Serological and virological profile of chronic HBV infected women at reproductive age in Greece. A two-year single center study

Estimating the proportion of people with chronic hepatitis B virus infection eligible for hepatitis B antiviral treatment worldwide: a systematic review and meta-analysis

BACKGROUND

In 2016, of the estimated 257 million people living with chronic hepatitis B virus (HBV) infection worldwide, only a small proportion was diagnosed and treated. The insufficiency of information on the proportion of people infected with HBV who are eligible for treatment limits the interpretation of global treatment coverage. We aimed to estimate the proportion of people with chronic HBV infection who were eligible for antiviral treatment worldwide, based on the WHO 2015 guidelines.

METHODS

In this systematic review and meta-analysis, we searched Medline, EMBASE, and the Cochrane databases from Jan 1, 2007, to Jan 31, 2018, for studies describing HBsAg-positive people in the population or health-care facilities. We extracted information from published studies using a standardised form to estimate the frequency of cirrhosis, abnormal alanine aminotransferase (ALT), HBV DNA exceeding 2000 IU/mL or 20 000 IU/mL, presence of HBeAg, and eligibility for treatment as per WHO and other guidelines as reported in the studies. We pooled proportions through meta-analysis with random effects. The study was registered with PROSPERO, CRD42020132345.

FINDINGS

Of the 13 497 studies, 162 were eligible and included in our analysis. These studies included 145 789 participants. The pooled estimate of the proportion of cirrhosis was 9% (95% CI 8-10), ranging from 6% (4-8) in community settings to 10% (9-11) in clinic settings. Examining the proportion of participants who had characteristics used to determine eligibility in the WHO guidelines, 1750 (10·1%) of 17 394 had HBV DNA exceeding 20 000 IU/mL, and 20 425 (30·8%) of 66 235 had ALT above the upper limit of normal. 32 studies reported eligibility for treatment according to WHO or any other guidelines, with a pooled estimate of eligibility at 19% (95% CI 18-20), ranging from 12% (6-18) for studies in community settings to 25% (19-30) in clinic settings.

INTERPRETATION

Many studies described people with HBV infection, but few reported information in a way that allowed assessment of eligibility for treatment. Although about one in ten of the 257 million people with HBV infection (26 million) might be in urgent need of treatment because of cirrhosis, a larger proportion (12-25%) is eligible for treatment in accordance with different guidelines. Future studies describing people with HBV infection should report on treatment eligibility, according to broadly agreed definitions.

FUNDING

WHO and US Centers for Disease Control and Prevention.

Epidemiology of hepatitis C in Greece

Hepatitis C is a global health issue and constitutes a major cause of chronic liver disease worldwide. In this article, a comprehensive literature search was conducted for the prevalence of hepatitis C virus (HCV) infection in Greece, since data on the HCV prevalence, viremia and genotypes are important for developing strategies to manage or eliminate HCV infection. In addition, the pattern of HCV infection was analyzed according to the geographic region and the risk factors. These differences reflect not only distinct epidemiological characteristics among populations, but also differences on the strategy of data acquisition and quantification. Although there are not enough data, the estimation of the current prevalence of Hepatitis C in Greece ranges from 0.5% to 2%. The most important risk factors for HCV infection include blood product transfusion, intravenous drug use, chronic hemodialysis, organ transplantation, occupational exposure, sexual transmission, and vertical transmission. Because of lack of vaccine or effective post-exposure prophylaxis for HCV, the main focus of prevention is to recognize and control these risk factors. HCV infection in Greece is closely associated with the development of chronic liver disease, cirrhosis, and primary hepatocellular carcinoma. As far as the genotype distribution is concerned genotype 1 estimated to be 45%-47% and it constitutes the prevalent genotype in Greece, followed by genotype 3.

Birth order and risk of hepatocellular carcinoma in chronic carriers of hepatitis B virus: a case-control study in The Gambia

BACKGROUND & AIMS

Early age at infection with Hepatitis B virus (HBV) increases the risk of chronic infection. Moreover, early HBV infection may further independently increase the risk of hepatocellular carcinoma (HCC) beyond its effect on chronicity.

METHODS

The distribution of birth order, a proxy for mode and timing of HBV transmission, was compared in The Gambia between hepatitis B surface antigen (HBsAg)-positive HCC cases recruited from hospitals (n = 72) and two HBsAg-positive control groups without HCC: population-based controls from a community HBV screening (n = 392) and hospital-based controls (n = 63).

RESULTS

HCC risk decreased with increasing birth order in the population-based case-control analysis. Using first birth order as the reference, the odds ratios were 0.52 (95% CI: 0.20-1.36), 0.52 (0.17-1.56), 0.57 (0.16-2.05) and 0.14 (0.03-0.64) for second, third, fourth and greater than fourth birth order respectively (P = 0.01). A similar inverse association was observed in the hospital-based case-control comparison (P = 0.04).

CONCLUSIONS

Compared to controls, HCC cases had earlier birth order, a proxy for young maternal age and maternal HBV viraemia at birth. This finding suggests that in chronic HBV carriers perinatal mother-to-infant transmission may increase HCC risk more than horizontal transmission. Providing HBV vaccine within 24 h of birth to interrupt perinatal transmission might reduce the incidence of HCC in The Gambia.

Post-partum reactivation of chronic hepatitis B virus infection among hepatitis B e-antigen-negative women

AIM: To investigate the frequency and timing of post-partum chronic hepatitis B virus (HBV) reactivation and identify its pre-partum predictors.

METHODS: Forty-one hepatitis B e antigen (HBeAg)-negative chronic HBV infected pregnant women were prospectively evaluated between the 28^th and the 32^nd week of gestation. Subjects were re-evaluated at 3-mo intervals during the first post-partum year and every 6 mo during the following years. HBV DNA was determined using real-time reverse transcription polymerase chain reaction (Cobas TaqMan HBV Test) with a lower detection limit of 8 IU/mL. Post-partum reactivation (PPR) was defined as abnormal alanine aminotransaminase (ALT) levels and HBV DNA above 2000 IU/mL.

RESULTS: Fourteen out of 41 women (34.1%) had pre-partum HBV DNA levels > 2000 IU/mL, 18 (43.9%) had levels < 2000 IU/mL and 9 (21.9%) had undetectable levels. Fourteen women were lost to follow-up (failure to return). PPR occurred in 8 of the 27 (29.6%) women evaluated, all within the first 6 mo after delivery (5 at month 3; 3 at month 6). Five of the 6 (83.3%) women with pre-partum HBV DNA > 10000 IU/mL exhibited PPR compared with 3 of the 21 (14.3%) women with HBV DNA < 10000 IU/mL (two with HBV DNA > 2000 and the third with HBV DNA of 1850 IU/mL), P = 0.004. An HBV DNA level ≥ 10000 IU/mL independently predicted post-partum HBV infection reactivation (OR = 57.02, P = 0.033). Mean pre-partum ALT levels presented a non-significant increase in PPR cases (47.3 IU/L vs 22.2 IU/L, respectively, P = 0.094).

CONCLUSION: In the present study, PPR occurred in approximately 30% of HBeAg-negative pregnant women; all events were observed during the first semester after delivery. Pre-partum HBV DNA level > 10000 IU/mL predicted PPR.

Higher rates of chronic hepatitis B infection and low vaccination-induced protection rates among parturients escaping HBsAg prenatal testing in Greece: a 2-year prospective study

OBJECTIVES

Universal screening for the identification of hepatitis B surface antigen [HBsAg(+)] mothers is essential to prevent perinatal hepatitis B virus (HBV) infection. In Greece, although adherence to HBV prenatal testing has improved significantly, there are still pregnant women who do not receive testing, and there is concern that this group may include women with a higher disease burden.

METHODS

The seroprevalence of HBV markers among parturient women escaping HBsAg prenatal testing was assessed prospectively. Seropositivity rates were compared with those from a control group of women [n=1304, Greek: 1156 (88.7%), Albanian: 148 (11.3%)], with appropriate prenatal HBsAg documentation, who delivered in the same public hospital.

RESULTS

Between January 2007 and March 2009, 9546 women delivered at the Alexandra Hospital, Athens, Greece, and 1000 (10.6%, mean age: 26.6±6.2 years) were unable to document their HBsAg status. Among women tested for the first time in the delivery room, 70.4% were immigrants (Albanians: 41.7%, Eastern European: 14.7%, African: 7.2%, Asian: 6.9%), 15.2% were of Roma origin, and 14.4% were Greek. Overall, 53/1000 (5.3%, 95% confidence interval: 4.1-6.9%) HBsAg(+) cases were found (Albanians: 7.4%, Roma: 5.3%, Asians: 4.3%, Eastern European: 3.4%, Greeks: 2.8%, African: 2.8%, P<0.05 between Greek and Albanian women) versus 15/1304 (1.2%, 95% confidence interval: 0.7-1.9%) in the control group (P<0.0001). Greek women nonadherent to HBV maternal testing were more likely to be chronically infected with HBV (0.6 vs. 2.8%, P<0.05), whereas a similar trend was observed in Albanian women (5.4 vs. 7.4%, P=0.45). Disappointingly low vaccination-induced protection rates (mean 21.4%) were observed among women escaping HBV maternal testing.

CONCLUSION

Higher HBV disease burden and low vaccination-induced protection are characteristic in pregnant women nonadherent to HBsAg prenatal testing. More intense surveillance and implementation of immunization programs should be applied in these populations.

Reconstruction of the epidemic history of hepatitis B virus genotype D in Albania

Despite a recent decrease in the prevalence of HBsAg in the general population, Albania is still highly endemic for HBV infection. Genotype D is the most prevalent HBV strain in the Mediterranean area. We studied the prevalence and distribution of HBV genotypes and subgenotypes in a total of 73 HBsAg-positive patients living in Albania, and reconstructed the epidemiological history of the most prevalent HBV D subgenotype using a "phylodynamic" framework. A time-scaled genealogy of the Albanian patients' and reference P gene sequences with known sampling dates was reconstructed using an MCMC Bayesian approach that allows population growth to be estimated on the basis of coalescent theory. All of the Albanian subjects were infected with the HBV D genotype, and a percentage varying from 44.4% to 100% (depending on the ethnic or risk group) were infected with subgenotype D2, the most prevalent in the study population (72.4%). The other subgenotypes present in a minority of subjects were D1 (13.8%) and D3 (13.8%). The Bayesian skyline plot population dynamics analysis showed that genotype D2 entered the Albanian population in the late 1960s, and that the effective number of infections grew gradually until the second half of the 1980s and more rapidly until the mid-1990s, when it reached a plateau that still persists today. Our data suggest that political and socio-economic factors played an important role in determining the rapid spread of HBV infection in Albania.

Seroepidemiology of hepatitis B virus infection in pregnant women in Catalonia (Spain)

BACKGROUND

In recent years there has been a substantial reduction in hepatitis B incidence as a result of routine vaccination of preadolescents and the selective vaccination of high risk groups and newborns of HBsAg+ mothers.

OBJECTIVES

To determine the prevalence of hepatitis B virus infection markers and of serologic markers of hepatitis B vaccination in a representative sample of pregnant women in Catalonia.

STUDY DESIGN

A representative sample was obtained by random cluster sampling (hospitals with maternity units) stratified by provinces. Anti-HBc, anti-HBs and HBsAg were determined using an ELISA test (Behring, Marburg, Germany). The crude and adjusted odds ratios for the sociodemographic variables analyzed were also calculated.

RESULTS

The global prevalence of carriers of HBsAg+ was 0.1% (95% CI 0.0-0.3), that of hepatitis B infection (anti-HBc+) was 5% (95% CI 3.9-6.1) and that of serologic markers of vaccination (anti-HBs+ and anti-HBc-) was 16.4% (95% CI 14.5-18.2) The prevalence of infection increased with age from 3.0% (15-19 years age group) to 14.8% (40-44 years age group). The prevalence of anti-HBc+ was higher in women born in Asia (27.6%) and Africa (18.8%) than in those born in Spain (3.7%), Europe (3.3%) and America (4.6%), with the differences being statistically significant.

CONCLUSIONS

The results of this study confirm the change in the pattern of endemicity of hepatitis B infection in pregnant women in Catalonia after the introduction of vaccination programmes. They also confirm the increasingly important role played by immigration in the epidemiology of hepatitis B.