Global elimination of mother-to-child transmission of hepatitis B: revisiting the current strategy

doi:10.1016/S1473-3099(15)00158-9

The Lancet Infectious Diseases

Volume 15, Issue 8, August 2015, Pages 981-985

https://doi.org/10.1016/S1473-3099(15)00158-9 Get rights and content

Summary

Mother-to-child transmission (MTCT) of hepatitis B virus (HBV) is a major route of HBV transmission worldwide despite an existing immunoprophylaxis regimen. The implementation of immunoprophylaxis has been challenging, especially in low-income and middle-income countries, where MTCT is common, because of difficulty obtaining and delivering the monovalent HBV vaccine and the HBV immunoglobulin. Global control of the HBV epidemic will need improved prevention of MTCT. We discuss research gaps that hinder development of new options for the elimination of MTCT as well as policy changes that may help the current vaccine-based strategy to live up to its full potential. We propose that decreasing hepatitis B viral concentrations before delivery, along with HBV vaccine use, could provide an alternative strategy that would decrease MTCT of HBV.

Introduction

Despite substantial global progress in reducing mother-to-child transmission (MTCT) of hepatitis B due to immunisation programmes during the past two decades,¹ chronic hepatitis B virus (HBV) infection and its complications, cirrhosis and hepatocellular carcinoma, remain major public health problems. Chronic hepatitis B affects around 400 million people worldwide with an estimated 4·5 million incident infections annually.²

MTCT is a major mode of HBV transmission globally and is mainly driven by resource-limited countries with high HBV endemicity (where prevalence exceeds 8%).² For example, in China, despite improved childhood HBV vaccination with 94% of children receiving three doses of the hepatitis B vaccine, MTCT still accounts for 40–50% of new HBV infections.³ Since more than 90% of infants infected perinatally become chronically infected, control of the HBV epidemic can only be achieved with effective prevention of MTCT, a goal that is currently not met. In this Personal View, we discuss the challenges of the current prevention strategy and we propose that decreasing hepatitis B viral concentrations before delivery, along with HBV vaccine use, could provide an alternative strategy that would decrease MTCT of HBV.

Section snippets

Heterogeneity of transmission patterns between low-income countries

Although MTCT is an important problem in many Asian countries, the frequency of MTCT is lower in sub-Saharan Africa. Reasons for this pattern remain incompletely understood, but might include lower proportions of hepatitis B e antigen (HBeAg) positivity in pregnant women, the main predictor of MTCT.⁴ However, even in areas of low endemicity, up to a third of incident HBV infections are due to perinatal or early childhood transmission; thus, decreasing MTCT is a global problem.⁵ Furthermore, the

Potential problems of the current prevention strategy of global MTCT of HBV

Without any intervention, 70–90% of infants born to mothers positive for both hepatitis B surface antigen (HBsAg) and HBeAg will acquire HBV perinatally. In 1991, in an attempt to eliminate this major mode of HBV transmission, the Global Advisory Group of EPI (Expanded Programme on Immunization) set 1997 as the target for integration of the hepatitis B vaccination into national immunisation programmes worldwide. The group recommended strategies for implementation and delivery that vary

Mothers with high HBV DNA—a critical population

Even when administered optimally, the current immunoprophylaxis regimen fails in 8–32% of mothers who have the highest risk of transmitting HBV—ie, those who are HBeAg positive.¹⁶ Although several factors have been associated with MTCT of HBV,¹⁵ studies have repeatedly shown that the most important risk factor is high circulating concentrations of HBV DNA in the mothers, with about 10⁷ IU/mL being the cutoff.15, 17 Such high HBV DNA concentrations are generally found in people who are HBeAg

Crucial research gaps and policy challenges needed to decrease MTCT of HBV

Improvement of the health system infrastructure in countries that contribute substantially to global MTCT of HBV is of utmost importance. This, however, applies for almost all public health problems and is not specific enough to be considered in more detail here. We discuss three additional critical steps specific to decreasing MTCT of HBV. The panel lists the key points of this Personal View.

First, reliable and cost-effective point-of-care rapid diagnostic tests (RDTs) for HBsAg and HBeAg are

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Personal ViewGlobal elimination of mother-to-child transmission of hepatitis B: revisiting the current strategy

Summary

Introduction

Section snippets

Heterogeneity of transmission patterns between low-income countries

Potential problems of the current prevention strategy of global MTCT of HBV

Mothers with high HBV DNA—a critical population

Crucial research gaps and policy challenges needed to decrease MTCT of HBV

J Hepatol

Vaccine

J Hepatol

BMC Infect Dis

Clin Gastroenterol Hepatol

J Hepatol

J Hepatol

J Infect

Global immunization data

Hepatitis B: epidemiology and prevention in developing countries

World J Hepatol

The next step in controlling HBV in China

BMJ

The epidemiology and prophylaxis of hepatitis B in sub-Saharan Africa: a view from tropical and subtropical Africa

Gut

Hepatitis B vaccines

Wkly Epidemiol Rec

Temperature sensitivity of vaccines. WHO/IVB/06.10

Global routine vaccination coverage—2012

MMWR Morb Mortal Wkly Rep

Screening of pregnant women for hepatitis B virus surface antigen (HBsAg) and subsequent management, Qiandongnan prefecture, Guizhou, China, 2010

Vaccine

Hepatitis B vaccine birthdose practices in a country where hepatitis B is endemic—Laos, December 2011–February 2012

MMWR Morb Mortal Wkly Rep

Hepatitis B vaccination of newborn infants in rural China: evaluation of a village-based, out-of-cold-chain delivery strategy

Bull World Health Organ

Management of hepatitis B during pregnancy

Nat Rev Gastroenterol Hepatol

Prevention of neonatal hepatitis B virus transmission

J Clin Gastroenterol

The risk of perinatal hepatitis B virus transmission: hepatitis B e antigen (HBeAg) prevalence estimates for all world regions

BMC Infect Dis

Personal View
Global elimination of mother-to-child transmission of hepatitis B: revisiting the current strategy