Hepatitis B e antigen status and hepatitis B DNA levels in women of childbearing age with chronic hepatitis B infection screening for clinical trials

Associations of hepatitis B and C in women aged 15-49 years with neonatal preterm birth in 66 high-income countries, 1990-2019

OBJECTIVE

To assess the associations between hepatitis B and C in women aged 15-49 years and neonatal preterm birth in high-income countries (HICs).

METHODS

This ecological study collected hepatitis B and C prevalence data in women aged 15-49 years and age-standardized incidence rates (ASIRs) of neonatal preterm birth in HICs in 1990-2019 from the Global Burden of Disease study. Estimated annual percentage changes (EAPCs) in hepatitis B and C prevalence and ASIRs of neonatal preterm birth were calculated to quantify their temporal trends. Pearson correlation tests and generalized additive mixed models were used to estimate the associations between hepatitis B and C prevalence and ASIR of neonatal preterm birth.

RESULTS

Among women aged 15-49 years in HICs, hepatitis B prevalence increased only in the Northern Mariana Islands (EAPC, 0.16 [95% confidence interval (CI), 0.05-0.27]) and the United Kingdom (EAPC, 0.08 [95% CI, 0.04-0.12]) and hepatitis C prevalence increased in more than 20% of HICs in 1990-2019, with the largest increase in Belgium (EAPC, 1.00 [95% CI, 0.65-1.35]). Nearly 80% of HICs showed an increasing trend in ASIR of neonatal preterm birth in 1990-2019, with the largest increase in Greece (EAPC, 3.91 [95% CI, 3.65-4.18]). A positive association between hepatitis C prevalence in women aged 15-49 years and ASIR of neonatal preterm birth was observed in Pearson correlation tests and generalized additive mixed models (P ≤ 0.01).

CONCLUSION

ASIR of neonatal preterm birth was associated with hepatitis C prevalence in women aged 15-49 years in HICs. Universal screening for hepatitis C virus is recommended at least once for women of reproductive age and during each pregnancy.

Disproportionate Distribution of HBV Genotypes A and D and the Recombinant Genotype D/E in the High and Low HBV Endemic Regions of Uganda: A Wake-Up Call for Regional Specific HBV Management

BACKGROUND

Hepatitis B virus (HBV) is the leading cause of liver-related diseases. In Uganda, there is a regional disparity in the HBV burden. Our study was aimed at establishing the circulating genotypes in a low and a high endemic region to give plausible explanations for the differences in regional burden and guide the future management of the disease.

METHODS

A total of 200 HBsAg-seropositive subjects were recruited into the study by convenience sampling. The HBsAg Rapid Test Strip (Healgen Scientific Limited Liability Company, Houston, TX77047- USA) was used to screen for HBsAg while the Roche machine (Roche, Basel Switzerland/Abbot Technologies (USA)) was used to determine the viral load. The Chemistry Analyzer B120 (Mindray, China) was used for chemistry analysis. For HBV genotyping, total DNA was extracted from whole blood using the QIAamp® DNA extraction kit. Nested PCR amplification was performed using Platinum Taq DNA Polymerase (Invitrogen Corporation, USA) to amplify the 400 bp HBV polymerase gene. Purification of nested PCR products was performed using Purelink PCR product purification kit (Life Technologies, USA). Automated DNA sequencing was performed using BigDye Terminator v3.1 Cycle Sequencing Kit on 3130 Genetic Analyzer (Applied Biosystems, USA). The NCBI HBV genotyping tool (https://www.ncbi.nlm.nih.gov/projects/genotyping/formpage.cgi) was used for determination of genotype for each HBV sequence. Pearson's chi-square, multinomial logistic regression, and Mann-Whitney U tests were used for the analysis. All the analyses were done using SPSS version 26.0 and MedCalc software version 19.1.3 at 95% CI. A p < 0.05 was considered statistically significant.

RESULTS

Majority of our study subjects were female (64.5%), youth (51.0%), and married (62.0%). Overall, genotype A was the most prevalent (46%). Genotype D and the recombinant genotype D/E were proportionately more distributed in the high endemic (38.2%) and low endemic (36.5%) regions, respectively. Genotype D was significantly more prevalent in the high endemic region and among the elderly (p < 0.05). Genotype D was significantly associated with elevated viral load and direct bilirubin (p < 0.05). The recombinant genotype D/E was significantly associated with elevated viral load (p < 0.05). Similarly, genotype A was significantly associated with elevated AST and GGT, lowered viral load, and normal direct bilirubin levels (p < 0.05).

CONCLUSION

There is disproportionate distribution of genotypes A and D and the recombinant genotype D/E in the low and high endemic regions of Uganda. This probably could explain the differences in endemicity of HBV in our country signifying the need for regional specific HBV management and control strategies.

Factors associated with non-compliance with breastfeeding recommendation: a retrospective survey in hepatitis B virus-infected mothers who had taken Nucleos(t)ide analogs during pregnancy

BACKGROUND

We encourage Hepatitis B virus-infected mothers to breastfeed postpartum, even when continuing pregnancy category B nucleos(t)ide analogs (NAs) treatment. However, a large proportion of the Hepatitis B virus-infected mothers were noncompliant with this breastfeeding recommendation. This study aimed to investigate the factors associated with noncompliance with breastfeeding recommendation in Hepatitis B virus-infected mothers who had received NAs treatment during pregnancy.

METHODS

A total of 155 mothers with chronic hepatitis B receiving NAs treatment for preventing mother-to-child transmission during the late gestation period were included and divided into exclusive breastfeeding (n = 63), mixed feeding (n = 34), and artificial feeding (n = 58) groups according to the postpartum feeding methods. Independent variables associated with feeding methods were analyzed using logistic regression analysis.

RESULTS

Compared to the breastfeeding and mixed feeding groups, the artificial feeding group had significantly more multiparity, later postpartum timing of stopping NAs treatment, and a lower proportion of having knowledge of NAs medications (all P < 0.05). In addition, multivariable logistic regression analysis confirmed that multiparity, later postpartum timing of stopping NAs treatment, and lacking knowledge of medication were independent factors associated with noncompliance with breastfeeding recommendation.

CONCLUSIONS

Hepatitis B virus-infected mothers who stopped NAs treatment at late postpartum period or had less knowledge of medication were more likely to be noncompliant with breastfeeding recommendation. Strengthening health education for participants taking NAs may be an important method to improve compliance with breastfeeding recommendation.

Maternal age and educational level modify the association between chronic hepatitis B infection and preterm labor

BACKGROUND

Few studies have investigated whether maternal age and education level modify the association of chronic hepatitis B virus (HBV) infection with preterm labor. We hypothesized that the association of HBV infection with preterm labor is modified by maternal age and education level.

METHODS

A retrospective cohort study was conducted on the HBsAg-positive and HBsAg-negative pregnant women delivered from June 2012 to August 2017 at Wuhan Medical Care Center for Women and Children, Wuhan, China. A multivariate regression model was used in this study.

RESULTS

This study included 2050 HBsAg-positive pregnant women and 2050 HBsAg negative women. In the stratified analyses, positive HBsAg status was associated with the increased risk of preterm labor in women aged < 30 years, having low educational level, with an odds ratio of 1.65(95% CI 1.07-2.54) and 2.59(95% CI 1.41-4.76), respectively. Breslow-Day test showed that there existed significant differences in the ORs for HBsAg carriage across each stratum of maternal age (p = 0.023), educational level (p = 0.002). After adjusting other co-variables, we observed maternal HBV infection (OR 1.60, 95% CI 1.03-2.49) was still associated with risk of preterm labor in pregnancy women with age < 30. Similarly, the significant association of HBV infection (OR 2.49, 95% CI 1.34-4.63) with preterm labor remained in low educated women.

CONCLUSIONS

Our results indicated that HBV infection was associated with high risk of preterm labor, but maternal age and educational level could modify the association between HBV infection and preterm labor.

Incidence and Risk Factors of Intrauterine Transmission Among Pregnant Women With Chronic Hepatitis B Virus Infection

GOALS

To identify the potential risk factors of hepatitis B virus (HBV) intrauterine transmission and predict the incidence of HBV intrauterine transmission among hepatitis B surface antigen-positive pregnant women with diverse viral load.

BACKGROUND

The intrauterine transmission of HBV significantly contributes to the persistence of a high number of patients infected with HBV. However, its risk factors remain unclear.

MATERIALS AND METHODS

A prospective study was performed on hepatitis B surface antigen-positive pregnant women who delivered from June 2012 to December 2016 at Wuhan Medical Care Center for Women and Children, Wuhan, China.

RESULTS

In total, 1200 women paired with 1219 infants were enrolled. In total, 11 (0.9%) infants were identified with intrauterine transmission. We observed that all infants with intrauterine transmission were born to hepatitis B e antigen-positive mothers who had serum HBV DNA levels >7 log10 copies/mL. Our study suggested that the HBV DNA levels (for each log10 copies/mL increase, odds ratio=5.43; 95% confidence interval, 1.31-22.43; P=0.019) had independent effects on HBV intrauterine transmission in a multivariate logistic regression model. Moreover, cesarean section (odds ratio=0.18; 95% confidence interval, 0.04-0.74; P=0.018) was associated with a reduced risk of HBV intrauterine transmission. The predictive rates of intrauterine transmission were 0.06%, 0.50%, 2.81%, 8.89% in infants with maternal HBV DNA levels of 10, 10, 10, 10 copies/mL, respectively.

CONCLUSIONS

Our data confirmed that increasing maternal viral load has the ability to predict intrauterine HBV transmission. Vaginal delivery increased risk of HBV transmission in infants compared with cesarean section. Further studies are warranted to clarify the possible mechanism underlying these associations.

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.

The characteristics and predictors of postpartum hepatitis flares in women with chronic hepatitis B

INTRODUCTION

We aimed to characterize postpartum disease flares among treatment-naive mothers with chronic hepatitis B (CHB). CHB mothers were enrolled and compared with non-infected mothers in terms of postpartum alanine aminotransferase (ALT) abnormalities.

METHODS

Demographic, virological, and biochemical parameters were collected up to postpartum week 16, with flares and exacerbations defined as ALT levels 5-10 and >10 times the upper limit of normal, respectively. Outcome assessments included ALT flares or exacerbation and their predictive parameters.

RESULTS

Among 4236 patients enrolled, 869 and 3367 had no infection (group A) and had CHB (group B), respectively. Infected mothers were further stratified into two subgroups by the presence (B1, n = 1928) or absence (B2, n = 1439) of detectable serum levels of hepatitis B virus (HBV) DNA (lowest level of quantitation, 100 IU/mL). A significantly higher frequency of abnormal ALT levels was observed in group B vs. group A (28.27 vs. 20.37%, p < 0.001). ALT events mainly occurred in group B1 (flares, 115/1928, 5.96%; exacerbations, 57/1928, 2.96%). The ALT levels had a bimodal pattern, with peaks at postpartum weeks 3-4 and 9-12. On multivariate analysis, elevated ALT levels and detectable levels of HBV DNA at delivery were independent risk factors for postpartum disease flares. Further subgroup analysis in group B1 demonstrated that a cut-off HBV DNA level of 5 log₁₀ IU/mL at delivery predicted ALT events (positive predictive value, 14.4%; negative predictive value, 98.2%).

CONCLUSIONS

Postpartum ALT level elevation is common in CHB patients. ALT flares or exacerbations are mainly observed in mothers with elevated ALT or HBV DNA levels ≥5 log₁₀ IU/mL at delivery.

Prevention of mother-to-child transmission of hepatitis B virus: Research progress and controversy

Hepatitis B virus (HBV) infection is a global health problem. Mother-to-child transmission (MTCT, also known as vertical transmission) is the main cause of chronic HBV infection. Although combined active and passive immunization has greatly reduced the vertical transmission of HBV, about 8%-10% of newborns still acquire HBV infection, especially those from hepatitis B e antigen (HBeAg) positive mothers. Previous studies have shown that high levels of HBV DNA and positive HBeAg in serum of pregnant woman may be related to the vertical transmission of HBV. Thus, the prevention of MTCT of HBV has always been a practical question that clinicians must face and urgently needs to solve. However, there is still much controversy over the following aspects: indications of antiviral therapy, drug choice, timing of initiating and ending of antiviral agents, postpartum breast-feeding and so on. This review focuses on the consensus and controversy regarding the prevention of the vertical transmission of HBV.

Perinatal management of hepatitis B virus: Clinical implementation of updated Australasian management guidelines

Objective

To evaluate the implementation of the 2013 Royal Australian and New Zealand College of Obstetricians and Gynaecologists 'Management of Hepatitis B in Pregnancy' guideline.

Methods

Retrospective cohort study of the clinical management and obstetric outcomes among hepatitis B virus-positive women in a single tertiary maternity hospital. Women with viral load >200,000 IU/ml were referred to a specialised clinic for consideration of tenofovir disoproxil fumarate therapy to reduce mother to child transmission.

Results

A total of 11,496 women gave birth during the study period, of which 101 (0.9%) women were hepatitis B virus positive. Viral load was measured in 99 (98%) of 101 hepatitis B virus-positive women; 30 (30%) had a viral load >200,000 IU/ml. Twenty-six women accepted tenofovir disoproxil fumarate; of these, 23 had a successful virological response (viral load <200,000 IU/ml before delivery).

Conclusions

Adherence to updated management guidelines and patient acceptance of tenofovir disoproxil fumarate in our Australian population were high when provided in the context of a dedicated perinatal service.

Correlations between ASCC3 Gene Polymorphisms and Chronic Hepatitis B in a Chinese Han Population

We have previously identified 8 SNPs in Han Chinese HBV carriers that are associated with disease progression. Although not well studied, genetic factors may also play a significant role in developing chronic HBV disease after exposure. We extend the effect of these eight SNPs on persistent HBV infection in this study. A total of 875 unrelated Han Chinese, 493 chronic hepatitis B subjects (CHB) and 382 HBV clearance individuals (Clear), were recruited from Hubei Province from September 2007 to March 2010. SNPs were verified by using TaqMan 7900HT Sequence Detection System. By using multiple logistic regression analysis, each of the 8 SNP associations was tested using 3 different genetic models (Dominant, Recessive and Additive model), in 4 types of analyses (full sample, men, women, age stratified). A Bonferroni correction was used to account for multiple statistical tests for each SNP association (P<0.05/8 = 0.0063). A significant correlation was observed at SNP rs10485138 located in ASCC3 gene in female patients (OR, 0.445; 95% CI, 0.253–0.784; P = 0.005). Females bearing C allele infected by HBV had an increased susceptibility to CHB compared with those T allele carriers. Our results indicated that SNP rs10485138 located in ASCC3 gene was associated with persistent HBV infection in Han Chinese.