importance.

MATERIALS AND METHODS

The PubMed and Scopus databases were searched through September 2017, for all the journal articles possessing original results regarding treatment of CHB pregnant women with any nucleos(t)ide analogue (NA) therapies, including lamivudine (LAM), adefovir (ADV), entecavir (ETV), telbivudine (LdT), and tenofovir (TDF).

RESULTS

After the primary search, 882 studies were recognized, and updating the searching results, 41 journal articles with original data were investigated, involving 3874 newborn infants from mothers with CHB, and their mothers completed follow-up until the delivery. The most important basic data and results regarding the efficacy of drugs, the rate of vertical transmission, safety issues associated with pairs of mothers and infants, median levels of HBV DNA, breastfeeding data, and rate of rate of vaccination success were collected. Moreover, possible key conclusion, recommendations, and learned lessons were discussed. Among the evaluated NAs, all LAM was efficient and safe. LdT was found to be very effective but had some safety concerns. In contrast, TDF had the advantages of both effectiveness and safety.

CONCLUSION

According to data in the literature, initiation of TDF at the trimester of pregnancy in combination with immunoprophylaxis to prevent mother-to-child transmission (MTCT) of CHB infection is strongly recommended as well as successful immunization of CHB pregnant women by anti-HBV vaccines.