Management algorithm for prevention of mother-to-child transmission of hepatitis B virus
image: HBsAg, hepatitis B surface antigen; ALT, alanine aminotransferase; ULN, the upper limit of normal; TDF, tenofovir disoproxil fumarate; HBV, hepatitis B virus; anti-HBs, hepatitis B surface antibody.
Credit: Jinlin Hou, Xiaoguang Dou
In May 2016, the World Health Assembly adopted the Global Health Sector Strategy on Viral Hepatitis (2016-2021), setting an ambitious target to eliminate viral hepatitis as a public health threat by 2030. This strategy aims to reduce new viral hepatitis infections by 90% and mortality by 65% by 2030, using 2015 as the baseline. Additionally, it mandates reducing the hepatitis B virus (HBV) infection rate among children under five years old to 0.1%. Mother-to-child transmission (MTCT) is a significant pathway for HBV spread, making its prevention crucial for HBV elimination. Strengthening the standardized management of pregnant women with chronic HBV and their newborns is a vital strategy to curb MTCT. Recent efforts in China and globally to combat viral hepatitis have created a conducive environment for eliminating HBV MTCT. To enhance the clinical management of HBV MTCT prevention in China, the Chinese Foundation for Hepatitis Prevention and Control convened experts to develop and publish a management algorithm in 2017. This algorithm, widely adopted in clinical settings, has significantly reduced HBV MTCT. The prevention of HBV MTCT has emerged as a critical focus in public health, with substantial advancements in related research. To further standardize clinical practices and achieve zero HBV infections in infants, the foundation updated the management algorithm, incorporating the latest research and guidelines.
The updated algorithm outlines ten key steps for pregnancy management and postpartum follow-up, with screening, antiviral therapy, and infant immunization at its core.
The guidelines also propose the following problems. Preventing mother-to-child transmission (MTCT) of HBV remains a global health priority. Tenofovir alafenamide, approved in China in 2018, shows promise for MTCT prevention due to its improved safety profile compared to tenofovir disoproxil fumarate. Preliminary studies suggest that Tenofovir alafenamide is effective and safe, but further randomized controlled trials are needed for validation.
In resource-limited settings, the accessibility of hepatitis B immunoglobulin (HBIG) poses challenges. Research is exploring whether antiviral therapy during pregnancy combined with infant vaccination alone can effectively prevent MTCT without HBIG.
While antiviral therapy during pregnancy is generally safe, most safety data come from third-trimester use. Gaps remain regarding risks associated with earlier initiation (before 24 or 12 weeks). Establishing a national registry for pregnant women on antiviral therapy could provide valuable safety insights.
Pregnancy-induced immunological changes may influence HBV infection outcomes, but their effects are unclear. Chronic HBV infection is linked to adverse pregnancy outcomes, such as preterm birth. Antiviral therapy may mitigate these risks, but optimal postpartum management, including whether to continue treatment, requires further study.
Neonatal immunization has significantly reduced MTCT in China, with HBsAg prevalence among children under five dropping to 0.32% in 2014. Recent studies show MTCT rates as low as 0.3% with comprehensive prevention strategies, surpassing the WHO’s 2% target, which suggests the WHO target could be revised to below 0.3% to reflect current achievements.
In conclusion, while progress has been made, further research is needed to optimize MTCT prevention strategies, including the use of TAF, HBIG-free regimens, and early antiviral therapy. Robust registries and long-term follow-up studies will be essential to achieving the goal of eliminating HBV by 2030.
Full text
https://www.xiahepublishing.com/2310-8819/JCTH-2022-00047
The study was recently published in the Journal of Clinical and Translational Hepatology.
The Journal of Clinical and Translational Hepatology (JCTH) is owned by the Second Affiliated Hospital of Chongqing Medical University and published by XIA & HE Publishing Inc. JCTH publishes high quality, peer reviewed studies in the translational and clinical human health sciences of liver diseases. JCTH has established high standards for publication of original research, which are characterized by a study’s novelty, quality, and ethical conduct in the scientific process as well as in the communication of the research findings. Each issue includes articles by leading authorities on topics in hepatology that are germane to the most current challenges in the field. Special features include reports on the latest advances in drug development and technology that are relevant to liver diseases. Regular features of JCTH also include editorials, correspondences and invited commentaries on rapidly progressing areas in hepatology. All articles published by JCTH, both solicited and unsolicited, must pass our rigorous peer review process.
Follow us on X: @xiahepublishing
Follow us on LinkedIn: Xia & He Publishing Inc.