Chronic hepatitis B in pregnant women: Current trends and approaches

Antiviral Therapy-Induced Changes in Long Non-Coding RNA Expression Profiles in Umbilical Cord Blood and Placental Tissues of Hepatitis B Virus-Infected Pregnant Women

Background

Hepatitis B virus (HBV) is a major global health concern, with maternal-fetal transmission being the primary route of transmission, which can lead to chronic HBV infection in newborns. Long non-coding RNAs (lncRNAs) play crucial roles in gene regulation and immune responses, but their involvement in HBV transmission during pregnancy remains unclear. This study aimed to assess the impact of tenofovir disoproxil fumarate (TDF)-based antiviral therapy on lncRNA expression profiles and immune signaling pathways in umbilical cord blood and placental tissues and to identify potential therapeutic targets for preventing intrauterine HBV infection.

Materials and Methods

Umbilical cord serum and placental tissues were collected from six HBV carriers. Three carriers received TDF-based antiviral therapy, and the remaining carriers who did not receive antiviral therapy served as controls. LncRNA microarray analysis and bioinformatics were used to evaluate the effects of antiviral therapy on lncRNA expression profiles and signaling pathways.

Results

Antiviral therapy exerted minimal effects on lncRNA expression profiles in umbilical cord blood. In placental tissues, significant alterations in lncRNA expression profiles were observed, including 249 upregulated and 381 downregulated lncRNAs. Antiviral therapy activated innate immune pathways, such as intracellular DNA sensing, chemokine signaling, type I interferon, Jak-Stat, and interferon-γ-mediated adaptive immunity. Through intersection analysis, CPED1 was found differentially expressed in both cord blood and placental tissues. KEGG pathway analysis suggested that low CPED1 expression may inhibit virus transmission via the JAK-STAT pathway.

Conclusion

This study demonstrated that TDF-based antiviral therapy altered lncRNA expression and activated immune signaling pathways in placental tissues, offering insights into the molecular mechanisms of maternal-fetal HBV transmission.

Global elimination of HBV: Is it really achievable?

Hepatitis B virus (HBV) infection is a major cause of premature death worldwide. In 2016, the World Health Organization (WHO) called for HBV elimination and set up very ambitious elimination targets. The development of effective vaccines, accurate diagnostic tools and safe antiviral drugs make HBV elimination a realistic goal. However, the most constrained-resource regions, which bear the highest burden of HBV, are facing major challenges in implementing strategies to reduce HBV incidence and mortality. Developing simplified approaches adapted to resource-limited settings and scaling up interventions for the prevention and control of HBV globally are urgently needed. Whether HBV elimination will be achieved in an equitable manner and in a reasonable timeframe remains highly uncertain.

Safety of Tenofovir Disoproxil Fumarate Among Breastfeeding Infants of Patients With Chronic Hepatitis B: A Systematic Review

An integral component to achieving worldwide chronic hepatitis B (CHB) elimination is addressing vertical transmission. Guidelines differ in their recommendations for breastfeeding while on tenofovir disoproxil fumarate (TDF). To conduct a systematic review of published studies analysing the concentration of tenofovir (TFV) in the breast milk of mothers receiving TDF and determining infant exposure from breastfeeding. We conducted a systematic literature search of studies evaluating infant safety from the breast milk of breastfeeding mothers receiving TDF for any indication that reported a TFV breast milk concentration. Daily infant exposure was used to calculate the relative dose of TFV in infants. Other pertinent information collected was the concentration of TFV in maternal and infant plasma, the duration of therapy of TDF and the indication for TDF. We identified 10 studies including 443 patients-266 of whom were mothers, and the remaining were infants-that reported the TFV concentration of breast milk in breastfeeding mothers receiving TDF. A total of 654 breast milk samples were included. The mean TFV concentration from all the studies that reported a median concentration of TFV was 4.8 ng/mL (95% CI [3.8, 5.8]). The mean infant exposure of TFV from breast milk was 0.56 μg/kg/day (95% CI [0.44, 0.68]). The mean relative dose was determined to be 0.01% of the weight-based recommended infant dose. Infant plasma levels of TFV were also collected. This was undetectable in a majority of the studies that reported it. Based on the negligible infant exposure of TFV while breastfeeding, from a pharmacologic and toxicity standpoint, maternal dosing of TDF appears safe for breastfeeding infants.

Functional cure of chronic hepatitis B-hope or hype?

Chronic hepatitis B constitutes a substantial disease burden worldwide. The steps advocated by the World Health Organization in 2016 to eradicate hepatitis B by 2030 has failed to achieve significant progress, especially with respect to immunization coverage and linkage to care. The lack of governmental and public awareness regarding the long-term implications of hepatitis B burden cause underfunding of developmental projects. The presently approved treatment modalities have limited efficacy in complete viral eradication, hence the need for newer molecules to achieve functional cure (sustained undetectable hepatitis B surface antigen (HBsAg) and hepatitis B virus DNA in peripheral blood after a finite period of therapy). However, preliminary results from trials of novel therapies show their inadequacy to achieve this end by themselves but better performance with a low baseline serum HBsAg with nucleos(t)ide analogues (NA) treatment which need to be combined with/without pegylated interferon as an immunomodulator. Such therapy is limited by cost and adverse events and need to show incremental benefit over the standard of care (long-term NA therapy) with respect to efficacy and drug toxicities, making the development process tenuous. Thus, while such therapies continue to be tested, strategies should still focus on prevention of transmission by non-pharmaceutical measures, vaccination and increasing linkage to care.

Epidemiology of hepatitis B virus infection among pregnant women in Africa: a systematic review and meta-analysis

BACKGROUND

Although hepatitis B infection is highly endemic in Africa, information on its epidemiology among pregnant women in the region is limited. Therefore, this systematic review provided up-to-date information on the epidemiology of hepatitis B virus (HBsAg) infection among pregnant women in Africa.

METHODS

A systematic review and meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews. The Web of Science, Scopus, PubMed, Google Scholar, and African journals online were searched to identify relevant studies published between January 1, 2015, and May 21, 2024, on hepatitis B virus infection in pregnant women living in Africa. The Joanna Briggs Institute tool was used to assess the methodological qualities of the included studies. The random effects model was used to estimate the pooled prevalence of HBV infection. I2 assessed the amount of heterogeneity. Publication bias was assessed using Egger's test and a funnel plot.

RESULTS

We included 91 studies from 28 African countries. The pooled prevalence of hepatitis B infection among pregnant women in Africa was 5.89% (95% CI: 5.26-6.51%), with significant heterogeneity between studies (I2 = 97.71%, p < 0.001). Family history of hepatitis B virus infection (AOR = 2.72, 95%CI: 1.53-3.9), multiple sexual partners (AOR = 2.17, 95%CI: 1.3-3.04), and sharing sharp materials were risk factors for hepatitis B infection.

CONCLUSION

An intermediate endemic level of hepatitis B virus infection (2-7%) was observed among pregnant women in Africa. To prevent disease transmission, interventions should focus on pregnant women with a family history of hepatitis B infection, multiple sexual partners, and sharing sharp materials.

Hepatitis B virus infection during pregnancy and the risk of postpartum hemorrhage: a protocol for systematic review and meta-analysis

Background

Hepatitis B virus (HBV) infection is a significant public health issue worldwide, with a hepatitis B surface antigen (HBsAg) seroprevalence of 3.5%. Maternal HBV infection during pregnancy, a common comorbidity, is associated with an increase in the risk of adverse obstetric and perinatal outcomes. However, the relationship between maternal HBV infection and postpartum hemorrhage (PPH), a leading contributor to maternal morbidity and mortality, is currently uncertain. The aim of this study is to comprehensively clarify the potential impact of maternal HBV on PPH risk.

Methods and Analysis

The authors initially searched five English databases and three Chinese databases from their inception to 26th June 2023. Two reviewers will independently conduct study selection, data extraction, and quality assessment. Cohort and case-control studies investigating the effect of maternal HBV infection on PPH will be included, with study quality assessed using the Newcastle-Ottawa Scale (NOS). Meta-analyses will be performed using a fixed-effects model for I 2≤50% or a random-effects model otherwise. Several categories of subgroup analyses (e.g. sample size more than 1000 vs. less than 1000) and sensitivity analyses (e.g. omit NOS scores less than 7) will be conducted, and publication bias will be assessed through funnel plots, Begg's and Egger's tests using STATA 18.0.

Ethics and Dissemination

This systematic review and meta-analysis do not require ethics approval and the results will be published in peer-reviewed journals. The findings of this systematic review will provide evidence on the impact of maternal HBV infection on PPH, which will contribute to better prevention and management of PPH in clinical practice and a better understanding of the disease burden of HBV infection.

PROSPERO registration number

CRD42023442626.

Sociodemographic Determinants of Knowledge, Attitudes, and Practices Toward Hepatitis B Infection Among Pregnant Women: A Cross-National Study in Jordan

Background Mother-to-child transmission (MTCT) of the hepatitis B virus (HBV) is significant, as most infants infected at birth go on to develop chronic hepatitis B. Vaccination and antiviral treatment during pregnancy could primarily prevent vertical transmission. Therefore, the purpose of this study is to assess pregnant Jordanian females' knowledge, attitude, and practices (KAP) toward HBV. In addition, to explore the relationship between the level of KAP toward HBV infection and its predictors. Methods Our cross-sectional study was conducted among pregnant women in Jordan. We enrolled 621 participants between January and April 2023. Our survey was derived from a previously validated tool that was used to investigate a similar aim as our study. The survey was done via Google Forms (Google LLC, Mountain View, California, United States) and it contained questions divided into four main sections: participants' demographics, knowledge section, attitudes section, and practices section. Results The majority of participants have neither a personal nor family history of HBV, and only 91 (14.7%) of the participants had a medical degree. The overall knowledge, attitude, and practice (KAP) scores were low, as only 176 (28.3%), 315 (50.7%), and 244 (39.3%) of participants achieved high levels of knowledge, attitude, and practice scores, respectively. A significant association was found between knowledge level, practice assessment, and the following variables: age, educational level, job, study field, history of HBV in the family, and source of knowledge. Regarding attitude, a significant association was found with the job, study field, and source of knowledge. Conclusion This study found that pregnant women in Jordan had a low level of awareness of HBV infection. Thus, more efforts should be made to raise awareness about HBV among high-risk groups, especially pregnant women.

A Improving Birth-dose Hepatitis-B Vaccination in a Tertiary Level IV Neonatal Intensive Care Unit

Background

Perinatal hepatitis B is a global public health concern. To reduce perinatal hepatitis B and its complications, the Hepatitis B vaccine (HBV) is recommended by the New York State Department of Health and Advisory Committee on Immunization Practices within 24 hours of life for infants born with a birth weight ≥2000 g. Infants admitted to the neonatal intensive care unit (NICU) weighing over 2000 g missed their birth dose HBV frequently, which prompted the implementation of a quality improvement initiative to increase birth dose HBV immunization in a level IV NICU in New York.

Methods

May 2019 to April 2021 baseline data showed the birth dose HBV rate of infants born ≥2000 g at 24% and 31% within 12 and 24 hours, respectively. The multidisciplinary QI team identified barriers using an Ishikawa cause-and-effect diagram. Our interventions included multidisciplinary collaboration, electronic medical record reminders, education, posters, and improved communication between staff and parents. We aimed to achieve a 25% improvement from the baseline.

Results

After 19 months of QI interventions (four Plan-Do-Study-Act cycles), the rate of administering birth dose HBV within 12 hours of life increased from 24% to 56% and within 24 hours from 31% to 64%. Process measure compliance improved, exceeding the 25% target, and showed sustained improvement.

Conclusion

This QI initiative improved the rate of eligible infants receiving HBV within the first 24 hours of life in the NICU. This work can serve as a model for other healthcare institutions to improve HBV immunization rates in NICUs.

Low levels of tenofovir in breast milk support breastfeeding in HBV-infected mothers treated with tenofovir disoproxil fumarate

OBJECTIVE

Tenofovir disoproxil fumarate (TDF) is recommended for the prevention of mother-to-infant transmission of the hepatitis B virus (HBV). This study investigated the safety of infants whose mothers continued to receive TDF while breastfeeding.

PATIENTS AND METHOD

Thirty women taking TDF daily from the second or third trimester of pregnancy to three months postpartum were enrolled. Tenofovir (TFV) concentrations in breast milk were determined and compared with those in umbilical cord (UC) blood and amniotic fluid. Infant growth parameters were assessed at birth, and at 3, 6, and 12 months. TFV uptake experiments were conducted in vitro to elucidate the mechanisms of TFV exposure via breast milk.

RESULTS

TFV concentrations in breast milk ranged from 1.4 to 11.7 ng/mL within 24 h after dosing in the third month postpartum. The median trough concentration of TFV in breast milk was 3.7 (interquartile range, 2.6-6.2) ng/mL, which is lower than that in UC blood (median = 53.5 ng/mL) and amniotic fluid (median = 531.0 ng/mL). The low permeability of TFV in MCF-10A cells may explain the minimal exposure to TFV in breast milk. Body weights, body lengths, and head circumferences of the breastfed infants were comparable to the national standards for physical development.

CONCLUSION

Infant exposure to TFV from breast milk is much lower than the exposure from placental transfer and swallowing from amniotic fluid. The physical growth parameters of all infants in this study were normal. The findings indicate that breastfeeding is safe for infants of HBV-infected mothers who continue to receive TDF through three months postpartum.

Predictive Values of Programmed Death-1, CC Chemokine Ligand 20, and Treg/T Helper 17 Cytokines for Patients with Hepatitis B Virus-Related Acute-on-Chronic Liver Failure

Background: This study aimed to explore the correlations of programmed death-1 (PD-1) and CC chemokine ligand 20 (CCL20) with Treg/T helper 17 (Th17) balance in patients with HBV-ACLF. Methods: In this cross-sectional study, 50 patients with HBV-ACLF and 50 cases with chronic hepatitis B (CHB) diagnosed from February 2021 to February 2022 were selected, and another 50 healthy volunteers who received physical examinations in the same period were selected as a control group. The expression levels of PD-1, CCL20, and Treg/Th17 cytokines were detected by Western blotting, immunoturbidimetry, and enzyme-linked immunosorbent assay (ELISA), respectively. The correlations of PD-1 and CCL20 with Treg/Th17 cytokines were explored by Pearson analysis. The predictive values of PD-1, CCL20, and Treg/Th17 cytokines for the prognosis of HBV-ACLF patients were analyzed. Results: The expression levels of PD-1 and CCL20 were higher in the HBV-ACLF group than in the CHB and control groups (P < 0.05). Severe HBV-ACLF patients had higher levels of PD-1 and CCL20 compared with mild and moderate HBV-ACLF patients (P < 0.05). Hepatitis B virus-related acute-on-chronic liver failure patients with poor prognosis had higher levels of PD-1 and CCL20 than those with good prognosis (P < 0.05). The levels of transforming growth factor β (TGF-β), interleukin 10 (IL-10), IL-23, and tumor necrosis factor α (TNF-α) were higher in the HBV-ACLF group than in the CHB and control groups (P < 0.05). The levels of PD-1 and CCL20 in the HBV-ACLF group were positively correlated with those of Treg/Th17 cytokines (TGF-β, IL-10, IL-23, and TNF-α; P < 0.05). The combined detection of PD-1, CCL20, and Treg/Th17 cytokines had higher sensitivity and lower specificity than single detection in predicting the prognosis of HBV-ACLF patients (P < 0.05). Conclusions: The expression levels of PD-1 and CCL20 are higher in HBV-ACLF patients, being correlated with Treg/Th17 balance. The combined detection of PD-1, CCL20, and Treg/Th17 cytokines has a higher value for predicting the prognosis of HBV-ACLF patients.

Rapid Diagnostic Test for Hepatitis B Virus Viral Load Based on Recombinase Polymerase Amplification Combined with a Lateral Flow Read-Out

Hepatitis B (HBV) infection is a major public health concern. Perinatal transmission of HBV from mother to child represents the main mode of transmission. Despite the existence of effective immunoprophylaxis, the preventive strategy is inefficient in neonates born to mothers with HBV viral loads above 2 × 105 IU/mL. To prevent mother-to-child transmission, it is important to identify highly viremic pregnant women and initiate antiviral therapy to decrease their viral load. We developed a simple innovative molecular approach avoiding the use of automatic devices to screen highly viremic pregnant women. This method includes rapid DNA extraction coupled with an isothermal recombinase polymerase amplification (RPA) combined with direct visual detection on a lateral flow assay (LFA). We applied our RPA-LFA approach to HBV DNA-positive plasma samples with various loads and genotypes. We designed a triage test by adapting the analytical sensitivity to the recommended therapeutic decision threshold of 2 × 105 IU/mL. The sensitivity and specificity were 98.6% (95% CI: 92.7−99.9%) and 88.2% (95% CI: 73.4−95.3%), respectively. This assay performed excellently, with an area under the ROC curve value of 0.99 (95% CI: 0.99−1.00, p < 0.001). This simple method will open new perspectives in the development of point-of-care testing to prevent HBV perinatal transmission.