Ethical issues in preventing mother-to-child transmission of hepatitis B by immunisation

Asian Pacific association for the study of liver (APASL) guidelines: hepatitis B virus in pregnancy

Hepatitis B virus (HBV) infection still remains a major public health issue in the Asia-Pacific region. Most of the burden of HBV-related disease results from infections acquired in infancy through perinatal or early childhood exposure to HBV in Asia-Pacific. Hepatitis B during pregnancy presents unique management issues for both the mother and fetus. These APASL guidelines provide a comprehensive review and recommendations based on available evidence in the literature, for the management of females with HBV infection through every stage of pregnancy and postpartum. These also address the concerns, management challenges, and required follow-up of children born to hepatitis B-positive mothers.

Effects of intrauterine exposure to hepatitis B virus in foetuses

Foetal response to hepatitis B viral infection is still unknown. The mechanisms of persistent infection that occurs more often in mother-to-child transmission than adult transmission are also unclear. Various aspects of the environmental factors that accelerate or inhibit infection and the cytokine responses are associated with the persistence of infection. Several studies showed that the cytokine poor immune response in immaturity causes the persistence of the infection. However, some reports suggested that a mature immune response was the cause of this persistent infection. This review comprehensively summarized the reports from in vitro, in vivo as well as clinical reports regarding the responses of the foetuses of hepatitis B infected mothers to the micro-organism. The mechanism of more opportunities to be persistently infected via the mother-to-child transmission route is also summarized and discussed. Since there are limited clinical reports at this time, this review will provide evidence for future studies regarding the intrauterine infection mechanism and foetal response to hepatitis B virus to elucidate the mechanisms responsible for mother-to-child transmission. This understanding may lead to effective interventions to control mother-to-child hepatitis B infection in the future.

Current understandings of the impact of mandatory vaccination laws in Europe

Vaccinations are among the most successful preventive tools to protect collective health. In response to alarming vaccines preventable diseases (VPDs) outbreaks resurgence, decreased vaccination coverage and vaccine refusal, several European countries have recently revised their vaccination policies introducing or extending mandatory vaccinations. This review examines the health, political and ethical aspects of mandatory vaccination.The authors first clarify terms and definitions and propose a conceptual framework of mandatory policies. Second, they describe the current status of mandatory childhood immunization programmes in Europe, assessing selected mandatory laws. Third, as the authors conduct a systematic review of the literature (retrieving from Medline 17 relevant records between 2010 and 2020), they take an analytical approach to measure the impact of mandatory vaccination policies on both VPDs control and immunization coverage, but also on population attitudes toward vaccines. 40% of European countries currently have mandatory vaccination policies; however, policies vary widely and, although there is evidence of increased vaccine uptake, their impact on informed adherence to preventive behaviors is scant.Although mandatory vaccination policies might be needed to protect collective health in times of emergency, public health goals of VPD prevention and health promotion should primarily be pursued through health education and population empowerment.

Chronic hepatitis B in pregnant women: Current trends and approaches

Chronic hepatitis B (CHB) is a significant public health problem worldwide. The aim of the present review is to summarize the actual trends in the management of CHB in pregnant women. The prevalence of hepatitis B virus (HBV) infection in pregnant women is usually comparable to that in the general population in the corresponding geographic area. All women have to be screened for hepatitis B surface antigen (HBsAg) during pregnancy. Additional examinations of pregnant women with CHB may include maternal hepatitis B e antigen, HBV viral load, alanine aminotransferase level, and HBsAg level. The management of pregnancy depends on the phase of the HBV infection, which has to be determined before pregnancy. In women of childbearing age with CHB, antiviral therapy can pursue two main goals: Treatment of active CHB, and vertical transmission prevention. During pregnancy, tenofovir is the drug of choice in both cases. A combination of hepatitis B immunoglobulin and vaccine against hepatitis B should be administered within the first 12 h to all infants born to mothers with CHB. In such cases, there are no contraindications to breastfeeding.

Gender Equity and Vertically Transmitted Infections: A Country-Level Analysis Across 153 Countries

Purpose: Gender inequality is a barrier to education toward women and accessibility to health facilities, which are important for preventing vertical transmission. This study was conducted to analyze the impact of gender equity on vertically transmitted infections (hepatitis viruses, human immunodeficiency virus [HIV], and syphilis) using country-level indicators.

Methods: The relationship between the Global Gender Gap Index (GGGI), which is indicator of gender equity, and vertical transmission was analyzed. GGGI scores were collected from 153 countries in 2020. Vertical transmission included 10 outcomes for hepatitis viruses, HIV, and syphilis. Generalized linear model (GLM) was used for analyzing the relationship. Other predictors included skilled birth attendant and country income.

Results: The median GGGI score was 0.706 (interquartile range, 0.664–0.736). GLM showed that the GGGI score was significantly associated with the incidence of both chronic hepatitis B and C in under 5 years (both p<0.001). For HIV, GGGI score was significantly associated with the pregnant women with unknown HIV status (p=0.001), no early infant diagnosis (p=0.027), and final transmission rate (p=0.005). There was no significant predictor for pregnant women who have not received antiretroviral therapy for prevention of mother-to-child transmission. All syphilis indicators have improved in high-income countries compared to low-income countries. GGGI score had a significant association only with no syphilis screening (p<0.001).

Conclusions: A lower GGGI score was associated with higher vertical transmission of hepatitis and HIV. The improvement of gender equity might prevent vertical transmission of these viruses. Further intervention studies are warranted to verify the results.

Viral hepatitis and pregnancy

The management of viral hepatitis in the setting of pregnancy requires special consideration. There are five liver-specific viruses (hepatitis A, B, C, D, E), each with unique epidemiology, tendency to chronicity, risk of liver complications and response to antiviral therapies. In the setting of pregnancy, the liver health of the mother, the influence of pregnancy on the clinical course of the viral infection and the effect of the virus or liver disease on the developing infant must be considered. Although all hepatitis viruses can harm the mother and the child, the greatest risk to maternal health and subsequently the fetus is seen with acute hepatitis A virus or hepatitis E virus infection during pregnancy. By contrast, the primary risks for hepatitis B virus (HBV), hepatitis C virus (HCV) and hepatitis D virus are related to the severity of the underlying liver disease in the mother and the risk of mother-to-child transmission (MTCT) for HBV and HCV. The prevention of MTCT is key to reducing the global burden of chronic viral hepatitis, and prevention strategies must take into consideration local health-care and socioeconomic challenges. This Review presents the epidemiology of acute and chronic viral hepatitis infection in pregnancy, the effect of pregnancy on the course of viral infection and, conversely, the influence of the viral infection on maternal and infant outcomes, including MTCT.

The Stigma of Sexually Transmitted Infections

Evidence-based guidelines have improved diagnosis and treatment of sexually transmitted infections (STI). Social stigma remains a barrier to STI testing and is associated with underutilization of prevention services. Alternatives for STI testing (eg, in-home testing) are convenient. However, some individuals decline follow-up treatment in fear of unintentional disclosure of their diagnosis. This article reviews STI treatment guidelines and examines the impact of stigma and ethical issues on testing, adherence, partner notification, and transmission rates. An understanding of STI-associated ethical issues and controversies is an important step toward eliminating stigma and reducing STI prevalence and morbidity.

Hepatitis B - Vertical transmission and the prevention of mother-to-child transmission

Hepatitis B virus (HBV) infection is the commonest cause of chronic hepatitis, with an estimated global prevalence of 3.5%, and which leads to significant morbidity and mortality. Mother-to-child transmission (MTCT) during pregnancy is the leading form of transmission in endemic populations, and its interruption is thus crucial as the initial step in the elimination of HBV infection, notwithstanding the availability of potent antiviral medications. The risk of MTCT is dramatically reduced by timely neonatal HBV vaccination and the administration of hepatitis B immunoglobulin after birth in high-risk infants. Maternal HBV DNA quantification during pregnancy allows the assessment of the risk of newborn immunoprophylaxis failure (IF). Maternal antiviral treatment in highly viremic women can reduce the risk of IF. However, the optimal HBV DNA cutoff level for the initiation of antiviral treatment remains to be determined.

Prevention of perinatal hepatitis B virus transmission

PURPOSE

Chronic hepatitis B virus (HBV) infection remains endemic and continues to cause significant morbidity and mortality. It is a global health issue and the World Health Organization aims to eradicate HBV by 2030. Since vertical transmission accounts for the majority of chronic HBV infection, pregnancy offers an excellent opportunity to achieve complete HBV eradication by providing effective immunization of the offspring.

METHODS

We reviewed recent publications identified from PubMed database using a combination of the relevant keywords for HBV, pregnancy, vertical transmission, immunoprophylaxis failure and antiviral treatment.

RESULTS

We summarized the evidence of factors associated with, and measures to reduce and prevent maternal to child transmission, including the use of antiviral treatment during pregnancy to prevent immunoprophylaxis failure. Evidence suggested that highly viremia mother can be offered antenatal antiviral treatment to prevent immunoprophylaxis failure. We elaborated the viral load threshold to start maternal antiviral treatment and the importance of timely neonatal vaccination. A clinical algorithm to manage HBV carriers during pregnancy was proposed.

CONCLUSION

Eradication of HBV is achievable with optimal management of HBV carriers, especially during pregnancy by interruption of vertical transmission. Routine antenatal screening and neonatal immunoprophylaxis remain the key measures to reduce the global HBV burden, and additional antenatal antiviral treatment could further minimize the chance of persistent infection in newborns.

Effectiveness of prevention of mother-to-child transmission practice in three provinces of Southern China

Vaccination in prevention mother-to-child transmission (PMTCT) of hepatitis B has been recommended since plasma-derived hepatitis B vaccines became available in China in 1986; however, less study evaluated practice effectiveness of PMTCT systematically. We conducted a prospective survey to evaluate the effectiveness of PMTCT practices in 3 provinces of southern China. We selected prefectures with low timely birth dose coverage in Yunnan, Guangxi, and Hunan provinces. Infants born to HBsAg positive mothers were evaluated at 7-12 months of age. We tested hepatitis B virus (HBV) surface antigen (HBsAg) and HBV e antigen (HBeAg) of mothers and tested HBsAg of infants born to HBsAg positive mothers using Enzyme-linked Immunosorbent Assay (ELISA) at provincial CDC laboratories. We used logistic regression analysis to analyze the risk factors for HBV infection. Among 3,094 infants born to HBsAg positive mothers, 172 were positive for HBsAg (5.6%). HBeAg status of pregnant women, timely birth dose (TBD) of hepatitis B vaccine were major predictors for HBV infection of infants. PMTCT practices greatly reduced the prevalence of HBsAg among infants born to HBsAg positive mothers China. However, the effectiveness of strategies used in PMTCT varied. HBsAg screening for pregnant women, monitoring of infants born to HBsAg positive mother should be enhanced to evaluate the effectiveness of program.

What the world's religions teach, applied to vaccines and immune globulins

For millennia, humans have sought and found purpose, solace, values, understanding, and fellowship in religious practices. Buddhist nuns performed variolation against smallpox over 1000 years ago. Since Jenner developed vaccination against smallpox in 1796, some people have objected to and declined vaccination, citing various religious reasons. This paper reviews the scriptural, canonical basis for such interpretations, as well as passages that support immunization. Populous faith traditions are considered, including Hinduism, Buddhism, Jainism, Judaism, Christianity, and Islam. Subjects of concern such as blood components, pharmaceutical excipients of porcine or bovine origin, rubella strain RA 27/3, and cell-culture media with remote fetal origins are evaluated against the religious concerns identified. The review identified more than 60 reports or evaluations of vaccine-preventable infectious-disease outbreaks that occurred within religious communities or that spread from them to broader communities. In multiple cases, ostensibly religious reasons to decline immunization actually reflected concerns about vaccine safety or personal beliefs among a social network of people organized around a faith community, rather than theologically based objections per se. Themes favoring vaccine acceptance included transformation of vaccine excipients from their starting material, extensive dilution of components of concern, the medicinal purpose of immunization (in contrast to diet), and lack of alternatives. Other important features included imperatives to preserve health and duty to community (e.g., parent to child, among neighbors). Concern that 'the body is a temple not to be defiled' is contrasted with other teaching and quality-control requirements in manufacturing vaccines and immune globulins. Health professionals who counsel hesitant patients or parents can ask about the basis for concern and how the individual applies religious understanding to decision-making about medical products, explain facts about content and processes, and suggest further dialog with informed religious leaders. Key considerations for observant believers for each populous religion are described.

An ethical framework for public health immunisation programs

This paper presents seven ethical principles associated with the implementation of immunisation programs. For a public health immunisation program to be ethically justifiable, its principles and operation should be based on sound ethical values: the program should benefit the individual and the community; targeted diseases should be sufficiently severe and frequent to justify the risks and expense of the program, and vulnerable groups within the population should be targeted. The principles also deal with the obligation to monitor for adverse events and for disease incidence to ensure safety and effectiveness. When immunisations are voluntary, vaccine recipients or their parents or carers should be given sufficient information to make autonomous, informed decisions and incentives to participate in public health immunisation programs should not be coercive. Public health immunisation programs depend on mutual trust, which may be threatened by circumstances such as excessive media publicity about adverse events associated with vaccines.