Untreated highly viraemic pregnant women from Asia or sub-Saharan Africa often transmit hepatitis B virus despite serovaccination to newborns

Prevention of hepatitis B mother-to-child transmission in Namibia: A cost-effectiveness analysis

Despite access to a safe and effective vaccine, mother-to-child transmission (MTCT) of hepatitis B virus (HBV) persists in Africa. This is of concern since perinatally-infected infants are at highest risk of developing hepatocellular carcinoma, a life-threatening consequence of chronic HBV infection. While tools to prevent HBV MTCT are available, the cost implications of these interventions need consideration prior to implementation. A Markov model was developed to determine the costs and health outcomes of (1) universal HBV birth dose (BD) vaccination, (2) universal BD vaccination and targeted hepatitis B immunoglobulin (HBIG), (3) maternal antiviral prophylaxis using sequential HBV viral load testing added to HBV BD vaccination and HBIG, and (4) maternal antiviral prophylaxis using sequential HBeAg testing combined with HBV BD vaccination and HBIG. Health outcomes were assessed as the number of paediatric infections averted and disability-adjusted life years (DALYs) averted. Primary cost data included consumables, human resources, and hospital facilities. HBV epidemiology, transitions probabilities, disability weights, and the risks of HBV MTCT were extracted from the literature. Incremental cost-effectiveness ratios (ICERs) were calculated to compare successive more expensive interventions to the previous less expensive one. One-way sensitivity analyses were conducted to test the robustness of the model's outputs. At the Namibian cost/DALY averted threshold of US$3 142, the (1) BD vaccination + targeted HBIG, and (2) maternal antiviral prophylaxis with sequential HBeAg testing interventions were cost-effective. These interventions had ICERs equal to US$1909.03/DALY and US$2598.90/DALY averted, respectively. In terms of effectiveness, the maternal antiviral prophylaxis with sequential HBeAg testing intervention was the intervention of choice. The analysis showed that elimination of HBV MTCT is achievable using maternal antiviral prophylaxis with active and passive immunization. There is an urgent need for low cost diagnostic tests to identify those women who will most benefit from drug therapy to attain this laudable goal.

Hepatitis B e Antigen (HBeAg) Rapid Test and Alanine Aminotransferase Level-Based Algorithm to Identify Pregnant Women at Risk of HBV Mother-to-Child Transmission: The ANRS 12345 TA PROHM Study

Background

The paucity of hepatitis B virus (HBV) DNA measurement in low-/middle-income countries hinders the identification of HBV-infected pregnant women at risk of perinatal transmission. This study evaluates the validity of an algorithm selecting HBeAg-positive women and HBeAg-negative women with alanine aminotransferase (ALT) ≥40 IU/L as a predictor of high HBV DNA level.

Methods

All women with reactive samples for hepatitis B surface antigen (HBsAg) were assessed with an SD BIOLINE HBeAg rapid test and HBV DNA quantification was performed. Validities of HBeAg and of the algorithm to identify HBV DNA >2 thresholds (5.3 and 7.3 log10 IU/mL) were evaluated.

Results

For the 515 HBsAg-positive women, median age was 29 years, 92 (17.9%) were HBeAg positive, 47 (9.1%) were HBeAg negative with ALT ≥40 IU/L, and 144 (28.0%) had an HBV DNA >5.3 log₁₀ IU/mL. Sensitivity and specificity of HBeAg were 61.8% and 99.2% for HBV DNA >5.3 log₁₀ IU/mL and 81.3% and 96.7% for HBV DNA >7.3 log₁₀ IU/mL. For the algorithm, sensitivity and specificity were 79.2% and 93.3% for HBV DNA level >5.3 log₁₀ IU/mL and 92.7% and 88.1% for HBV DNA >7.3 log₁₀ IU/mL. The AUCs for the algorithm (0.92 and 0.94 for HBV DNA >5.3 and 7.3, respectively) were significantly greater (P < .001) than the AUCs for HBeAg (0.81 and 0.89 for HBV DNA >5.3 and 7.3, respectively).

Conclusions

An algorithm using HBeAg and ALT level could be an effective strategy to identify HBV-infected pregnant women at risk of perinatal transmission in countries where HBV DNA quantification is not routinely available.

Viral hepatitis B and C in HIV-exposed South African infants

Background

Whilst much attention is given to eliminating HIV mother-to-child transmission (MTCT), little has been done to ensure the same for hepatitis B virus (HBV) transmission. The introduction of HBV immunization at six weeks of age has reduced HBV horizontal transmission in South Africa. However, in order to eliminate HBV MTCT, further interventions are needed. The risk of hepatitis C virus (HCV) MTCT in HIV-infected (HIV+) African women is not yet well described. This study aimed to determine the rate of HBV and HCV vertical transmission in HIV-exposed infants in South Africa.

Methods

Serum samples from infants enrolled in an isoniazid prevention study (P1041) were screened for HBV and HCV serology markers; screening was performed on samples collected at approximately 60 weeks of age of the infants. HBV DNA was quantified in HBsAg positive samples and HBV strains characterized through gene sequencing. All HCV antibody samples with inconclusive results underwent molecular testing.

Results

Three of 821 infants were positive for both HBsAg and HBV DNA. All HBV strains belonged to HBV sub-genotype A1. The rtM204I mutation associated with lamivudine resistance was identified in one infant, a second infant harboured the double A1762T/G1764A BCP mutation. Phylogenetic analysis showed clustering between mother and infant viral genomic sequences. Twenty-one of 821 HIV-exposed infants tested had inconclusive HCV antibody results, none were HCV PCR positive.

Conclusions

This study suggests that HBV vertical transmission is likely to be occurring in HIV-exposed infants in South Africa.. A more robust strategy of HBV prevention, including birth dose vaccination, is required to eradicate HBV MTCT. HCV infection was not detected.

Hepatitis B Infection and Mother-to-Child Transmission in Haiphong, Vietnam: A Cohort Study with Implications for Interventions

Background

There is little data available on HBV infection and mother-to-child transmission (MTCT) in Vietnam.

Objective

This study is aimed at assessing the prevalence of HBV infection and the current situation of MTCT in Haiphong, Vietnam.

Methods

A transversal survey of 1721 pregnant women followed by an observational prospective cohort study of 183 HBV-infected women was conducted at Haiphong Gyneco-Obstetric Hospital. Women were followed up up to 12-month postpartum; use of prevention measures and the MTCT rate were evaluated. HBV infection in children was defined by a HBsAg-positive test at 12 months of age.

Results

At baseline, 183 of 1721 pregnant women (10.6%) tested HBsAg positive. Among them, 23.0% were HBeAg positive, 26.2% had a detectable load of HBV DNA, and 13.1% had a HBV DNA load ≥ 200,000 IU/mL. All women underwent MTCT prevention antiviral therapy. At delivery, 98.9% of newborns receive a HBV vaccine birth dose, and 82% received HBIG. At 12 months of age, 94.7% have received the scheduled HBV vaccines. Eight percent of infants born from followed-up women were HBsAg positive. The mother's HBeAg-positive status was associated with a higher risk of HBV infection in infants.

Conclusion

The HBV prevalence and MTCT rates are high in Haiphong. A strong national plan to increase the access to preventive measures and to monitor results is needed in order to decrease this prevalence.

Efficacy and safety of continuous antiviral therapy from preconception to prevent perinatal transmission of hepatitis B virus

Few studies were conducted to assess safety and efficacy of continuous antiviral therapy administrated from preconception. In the present study, 136 eligible women with chronic HBV infection were recruited, and assigned to active chronic hepatitis B (CHB) (Group A, B or C) or chronic HBV carrier (Group D). Antiviral therapy was administrated in preconception (Group A), in early (Group B) or late pregnancy (Group C and Group D). Immunoprophylaxis was administrated to all infants. Mothers’ HBV status and ALT were assessed at delivery and 7 months postpartum. Offspring’s HBV status was examined at 7 months old. Group A women showed low HBV DNA level and normal ALT throughout pregnancy. All women at delivery had an HBV DNA level of less than 10⁶ IU/ml, but the proportion of patients with lower HBV DNA level in Group A was higher than any of other three groups (P < 0.05). No differences in obstetrical complications were found among the four groups. None of infants who completed follow-up showed positive HBsAg at age of 7 months. Congenital malformation and infant growth indicators were similar among study cohorts. Continuous antiviral therapy from preconception to entire pregnancy is effective and safe for active CHB mothers and their infants.

HBV genotypes circulation in pregnant women in Romania: a pilot study

Background: The risk of mother to child transmission of hepatitis B virus (HBV) is recognized worldwide, a reason for which the World Health Organization aims to reduce this public health issue of major concern in the next ten years. The aim of our study was to detect circulating HBV genotypes in a selected population of pregnant women, as scientific evidence to recommend personalized antiviral therapy and to obtain updated epidemiological information.

Methods: HBsAg positive pregnant women were selected by the National Institute of Public Health Romania. Blood samples were collected after signing the informed consent. The HBV genotypes were tested by INNO LiPA HBV genotyping method.

Results. The D genotype was detected in 9/18 (50%) patients, genotype A in 3/18 (16.7%), and genotype F in 3/18 (16.7%) patients. Three patients had double infection, 11 had unique infection, and 4 had no detectable genotype.

Conclusion. This study confirmed the results of previous studies regarding HBV genotype circulation in our country, with the mention that F genotype was a new one for our area. These data are useful from an epidemiological point of view and also for therapeutical reasons, as it is known that therapy should be genotype guided.

Usefulness of a serial algorithm of HBsAg and HBeAg rapid diagnosis tests to detect pregnant women at risk of HBV mother-to-child transmission in Cambodia, the ANRS 12328 pilot study

BACKGROUND

In Cambodia, access to hepatitis B surface antigen (HBsAg) screening is low for pregnant women and Hepatitis B Virus (HBV) DNA quantification is poorly accessible.

OBJECTIVES

To evaluate the performance of a serial algorithm using two HBV rapid diagnostic tests (RDTs), in which samples positive for HBsAg were further tested for HBeAg as a surrogate marker for HBV DNA quantification.

STUDY DESIGN

In 2015, we prospectively collected plasma samples from 250 pregnant women consulting for antenatal care in one hospital in Phnom Penh including 128 with a known positive HBsAg status. All specimens were tested with the SD BIOLINE HBsAg RDT and HBsAg ELISA assay. In ELISA-positive samples, HBeAg status was determined using the SD BIOLINE HBeAg RDT and HBV DNA quantification was assessed.

RESULTS

Sensitivity and specificity of HBsAg RDT were 99.2% (97.7-99.9) and 100% (97.0-100), respectively. Among the 128 ELISA-positive samples, 29 (23%) tested HBeAg positive and 34 (26.5%) had HBV DNA > 5.3 Log₁₀ IU/mL. Sensitivity and specificity of HBeAg RDT in identifying viremic samples were 76.5% (62.2.0-90.7) and 96.8% (93.3-100) for HBV DNA > 5.3 Log₁₀ IU/mL and 89.3% (77.8-100) and 96.0% (92.2-99.8) for HBV DNA > 7.3 Log₁₀IU/mL. Among the 99 negative HBeAg RDT women, 8 had HBV DNA > 5.3 Log10 IU/mL and 7 of them harbored BCP/PC HBV mutants.

CONCLUSIONS

A combination of HBsAg and HBeAg RDTs could be a low-cost strategy to identify HBV-infected pregnant women at risk of perinatal transmission in a country were HBV DNA quantification is not routinely available.

Elimination of Vertical Transmission of Hepatitis B in Africa: A Review of Available Tools and New Opportunities

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.

Hepatitis B virus serosurvey and awareness of mother-to-child transmission among pregnant women in Shenyang, China: An observational study

Preventing hepatitis B virus (HBV) mother-to-child transmission (MTCT) is the key to controlling the prevalence of chronic HBV infection. Adequate awareness of hepatitis B in hepatitis B s antigen (HBsAg) positive pregnant women may be helpful to reduce HBV MTCT.The aim of this study was to explore HBV seroprevalence among pregnant women and investigate the level of hepatitis B awareness among HBsAg positive pregnant women.HBV serum biomarkers were tested among pregnant women visiting Shengjing Hospital of China Medical University. HBsAg-positive pregnant women received a HBV DNA test and completed a questionnaire. The different HBV DNA loads were interpreted as follows: 20 to  < 2 × 10 IU/mL was low viral load, 2 × 10 to  < 2 × 10 IU/mL was intermediate viral load and ≥2 × 10 IU/mL was high viral load. The pregnant women with high viral load were treated with telbivudine (LdT). HBV DNA at different times was tested. The rate of HBV MTCT was confirmed at 28 weeks postpartum.HBsAg prevalence among pregnant women was 3.1% (441/14314). There was significant difference in comparing HBsAg prevalence in different age groups (χ = 13.86, P < .01). Among 441 HBsAg-positive pregnant women, 151 (34.2%) were hepatitis B e antigen (HBeAg) positive and 112 (25.4%) had high viral load. After 4 weeks of treatment, the average HBV DNA load of 66 cases with high viral load was (5.0 ± 0.8) log10 IU/mL. The average HBV DNA load at 4 weeks postpartum rebounded to (7.9 ± 1.0) log10 IU/mL, which was not significantly different from that at baseline (t = 1.23, P = .22). At 28 weeks postpartum, the rate of HBV MTCT in the treatment group was significantly lower than that in the observation group (0% vs 12.2%; P = .02). Only 23.4% of pregnant women knew their HBV status before gestation and 17.7% of pregnant women knew the HBV status before delivery. However, only 21.3% of pregnant women realized to need antiviral treatment to prevent MTCT.The pregnant women in Shenyang had a low HBsAg prevalence. Antiviral treatment for pregnant women with high viral load can effectively reduce the rate of HBV MTCT. HBV screening and education among HBsAg-positive pregnant women should be strengthened.

Hepatitis B Virus-Hepatitis D Virus mother-to-child co-transmission: A retrospective study in a developed country

BACKGROUND & AIMS

Hepatitis B Virus (HBV) DNA during chronic infection can reach levels at which mother-to-child (MTC) transmission frequently occurs despite passive-active immunization of newborns. Hepatitis D Virus (HDV) RNA can reach high levels, we assessed HBV/HDV MTC co-transmission.

METHODS

Monocentric retrospective study (registered in ClinicalTrials.gov (NCT02044055)), after informed consent in HBV/HDV co-infected women pregnant between 01/01/2004 and 01/01/2015 in Paris, France. The children were tested when 24 months of age or older.

RESULTS

Twenty-two (3%) of 742 HBV infected women, HDV co-infected, gave birth to 54 children during the study period. HBV DNA was above 5 Log₁₀ I.U/mL in 10 pregnancies previous any treatment, with HDV RNA of less than 2.3 Log₁₀ I.U/mL. HDV RNA was above 5 Log₁₀ I.U/mL in eight pregnancies previous any treatment, with HBV DNA of less than 1.5 Log₁₀ I.U/mL. Inverse patterns of HBV DNA and HDV RNA were observed in 17 of 35 (49%) pregnancies: 13 (76%) received no HBV treatment; four (24%) were treated. HBV DNA was under 5 Log₁₀ I.U/mL in 46 of the 50 assessed women (92%) at birth. Of the 36 assessed children, given passive-active immunization, 24 (66%) were protected, 10 (28%) were neither infected nor protected, one was chronically HBV infected, and one had a past HBV infection. HDV Ab was negative in the 36 children.

CONCLUSIONS

These results suggest that HBV/HDV MTC co-transmission is exceptional. Studies are needed, mainly in developing countries.

Efficacy and safety of nucleos(t)ide analogues to prevent hepatitis B virus mother-to-child transmission in pregnant women with high viremia: real life practice from China

Purpose: To evaluate the efficacy and safety of nucleos(t)ide analogues, especially telbivudine (LdT) for the prevention of mother-to-child transmission (MTCT) of hepatitis B virus (HBV) in women with high viremia. Methods: We conducted a prospective, open-label, multicenter study of LdT for treating pregnant women having high viral loads of hepatitis B virus (HBV DNA>5 log₁₀ IU/mL) but normal levels of alanine aminotransferase (ALT). Maternal HBV DNA, HBV serologic status and ALT were measured at baseline, 4 weeks after therapy, before delivery, 4 weeks after delivery, and 12 weeks after delivery. Infant HBV serologic status and HBV DNA levels were measured at 7 months. We calculated the MTCT rate of LdT-treated and LdT-untreated groups and analyzed the efficacy and safety of LdT. Results: Ninety-one women (the treatment group) were treated with LdT, and twenty-one patients (the observation group) did not undergo antiviral therapy. The baseline HBV DNA levels were 8.15±0.82 log₁₀ IU/mL in the treatment group, and 8.09±1.04 log₁₀ IU/mL in the observation group. The MTCT rate was 0% in the treatment group, and 9.5% in the observation group (p=0.042). In the treatment group, HBV DNA levels were 5.02±0.74 log₁₀ IU/mL at one month after therapy, and 3.95±0.94 log₁₀ IU/mL before delivery. Both groups had significant differences from baseline levels in HBV DNA levels (p<0.001). In total, five patients had elevated ALT levels but without evidence of decompensate liver function. No severe adverse events or complications were observed in women or infants. Conclusions: For pregnant women with HBV DNA greater than 5 log₁₀IU/mL, LdT therapy was effective in reducing HBV MTCT. If serum HBV DNA was detectable at delivery, discontinuation of LdT immediately was found to be safe and rarely induced off-treatment hepatitis flare.

Prospective interventional study of tenofovir in pregnancy to prevent vertical transmission of hepatitis B in highly viremic women

BACKGROUND

The risk of vertical transmission of hepatitis B virus (HBV) increases as maternal HBV DNA increase, despite serovaccination to newborns.

METHODS

From 1 July 2012 to 1 January 2016, all pregnant women in Lariboisiere Hospital, Paris, France, with HBV DNA of 5 log10 IU/ml and above were administered tenofovir from week 28 of pregnancy until delivery. HBV DNA was measured at months 1, 2 of tenofovir and at delivery. The newborns were serovaccinated, tested for hepatitis B surface antigen, hepatitis B core antibody (HBcAb)±HBV DNA, and hepatitis B surface antibody (HBsAb) when aged 9 months, and then 24 months. This study was registered in http://www.ClinicalTrials.gov (NCT02039362).

RESULTS

Thirty-one women gave birth to 37 newborns. Maternal HBV DNA at baseline was 8.23 log10 IU/ml and above in 12 pregnancies. The mean (median) HBV DNA were 4.4±1.2 (4.8), 3.3±1.7 (3.8), and 2.1±1.9 (2.0) log10 IU/ml at months 1, 2 of tenofovir and at delivery, respectively. Twenty-seven newborns were followed up: none of the 19 children aged 9 months or older was positive for hepatitis B surface antigen when aged 9 months; 14 children tested positive for HBcAb (probably transferred maternal antibodies, not found when aged 24 months) and for HBsAb without HBV DNA. Four of the 19 children showed HBsAb without HBcAb, the last being doubtful for HBcAb and HBsAb without HBV DNA. Eight newborns aged less than 9 months were not tested.

CONCLUSION

Tenofovir from week 28 of pregnancy to highly viremic HBV women plus serovaccination to newborns could prevent chronic and past infection.

Short article: Hepatitis B virus status in children born to HIV/HBV coinfected women in a French hospital: a cross-sectional study

OBJECTIVES

We assessed hepatitis B virus (HBV) status in children born to HIV/HBV coinfected women with large access to antiretroviral therapy.

METHODS

All HIV/HBV coinfected pregnant women from 01 January 2000 to 01 January 2012 were included in the retrospective study (NCT02044068). Antiretroviral therapy during pregnancy and injection of HBV immunoglobulin/vaccine to newborns was recorded. We assessed HBV status of children aged at least 2 years.

RESULTS

Twenty-one women (35 children) were studied. Twenty-six children (74%) had HBsAb: 22 had received immunoglobulin and 24 had received a complete vaccine (with immunoglobulin in 21 cases); their mothers had been administered lamivudine or tenofovir/emtricitabine during eight and nine pregnancies, respectively. Eight children (23%) were negative for HBsAg, HBsAb, and HBcAb: four (11.5%) had received immunoglobulin and a complete vaccine; in two children, it was not known whether they had received an immunoglobulin injection; in one child, the vaccine was incomplete; and in the last one, it was not known whether he had received immunoglobulin/vaccine. Their mothers had been administered lamivudine or tenofovir/emtricitabine during five and two pregnancies, respectively. No infant has chronic HBV infection (HBsAg) after prenatal mothers' antiretroviral therapy combined with a complete postnatal HBV protection. One child had HBcAb and HBsAb: it was not known whether she had received an immunoglobulin injection; the vaccine was incomplete. The mother had been administered lamivudine during the last trimester of pregnancy.

CONCLUSION

Antiretroviral therapy in HBV/HIV coinfected women following current national HBV guidelines may prevent mother-to-child-transmission of HBV. Negativity of surrogate markers of vaccine-induced protection is frequent; large studies on long-term protection are needed.

[Pregnancy and viral hepatitis B and C]

The screening for HBsAg is a medical obligation in France during pregnancy. A serovaccination with antiHBs immunoglobulins (100 IU) and a 1st dose of vaccine (10 μg) has to be realized during the first 12 hours of life when the mother is HBsAg+. The serovaccination failures are related to high maternal viral load (HBV-DNA>7 log IU/mL). In this case, a treatment with analogue (tenofovir) associated with serovaccination could be performed during the last trimester of pregnancy. The risk of mother-to-child transmission of virus C is around 3 to 5% in case of HCV-RNA positive without co-infection with HIV. The mode of delivery is unchanged in case of maternal HBV or HCV. Breast-feeding is not contra-indicated in case of maternal HBV or HCV infection.