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