Correlation between vertical transmission of hepatitis B virus and the expression of HBsAg in ovarian follicles and placenta

Positive hepatitis B surface antigen leads to a decrease in ovarian reserve in infertile patients receiving first in vitro fertilization treatment

BACKGROUND

This study assessed the impact of chronic hepatitis B virus (HBV) infection on ovarian reserve in women.

METHODS

We analyzed data from 38,861 infertile women undergoing their first in vitro fertilization (IVF) treatment (2016-2022), including 1574 HBsAg-positive cases. A control group of 1574 HBsAg-negative women was matched by age and body mass index (BMI). Comparison of clinical characteristics, antral follicle count (AFC), follicle-stimulating hormone (FSH), luteinizing hormone (LH)/FSH ratio, anti-Müllerian hormone (AMH), gonadotropins (Gn) days, total Gn dosage, number of retrieved oocytes, number of mature metaphase II (MII) oocytes, and the proportion of patients with diminished ovarian reserve (DOR; AMH < 1.1 ng/ml) between two groups.

RESULTS

HBsAg-positive women showed lower basal AFC and AMH, higher basal FSH, received more Gn, and had fewer retrieved and MII oocytes than HBsAg-negative women. No significant differences in ovarian reserve or stimulation outcomes were found between e antigen-positive and e antigen-negative HBV-infected groups. DOR was less prevalent in HBsAg-negative women, and logistic regression indicated a higher DOR risk with HBV infection.

CONCLUSIONS

HBsAg positivity significantly impairs ovarian reserve in women, but e antigen status does not notably affect it among HBV-infected individuals.

Vertical Transmission of Hepatitis B Virus-An Update

Hepatitis B virus (HBV) infection is a major public health problem in the world. Approximately 296 million people are chronically infected. In endemic areas, vertical transmission is a common route of transmission. There are several strategies for the prevention of HBV vertical transmission, such as antiviral treatment during the third trimester of pregnancy and immunoprophylaxis to newborns that includes the administration of hepatitis B immune globulin (HBIG) and an HBV vaccine. Despite this, immunoprophylaxis failure can occur in up to 30% of infants born to HBeAg-positive mothers and/or with high viral load. Therefore, management and prevention of HBV vertical transmission is of paramount significance. In this article, we provided a review of the epidemiology, mechanisms of pathogenesis and risk factors of vertical transmission, as well as the strategies implemented to prevent the infection.

Prevalence of hepatitis B and C virus infections in Lao People's Democratic Republic: The first national population-based cross-sectional survey

Population-based seroprevalence of chronic hepatitis B and C infections has not been examined in Lao People's Democratic Republic (PDR). Therefore, this study aimed to estimate the seroprevalence of these infections in the general population of Lao PDR and perform subgroup analysis. A nationwide seroprevalence survey was conducted in Lao PDR in June 2019 using the multistage cluster sampling method. Dried blood spot samples were collected onto WhatmanTM 903 filter paper by finger prick. A chemiluminescent microparticle immunoassay was used to measure the levels of hepatitis B surface antigen (HBsAg) and hepatitis C antibody (HCV-Ab). Samples in which the HBsAg level was above 0.05 IU/ml and HCV-Ab was above the signal/cutoff ratio of 1.0 were considered positive based on comparisons with the relative light unit value of a calibration sample. A total of 1,927 samples (male: 47.3%, mean age: 23.0 years) were included in the analysis. The prevalence was estimated to be 4.2% (95% confidence interval [CI]: 2.7-6.3) for HBsAg and 1.6% (95% CI: 0.5-5.3) for HCV-Ab. Multivariable analysis revealed that those aged 20-24 years (adjusted odds ratio (AOR): 2.3, 95% CI: 1.1-4.6), those aged 25-29 years (AOR: 2.7, 95% CI: 1.3-5.6), those from the Northern region (AOR: 2.8, 95% CI: 1.2-6.6), and those who were Khmu (AOR: 3.6, 95% CI: 2.0-6.8) or Hmong (AOR: 5.0, 95% CI: 3.3-7.5) were significantly more likely to be positive for HBsAg. Although there were no statistically significant differences in the HCV-Ab prevalence according to each variable, males (2.9%, 95% CI: 0.7-10.7), those aged ≥40 years (6.1%, 95% CI: 2.1-16.8), and those from the Southern region (3.3%, 95% CI: 0.6-15.3) tended to have a higher prevalence. This novel population-based survey found differences in the prevalence of chronic hepatitis B and hepatitis C virus infections in Lao PDR according to sex, age group, region, and ethnicity; however, the results of this study should be confirmed in future studies, and relevant responses tailored for each target also need to be determined to control the transmission of hepatitis B and C infections.

Pharmacological approaches to prevent vertical transmission of HIV and HBV

INTRODUCTION

Mother-to-child transmission (MTCT) is mainly responsible for the global pediatric HIV and HBV epidemic. Vertical transmission can be prevented and reduced through a series of interventions at the primary healthcare level, including extensive screening of pregnant women, administration of antivirals or immune-based treatments, counselling on type of delivery and breastfeeding.

AREAS COVERED

In this narrative review, approved therapeutic options for the treatment of pregnant women living with HIV or HBV are discussed with special focus on efficacy and safety profiles of each agent or drug class examined. The search was performed using Medline (via PubMed), Web of Science, and Google Scholar to identify studies assessing vertical transmission of both HIV and HBV.

EXPERT OPINION

Elimination of MTCT of both infections is firmly endorsed by major global commitments and the integration of tailored preventive interventions into maternal and newborn health services is of strategical importance to achieve this critical target. However, further research centered on antiviral-based and immunization trials among pregnant women is urgently needed to mitigate the risk of maternal and neonatal adverse outcomes, effectively prevent transmission to the offspring and finally eliminate the pediatric HIV and HBV epidemic, one of the key global health challenges of our time.

Benefits and Risks of Antiviral Treatment during Pregnancy in Patients with Chronic Hepatitis B

Hepatitis B virus (HBV) is a main cause of chronic liver disease worldwide and can lead to severe liver diseases. The World Health Organization has planned to eliminate viral hepatitis, including hepatitis caused by HBV and hepatitis C virus, by 2030. As mother-to-child transmission (MTCT) of HBV is a main cause of chronic HBV infection, MTCT prevention is the main target to reduce the risk of chronic HBV infection and eliminate the disease. Recent clinical trials and meta-analyses found that antiviral therapy could prevent MTCT effectively in mothers with ≥200,000 IU/mL of HBV DNA, in combination with serial vaccination and hepatitis B immune globulin administration in infants. Despite the preventive role of antivirals for MTCT of HBV, there are several concerns regarding antiviral therapy with respect to the safety of the mother and fetus during pregnancy. This review summarizes the benefits and risks of antiviral treatment during pregnancy in women with chronic HBV infection.

Post exposure prophylaxis coverage, vertical transmission and associated factors among hepatitis B exposed newborns delivered at Arsi zone health institutions, 2019

INTRODUCTION

One third of the world population has been exposed to hepatitis B virus and an estimated 257 million people are chronically infected. The main route of hepatitis B virus (HBV) infection is vertical transmission. Post exposure prophylaxis is recommended by world health organization to have free Hepatitis B infection by 2030.

OBJECTIVE

The main purpose of this research project was to assess Hepatitis B virus post exposure prophylaxis coverage, rate of vertical transmission and factors among exposed newborns delivered at Arsi zone health institution.

METHODS

A cross-sectional study was conducted in Arsi zone health institutions among hepatitis B virus exposed newborns delivered at Arsi zone health institutions from January 2018 to September 2019. Systematic sampling technique was used to select 422 exposed newborns into the study. A pre-tested structured questionnaire and checklist were used to collect relevant data. Data was entered and cleaned using epidata7 & analyzed using SPSS version 25 software package. Both bivariate and multivariate analyses was carried out to identify associations. Odds ratio with 95% CI and P-value <0.05 was considered statistically significant.

RESULTS

The study revealed that among 401 exposed newborns only 83(20.7%), have been administered post exposure prophylaxis. But vertical transmission of hepatitis B virus (HBV) was observed in 32.4% (27.9%-36.9%) exposed newborns. Antenatal (ANC) attendance (AOR = .40, 95%CI = .23-.69), Instrumental delivery (AOR = 4.18, 95%CI = 2.05-8.51) HIV coinfection (AOR = 9.7, 95%CI = 4.37-21.34), Post exposure Prophylaxis (AOR = .20, 95%CI = .08-.50) and Knowledge on HBV (AOR = .27, 95%CI = .14-.53) are significant predictors of HBV vertical transmission.

CONCLUSION

Magnitude of HBV post exposure prophylaxis coverage is very low while Rate of vertical transmission is high. Antenatal attendance, Instrumental delivery, Post exposure Prophylaxis and Knowledge on hepatitis B virus transmission are significant predictors of HBV vertical transmission.

Ovarian HBV replication following ovulation induction in female hepatitis B carriers undergoing IVF treatment: A prospective observational study

Hepatitis B virus (HBV) can be found in ovarian tissues. This study compared HBV DNA levels in follicular fluid collected during oocyte retrieval with paired serum samples in HBV carriers after ovarian stimulation during IVF treatment for infertility. Sixty-four HBV carrier women referred to the Assisted Reproductive Units of two Hong Kong hospitals were recruited. At oocyte retrieval, the follicular fluid aspirated from the first follicle was collected for study. In 22 women, the first follicular fluid sample from both ovaries was similarly collected and studied. These women were also tested for liver function test and HBeAg. In 28 (43.8%) women, HBV DNA was detected in follicular fluid and the level correlated with serum levels (Spearman's correlation P < .001). There was concordant detection of HBV DNA in both ovaries, and the levels were significantly correlated (Spearman's correlation P = .029). In 40% of women with FF HBV DNA, the follicular fluid:serum ratio was >1.0, suggesting stimulation of HBV replication. These women also had significantly different liver function test results. Increased HBV replication exists in 40% of women with HBV DNA detected in follicular undergoing ovarian stimulation during IVF treatment.

Maternal HBeAg positivity and viremia associated with umbilical cord blood hepatitis B viremia

BACKGROUND

Hepatitis B (HBV) transmission may result from in utero transmission. We aimed to determine the correlation between maternal serum and umbilical cord blood HBV DNA levels in infants delivered by chronic HBV-infected mothers and to describe the effect of cord blood viremia on vertical transmission.

METHODS

A prospective cohort of 92 chronic HBV-infected mother-and-child pairs recruited over three years was analyzed. Maternal and cord blood were tested for HBV DNA by real-time PCR. Standard immunoprophylaxis with both active and passive immunization was administered to all infants. Serological testing was performed on all infants at 9 months of age.

RESULTS

Moderate positive correlation of the maternal HBV DNA with cord blood HBV DNA was demonstrated (r² = 0.521, p = <0.001). HBeAg +ve mothers were younger with higher HBV and cord viremia. At 9 months of age, one infant was infected. Infants delivered by HBeAg positive mothers and mothers with high HBV DNA of more than 6 LOG IU/mL (1 x 10⁶ IU/mL) have increased relative risk of cord blood viremia.

CONCLUSIONS

Maternal HBV DNA and presence of HBeAg were positively correlated to cord blood HBV DNA in infants delivered by chronic HBV-infected mothers. Our data suggest that reducing maternal viremia during the antenatal period may help to reduce cord blood viremia.

Maternal chronic hepatitis B virus infection does not affect pregnancy outcomes in infertile patients receiving first in vitro fertilization treatment

OBJECTIVE

To evaluate whether maternal chronic hepatitis B virus (HBV) infection affects pregnancy outcomes in infertile patients undergoing their first in vitro fertilization (IVF) treatment.

DESIGN

A retrospective case control study.

SETTING

Fertility center.

PATIENT(S)

Female patients, comprising 8,550 infertile women including 180 HBsAg+HBeAg+, 714 HBsAg+HBeAg-, and 7,656 HBsAg seronegative controls undergoing their first IVF treatments.

INTERVENTION(S)

Clinical characteristics, pregnancy and neonatal outcomes were analyzed by Kruskal-Wallis test, analysis of variance, or chi-square test. Logistic regression was employed to verify the contribution of maternal HBV to clinical pregnancy, live birth, and miscarriage.

MAIN OUTCOME MEASURE(S)

Primary outcome: live-birth rate; secondary outcomes: implantation, clinical pregnancy, and miscarriage rates.

RESULT(S)

An increased duration of infertility and more secondary infertility and ovulatory disorders were observed in the HBV patients. The implantation rate was statistically significantly lower in the HBsAg+HBeAg- group compared with the controls. However, the clinical pregnancy rate, miscarriage rate, live-birth rate, neonatal outcomes, and pregnancy complications showed no statistically significant differences among the groups. The logistic regression analysis showed that HBV infection status did not affect the clinical pregnancy, miscarriage, or live-birth rates, unlike maternal age, endometrial thickness, and use of high-quality embryos.

CONCLUSION(S)

Hepatitis B virus infection is not an independent contributor to pregnancy outcomes, although it is associated with prolonged infertility duration, a high frequency of secondary infertility and ovulatory disorders, and a reduced implantation rate.

Maternal viral load and hepatitis B virus mother-to-child transmission risk: A systematic review and meta-analysis

AIM

The aim of this study was to assess the relationship between maternal viral load and mother-to-child transmission (MTCT) risk in hepatitis B envelope antigen (HBeAg)-positive mothers.

METHODS

PubMed and Web of Science were systematically searched. We compared MTCT incidence between maternal hepatitis B virus (HBV)-DNA-positive and HBV-DNA-negative groups. We also examined the dose-response effect of this relationship.

RESULTS

Twenty-one studies with 10 142 mother-child pairs were included in the studies. The mean MTCT incidence was 13.1% in the maternal HBV-DNA-positive group, compared with 4.2% in the negative group. The summary MTCT odds ratio of maternal HBV-DNA positive compared with negative was 9.895 (95% confidence interval [CI], 5.333 to 18.359; Z = 7.27, P < 0.00001) by random-effects model. In maternal HBV-DNA <6 log10 copies/mL, 6-8 log10 copies/mL, and >8 log₁₀ copies/mL level stratifications, the pooled MTCT incidences were 2.754% (95% CI, 1.198-4.310%; Z = 3.47, P = 0.001), 9.932% (95% CI, 6.349-13.516%; Z = 5.43, P < 0.00001), and 14.445% (95% CI, 8.317-20.572%; Z = 4.62, P < 0.00001), respectively. A significant linear dose-response association was found between maternal viral load and MTCT risk, with the points estimate of increased MTCT risk 2.705 (95% CI, 1.808-4.047) at 6 log10 copies/mL compared with reference (3 log10 copies/mL), and 7.316 (95% CI, 3.268-16.378) at 9 log₁₀  copies/mL. A significant non-linear dose-response association was also found between maternal viral load and HBV MTCT risk (model χ²  = 23.43, P < 0.00001).

CONCLUSION

Our meta-analysis indicated that maternal viral load was an important risk factor for MTCT in HBeAg-positive mothers, and maternal viral load was dose-dependent with HBV MTCT incidence.

Mechanisms and Prevention of Vertical Transmission in Chronic Viral Hepatitis

Vertical transmission (VT) is the primary route of transmission of viral hepatitis in children. The rate of VT ranges from 1-28% with hepatitis B virus (HBV) and 3-15% with hepatitis C virus (HCV). VT for both viruses can occur during the intrauterine or peripartum period. VT of HBV primarily occurs by intrauterine transmission (IUT). Hepatitis B surface antigen is unable to cross the placenta and, therefore, relies on processes like transplacental leakage, placental infection, cellular transmission by peripheral blood mononuclear cells, and germline transmission. HCV can also infect the fetus by IUT. Both viruses also have the potential for transmission during delivery, when there is increase chance of maternal-fetal blood exposure. HBV and HCV share some common risk factors for VT, including maternal viral load, human immunodeficiency virus co-infection and neonatal sex. Prevention of VT differs greatly between HBV and HCV. There are several alternatives for prevention of HBV VT, including antiviral medications during the third trimester of pregnancy and HBV vaccine, as well as hepatitis B immunoglobulin administration to infants post-partum. In contrast, there are no preventative interventions available for HCV. Despite these differences, the key to prevention with both viruses is screening women prior to and during pregnancy.

Serological positive markers of hepatitis B virus in femoral venous blood or umbilical cord blood should not be evidence of in-utero infection among neonates

Background

Maternal-infant transmission of hepatitis B virus(HBV) occurs even after passive-active immunization. Some scholars speculate that in-utero infection may be the main cause of immunoprophylaxis failure. However, there is a lack of evidence about the possible occurrence periods of perinatal transmission.

Methods

From 2008 to 2012, 428 pairs of HBsAg-positive mothers and neonates were enrolled and 385 infants aged 8–12 months were followed. HBV markers (HBsAg, anti-HBs, HBeAg, anti-HBe, anti-HBc, HBV-DNA) were performed on all subjects.

Results

Of mothers who were positive for HBsAg, HBeAg, HBV-DNA, 35.1 %, 94.3 %, 12.7 % of their neonates were positive for those indices, respectively. Neonates’ mean titers of those indices were significantly lower than their mothers’. There were no significant differences in rates of positivity and mean titers of anti-HBe and anti-HBc between neonates and mothers. Most of the positive indices turned negative during the follow-up period. Immunoprophylaxis failed in seventeen infants: four infants had HBV-DNA > 6 log ₁₀copies/mL both at birth and in follow-up; in six infants, mean viral load was 3.72 ± 0.17 log ₁₀copies/mLat birth and 7.62 ± 0.14 log ₁₀copies/mL at follow-up; seven infants were HBV-DNA negative at birth but were found to have > 6 log ₁₀copies/mL during follow-up. Infants that were immunoprophylaxis failures were all born to HBeAg-positive mothers with HBV-DNA > 6 log ₁₀copies/mL.

Conclusions

The placental barrier can partly prevent maternal HBsAg, HBeAg, HBV-DNA from passing through to fetus. Performing HBsAg, HBeAg, HBV-DNA once at birth can neither diagnose nor exclude maternal-infant transmission. The diagnosis of infection period depends on the dynamic changes in viral load from birth through the follow-up period but whether the infection occurred in utero, at delivery or during the neonatal period could not be determined.

Maternal hepatitis B virus carrier status and pregnancy outcomes: a prospective cohort study

Background

Infection with hepatitis B virus (HBV) in pregnant women may be a threat for both mothers and fetuses. This study was performed to explore the impact of maternal HBV carrier status on pregnancy outcomes.

Methods

We conducted a prospective cohort study at the Obstetrics & Gynecology Hospital of Nantong University between January 1, 2012 and September 30, 2015. A consecutive sample of 21,004 pregnant women, 513 asymptomatic HBV carriers and 20,491 non-HBV controls, was included in this study. The main outcomes of interest were selected pregnancy outcomes including miscarriage, stillbirth, preterm birth (PTB), gestational diabetes (GDM), intrahepatic cholestasis of pregnancy (ICP), preterm premature rupture of the membrane (PPROM), low birth weight (LBW), small for gestational age (SGA) and Apgar scores. The incidence of adverse pregnancy outcomes between asymptomatic HBV carriers and non-HBV controls were compared using the chi-square test and logistic regression. P values were two sided, and P <0.05 was considered to indicate statistical significance.

Results

The incidences of stillbirth, PTB, GDM, ICP, PPROM, LBW, and SGA were similar between the HBV carrier and non-HBV groups. The proportion of miscarriage was significantly higher among the HBV carriers than the controls (9.36 % vs 5.70 %; P <0.001). After using multivariate modelling to adjust for possible socio-demographical variables and obstetric complications, women with HBV carrier status were still more likely to have miscarriage (adjusted OR 1.71, 95 % CI 1.23–2.38). In addition, the incidences of other maternal and neonatal outcomes were similar between the two groups.

Conclusion

Maternal HBV carrier status may be an independent risk factor for miscarriage and careful surveillance is warranted.

Management of mother-to-child transmission of hepatitis B virus: Propositions and challenges

Chronic hepatitis B virus (HBV) infection due to mother-to-child transmission (MTCT) during perinatal period remains an important global health problem. Despite standard passive-active immunoprophylaxis with hepatitis B immunoglobulin (HBIG) and hepatitis B vaccine in neonates, up to 9% of newborns still acquire HBV infection, especially these from hepatitis B e antigen (HBeAg) positive mothers. Management of HBV infection in pregnancy still need to draw careful attention because of some controversial aspects, including the failure of passive-active immunoprophylaxis in a fraction of newborns, the effect and necessity of periodical hepatitis B immunoglobulin (HBIG) injection to the mothers, the safety of antiviral prophylaxis with nucleoside/nucleotide analogs, the benefit of different delivery ways, and the safety of breastfeeding. In this review, we highlight these unsettled issues of preventive strategies in perinatal period, and we further aim to provide an optimal approach to the management of preventing MTCT of HBV infection.

Trained immunity in newborn infants of HBV-infected mothers

The newborn immune system is characterized by an impaired Th1-associated immune response. Hepatitis B virus (HBV) transmitted from infected mothers to newborns is thought to exploit the newborns’ immune system immaturity by inducing a state of immune tolerance that facilitates HBV persistence. Contrary to this hypothesis, we demonstrate here that HBV exposure in utero triggers a state of trained immunity, characterized by innate immune cell maturation and Th1 development, which in turn enhances the ability of cord blood immune cells to respond to bacterial infection in vitro. These training effects are associated with an alteration of the cytokine environment characterized by low IL-10 and, in most cases, high IL-12p40 and IFN-α2. Our data uncover a potentially symbiotic relationship between HBV and its natural host, and highlight the plasticity of the fetal immune system following viral exposure in utero.

The ability to fight infections matures after birth and is thus termed ‘trained immunity’. Here the authors show that cord blood cells from hepatitis B virus-infected mothers respond more strongly to bacterial infections, suggesting that viral exposure in utero promotes trained immunity in newborns.

Management of hepatitis B during pregnancy

Chronic HBV infection is estimated to affect >350 million people worldwide and represents a substantial source of morbidity and mortality related to cirrhosis and hepatocellular carcinoma. Mother-to-child transmission (MTCT) remains an important source of incident cases of hepatitis B. Immunoprophylaxis of infants born to mothers who are positive for hepatitis B surface antigen is used to prevent MTCT; however, under-utilization of this intervention in certain regions endemic for HBV infection and failure of immunoprophylaxis in 5-10% of cases are barriers to preventing HBV transmission via this route. Data suggest that a high level of HBV viraemia in pregnant women is a substantial risk factor for immunoprophylaxis failure. Potential means of reducing viral load include antiviral therapy in the third trimester to reduce exposure of the neonate to the virus. Determining the optimal time to treat active HBV-related liver disease in women who wish to become pregnant, as well as managing antiviral therapy in patients who become pregnant, remains challenging. Owing to the vulnerable population affected by these issues, clinical trials are difficult and, thus, evidence-based recommendations are limited. Emerging data are addressing management of HBV during pregnancy that health-care providers should be made aware of. Here, we provide an overview of issues pertinent to HBV infection during pregnancy and present a management algorithm.