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Badell ML, Prabhu M, Dionne J, Tita ATN, Silverman NS. Society for Maternal-Fetal Medicine Consult Series #69: Hepatitis B in pregnancy: updated guidelines. Am J Obstet Gynecol 2024; 230:B2-B11. [PMID: 38141870 DOI: 10.1016/j.ajog.2023.12.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2023]
Abstract
More than 290 million people worldwide, and almost 2 million people in the United States, are infected with hepatitis B virus, which can lead to chronic hepatitis B, a vaccine-preventable communicable disease. The prevalence of chronic hepatitis B infection in pregnancy is estimated to be 0.7% to 0.9% in the United States, with >25,000 infants born annually at risk for chronic infection due to perinatal transmission. Given the burden of disease associated with chronic hepatitis B infection, recent national guidance has expanded both the indications for screening for hepatitis B infection and immunity and the indications for vaccination. The purpose of this document is to aid clinicians caring for pregnant patients in screening for hepatitis B infection and immunity status, discuss the perinatal risks of hepatitis B infection in pregnancy, determine whether treatment is indicated for maternal or perinatal indications, and recommend hepatitis B vaccination among susceptible patients. The following are the Society for Maternal-Fetal Medicine recommendations: (1) we recommend triple-panel testing (hepatitis B surface antigen screening, antibody to hepatitis B surface antigen, and total antibody to hepatitis B core antigen) at the initial prenatal visit if not previously documented or known to have been performed (GRADE 1C); (2) we recommend universal hepatitis B surface antigen screening alone at the initial prenatal care visit for all pregnancies where there has been a previously documented negative triple-panel test (GRADE 1B); (3) we recommend that individuals with unknown hepatitis B surface antigen screening status be tested on any presentation for care in pregnancy; we also recommend that those with clinical hepatitis or those with risk factors for acute hepatitis B infection be tested at the time of admission to a birthing facility when delivery is anticipated (GRADE 1B); (4) we do not recommend altering routine intrapartum care in individuals chronically infected with hepatitis B; administration of neonatal immunoprophylaxis is standard of care in these situations (GRADE 1B); (5) we do not recommend cesarean delivery for the sole indication of reducing perinatal hepatitis B virus transmission (GRADE 1B); (6) we recommend that individuals with HBV infection can breastfeed as long as the infant has received immunoprophylaxis at birth (GRADE 1C); (7) we suggest individuals with hepatitis B infection who desire invasive testing may have the procedure performed after an informed discussion on risks and benefits in the context of shared decision-making and in the context of how testing will affect clinical care (GRADE 2C); (8) in individuals with hepatitis viral loads >200,000 IU/mL (>5.3 log 10 IU/mL), we recommend antiretroviral therapy with tenofovir (tenofovir alafenamide at 25 mg daily or tenofovir disoproxil fumarate at 300 mg daily) in the third trimester (initiated at 28-32 weeks of gestation) as an adjunctive strategy to immunoprophylaxis to reduce perinatal transmission (GRADE 1B); (9) we recommend administering hepatitis B vaccine and hepatitis B immunoglobin within 12 hours of birth to all newborns of hepatitis B surface antigen-positive pregnant patients or those with unknown or undocumented hepatitis B surface antigen status, regardless of whether antiviral therapy has been given during the pregnancy to the pregnant patient (GRADE 1B); and (10) we recommend hepatitis B vaccination in pregnancy for all individuals without serologic evidence of immunity or documented history of vaccination (GRADE 1C).
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Matthews PC, Ocama P, Wang S, El-Sayed M, Turkova A, Ford D, Torimiro J, Garcia Ferreira AC, Espinosa Miranda A, De La Hoz Restrepo FP, Seremba E, Mbu R, Pan CQ, Razavi H, Dusheiko G, Spearman CW, Hamid S. Enhancing interventions for prevention of mother-to-child- transmission of hepatitis B virus. JHEP Rep 2023; 5:100777. [PMID: 37554925 PMCID: PMC10405098 DOI: 10.1016/j.jhepr.2023.100777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 03/29/2023] [Accepted: 03/31/2023] [Indexed: 08/10/2023] Open
Abstract
Prevention of mother-to-child transmission of hepatitis B virus (HBV) infection is a cornerstone of efforts to support progress towards elimination of viral hepatitis. Current guidelines recommend maternal screening, antiviral therapy during the third trimester of high-risk pregnancies, universal and timely HBV birth dose vaccination, and post-exposure prophylaxis with hepatitis B immunoglobulin for selected neonates. However, serological and molecular diagnostic testing, treatment and HBV vaccination are not consistently deployed, particularly in many high endemicity settings, and models predict that global targets for reduction in paediatric incidence will not be met by 2030. In this article, we briefly summarise the evidence for current practice and use this as a basis to discuss areas in which prevention of mother-to-child transmission can potentially be enhanced. By reducing health inequities, enhancing pragmatic use of resources, filling data gaps, developing advocacy and education, and seeking consistent investment from multilateral agencies, significant advances can be made to further reduce vertical transmission events, with wide health, societal and economic benefits.
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Affiliation(s)
- Philippa C. Matthews
- The Francis Crick Institute, 1 Midland Road, London, NW1 1AT, UK
- Division of Infection and Immunity, University College London, Gower St, London WC1E 6BT, UK
- Department of Infection, University College London Hospitals, 235 Euston Rd, London NW1 2BU, UK
| | - Ponsiano Ocama
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Su Wang
- Cooperman Barnabas Medical Center, Florham Park, NJ, USA
- Hepatitis B Foundation, Doylestown, PA, USA
| | - Manal El-Sayed
- Department of Paediatrics, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Anna Turkova
- Medical Research Council Clinical Trials Unit, University College London, 90 High Holborn, London WC1V 6LJ, UK
| | - Deborah Ford
- Medical Research Council Clinical Trials Unit, University College London, 90 High Holborn, London WC1V 6LJ, UK
| | - Judith Torimiro
- Chantal Biya International Reference Centre for Research on Prevention and Management of HIV/AIDS (CIRCB), Yaounde, Cameroon
- Faculty of Medicine and Biomedical Sciences, University of Yaounde, Yaounde, Cameroon
| | - Ana Cristina Garcia Ferreira
- Ministry of Health, Health Surveillance Department, Department of Chronic Diseases and Sexually Transmitted Infections, SRTVN Quadra 701, Lote D, PO700 Building, CEP: 70719-040, Brasília/DF, Brazil
| | - Angélica Espinosa Miranda
- Ministry of Health, Health Surveillance Department, Department of Chronic Diseases and Sexually Transmitted Infections, SRTVN Quadra 701, Lote D, PO700 Building, CEP: 70719-040, Brasília/DF, Brazil
| | | | - Emmanuel Seremba
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Robinson Mbu
- Faculty of Medicine and Biomedical Sciences, University of Yaounde, Yaounde, Cameroon
| | - Calvin Q. Pan
- Division of Gastroenterology and Hepatology, NYU Langone Health, NYU Grossman School of Medicine, NY, USA
| | - Homie Razavi
- Center for Disease Analysis Foundation, 1120 W South Boulder Rd Suite 102, Lafayette, CO 80026, USA
| | - Geoffrey Dusheiko
- Liver Unit, King’s College Hospital, Denmark Hill, London SE5 9RS, UK
| | - C. Wendy Spearman
- Division of Hepatology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, South Africa
| | - Saeed Hamid
- Department of Medicine, Aga Khan University, Karachi, Pakistan
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Anderson ACT, Richards A, Delucchi K, Khalili M. Coverage, inequity and predictors of hepatitis B birth vaccination in Myanmar from 2011-2016: results from a national survey. BMC Health Serv Res 2022; 22:516. [PMID: 35436953 PMCID: PMC9016947 DOI: 10.1186/s12913-022-07902-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 04/04/2022] [Indexed: 01/05/2023] Open
Abstract
Background Hepatitis B virus birth dose (HepB-BD) vaccination is recommended to reduce mother to infant transmission. We evaluated the HepB-BD status of women who gave birth between 2011 and 2016 (N = 3,583) using the 2015–2016 Myanmar Demographic and Health Survey. Methods Frequency distributions of HepB-BD vaccination across maternal and health system factors, concentration indices, and logistic regression models were used to estimate coverage, inequity, and factors associated with vaccination. Results The majority of participants were younger than 30 years of age, lived in rural areas, and were multiparous. Almost all received antenatal care (ANC), but only 43% received recommended ANC services, and 60% gave birth at home. The overall HepB-BD coverage rate was 26%. Vaccination coverage was higher in urban areas and was inequitably concentrated among children of more educated and wealthier women. HepB-BD coverage was also positively associated with receipt of ANC at non-governmental facilities, and delivery at a facility, skilled provider at birth and Cesarean delivery. After adjusting for sociodemographic and health system factors, receipt of the HepB-BD was positively associated with weekly media exposure, receipt of recommended ANC, and Cesarean delivery, and inversely associated with home delivery. Conclusions Both socioeconomic and health systems factors influenced suboptimal and inequitable vaccination coverage. Improved access to quality ANC and delivery services may increase HepB-BD coverage although targeted approaches to reach home births are likely required to achieve national goals. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07902-w.
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Affiliation(s)
- August C T Anderson
- School of Medicine, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA, 94143, USA
| | - Adam Richards
- Department of Global Health, Milken Institute School of Public Health, The George Washington University, 950 New Hampshire Ave, Washington, DC, NW, 20052, USA
| | - Kevin Delucchi
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, 401 Parnassus Ave, San Francisco, CA, 94143, USA
| | - Mandana Khalili
- Department of Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital, 1001 Potrero Ave, Building 5, Suite 3D4, San Francisco, CA, 94110, USA.
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Nguyen HT, Thavorncharoensap M, Phung TL, Anothaisintawee T, Chaikledkaew U, Sobhonslidsuk A, Talungchit P, Chaiyakunapruk N, Attia J, McKay GJ, Thakkinstian A. Comparative efficacy and safety of pharmacologic interventions to prevent mother-to-child transmission of hepatitis B virus: a systematic review and network meta-analysis. Am J Obstet Gynecol 2022; 227:163-172. [PMID: 35263648 DOI: 10.1016/j.ajog.2022.02.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 02/12/2022] [Accepted: 02/23/2022] [Indexed: 11/01/2022]
Abstract
OBJECTIVE This study investigated the efficacy and safety of pharmacologic interventions to prevent vertical transmission of the hepatitis B virus. DATA SOURCES Medline, Cochrane, and Scopus databases were searched up to October 28, 2020. STUDY ELIGIBILITY CRITERIA All randomized controlled trials reporting vertical hepatitis B virus transmission with pharmacologic intervention were included. METHODS Risk of bias was assessed using the Cochrane Risk-of-Bias tool, version 2. Treatment efficacy was estimated using stratified network meta-analysis on the basis of maternal hepatitis B envelope antigen status. RESULTS Nineteen studies were included for mothers positive for hepatitis B surface and envelope antigens. Pooling indicated that a combination of hepatitis B vaccination and hepatitis B immunoglobulin in infants significantly reduced transmission risk compared with vaccination alone, with a risk ratio of 0.52 (95% confidence interval; 0.30-0.91). Only the addition of maternal tenofovir disoproxil fumarate, but not telbivudine, lamivudine, or maternal hepatitis B immunoglobulin further reduced transmission risk compared with a combination of hepatitis B vaccination and hepatitis B immunoglobulin in infants, with a pooled risk ratio of 0.10 (0.03-0.35). Twelve studies conducted in mothers with hepatitis B surface antigen positivity and mixed, unknown, or negative hepatitis B envelope antigen status provided limited evidence to suggest that maternal hepatitis B immunoglobulin combined with hepatitis B vaccination and immunoglobulin in infants was the likely best treatment, but this failed to reach statistical significance compared with a combination of hepatitis B vaccination and immunoglobulin in infants. Similarly, infant hepatitis B immunoglobulin, added to vaccination, likely provides additional benefit but failed to reach statistical significance. CONCLUSION A combination of hepatitis B vaccination and immunoglobulin in infants is the cornerstone for prevention of vertical transmission for mothers positive for both hepatitis B surface and envelope antigens. The addition of maternal tenofovir to this infant combination regimen was considered the likely most effective treatment. For infants of mothers with hepatitis B surface antigen positivity and mixed, unknown, or negative hepatitis B envelop antigen status, no additional agents provided further benefit beyond hepatitis B vaccination alone.
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Doran Brubaker S, Ward JW, Hiebert L, Morgan RL. Developing an Evidence Base for the Delivery of Hepatitis B Virus Birth Dose Vaccination: An Evidence Map and Critical Appraisal of Systematic Reviews and Guidelines. Clin Liver Dis (Hoboken) 2021; 17:375-381. [PMID: 34136145 PMCID: PMC8177836 DOI: 10.1002/cld.1103] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 02/10/2021] [Accepted: 02/12/2021] [Indexed: 02/04/2023] Open
Affiliation(s)
| | | | | | - Rebecca L Morgan
- Evidence Foundation Cleveland Heights OH.,Department of Health Research Methods, Evidence and Impact McMaster University Hamilton ON Canada
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Du J, Wang Z, Wu B. Expanding Antiviral Prophylaxis During Pregnancy to Prevent Perinatal Hepatitis B Virus Infection: A Cost-effectiveness Study. Open Forum Infect Dis 2020; 7:ofaa137. [PMID: 32478119 PMCID: PMC7246348 DOI: 10.1093/ofid/ofaa137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 04/17/2020] [Indexed: 11/13/2022] Open
Abstract
Background Mother-to-child transmission (MTCT) cannot be completely prevented by the administration of active-passive immunoprophylaxis in pregnant women with hepatitis B virus (HBV) DNA levels <106 copies/mL. This study will assess the economic outcomes of expanding antiviral prophylaxis in pregnant women with HBV DNA levels <106 copies/mL. Methods A decision model was adopted to measure the economic outcomes of expanded antiviral prophylaxis at different cutoff values of HBV DNA in HBsAg(+) pregnant women in the context of the United States and China. The model inputs, including clinical, cost, and utility data, were extracted from published studies. Sensitivity analyses were carried out to examine the uncertainty of the model outputs. Quality-adjusted life-years (QALYs) and direct medical costs were expressed over a lifetime horizon. Results Compared with standard antiviral prophylaxis at HBV DNA ≥106 copies/mL, expanded antiviral prophylaxis improved the health outcomes, and the incremental cost of expanded antiviral prophylaxis varied from $2063 in pregnant women with HBV DNA ≥105 copies/mL to $14 925 in all HBsAg(+) pregnant women per QALY gained in the United States, and from $1624 to $12 348 in China. The model outcome was considerably influenced by the discount rate, key clinical parameters related to the incidence of MTCT, and efficacy of the prophylaxis strategy. Conclusions This study indicates that antiviral prophylaxis using tenofovir among pregnant women with HBV DNA <106 copies/mL may be a cost-effective option, and the cutoff value of the HBV DNA load for antiviral prophylaxis needs to be tailored.
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Affiliation(s)
- Jiangyang Du
- Medical Decision and Economic Group, Department of Pharmacy, Ren Ji Hospital, South Campus, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Zhenhua Wang
- Department of Gastroenterology, Ren Ji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Bin Wu
- Medical Decision and Economic Group, Department of Pharmacy, Ren Ji Hospital, South Campus, School of Medicine, Shanghai Jiaotong University, Shanghai, China
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Maraolo AE, Gentile I, Buonomo AR, Pinchera B, Borgia G. Current evidence on the management of hepatitis B in pregnancy. World J Hepatol 2018; 10:585-594. [PMID: 30310536 PMCID: PMC6177570 DOI: 10.4254/wjh.v10.i9.585] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 04/26/2018] [Accepted: 06/09/2018] [Indexed: 02/06/2023] Open
Abstract
Hepatitis B virus (HBV) infection is one of the main public health problems across the globe, since almost one third of the world population presents serological markers of contact with the virus. A profound impact on the epidemiology has been exerted by universal vaccination programmes in many countries, nevertheless the infection is still widespread also in its active form. In the areas of high endemicity (prevalence of hepatitis B surface antigen positivity > 7%), mother-to-child transmission represents the main modality of infection spread. That makes the correct management of HBV in pregnancy a matter of utmost importance. Furthermore, the infection in pregnancy needs to be carefully assessed and handled not only with respect to the risk of vertical transmission but also with respect to gravid women health. Each therapeutic or preventive choice deserves to be weighed upon attentively. On many aspects evidence is scarce or controversial. This review will highlight the latest insights into the paramount steps in managing HBV in pregnancy, with particular attention to recommendations from recent guidelines and data from up-do-date research syntheses.
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Affiliation(s)
- Alberto Enrico Maraolo
- Section of Infectious Diseases, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples 80131, Italy
| | - Ivan Gentile
- Section of Infectious Diseases, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples 80131, Italy
| | - Antonio Riccardo Buonomo
- Section of Infectious Diseases, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples 80131, Italy
| | - Biagio Pinchera
- Section of Infectious Diseases, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples 80131, Italy
| | - Guglielmo Borgia
- Section of Infectious Diseases, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples 80131, Italy
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Dionne-Odom J, Njei B, Tita ATN. Elimination of Vertical Transmission of Hepatitis B in Africa: A Review of Available Tools and New Opportunities. Clin Ther 2018; 40:1255-1267. [PMID: 29983265 PMCID: PMC6123260 DOI: 10.1016/j.clinthera.2018.05.016] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 05/21/2018] [Accepted: 05/21/2018] [Indexed: 02/06/2023]
Abstract
PURPOSE This review article focuses on preventing vertical transmission of hepatitis B virus (HBV) among pregnant women living in sub-Saharan Africa (SSA), where disease is endemic and the estimated maternal HBV seroprevalence is >8%. Available interventions that have been studied in low- and middle-income countries are compared in terms of efficacy and effectiveness in clinical practice. Global disease-elimination targets, barriers to HBV-prevention efforts, and critical research gaps are discussed. METHODS A PubMed literature search in February 2018 identified relevant studies of interventions to reduce or prevent the transmission of HBV during pregnancy or in the peripartum period. Studies that focused on interventions that are currently available or could be made available in SSA were included. Trials conducted in SSA and other low-income countries were prioritized, although studies of interventions in middle- and high-income countries were included. FINDINGS Among 127 studies and reports included in the review, 60 included data from SSA. The most cost-effective intervention to reduce HBV infection rates in SSA is timely birth-dose vaccination followed by completion of the 3-dose infant-vaccination series. The identification and treatment of pregnant women with elevated HBV viral load to further reduce the risk for vertical transmission in SSA show promise, but efficacy and tolerability trials in Africa are lacking. IMPLICATIONS Scale-up of currently available tools is required to reach HBV disease-elimination goals in SSA. Many countries in SSA are in the process of rolling out national birth-dose vaccination campaigns; this roll out provides an opportunity to evaluate and improve processes in order to expand coverage. Early antenatal care, promotion of facility deliveries, and increased awareness of HBV prevention are also key components of prevention success. Future studies in SSA should identity an HBV-prevention package that is effective, well tolerated, and feasible and can be administered in the antenatal clinic and tailored to vertical-transmission risk.
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Affiliation(s)
- Jodie Dionne-Odom
- Department of Medicine, Division of Infectious Diseases, University of Alabama, Birmingham, Alabama.
| | - Basile Njei
- Department of Medicine, Section of Digestive Disease, Yale University, New Haven, Connecticut
| | - Alan T N Tita
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Center for Women's Reproductive Health, University of Alabama, Birmingham, Alabama
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