Horizontal transmission of hepatitis B virus in children with chronic hepatitis B

Chronic Hepatitis B In Children: Case Series From A Tertiary Paediatric Hospital

BACKGROUND

Chronic hepatitis B (CHB) remains an important global public health problem. Seroconversion is highly correlated with favourable long-term outcome. There is no consensus on the treatment method, onset time and duration for paediatric CHB patients. In this study, we aimed to evaluate the course of children with CHB, to determine the characteristics of the patients who developed spontaneous seroconversion and treatment indications, and to compare the effectiveness of different treatment modalities.

PATIENTS AND METHODS

Patients aged 1-18 years with a diagnosis of CHB were included in this study and evaluated for the development of spontaneous hepatitis B envelope antigen (HBeAg)/surface antigen (HBsAg) seroconversion and treatment modalities. The treated patients were divided into two groups according to their treatment regimen.

RESULTS

Of the 114 patients, the median age at diagnosis was 8.4 years and median follow-up period was 5.2 years. Spontaneous HBeAg and HBsAg seroconversion developed in 18 (20.6%) of 87 HBeAg positive patients and two (1.8%) patients, respectively. Thirty-one patients were treated. The follow-up period was higher in the group with HBeAg seroconversion (p:0.005). There was no statistical difference between the patients in terms of seroconversion development and treatment status. The serum alanine aminotransferase (ALT) values at the time of diagnosis were statistically higher in treated patients.

CONCLUSION

HBV infection and CHB continue to be an important problem for children in our country. Consensus on the appropriate ALT ULN is needed for the treatment of hepatitis in children.

Horizontal Modes of Transmission of Hepatitis B Virus (HBV): A Systematic Review and Meta-Analysis

Background

Horizontal transmission of hepatitis B virus (HBV) is a significant transmission route in households, among contact sport athletes and institutionalized individuals. Children often are infected by non-sexual close contacts with an increased tendency to become chronic carriers. Hence, the awareness about various high-risk behaviours leading to horizontal transmission in the community is essential. A systematic review and meta-analysis was carried out to assess quantitatively the pooled prevalence of horizontally transmitted HBV infection globally.

Methods

The study was started after ruling out registered or ongoing systematic reviews related to this topic in the PROSPERO database. The study protocol was documented in PROSPERO with a registration number CRD42021235165. We searched electronic databases for published articles in English between 1981 and April 2021 reporting horizontal modes of hepatitis B transmission among unvaccinated contacts. Meta-analysis was carried out in STATA version 13.0 (College Station, Texas 77,845 USA). The forest plots were constructed using metaprop package in STATA.

Results

Forty-one studies were systematically reviewed and 15 studies were qualified for the meta-analysis, including 1619 hepatitis B cases and 4869 contacts. The overall pooled prevalence of horizontally transmitted HBV infection among the contacts was 38% (95% CI 30%-46%). The pooled prevalence among 3,912 household contacts from nine qualified studies was estimated as 44% (95% CI 35%-54%). The pooled prevalence rates among institutionalized individuals and contact sport athletes were 30% (95% CI 23%-37%) and 18% (95% CI 5%-32%), respectively.

Conclusion

The likelihood of horizontal transmission of HBV is greater among household contacts of chronic carriers of HBV and institutionalized individuals.

Together let us confront it: An outbreak investigation of hepatitis B in Pathanamthitta district, Kerala

INTRODUCTION

Hepatitis B is a potentially life-threatening liver infection caused by the Hepatitis B virus (HBV). The established routes of transmission are from mother to infant, sexual contact, and exposure to blood or body fluids. Though HBV is preventable by vaccine and robust infection control practices, outbreaks of HBV infection do occur in India. However, the state of Kerala with its health parameters, one among the best in the country, cannot afford to have continuing outbreaks. An unusual increase in the reported cases of Hepatitis B in a rural area of Pathanamthitta district of Kerala, called for an outbreak investigation.

AIMS

To describe the epidemiological features, to determine the risk factors associated with HBV transmission, and to suggest measures to prevent future transmission.

METHODS

A community-based case-control study (1:2) was undertaken. A total of 162 participants (54 cases and 108 age, gender, and neighborhood matched controls) took part in the study. Focus group discussions were conducted with subject experts to develop an interview schedule assessing 40 risk factors. It was further reviewed by the University of Sydney. Data was collected by trained Junior Health Inspectors and Junior Public Health Nurses of the Primary Health Centers. Data was analyzed using SPSS v. 20. Proportions were compared by Univariate analysis, sub-group analysis, and logistic regression. Population Attributable Risk (PAR) was also calculated.

RESULTS AND CONCLUSION

More than 90% of the infections were IgM anti-HBc positive, suggesting a recent infection. Interventions during hospitalization [OR: 7.98 (95% CI - 2.17--29.4)], family history of Hepatitis B [OR. 4.14 (95%CI - 1.73--9.9)], and laboratory investigations [OR: 3.99 (1.72--9.31)] were found to be significant risk factors. PAR was highest for laboratory interventions (32%). Vaccinating household contacts and strict enforcement of infection control practices could substantially reduce the burden of this fatal disease.

Mother-to-Child Transmission of Hepatitis B Virus in Ethiopia

High viral load and positive hepatitis B e-antigen (HBeAg) results are risk factors for mother-to-child transmission (MTCT) of hepatitis B virus (HBV). In sub-Saharan Africa, little is known about the distribution of these risk factors, as well as early childhood HBV transmission. In this study, Ethiopian women aged 18–45 years with chronic hepatitis B were assessed for the presence of HBeAg and high viral load. Their children below 4 years of age were invited for assessment of viral markers, defining active HBV infection as a positive hepatitis B s-antigen (HBsAg) and/or detectable HBV DNA. In total, 61 of 428 HBV-infected women (14.3%) had a positive HBeAg result and/or a high viral load. Of note, 26 of 49 women (53.1%) with viral load above 200,000 IU/mL were HBeAg negative. Among 89 children born of HBV-infected mothers (median age 20 months), 9 (10.1%) had evidence of active HBV infection. In conclusion, one in seven women with chronic hepatitis B had risk factors for MTCT, and HBeAg was a poor predictor of high viral load. One in ten children born of HBV-infected women acquired HBV-infection despite completing their scheduled HBV vaccination at 6, 10 and 14 weeks of age.

Early detection of chronic hepatitis B and risk factor assessment in Turkish migrants, Middle Limburg, Belgium

Background

Turkey is an intermediate hepatitis B virus (HBV) endemic country. However, prevalence among Turkish migrants in Belgium is unknown, especially in those born in Belgium with a foreign-born parent, i.e. second-generation migrants (SGM).

Aims

To evaluate the prevalence of HBV infection and associated risk factors in Turkish first-generation migrants (FGM), i.e. foreign-born, and SGM.

Methods

Between September 2017 and May 2019, free outreach testing for hepatitis B surface antigen (HBsAg), hepatitis B core antibodies (anti-HBc), and antibodies against HBsAg was offered to Turkish migrants in Middle-Limburg, Belgium. Face-to-face questionnaire assessed HBV risk factors. HBsAg positive patients were referred and followed up. Turkish SGM were stratified into birth cohort born before and after 1987, since those born after 1987 should be covered by the universal infant vaccination program.

Results

A total of 1,081/1,113 (97.1%) Turkish did go for HBV testing. Twenty-six (2.4%) were HBsAg positive; 11/26 were unaware of their status and 10/11 were successfully referred. HBsAg prevalence was 3.0% in FGM and 1.5% in SGM, p = .070. Only one out of seven HBsAg positive SGM was born after 1987. In the multiple generalized estimating equations model, the most important risk factors for anti-HBc positivity were male gender (p = .021), older age (p < .001), FGM (p < .001), low educational level of the mother (p = .003), HBV infected mother (p = .008), HBV infected siblings (p = .002), HBV infected other family member (p = .004), gynaecological examination in Turkey or unsafe male circumcision (p = .032) and dental treatment in Turkey (p = .049).

Conclusion

Outreach testing was well-accepted and referral to specialist care was generally successful. National HBV screening should be implemented in the Turkish FGM population and might be considered in SGM not covered by primary prevention strategies.

The influence of ethnicity on disease outcome in patients with chronic hepatitis B infection

Since the cultural diversity in Western Europe is growing, this study assessed whether foreign‐born chronic hepatitis B (CHB) patients have more cirrhosis than Dutch‐ or Belgian‐born patients, with a main focus on the Turkish population. Baseline characteristics (eg, socioeconomic status [SES]), biological characteristics, and disease outcome (eg, cirrhosis) were collected for all patients. Between December 2009 and January 2015, 269 CHB patients participated from the outpatient departments of three hospitals in the Netherlands, Belgium, and Turkey. Out of the 269 CHB patients, 210 were foreign‐born and 59 were Dutch‐ or Belgian‐born. Compared with Dutch‐ or Belgian‐born patients, foreign‐born patients had a higher prevalence of low SES (58% vs 31%; P = 0.001) and cirrhosis (27% vs 10%; P = 0.007). Among the Turkish population, there were no significant differences regarding the prevalence of low SES (73% vs 61%; P = 0.170), alcohol abuse (1% vs 5%; P = 0.120), anti‐hepatitis C virus positivity (4% vs 0%; P = 0.344), anti‐hepatitis D virus positivity (1% vs 6%; P = 0.297), and cirrhosis (37% vs 27%; P = 0.262) between patients (n = 102) living in Turkey (local) and Turkish CHB (n = 38) patients living in the Netherlands or Belgium (immigrant). In multivariate analysis, low SES (odds ratio, 5.7; 95% confidence interval, 2.3‐14.5; P < 0.001) was associated with cirrhosis. In this study, foreign‐born CHB patients were associated with more advanced HBV‐related liver disease with 27% having cirrhosis. However, ethnicity was not associated with cirrhosis when SES was included in the multivariate analysis. The similar prevalence of cirrhosis in local Turkish compared to immigrant Turkish CHB patients is novel and warrants further investigation.

Foreign‐born individuals have a higher prevalence of cirrhosis than Dutch‐ or Belgian‐ born individuals

There was a lower socioeconomic status in the foreign‐born individuals

No difference in the prevalence of cirrhosis was seen between the local and immigrant Turkish population

Socioeconomic status and not ethnicity was an independent predictor of cirrhosis

The association of adverse outcomes in the mother with disease progression in offspring in families with clusters of hepatitis B virus infection and unfavorable prognoses in Northwest China

To investigate the transmission routes of hepatitis B virus (HBV) in families with clusters of infection and unfavorable prognoses and to analyze the prevalence of liver cirrhosis (LC) or hepatocellular carcinoma (HCC) in the offspring of these families.Families with clusters of HBV infection and unfavorable prognoses were enrolled in the study, and general information and serum samples were collected. The prevalence of LC or HCC was compared in offspring of different genders whose parents were diagnosed with LC or HCC.This analysis comprised 102 probands with 51 siblings, 15 parents, 284 children, and 74 spouses. Interestingly, 88.2% of the siblings and 76.8% of the children of these probands were positive for hepatitis B surface antigen (HBsAg), compared with only 9.5% of the spouses (P < .001). There were 266 nuclear families from 102 clustering families. The prevalence of LC or HCC in sons (44.8%) was higher than that in daughters (8.2%; P < .05) in families with mothers with LC or HCC, but there was no difference in families with fathers with LC or HCC. Moreover, the prevalence of LC or HCC in sons from families with mothers with LC or HCC (44.8%) was higher than in the families with fathers with LC or HCC (21.0%, P = .016).The development of LC or HCC in offspring showed a greater relationship with the adverse outcomes induced by HBV infection in the mother compared with the father, and the prevalence of LC or HCC was much higher in male offspring.

The Prevalence of Hepatitis B Virus Among Municipal Solid Waste Workers: Necessity for Immunization of At-Risk Groups

BACKGROUND

Hepatitis B virus (HBV) is likely to be more prevalent in certain populations and occupational groups, such as municipal solid waste workers (MSWWs).

OBJECTIVES

The current study aimed to estimate the prevalence of HBV and its risk factors among MSWWs compared to other municipal employees not exposed to waste.

PATIENTS AND METHODS

The current cross-sectional study included 654 municipal employees in Zahedan (south-eastern Iran). A sample of blood was taken from each participant and tested for HBsAg through the enzyme-linked immunosorbent assay (ELISA). Demographic and other data on high risk behaviors were also collected through in-depth interviews. Data were analyzed using chi-square test and multiple regression analysis by STATA.

RESULTS

The overall prevalence of HBV among municipal employees was 3.06% (95% CI: 1.70 - 4.30); however, it varied among the different employee subgroups as follows: 6.20% (95% CI: 2.70 - 9.70) in MSWWs, 3.3% (95% CI: 0.08 - 5.80) in drivers and 1% among staff who were not exposed to waste. Multiple regression analysis showed that exposure to waste [OR = 9.36; 95% CI = 2.01 - 43.7], lack of vaccination against HBV [OR = 3.83; 95% CI = 1.86 - 25.2], jaundice [OR = 6.91; 95% CI = 1.51 - 31.5], history of endoscopy [OR = 2.86; 95% CI = 1.08 - 7.62], and high risk behaviors [OR = 4.80; 95% CI = 1.96 - 27.2] were independently associated with HBV.

CONCLUSIONS

Greater encouragement for immunization against HBV as well as better education on HBV transmission routes and work safety precautions should be implemented to reduce the prevalence of HBV in MSWWs.

Epidemiology and clinical features of childhood chronic hepatitis B infection diagnosed in England

BACKGROUND

This study aimed to estimate the prevalence of childhood chronic hepatitis B (CHB) infection diagnosed in England using capture-recapture analysis of 2 independent data sources and to describe the clinical and epidemiological characteristics, management, complications and outcome of children with CHB.

METHODS

Pediatric specialists were contacted to report all CHB cases in children aged <16 years and complete a standardized questionnaire. Capture-recapture analysis of cases diagnosed during 2001-2009 using 2 independent data sources was performed to estimate the prevalence of childhood CHB.

RESULTS

Capture-recapture analysis estimated 448 diagnosed CHB cases (prevalence, 4.6/100,000) in England, of whom only 44% had been referred for specialist follow up. Clinical information for 325 cases under specialist care revealed that half the cases (n = 164, 50%) had been born overseas, mainly Sub-Saharan Africa and Eastern Europe, whereas half the UK-born children were either Pakistani (25%) or Chinese (25%). Most children (n = 216, 66%) were asymptomatic, with only 60 (18.5%) ever receiving any antiviral therapy, although 2 developed cirrhosis in childhood and 1 hepatocellular carcinoma. Horizontal transmission among UK-born children was identified in only 3 children born since 2001, when universal antenatal hepatitis B virus screening was introduced. Most children born to antenatally diagnosed hepatitis B virus-positive mothers (49/51, 96%) had received at least 1 hepatitis B vaccine dose after birth.

CONCLUSIONS

In England, the prevalence of diagnosed childhood CHB is low, although the potential number of undiagnosed cases is difficult to estimate. Further efforts are required to strengthen the current antenatal screening program and newly diagnosed cases should be referred for specialist follow up.

Trends of hepatitis B notification rates in Turkey, 1990 to 2012

Turkey is a country with intermediate endemicity for hepatitis B, and approximately 4% of the population are HBsAg-positive. A number of measures have been implemented to prevent hepatitis B infection. In 1998, hepatitis B antigen was included in the national immunisation programme, and infants have since been vaccinated with three doses. Catch-up strategies, vaccination for high risk groups and screening measures were also adopted. The aim of this study was to evaluate the impact of the prevention and control strategies on hepatitis B notification rates in Turkey in the period from 1990 to 2012, using data from the national surveillance system. Secular trends revealed that rates showed an initial increasing trend, followed by a steady decline from 2005. The most dramatic decline occurred among children younger than 15 years, highlighting the benefits of vaccination and catch-up strategies. However, vaccination cannot fully explain the decrease in this age group. Socioeconomic development, through interrupting the horizontal transmission may also have contributed. After 2005, a steady decline was achieved also among those 15 years and older. The rates in adults were higher, which indicates that stronger prevention measures are needed to target this group, particularly men.

Familial clustering of HBV in families with children who are diagnosed as chronic hepatitis B or inactive carriers of HBV

The aim of this study was to assess and compare the spread of HBV infection in families with children who are diagnosed as chronic hepatitis B or are inactive carriers of HBV. A total of 570 patients aged 2-16 years and 2358 family members were included in the study. Patients were classified as inactive carriers (Group 1, 350 patients) or patients diagnosed as chronic active hepatitis B (Group 2, 220 patients). Demographic features of the families, HBV serological markers and routes of transmission were evaluated. Parental transmission was lower compared to nonparental transmission (34.8% and 65.1%, respectively). HBsAg positivity rate was found to be highest among mothers in both of the groups. HBeAg positivity and anti-HBs positivity were significantly higher in family members of Group 2. Transmission rates were significantly higher in families consisting of five or more members compared to families consisting of less than five members. HBsAg positivity of siblings was lowest when both parents were HbsAg negative and highest when both parents were HBsAg positive in both groups. A high risk of HBV transmission among mothers of HBsAg carriers and patients with chronic hepatitis B was demonstrated.

Hepatitis B virus transmission in pre-adolescent schoolchildren in four multi-ethnic areas of England

The aim of this study was to estimate the amount of childhood hepatitis B virus transmission in children born in the UK, a very low-prevalence country, that is preventable only by universal hepatitis B immunization of infants. Oral fluid specimens were collected from schoolchildren aged 7-11 years in four inner city multi-ethnic areas and tested for the presence of antibody to hepatitis B core antigen (anti-HBc). Those found positive or indeterminate were followed up with testing on serum to confirm their hepatitis B status. The overall prevalence of anti-HBc in children was low [0.26%, 95% confidence interval (CI) 0.14-0.44]. The estimated average annual incidence of hepatitis B was estimated to be 29.26/100 000 children (95% CI 16.00-49.08). The total incidence that is preventable only by a universal infant immunization programme in the UK was estimated to be between 5.00 and 12.49/100 000. The study demonstrates that the extent of horizontal childhood hepatitis B virus transmission is low in children born in the UK and suggests that schools in the UK are an uncommon setting for the transmission of the virus. Targeted hepatitis B testing and immunization of migrants from intermediate- and high-prevalence countries is likely to be a more effective measure to reduce childhood transmission than a universal infant immunization programme.

A review of chronic hepatitis B epidemiology and management issues in selected countries in the Middle East

Experts from seven countries convened as a Specialist Panel for the Middle East to share information on practical issues relating to the epidemiology, diagnosis and management of chronic hepatitis B (CHB) infection. The Middle East is regarded as a region of high-to-intermediate epidemicity; however, infant vaccination programmes have successfully lowered the prevalence of hepatitis B infection in most countries to that of low-to-intermediate endemicity. Vaccine issues still to be addressed included improving coverage in some rural/poor communities, instituting hepatitis B vaccine at birth and providing vaccines for high-risk population groups. Hepatitis B infection in the Middle East primarily occurs as a result of perinatal infection, horizontal transmission between family members and transmission from injections. Blood transfusion services have broadly efficient screening programmes, but immunocompromised and haemodialysis patients are at risk. The cost of screening, monitoring and treating CHB influences practice in a number of Middle East countries, and there is a need for information on the most cost-effective options.

[Hepatitis B vaccination: a major player in the control of primary liver cancer]

In worst cases, chronic hepatitis B ultimately leads to primary liver cancer. Populations the more at risk to develop hepatocellular carcinoma (HCC), i.e. patients infected perinatally, reside essentially in Asia. A quarter of century after its introduction in medical practice, data coming from Eastern Asia demonstrate a strong impact of the vaccine on HCC incidence. Strikingly, universal immunization of Taiwanese newborns reduced fourfold pediatric HCC incidence. However, residual cases still appear though among children infected at birth by HBe antigen-carrying mothers. Epidemiologic models indicate that the continuation of universal vaccination policy will reduce chronic hepatitis B endemicity 50-fold in three generations. Recently, mutant forms of HBV potentially escaping to vaccine appeared as a potential consequence of large-scale vaccination. Finally, lack of early immunization of newborns in developing countries still represents a major limitation to the progresses against liver cancer.

Genotype, phylogenetic analysis, and transmission pattern of occult hepatitis B virus (HBV) infection in families of asymptomatic HBsAg carriers

Occult hepatitis B is defined by the presence of hepatitis B virus (HBV) DNA in the serum in absence of hepatitis B surface antigen (HBsAg). Studies were conducted to screen for occult HBV infection among family members of HBV carriers, incidentally detected positive for HBV infection with a view to assess the pattern of virus transmission among them. Nested PCR assay, employing independent sets of primers to surface and core genes, was used for detection of HBV DNA in serum samples from 28 index cases with asymptomatic HBV infection, and in serum samples from 72 HBsAg negative/anti-HBc positive family members. HBV DNA was detected in 15 HBsAg negative family members of 10 HBsAg positive index patients and was studied in detail. Direct sequencing of S gene region of 25 isolates (10 index cases and 15 contacts) and phylogenetic analysis with data base sequences revealed that genotypes A, C, and D and subtype adw2, adr, and ayw3 were present among them. Evidence of transmission from outside family sources was found in addition to intrafamilial transmission among individuals with occult infection. Mutations in the major hydrophilic loop (MHL) of the S gene region were also detected, including the 'vaccine escape' mutation G145R in three cases. Although majority of the occult infection was associated with low viral load, 3/15 (20%) cases were with higher viral load and potential infectivity. These cases are especially notable in diagnostic, blood banking, and transplantation services.

Epidemiologic study of chronic hepatitis B virus infection in male volunteer blood donors in Karachi, Pakistan

Background

The magnitude of chronic infection with hepatitis B virus (HBV) varies substantially between the countries. A better understanding of incidence and/ or prevalence of HBV infection and associated risk factors provides insight into the transmission of this infection in the community. The purpose of this investigation was to estimate the prevalence of and to identify the risk factors associated with chronic infection with HBV, as assessed by HBV surface antigen (HBsAg) positivity, in asymptomatic volunteer male blood donors in Karachi, Pakistan.

Methods

Consecutive blood donations made at the two large blood banks between January 1, 1998 and December 31, 2002 were assessed to estimate the prevalence of HBsAg positivity. To evaluate the potential risk factors, a case-control study design was implemented; cases (HBsAg positives) and controls (HBsAg negatives), were recruited between October 15, 2001 and March 15, 2002. A pre-tested structured questionnaire was administered through trained interviewers to collect the data on hypothesized risk factors for HBV infection. Sera were tested for HBsAg using commercially available kits for enzyme linked Immunosorbant assay-III.

Results

HBsAg prevalence in the male volunteer blood donors was 2.0 % (7048/351309). Multivariate logistic regression analysis showed that after adjusting for age and ethnicity, cases were significantly more likely than controls to have received dental treatment from un-qualified dental care provider (adjusted odds ratio (OR) = 9.8; 95% confidence interval (CI): 2.1, 46.1), have received 1–5 injections (adjusted OR = 3.3; 95% CI: 1.1, 9.6), more than 5 injections (adjusted OR = 1.4; 95% CI: 1.4, 12.7) during the last five years or have received injection through a glass syringe (adjusted OR = 9.4; 95% CI: 2.6, 34.3). Injury resulted in bleeding during shaving from barbers (adjusted OR = 2.3; 95% CI: 1.1, 4.8) was also significant predictor of HBsAg positivity.

Conclusion

Prevalence of HBsAg positivity in the male volunteer blood donors in Karachi was 2%. Infection control measures in health-care settings including safe injection practices and proper sterilization techniques of medical instruments and education of barbers about the significance of sterilization of their instruments may reduce the burden of HBV infection in this and similar settings. There is also an urgent need of developing locally relevant guidelines for counseling and management of HBsAg positive blood donors.