Trends in Hepatitis B Infection and Immunity Among Women of Childbearing Age in the United States

Epidemiology of Chronic Hepatitis B Virus Infection, Alameda County, California, 2017-2021

CONTEXT

In the United States, chronic hepatitis B (CHB) virus infection predominantly affects ethnic minorities and vulnerable populations.

OBJECTIVE

We analyzed surveillance data to describe CHB epidemiology to guide hepatitis B virus (HBV) elimination efforts in Alameda County.

DESIGN

Persons with CHB during 2017-2021 were identified by ≥2 positive HBV tests (ie, HBsAg, HbeAg, and HBV DNA) ≥180 days apart using data from California Reportable Disease Information Exchange. Persons with CHB were stratified by age, race/ethnicity, zip code-based Healthy Places Index (HPI), and federally designated Medically Underserved Areas (MUA). Comparisons of reported CHB prevalence between groups utilized z test; comparisons between MUA regions utilized chi-square testing.

RESULTS

A total of 8122 persons with CHB were identified; reported 5-year CHB prevalence was 0.53% (95% confidence interval: 0.52%-0.54%). Reported CHB 5-year prevalence was significantly higher among persons aged 50 to 69 years old than persons aged 30 to 49 years old (0.99%, 0.78%; P < .001) and Asians, Native Hawaiian/Pacific Islanders, African Americans compared to Whites (1.22%, 0.56%, 0.18%, 0.06%; P < .001). Reported CHB 5-year prevalence in the 2 lowest and most disadvantaged HPI quartiles was significantly higher than the 2 highest quartiles (0.55%, 0.68%, 0.37%, 0.42%; P < .001). The 1918 persons with CHB in MUA, compared to 5859 non-MUA persons, were significantly more likely to be African American (7%, 3%; P < .001) and from the lowest HPI quartile (79%, 19%; P < .001).

CONCLUSIONS

Reported CHB 5-year prevalence in Alameda County was 1.5 times the national prevalence estimates, and reported prevalence was highest among Asians and persons in more disadvantaged areas. Analysis of local CHB surveillance data can guide public health efforts toward HBV elimination.

Epidemiology, linkage to care and natural history of women of childbearing age with chronic hepatitis B: A population-based study

Pregnant women with chronic hepatitis B (CHB) are a priority population for hepatitis B care. Identification of HBV status prior to pregnancy would facilitate timely maternal interventions and perinatal care. In our study, we aimed to study the epidemiology of CHB among women of childbearing age (WoCBA, 18-49 years) in Alberta, Canada. We retrospectively analysed Alberta Analytics databases to study CHB epidemiology, natural history and care linkage among WoCBA in Alberta, between April 2012 and March 2021. A Poisson regression was conducted to estimate incidence of newly identified CHB cases and prevalence trends, whereas predictors of care linkage were determined using logistic regression. Age/sex-adjusted incidence of newly identified CHB among WoCBA between 2015 and 2020 was 36.2/100,000 person/years, highest among individuals aged 30-39 years. Incidence of newly identified CHB decreased from 52.6 to 18.2/100,000 between 2015 and 2020, but prevalence increased from 131.7 to 248.6/100,000 in the same period. Newly identified CHB incident cases (n = 2124) had lower survival rates than age/sex-matched Canadians, with a standardized mortality ratio of 5.7 (95% CI 2.6-11.0). Increasing age (years) at diagnosis (HR, 1.2; 95% CI 1.1-1.3) was independently associated with mortality. Comorbid hepatocellular carcinoma, anti-HBV treatment and year of diagnosis were not significantly associated with mortality. Of the 1927 women with 2436 hepatitis B surface antigen-positive pregnancies from 2012 to 2020, only 27.6% had recommended HBV assessment during pregnancy. Of those women meeting criteria for antiviral therapy to prevent mother-to-child transmission (MTCT), only 66.4% received treatment. Suboptimal management during pregnancy and overall lower survival rates highlight the need to address care linkage barriers in women of childbearing age living with CHB.

Exploring blood lipids-immunity associations following HBV vaccination: evidence from a large cross-sectional study

Introduction

Serological responses following hepatitis B vaccination are crucial for preventing hepatitis B (HBV). However, the potential relationship between serum lipid levels and immunity from HBV vaccination remains poorly understood.

Methods

In this study, we conducted an analysis of the National Health and Nutrition Examination Survey (NHANES) data spanning from 2003 to 2016. Multivariable weighted logistic regression models, generalized linear analysis, stratified models, smooth curve fitting, segmentation effect analysis and sensitivity analysis were utilized to assess the relationships.

Results

After adjusting for relevant covariates, we observed that low levels of high-density lipoprotein cholesterol (HDL) were independently linked to a significantly lower seroprotective rate. Compared to HDL levels of ≥ 60 mg/dL, the odds ratios (ORs) for individuals with borderline levels (40-59 mg/dL for men, 50-59 mg/dL for women) and low levels (< 40 mg/dL for men, < 50 mg/dL for women) were 0.83 (95% CI 0.69-0.99) and 0.65 (95% CI 0.56-0.78), respectively. This association was particularly pronounced in individuals aged 40 or older. Conversely, higher levels of the triglyceride to HDL (TG/HDL) ratio (OR, 0.90; 95% CI, 0.84-0.98), total cholesterol to HDL (Chol/HDL) ratio (OR, 0.77; 95% CI, 0.64-0.92), and low-density lipoprotein to HDL (LDL/HDL) ratio (OR, 0.85; 95% CI, 0.76-0.96) were associated with a decreased likelihood of seroprotection.

Conclusion

This study suggests that lipid levels may play a role in modulating the immune response following HBV vaccination.

Maternal-to-Child Transmission of Hepatitis B Virus and Hepatitis Delta Virus

Maternal-to-child transmission of hepatitis B virus (HBV) and hepatitis delta virus (HDV) can lead to the risk of progressive liver disease in infants, but fortunately effective interventions exist to decrease transmission. Counseling on the risk of maternal-to-child transmission, care pathways to decrease transmission, and the implications of HBV and HDV on pregnancy outcomes are the key components of caring for pregnant people living with HBV and HDV.

Screening and Testing for Hepatitis B Virus Infection: CDC Recommendations - United States, 2023

Chronic hepatitis B virus (HBV) infection can lead to substantial morbidity and mortality. Although treatment is not considered curative, antiviral treatment, monitoring, and liver cancer surveillance can reduce morbidity and mortality. Effective vaccines to prevent hepatitis B are available. This report updates and expands CDC's previously published Recommendations for Identification and Public Health Management of Persons with Chronic Hepatitis B Virus Infection (MMWR Recomm Rep 2008;57[No. RR-8]) regarding screening for HBV infection in the United States. New recommendations include hepatitis B screening using three laboratory tests at least once during a lifetime for adults aged ≥18 years. The report also expands risk-based testing recommendations to include the following populations, activities, exposures, or conditions associated with increased risk for HBV infection: persons incarcerated or formerly incarcerated in a jail, prison, or other detention setting; persons with a history of sexually transmitted infections or multiple sex partners; and persons with a history of hepatitis C virus infection. In addition, to provide increased access to testing, anyone who requests HBV testing should receive it, regardless of disclosure of risk, because many persons might be reluctant to disclose stigmatizing risks.

Age-specific seroprotection after Hepatitis B virus vaccination among Korean American pediatric population in Queens, New York

Hepatitis B Virus (HBV) infection is a major health issue among Asian Americans. The prevalence of chronic Hepatitis B infection in New York City is estimated to be 2.7% compared with .3% in the overall United States. The efficacy and long-term immunity of HBV vaccination in the Korean American pediatric population in Queens, NY, are not well explored. This study aimed to 1) determine the age-specific prevalence of anti-HBs seropositivity in the Korean American pediatric population and 2) assess biologic/demographic factors influencing immunologic response to HBV vaccine. We performed a retrospective chart review of patients registered to a pediatric health clinic located in Queens, NY, from October 2014 to October 2020. Out of 604 medical records of patients aged ≤18 years who received a completed series of HBV vaccines during infancy, we analyzed 91 medical records where HBV serology test (HBsAg and anti-HBs) results were available. Three out of 91 subjects were born to HBsAg-positive mothers. Eight out of 91 subjects were born in South Korea. Overall, 54.9% of subjects were anti-HBs-seropositive. The seropositive rate in the 15 to 18-years-old-age group (14.3%) was significantly lower than that in other age groups: < 1 year (100%) (p = .015), 1–4 years (52.6%) (p = .033), 5–9 years (63.3%) (p = .0034), and 10–14 years (64%) (p = .0063). The mean duration since vaccination in seropositive subjects was 96.5 ± 53.9 months, and that in seronegative subjects was 121.7 ± 64.2 months (p < .047). Gender, BMI, and foreign birth were not significant risk factors affecting the nonseroprotective status. The role of routine screening of anti-HB titers and booster vaccination in this endemic community needs to be further explored.

Hepatitis C is associated with more adverse pregnancy outcomes than hepatitis B: A 7-year national inpatient sample study

Prior international studies have shown mixed results regarding the association of hepatitis B and hepatitis C with adverse pregnancy outcomes. We performed an updated evaluation of the prevalence of associated adverse pregnancy outcomes and evaluated trends over time of diagnosis of chronic hepatitis B (HBV) and chronic hepatitis C (HCV) in pregnant women in a national database. All pregnant women with HBV and HCV were identified from the National Inpatient Sample database 2012 to 2018. Multivariate logistic regression analyses were performed to compare pregnancy‐related complications, including rates of preeclampsia/eclampsia, gestational diabetes, intrauterine growth restriction, antepartum/intrapartum hemorrhage, preterm labor, and Cesarean section. We evaluated all‐cause in‐hospital mortality, length of stay, and total cost of hospitalizations. A total of 28.7 million pregnancy‐related hospitalizations that met our eligibility criteria were identified, including 51,200 with HBV and 131,695 with HCV. In comparison with the uninfected controls, the HBV group was significantly more likely to develop gestational diabetes (12.94% vs. 6.94%, p < 0.001). The HCV group was more likely to have preterm labor (9.63% vs. 6.27%, p < 0.001), intrauterine growth restriction (6.04% vs. 2.89%, p < 0.001), longer length of stay (3.4 days vs. 2.7 days, p < 0.001), and higher hospitalization cost (15,052 dollars vs. 14,258 dollars, p < 0.001). These findings should inform counseling of women who are found to have HBV or HCV during pregnancy regarding the risk of adverse pregnancy outcomes and support the need for an interdisciplinary approach to optimize maternal and neonatal outcomes.

Adherence to pregnancy hepatitis B care guidelines in women and infants in the United States and evaluation of two interventions to improve care: A multicentre hospital-based study

There has been an increase in hepatitis B (HBV) detection during pregnancy in the United States and an emphasis on measures to decrease mother-to-child transmission of HBV. We performed a multicentre retrospective study (2015-2018) evaluating care among all women with HBV during pregnancy. We determined rates and predictors of adherence to key maternal care measures including: (1) referral to HBV specialty care, (2) assessment of HBV DNA, and (3) initiation of antiviral therapy, and (4) rates of HBIG and HBV vaccine completion in infants. We evaluated two interventions to improve HBV care: (1) clinical decision support with best practice alert and (2) co-location of HBV care in obstetrics department. We identified 372 women with HBV during pregnancy. Patients had a median age of 33 (IQR 29, 36), were mostly of Asian (49%) or Black (36%) race, HBeAg-negative (83%) with HBV DNA ≤2000 IU/mL (65%) and maximum ALT ≤25 (66%). Regarding care measures, 62% were referred to an HBV specialist, 85% had HBV DNA checked during pregnancy and 68% with HBV DNA ≥200,000 were initiated on antiviral therapy. Co-located obstetric-liver diseases clinics appeared to improve adherence to maternal care measures. All infants received HBIG and the first HBV vaccine dose, 106 (81%) received the second, 94 (74%) received the 3rd dose, but fewer at the recommended time intervals. We identified clear gaps in adherence to HBV care measures for both mothers and infants. Co-location of HBV care in the obstetrics department shows promise in improving adherence to maternal care measures.

Screening for Hepatitis B Virus Infection in Nonpregnant Adolescents and Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

Importance

A 2014 review for the US Preventive Services Task Force (USPSTF) found antiviral therapy for hepatitis B virus (HBV) infection associated with improved intermediate outcomes, although evidence on clinical outcomes was limited.

Objective

To update the 2014 HBV screening review in nonpregnant adolescents and adults to inform the USPSTF.

Data Sources

Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, and Ovid MEDLINE (2014 to August 2019); with surveillance through July 24, 2020.

Study Selection

Randomized clinical trials (RCTs) on screening and antiviral therapy; cohort studies on screening, antiviral therapy clinical outcomes, and the association between achieving intermediate outcomes after antiviral therapy and clinical outcomes.

Data Extraction and Synthesis

One investigator abstracted data; a second investigator checked accuracy. Two investigators independently assessed study quality. Random-effects profile likelihood meta-analysis was performed.

Results

Thirty trials and 20 cohort studies, with a total of 94 168 participants, were included. No study directly evaluated the effects of screening for HBV infection vs no screening on clinical outcomes such as mortality, hepatocellular carcinoma, or cirrhosis. Screening strategies that focused on risk factors such as ever having immigrated from high-prevalence countries and demographic and behavioral risk factors would identify nearly all HBV infection cases. In 1 study (n = 21 008), only screening immigrants from high-prevalence countries would miss approximately two-thirds of infected persons. Based on 18 trials (n = 2972), antiviral therapy compared with placebo or no treatment was associated with greater likelihood of achieving intermediate outcomes, such as virologic suppression and hepatitis B e-antigen (HBeAg) or hepatitis B surface antigen loss or seroconversion; the numbers needed to treat ranged from 2.6 for virologic suppression to 17 for HBeAg seroconversion. Based on 12 trials (n = 4127), first-line antiviral therapies were at least as likely as nonpreferred therapies to achieve intermediate outcomes. Based on 16 trials (n = 4809), antiviral therapy might be associated with improved clinical outcomes, but data were sparse and imprecise. Nine cohort studies (n = 3893) indicated an association between achieving an intermediate outcome following antiviral therapy and improved clinical outcomes but were heterogeneous (hazard ratios ranged from 0.07 to 0.87). Antiviral therapy was associated with higher risk of withdrawal due to adverse events vs placebo or no antiviral therapy.

Conclusions and Relevance

There was no direct evidence for the clinical benefits and harms of HBV screening vs no screening. Antiviral therapy for HBV infection was associated with improved intermediate outcomes and may improve clinical outcomes.

Chronic Hepatitis B and HIV Coinfection: A Continuing Challenge in the Era of Antiretroviral Therapy

PURPOSE OF REVIEW

The burden of chronic hepatitis B (HBV) remains disproportionately high among people living with HIV (PLWH) despite the advent of HBV vaccination and HBV-active antiretroviral therapy (ART). This review summarizes new insights and evolving issues in HIV-HBV coinfection.

RECENT FINDINGS

HBV-HIV coinfection is still a leading cause of cirrhosis, hepatocellular carcinoma (HCC) and liver-related mortality more than a decade after the approval of tenofovir. While tenofovir-based ART has been shown to improve rates of HBV virologic suppression and halt fibrosis progression, the long-term benefits on the prevention of end-stage liver disease or HCC in HIV-HBV coinfection have yet to be convincingly demonstrated in PLWH. Missed opportunities for HBV vaccination persist despite evidence of ongoing risk for HBV infection in this population.

SUMMARY

Even as we work towards HBV elimination and functional cure, ongoing efforts should focus on optimizing risk stratification as well as uptake of HBV-active antiviral therapy and HBV immunization in this priority population.

Variations in Hepatitis B Vaccine Series Completion by Setting Among Adults at Risk in West Virginia

INTRODUCTION

West Virginia leads the nation with the highest rate of acute hepatitis B. From 2013 to 2015, the West Virginia hepatitis B Vaccination Pilot Project distributed more than 10,000 doses of hepatitis B vaccine to at-risk adults through local health department clinics and through outreach to correctional facilities and substance use treatment centers. This study aims to determine which setting type is associated with the greatest likelihood of at-risk adults receiving all 3 or at least 2 doses of hepatitis B vaccine.

METHODS

Data for this retrospective cohort study were accessed, extracted, and analyzed in 2019 from Pilot Project participant forms initially completed from 2013 to 2015. Odds of receiving all 3 or at least 2 doses were calculated using bivariate, multivariable, and mixed-effects regression models.

RESULTS

Data were available for 1,201 participants. In multivariable logistic regression, participants vaccinated at substance use treatment centers (AOR=1.37, 95% CI=1.01, 1.86) and local health department family planning clinics (AOR=3.74, 95% CI=1.98, 7.06) were more likely to receive the 3-dose series versus those vaccinated at local health department sexually transmitted disease clinics. Participants vaccinated through substance use treatment centers (AOR=1.79, 95% CI=1.31, 2.44), correctional facilities (AOR=3.34, 95% CI=2.09, 5.34), and local health department family planning clinics (AOR=3.97, 95% CI=1.72, 9.16) were more likely to receive at least 2 doses.

CONCLUSIONS

Hepatitis B vaccination delivered at local health department family planning clinics, substance use treatment centers, or correctional facilities may increase vaccine dose completion in West Virginia.