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Mohareb AM, Liu AF, Kim AY, Coffie PA, Kouamé MG, Freedberg KA, Boyd A, Hyle EP. Clearance of Hepatitis B e Antigen in Untreated Chronic Hepatitis B Virus Infection: A Systematic Review and Meta-analysis. J Infect Dis 2022; 226:1761-1770. [PMID: 35511194 DOI: 10.1093/infdis/jiac168] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 04/29/2022] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND In people with hepatitis B virus (HBV) infection, persistence of hepatitis B e antigen (HBeAg) is associated with clinical progression and need for treatment. HBeAg loss represents partial immune control and is a critical event in the natural history of chronic HBV. METHODS We conducted a systematic review and meta-analysis of cohort studies that report HBeAg loss among people with untreated chronic HBV. We evaluated HBeAg loss using a random-effects model and conducted subanalysis on region. RESULTS We screened 10 560 publications, performed 196 full-text analyses, and included 26 studies for meta-analysis. The pooled rate of HBeAg loss was 6.46/100 person-years (PYs) (95% confidence interval, 5.17-8.08). Meta-regression showed that older age of participants and studies in Europe were associated with higher rate of HBeAg loss. Rates per 100 PYs were 7.43 (95% confidence interval, 6.30-8.75; 1 study) in Africa, 3.24 (2.61--4.02; 1 study) in the Eastern Mediterranean, 13.67 (11.21-16.66; 4 studies) in Europe, 7.34 (4.61--11.70; 5 studies) in North America, and 5.53 (4.05--7.55; 15 studies) in the Western Pacific. CONCLUSIONS Spontaneous HBeAg loss occurs at a rate of 6.46/100 PYs. Variations by region and age group may reflect epidemiological, immunological, or HBV genotype-related differences.
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Affiliation(s)
- Amir M Mohareb
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA.,Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Anne F Liu
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Division of Gastroenterology, Hepatology, and Endoscopy, Brigham & Women's Hospital, Boston, Massachusetts, USA
| | - Arthur Y Kim
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Patrick A Coffie
- Department of Dermatology and Infectious Diseases, UFR des Sciences Médicales, Université Félix Houphouët-Boigny, Abidjan, Côte d'Ivoire.,Programme PAC-CI, ANRS Research site, Abidjan, Côte d'Ivoire
| | | | - Kenneth A Freedberg
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA.,Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Anders Boyd
- Stiching hiv monitoring, Amsterdam, the Netherlands.,Department of Infectious Diseases, Research and Prevention, Public Health Service of Amsterdam, Amsterdam, the Netherlands
| | - Emily P Hyle
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA.,Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
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2
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Nicastro E, Norsa L, Di Giorgio A, Indolfi G, D'Antiga L. Breakthroughs and challenges in the management of pediatric viral hepatitis. World J Gastroenterol 2021; 27:2474-2494. [PMID: 34092970 PMCID: PMC8160618 DOI: 10.3748/wjg.v27.i20.2474] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 03/04/2021] [Accepted: 04/07/2021] [Indexed: 02/06/2023] Open
Abstract
Chronic infections by hepatitis B virus (HBV) and hepatitis C virus (HCV) major causes of advanced liver disease and mortality worldwide. Although regarded as benign infections in children, their persistence through adulthood is undoubtedly of concern. Recent advances in HCV treatment have restored the visibility of these conditions and raised expectations for HBV treatment, which is currently far from being curative. Herein we describe direct-acting antivirals available for pediatric HCV (sofosbuvir/ledipasvir, sofosbuvir/velpatasvir, glecaprevir/pibrentasvir) and their real-world use. A critical review of the HBV pediatric classification is provided. Anti-HBV investigational compounds are reviewed in light of the pathophysiology in the pediatric population, including capsid assembly modulators, antigen secretion inhibitors, silencing RNAs, and immune modifiers. Recommendations for screening and management of immunosuppressed children or those with other risk factors or comorbidities are also summarized.
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Affiliation(s)
- Emanuele Nicastro
- Department of Pediatric Gastroenterology Hepatology and Transplantation, ASST Papa Giovanni XXIII, Bergamo 24127, Italy
| | - Lorenzo Norsa
- Department of Pediatric Gastroenterology Hepatology and Transplantation, ASST Papa Giovanni XXIII, Bergamo 24127, Italy
| | - Angelo Di Giorgio
- Department of Pediatric Gastroenterology Hepatology and Transplantation, ASST Papa Giovanni XXIII, Bergamo 24127, Italy
| | - Giuseppe Indolfi
- Department of Neurofarba, Meyer Children's University Hospital of Florence, Florence 50137, Italy
| | - Lorenzo D'Antiga
- Department of Pediatric Gastroenterology Hepatology and Transplantation, ASST Papa Giovanni XXIII, Bergamo 24127, Italy
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3
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Arnone OC, Serranti D, Bartolini E, Mastrangelo G, Stinco M, Trapani S, Ricci S, Resti M, Indolfi G. Chronic hepatitis B in children, report of a single-centre longitudinal study on 152 children. J Viral Hepat 2020; 27:1344-1351. [PMID: 32853482 DOI: 10.1111/jvh.13382] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 07/09/2020] [Accepted: 08/11/2020] [Indexed: 02/06/2023]
Abstract
The aims of this prospective study were as follows: (1) to describe the natural history of chronic hepatitis B virus (HBV) infection in a large cohort of untreated children followed at a single centre and (2) to evaluate whether or not the new European Association for the Study of Liver (EASL) classification for the phases of HBV infection in adults can be used for children. All children who presented at the Liver Unit of our hospital from 1 January 1987 to 31 December 2019 and were diagnosed with chronic HBV infection were enrolled. The final sample consisted of 152 children. The median duration of the follow-up was 83 months (range 7-232). At baseline, 125 patients (82.2%) were HBeAg positive (85.3% abnormal alanine aminotransferase (ALT) levels), and 24 (15.8%) were HBeAg-negative (93.3% abnormal ALT). At the end of the observation period, 62 of the HBeAg-positive patients (40.7%) achieved HBeAg seroconversion (median age 9.45 years, range 0.8-19) and 2 (1.4%) achieved HBsAg seroconversion. Elevated ALT serum levels at baseline (P = .011), lower baseline HBV DNA levels (P < .001) and Asian ethnicity (P = .0001) were identified as predisposing factors towards HBeAg seroconversion. EASL criteria could not be applied to 43.3% and 43.5% of the children at baseline and at end of observation, respectively, that were grouped into an undetermined phenotype category. According to the results of the present study, the new EASL guidelines for adults with HBV infection cannot be applied in a satisfactory manner in children.
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Affiliation(s)
- Olivia C Arnone
- Liver Unit, Meyer Children's University Hospital, University of Florence, Firenze, Italy
| | - Daniele Serranti
- Liver Unit, Meyer Children's University Hospital, University of Florence, Firenze, Italy
| | - Elisa Bartolini
- Liver Unit, Meyer Children's University Hospital, University of Florence, Firenze, Italy
| | | | - Mariangela Stinco
- Liver Unit, Meyer Children's University Hospital, University of Florence, Firenze, Italy
| | - Sandra Trapani
- Department of Health Sciences, University of Florence, Firenze, Italy
| | - Silvia Ricci
- Department of Health Sciences, University of Florence, Firenze, Italy
| | - Massimo Resti
- Liver Unit, Meyer Children's University Hospital, University of Florence, Firenze, Italy
| | - Giuseppe Indolfi
- Liver Unit, Meyer Children's University Hospital, University of Florence, Firenze, Italy.,Department NEUROFARBA, University of Florence, Firenze, Italy
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4
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Yang Y, Huang A, Zhao Y. Spontaneous loss of chronic HBV infection markers in treatment-naïve children: a systematic review and pooled meta-analyses. Expert Rev Anti Infect Ther 2020; 19:649-660. [PMID: 33164585 DOI: 10.1080/14787210.2021.1845652] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Objectives: Chronicity could be a serious threat to hepatitis B virus (HBV)-infected children. The necessity of antiviral treatment to HBV-infected children has caused much controversy. The authors aimed to conduct a systematic review and meta-analysis of synthesized evidence regarding the spontaneous loss of chronic HBV infection markers in treatment-naïve children for exploring their long-term management.Methods: Observational cohort studies and non-treatment arms of randomized controlled trials were searched that reported the spontaneous loss of chronic HBV infection markers in untreated children (characterized by the presence of HBsAg ≥6-month), via the rates of hepatitis B surface antigen (HBsAg) loss, hepatitis B e antigen (HBeAg) seroconversion, and HBV DNA suppression with random-effects model.Results: Of 7,427 studies screened, 20 were included in meta-analysis. With cumulative 23,153 person-years of follow-up, the pooled annual incidences of HBsAg and HBeAg loss, HBV DNA suppression were 1, 6, 7%, respectively. Rates within HBeAg loss and HBV DNA suppression did differ by the transmission modes and ALT levels, not in HBsAg.Conclusion: Spontaneous HBsAg loss (function cure) occurs infrequently in treatment-naïve children with chronic HBV infection. Design of practically applicable programs aiming at therapeutics of children may be necessary to support the goal of eliminating HBV infection worldwide.
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Affiliation(s)
- Yuting Yang
- National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation base of Child development and Critical Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Child Infection and Immunity, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Ailong Huang
- Institute for Viral Hepatitis, Ministry of Education Key Laboratory of Molecular Biology on Infectious Diseases, Chongqing Medical University, Chongqing, China
| | - Yao Zhao
- National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation base of Child development and Critical Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Child Infection and Immunity, Children's Hospital of Chongqing Medical University, Chongqing, China
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5
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Indolfi G, Easterbrook P, Dusheiko G, Siberry G, Chang MH, Thorne C, Bulterys M, Chan PL, El-Sayed MH, Giaquinto C, Jonas MM, Meyers T, Walsh N, Wirth S, Penazzato M. Hepatitis B virus infection in children and adolescents. Lancet Gastroenterol Hepatol 2019; 4:466-476. [PMID: 30982722 DOI: 10.1016/s2468-1253(19)30042-1] [Citation(s) in RCA: 102] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Revised: 01/20/2019] [Accepted: 01/22/2019] [Indexed: 02/06/2023]
Abstract
Hepatitis B virus (HBV) infection is a major cause of acute and chronic liver disease and associated morbidity and mortality worldwide. Vertical (mother-to-child) and horizontal early childhood transmission are the main routes of HBV transmission and are responsible for most chronic infections, including among adults who bear the greatest burden of morbidity and mortality. Universal hepatitis B immunisation at birth and in infancy is the key strategy for global elimination of HBV infection, and has been highly effective in reducing new vertical infections. However, global progress in scale-up of HBV testing and treatment has been slow in adults and children. In this Series paper, we summarise knowledge on the epidemiology, natural history, and treatment of chronic HBV infection in adolescents and children, and we highlight key differences from HBV infection in adults. The estimated global prevalence of HBV infection in children aged 5 years or younger is 1·3%. Most children are in the high-replication, low-inflammation phase of infection, with normal or only slightly raised aminotransferases; cirrhosis and hepatocellular carcinoma are rare. Although entecavir is approved and recommended for children aged 2-17 years, and tenofovir for those aged 12-18 years, a conservative approach to treatment initiation in children is recommended. Key actions to address current policy gaps include: validation of non-invasive tests for liver disease staging; additional immunopathogenesis studies in children with HBV infection; long-term follow-up of children on nucleoside or nucleotide analogue regimens to inform guidance on when to start treatment; evaluation of different treatment strategies for children with high rates of HBV replication; and establishment of paediatric treatment registries and international consortia to promote collaborative research.
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Affiliation(s)
- Giuseppe Indolfi
- Paediatric and Liver Unit, Meyer Children's University Hospital of Florence, Florence, Italy
| | - Philippa Easterbrook
- Global Hepatitis Programme and HIV Department, World Health Organization, Geneva, Switzerland.
| | - Geoffrey Dusheiko
- King's College Hospital, London, UK; University College London Medical School, London, UK
| | - George Siberry
- Office of the US Global AIDS Coordinator, US Department of State, Washington, DC, USA
| | - Mei-Hwei Chang
- Department of Paediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Claire Thorne
- UCL Great Ormond Street Institute of Child Health, University College London, NIHR GOSH BRC, London, UK
| | - Marc Bulterys
- Global Hepatitis Programme and HIV Department, World Health Organization, Geneva, Switzerland
| | - Po-Lin Chan
- World Health Organization Regional Office for the Western Pacific, Manila, Philippines
| | - Manal H El-Sayed
- Department of Paediatrics, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Carlo Giaquinto
- Department of Women and Child Health, University of Padova, Padova, Italy
| | - Maureen M Jonas
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - Tammy Meyers
- Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - Nick Walsh
- Pan American Health Organization, World Health Organization Regional Office for the Americas, Washington, DC, USA
| | - Stefan Wirth
- Department of Paediatrics, Helios Medical Centre Wuppertal, Witten-Herdecke University, Witten, Germany
| | - Martina Penazzato
- Global Hepatitis Programme and HIV Department, World Health Organization, Geneva, Switzerland
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6
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Abstract
The diagnosis and treatment of infection with hepatitis B and C has undergone a paradigm shift in the past decade. Although children with these infections are usually asymptomatic with normal liver function, their evaluation and management can often involve complex issues and require specialized expertise. Here the authors review the common clinical scenarios which might be encountered by a general pediatrician, explain the various tests available for diagnosis, and provide practical guidelines for managing these children.
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Affiliation(s)
- Rohan Malik
- Department of Pediatric Gastroenterology, Hepatology and Clinical Nutrition, Royal Children's Hospital, 50 Flemington Road, Parkville, 3052, Victoria, Melbourne, Australia
| | - Winita Hardikar
- Department of Pediatric Gastroenterology, Hepatology and Clinical Nutrition, Royal Children's Hospital, 50 Flemington Road, Parkville, 3052, Victoria, Melbourne, Australia.
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7
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Iwasawa K, Inui A, Tsunoda T, Kondo T, Kawamoto M, Sogo T, Komatsu H, Fujisawa T. Hepatitis B (HB) immunoglobulin plus HB vaccine for intrauterine HB virus infection. Pediatr Int 2015; 57:401-5. [PMID: 25331640 DOI: 10.1111/ped.12528] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Revised: 08/28/2014] [Accepted: 10/08/2014] [Indexed: 12/26/2022]
Abstract
BACKGROUND Vaccination against hepatitis B virus (HBV) infection in infants born to hepatitis B surface antigen (HBsAg)-positive mothers using HB immunoglobulin (HBIG) and hepatitis B (HB) vaccine was launched in Japan in 1985. Infants testing positive for HBsAg at 1 month of age are considered to have prenatally acquired the infection and are usually excluded from the prevention program. Infants born to HB e antigen (HBeAg)-positive mothers are at a high risk of perinatally acquiring the infection. In this study, long-term outcome was evaluated in children with prenatal HBV infection who received the HBIG and HB vaccine in Japan. METHODS Newborns of both HBsAg- and HBeAg-positive carrier mothers received HBIG within 48 h of birth and at 2 months of age. Subsequently, three doses of recombinant HB vaccine were given at 2, 3, and 5 months of age. Outcome was compared between the following two groups: infants who completed the vaccination program, even if they were HBsAg positive at 1 month of age (n = 15), and infants who did not (n = 51). RESULTS Seroconversion from HBeAg to anti-HBe antibody (HBeAb) before 3 years of age was observed in five children (33%) who completed the vaccination program and in two (4%) who did not (P = 0.005). In 2/5 children who completed the vaccination program and achieved HBeAb seroconversion, seroconversion from HBsAg to anti-HBs antibody was also noted. CONCLUSION This specific vaccination program for children with prenatal HBV infection has the potential to alter immune tolerance to HBV.
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Affiliation(s)
- Kentaro Iwasawa
- Division of Hepatology and Gastroenterology, Children's Center for Health and Development, Saiseikai Yokohamashi Tobu Hospital, Sakura, Chiba, Japan
| | - Ayano Inui
- Division of Hepatology and Gastroenterology, Children's Center for Health and Development, Saiseikai Yokohamashi Tobu Hospital, Sakura, Chiba, Japan
| | - Tomoyuki Tsunoda
- Division of Hepatology and Gastroenterology, Children's Center for Health and Development, Saiseikai Yokohamashi Tobu Hospital, Sakura, Chiba, Japan
| | - Takeo Kondo
- Division of Hepatology and Gastroenterology, Children's Center for Health and Development, Saiseikai Yokohamashi Tobu Hospital, Sakura, Chiba, Japan
| | - Manari Kawamoto
- Division of Hepatology and Gastroenterology, Children's Center for Health and Development, Saiseikai Yokohamashi Tobu Hospital, Sakura, Chiba, Japan
| | - Tsuyoshi Sogo
- Division of Hepatology and Gastroenterology, Children's Center for Health and Development, Saiseikai Yokohamashi Tobu Hospital, Sakura, Chiba, Japan
| | - Haruki Komatsu
- Department of Pediatrics, Sakura Hospital, Toho University Schowol of Medicine, Sakura, Chiba, Japan
| | - Tomoo Fujisawa
- Division of Hepatology and Gastroenterology, Children's Center for Health and Development, Saiseikai Yokohamashi Tobu Hospital, Sakura, Chiba, Japan
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8
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Li Z, Hou X, Cao G. Is mother-to-infant transmission the most important factor for persistent HBV infection? Emerg Microbes Infect 2015; 4:e30. [PMID: 26060603 PMCID: PMC4451268 DOI: 10.1038/emi.2015.30] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 03/24/2015] [Accepted: 04/06/2015] [Indexed: 02/06/2023]
Abstract
Of the infants born to hepatitis B surface antigen (HBsAg)-positive mothers globally, 42.1% who did not receive hepatitis B virus (HBV) passive-active immunoprophylaxis and 2.9% of infants who received the immunoprophylaxis acquired HBV infection perinatally. Moreover, perinatal infection occurred in 84.2% (18.8%-100%) and 8.7% (0.0-21.0%) of infants born to hepatitis B e-antigen (HBeAg)-positive mothers who did not and did receive immunoprophylaxis, respectively; by contrast, the infection rates were 6.7% (0.0-15.4%) and 0.4% (0.0-2.5%) for infants born to HBeAg-negative-carrier mothers, respectively. The chronicity rates of HBV infection acquired perinatally were 28.2% (17.4%-33.9%) in infants born to HBeAg-negative mothers and 64.5% (53.5%-100%) in infants born to HBeAg-positive mothers. HBV mother-to-child transmission was more frequent in East Asia relative to other areas. In addition to differences in the endemic HBV genotype, the interchange of allelic dominance in genetic polymorphisms in HLA class II and NF-κB between the Chinese and European populations may explain why chronic HBV infection frequently affects the Chinese. The risk of progressing into chronic infection was inversely related to the age of children at the time of horizontal transmission. To further diminish HBV chronic infection, it is necessary to enforce antiviral treatment after the 28th week of gestation for HBeAg-positive mothers and to improve the health habits of carrier mothers and household sanitary conditions.
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Affiliation(s)
- Zixiong Li
- Department of Epidemiology, Second Military Medical University , Shanghai 200433, China
| | - Xiaomei Hou
- Department of Epidemiology, Second Military Medical University , Shanghai 200433, China
| | - Guangwen Cao
- Department of Epidemiology, Second Military Medical University , Shanghai 200433, China
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9
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Torii Y, Kimura H, Hayashi K, Suzuki M, Kawada JI, Kojima S, Katano Y, Goto H, Ito Y. Causes of vertical transmission of hepatitis B virus under the at-risk prevention strategy in Japan. Microbiol Immunol 2013; 57:118-21. [PMID: 23252723 DOI: 10.1111/1348-0421.12009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Revised: 11/05/2012] [Accepted: 11/21/2012] [Indexed: 12/20/2022]
Abstract
The number of hepatitis B virus (HBV) carrier babies has decreased markedly since the introduction in Japan of an "at-risk" strategy for preventing HBV infection. However, elimination of HBV infection from our country appears difficult. To clarify the limitations of the at-risk strategy for preventing vertical transmission of HBV, causes of vertical transmission in a single hospital were retrospectively analyzed. The following causes were presumed in 17 carrier pediatric cases: five patients had prenatal HBV infection, HBV infection during/after the immunization program was confirmed in five cases, two patients had prenatal infection or infection during the immunization program and three cases were caused by human error (by the patients' guardians). Because their mothers were HBV-negative at screening and only developed acute hepatitis B in the perinatal period, another two cases (Cases 3 and 10) did not undergo immunization because they were not subjects of the at-risk strategy. Sequence analyses in ten patients revealed genotype C (subgenotype, C2/Ce) in nine cases and genotype A (subgenotype, A2/Ae) in one case (Case 3). In Japan, HBV subgenotype Ae has recently been found more frequently among sexually active men with acute hepatitis. There are concerns that horizontal transmission of HBV from these men to their pregnant partners could increase. These data suggest clear limitations to the at-risk strategy in Japan and the possibility that the increase in genotype A may influence vertical transmission of HBV.
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Affiliation(s)
- Yuka Torii
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Showa-ku, Nagoya, Japan
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