Efficacy and safety of tenofovir disoproxil fumarate or telbivudine used throughout pregnancy for the prevention of mother-to-child transmission of hepatitis B virus: A cohort study

OBJECTIVE

Tenofovir disoproxil fumarate (TDF) use compared with telbivudine (LdT) use throughout pregnancy has not been adequately investigated. To compare the efficacy and safety of TDF and LdT for the prevention of mother-to-child transmission (MTCT) of hepatitis B from highly viremic mothers throughout pregnancy in real-world settings.

STUDY DESIGN

This was a single-center, retrospective cohort study. From January 1, 2013, to December 31, 2018, we retrospectively enrolled 602 mothers with chronic hepatitis B (CHB) who received antiviral treatment throughout pregnancy at Beijing Ditan Hospital. A total of 562 mothers met the inclusion criteria, with 167 in the TDF group and 395 in the LdT group. Mothers and infants were followed for 28 weeks postpartum. The primary endpoint was the MTCT rate of HBV. The secondary endpoints were the safety profiles in mothers and infants.

RESULTS

The MTCT rates were 0 % in both the TDF and LdT groups. The rates of neonatal congenital abnormalities were similar between the TDF and LdT groups (1.2 % vs 1.8 %, P = 0.896). There were no significant differences in perinatal complications between the two groups (all P > 0.05). There were also no significant differences in gestational age or infant height, weight, Apgar score. The level of HBV DNA at 28 weeks postpartum was an independent risk factor for postpartum alanine aminotransferase (ALT) flares (OR = 2.348, 95 % CI: 1.100-5.016, P = 0.027).

CONCLUSION

TDF and LdT treatments throughout pregnancy in mothers with CHB were equally effective in preventing MTCT and safe.

One Year of COVID-19 in Pregnancy: A National Wide Collaborative Study

INTRODUCTION

Even though the risk of COVID-19 in pregnancy may be increased, large-scale studies are needed to better understand the impact of the infection in this population. The aim of this study is to describe obstetric complications and the rate of vertical transmission in pregnant women with SARS-CoV-2 infection.

MATERIAL AND METHODS

Detected cases of SARS-CoV-2 infection in pregnancy were registered in Portuguese hospitals by obstetricians. Epidemiological, pregnancy and childbirth data were collected.

RESULTS

There were 630 positive cases in 23 Portuguese maternity hospitals, most at term (87.9%) and asymptomatic (62.9%). The most frequent maternal comorbidity was obesity. The rates of preterm birth and small-to-gestational-age were 12.1% and 9.9%, respectively. In the third trimester, 2.9% of pregnant women required respiratory support. There were eight cases (1.5%) of fetal death, including two cases of vertical transmission. There were five cases of postpartum respiratory degradation, but no maternal deaths were recorded. The caesarean section rate was higher in the first than in the second wave (68.5% vs 31.5%). RT-PCR SARS-CoV-2 positivity among newborns was 1.3%.

CONCLUSION

SARS-Cov-2 infection in pregnancy may carry increased risks for both pregnant women and the fetuses. Individualized surveillance and the prophylaxis of this population with vaccination. is recommended in these cases.

Monkeypox in Pregnancy: Susceptibility, Maternal and Fetal Outcomes, and One Health Concept

An overlooked endemic zoonosis in Africa, monkeypox infection, which has spread to multiple non-endemic countries since early May 2022, was declared a Public Health Emergency of International Concern by the World Health Organization on July 23, 2022. As of August 8, 2022, over 28,000 confirmed and probable monkeypox cases were reported globally, including 6 deaths from the African continent and 4 deaths from the non-endemic regions. Although the current outbreak mostly belongs to the West African clade, which has a lower-case fatality ratio of <1%, there is limited data among immune-weakened individuals infected with monkeypox. It is still unknown if pregnant people are more susceptible to monkeypox. In addition, it is unclear whether having monkeypox increases the risk of birth defects. This commentary addresses reported cases of monkeypox infection in pregnancy and the possible maternal and fetal outcomes, including congenital monkeypox, miscarriage, or stillbirth. Factors behind the escalating global monkeypox outbreak, as well as the prevention and control of monkeypox via the One Health approach, are discussed to shed light on curbing the continuous emergence of monkeypox.

Maternal and Neonatal Complications, Outcomes and Possibility of Vertical Transmission in Iranian Women with COVID-19

BACKGROUND

The emergence and fast spread of coronavirus disease 2019 (COVID-19) threatens the world as a new public health crisis. Little is known about its effects during pregnancy. This study aimed to investigate the clinical manifestations of COVID-19 on maternal and neonatal outcomes.

METHODS

In this systematic review, PubMed, Scopus, Web of Science, and Google Scholar databases were searched focusing on pregnancy and perinatal outcomes of COVID-19.

RESULTS

The initial search yielded 1236 articles, from which finally 21 unique studies, involving 151 pregnant women and 17 neonates, met the criteria. Mean ± SD age of included mothers and mean ± SD gestational age at admission were 30.6 ± 6.2 years and 30.8 ± 8.9 weeks, respectively. The common symptoms were fever, cough, fatigue, dyspnea and myalgia. The mortality rates of pregnant women and neonates were 28 out of 151 (18.5%) and 4 out of 17 (23.5%), respectively. Most of the neonates were preterm at the time of delivery. Three neonates had positive RT-PCR test on the first day after birth and three others on day two. On the average, neonate's PCR became positive on day 4 for the first time.

CONCLUSION

Early diagnosis of COVID-19 is crucial due to the possibility of the prenatal complications. Strict prevention strategies may reduce the risk of mother to infant transmission.

Prevention of mother-to-child transmission of hepatitis B virus in Burkina Faso: Screening, vaccination and evaluation of post-vaccination antibodies against hepatitis B surface antigen in newborns

The low rate of screening for hepatitis B virus (HBV) in pregnant women is a highrisk factor for its vertical transmission. The objectives of this study were: i) to screen pregnant women for HBV infection; ii) vaccinate all children from birth against HBV regardless their mother HBV status; and iii) evaluate after 7 months of birth the level of their AbHBs among babies who received HBV vaccine at birth. Serological markers of HBV (HBsAg, HBeAg, AbHBs, AbHBe, and AbHBc) were determined on venous blood samples from 237 pregnant women and their children using the Abon Biopharm Kit. One hundred and two (102) children received the three doses of the EUVAX B® vaccine respectively at birth, two months and four months of life. Seven months after delivery, venous blood samples were collected from mothers and their children. Antibodies against hepatitis B surface antigen (AbHBs) were measured in vaccinated children using the ELISA Kit AbHBs Quantitative EIA. DNA extraction was performed on samples from HBV-seropositive mothers and their children using the Ribo Virus (HBV Real-TM Qual) Kit and for Real Time PCR, the HBV Real-TM Qual Kit was used. Serological diagnosis in pregnant women revealed 22 (9.28%) hepatitis B surface antigen (HBsAg) positive samples of which 21 were positive for viral DNA by real-time PCR. Among the 22 HBsAg+ women, five (05) transmitted the virus to their children with a vertical transmission rate of 22.73%. A transmission rate of 23.81% (5/21) was found with the PCR method. Analysis of AbHBs levels revealed that 98.31% of the children had an average concentration of 218.07 ± 74.66 IU/L, which is well above the minimum threshold for protection (11 IU/L). This study has confirmed that vertical transmission of HBV is a reality in Burkina Faso and that vaccination at birth would significantly reduce this transmission.

Prevalence and Identification of Serum Markers Associated with Vertical Transmission of Hepatitis B in Pregnant Women in Yaounde, Cameroon

OBJECTIVE

To determine the prevalence of Hepatitis B Virus (HBV) infection in pregnant women and identify markers associated with vertical transmission of HBV.

METHODS

Prospective and cross-sectional study over 10 months on 298 pregnant women attending antenatal clinics in the Cité Verte and Efoulan District hospitals in Cameroon. A dry tube blood collection was performed on all pregnant women and babies born to HBsAg-positive mothers. Serum from the women was used to test for HBsAg through immunochromatography and then confirmed by ELISA. The test for HBeAg, HBeAb and HBcAb and dosage of transaminases were performed on the serum of HBsAg-positive women. Only HBsAg was tested in babies within 24 hours after birth.

RESULTS

HBsAg was present in 23 (7.7%) mothers while 275 (92.3%) tested negative. Due to loss to follow-up, we assessed vertical transmission in 20 babies born to20 mothers. In all, eight babies tested HBsAg-positive; six mothers tested positive with HBeAg; 10 mothers with HBeAb and two were simultaneously infected with HBV and HIV.

CONCLUSION AND GLOBAL HEALTH IMPLICATIONS

HBeAg and increase in liver transaminases were serum markers associated with the vertical transmission of HBV while HBeAb and anti-HIV therapy were protective markers. There is need to systematically screen all pregnant women for hepatitis B, follow up those that are positive, and administer a dose of gammaglobulin anti-HBs to their children to reduce the risks of chronic hepatitis and hepatocellular carcinoma (CHC) and curb mortality and morbidity due to viral hepatitis B.

Hepatitis B Management in the Pregnant Patient: An Update

Chronic hepatitis B is a worldwide disease, with significant burden on health care systems. While universal vaccination programs have led to an overall decrease in incidence of transmission of hepatitis B, unfortunately, there remain large areas in the world where vaccination against hepatitis B is not practiced. In addition, vertical transmission of hepatitis B persists as a major concern. Hepatitis B treatment of the pregnant patient requires a thorough assessment of disease activity and close monitoring for flares, regardless of initiation of antiviral therapy. We discuss, in this article, the current and emergent strategies which aim to reduce the rate of transmission of hepatitis B from the pregnant mother to the infant and we review the updated guidelines regarding management of liver disease in pregnant women with hepatitis B.

Maternal and neonatal risk factors associated with vertical transmission of ophthalmia neonatorum in neonates receiving health care in Blantyre, Malawi

Context:

Neonatal conjunctivitis is associated with poor prenatal care worldwide.

Purpose:

Data on neonatal conjunctivitis is scarce in Malawi. This study describes risk factors associated with conjunctivitis in neonates born in a large tertiary care hospital in Blantyre, Malawi.

Materials and Methods:

Medical records of a retrospective cohort of 231 neonates diagnosed with conjunctivitis from January 2006 to December 2009 at a large tertiary hospital in Malawi were reviewed. All subjects were clinically diagnosed with ophthalmia neonatorum. Data were collected on patient demographics and clinical features. The frequencies were calculated of various risk factors in neonates with ophthalmia neonatorum and their mothers as well as the treatments administered.

Results:

Mean age of the mother was 23.45 years (range, 15-40 years), and the mean number of previous deliveries was 2.3 (range, 1-7) children. Nearly, 80% of mothers delivered preterm infants via spontaneous vaginal delivery. The mean birth weight of neonates was 2869.6 grams (1100-5000 grams). Among mothers, premature rupture of membranes was the leading risk factor (24%) followed by sepsis during labor (9%), and history of sexually transmitted infections (STI) (7%). Neonates presented with low Apgar scores (19%), fever (8%), and/or meconium aspiration (5%). Providers treated patients empirically with a varied combination of benzyl penicillin, gentamicin, tetracycline eye ointment, and saline eye wash. Tetracycline with a saline eyewash was used frequently (34%) compared with combinations of benzyl penicillin and gentamicin.

Conclusions:

Improving prenatal care to reduce sepsis, traumatic deliveries, and early diagnosis of STI with appropriate treatment may potentially reduce vertical transmission of neonatal conjunctivitis in this understudied population.

Mother-to-child transmission of hepatitis C virus: evidence for preventable peripartum transmission

BACKGROUND

Little information is available about the timing of mother-to-child transmission of hepatitis C virus (HCV), and no interventions to decrease transmission rates have been identified. We examined the effect of risk factors, including mode of delivery, on the vertical transmission rate.

METHODS

Data from HCV-infected women and their infants from three hospitals in Ireland and from a British Paediatric Surveillance Unit study of infants born to HCV-infected mothers were used to estimate the vertical transmission rate and risk factors for transmission. We used a probabilistic model using methods that simultaneously estimated the time to HCV-antibody loss in uninfected infants and the diagnostic accuracy of PCR tests for HCV RNA.

FINDINGS

441 mother-child pairs from the UK (227) and Ireland (214) were included. 50% of uninfected children became HCV-antibody negative by 8 months and 95% by 13 months. The estimated specificity of PCR for HCV RNA was 97% (95% CI 96-99) and was unrelated to age; sensitivity was only 22% (7-46) in the first month but rose sharply to 97% (85-100) thereafter. The vertical transmission rate was 6.7% (4.1-10.2) overall, and 3.8 times higher in HIV coinfected (n=22) than in HIV-negative women after adjustment for other factors (p=0.06). No effect of breastfeeding on transmission was observed, although only 59 women breastfed. However, delivery by elective caesarean section before membrane rupture was associated with a lower transmission risk than vaginal or emergency caesarean-section delivery (odds ratio 0 [0-0.87], p=0.04, after adjustment for other factors).

INTERPRETATION

The low sensitivity of HCV RNA soon after birth and the finding of a lower transmission rate after delivery by elective caesarean section suggest that HCV transmission occurs predominantly around the time of delivery. If the findings on elective caesarean section are confirmed in other studies, the case for antenatal HCV testing should be reconsidered.

Factors affecting attitudes towards mother-to-child transmission of HIV among pregnant women in a maternal and child hospital in Thailand

This study determines the factors which correlate with attitudes towards mother-to-child transmission of HIV in pregnant women. Using a structured questionnaire, 527 pregnant women who visited a hospital to have prenatal checkups were interviewed. The survey items were: sociodemographic characteristics, experiences of pre-test counselling, knowledge of mother-to-child transmission, and attitude towards termination of pregnancy. Results showed that many pregnant women (80%) did not have proper knowledge of the possibility of mother-to-child transmission. Logistic regression analysis also indicates that age and knowledge of the possibility of mother-to-child transmission were the significant determinants of attitudes towards termination of pregnancy. Older women who believe that all the babies of pregnant women with HIV will be infected are most likely to terminate their pregnancy when they are diagnosed as HIV positive. Considering the importance of informed decisions regarding pregnancy, this study must have important implications for future support programmes for HIV-positive pregnant women.

Experiences of breastfeeding and vulnerability among a group of HIV-positive women in Durban, South Africa

While international guidelines are currently being drawn up about HIV and infant feeding practices, and national and regional guidelines are under discussion in South Africa, there have been remarkably few studies that have sought to elicit HIV-positive mothers' experiences of breastfeeding and of paediatric infection. There is an urgent need to document this 'grass roots' knowledge in different sites, and for this data to be used to inform policy development, and for advocacy and counselling purposes. This qualitative investigation reports on the experiences and decisions taken around breastfeeding by a peer support group of 13 HIV-positive mothers meeting at King Edward VIII Hospital, Durban. In this study, the particular focus of information-giving and decision-making as to breast or formula feed is concerned with the impact on individual HIV-positive women and their babies. The most significant finding is that at no stage during their pregnancy were any of these mothers given information about the risks of HIV transmission through breastmilk. The study data were elicited in an in-depth group discussion, and individual women were invited to re-enact their stories in a follow-up discussion for clarification purposes. The women also discussed how they dealt with problems surrounding confidentiality in cases where few have been able to disclose their status to the extended family. There have been renewed calls for further investment in counsellors, with an enhanced role for community activists as peer educators. While there are severe resource constraints and low morale among many overworked nurses, one of the general problems in hospital settings remains the vertical health paradigm. This does not accommodate women's experiences, preferences, social networks and lay knowledge, and inhibits many women from becoming full participants in decisions affecting their own and their family's health.

Intrapartum and neonatal single-dose nevirapine compared with zidovudine for prevention of mother-to-child transmission of HIV-1 in Kampala, Uganda: HIVNET 012 randomised trial

BACKGROUND

The AIDS Clinical Trials Group protocol 076 zidovudine prophylaxis regimen for HIV-1-infected pregnant women and their babies has been associated with a significant decrease in vertical HIV-1 transmission in non-breastfeeding women in developed countries. We compared the safety and efficacy of short-course nevirapine or zidovudine during labour and the first week of life.

METHODS

From November, 1997, to April, 1999, we enrolled 626 HIV-1-infected pregnant women at Mulago Hospital in Kampala, Uganda. We randomly assigned mothers nevirapine 200 mg orally at onset of labour and 2 mg/kg to babies within 72 h of birth, or zidovudine 600 mg orally to the mother at onset of labour and 300 mg every 3 h until delivery, and 4 mg/kg orally twice daily to babies for 7 days after birth. We tested babies for HIV-1 infection at birth, 6-8 weeks, and 14-16 weeks by HIV-1 RNA PCR. We assessed HIV-1 transmission and HIV-1-free survival with Kaplan-Meier analysis.

FINDINGS

Nearly all babies (98.8%) were breastfed, and 95.6% were still breastfeeding at age 14-16 weeks. The estimated risks of HIV-1 transmission in the zidovudine and nevirapine groups were: 10.4% and 8.2% at birth (p=0.354); 21.3% and 11.9% by age 6-8 weeks (p=0.0027); and 25.1% and 13.1% by age 14-16 weeks (p=0.0006). The efficacy of nevirapine compared with zidovudine was 47% (95% CI 20-64) up to age 14-16 weeks. The two regimens were well tolerated and adverse events were similar in the two groups.

INTERPRETATION

Nevirapine lowered the risk of HIV-1 transmission during the first 14-16 weeks of life by nearly 50% in a breastfeeding population. This simple and inexpensive regimen could decrease mother-to-child HIV-1 transmission in less-developed countries.

Number of pregnancies, outcome expectancies, and social norms among HIV-infected young women

In this descriptive study, researchers examined pregnancies, sexually transmitted diseases (STDs), and sexual behaviors among 67 HIV-infected young women, as well as the women's outcome expectancies and peer and partner norms regarding pregnancy. Many of the women (69%) had been pregnant; 42% had been pregnant at least once since learning their HIV status, with 71% choosing to carry to term, resulting in 25% (N = 5) of the babies infected. The women had positive outcome expectancies related to pregnancy, which were significantly correlated with peer and partner social norms. Lack of knowledge regarding infant transmission, high rates of STDs, and inconsistent condom use all indicate a need for improved intervention regarding pregnancy and decision-making. Suggestions for better methods of providing information to HIV+ young women are provided.

Mother-to-child transmission of HIV: implications of variation in maternal infectivity

OBJECTIVES

To examine the implications of variation in maternal infectivity on the timing of mother-to-child HIV transmission through breastfeeding.

DESIGN AND METHODS

A mathematical model of mother-to-child HIV transmission was developed that incorporates two main features: (i) the fetus/child potentially experiences a series of exposures (in utero, intrapartum, and via breastmilk) to HIV; and (ii) variation in maternal infectivity. The model was estimated from different sources of epidemiological data: a retrospective cohort study of children born to HIV-1-infected women in Sao Paulo State, Brazil, the International Registry of HIV-Exposed Twins, and the AIDS Clinical Trials Group 076 trial, which assessed the effectiveness of zidovudine in preventing mother-to-child HIV transmission.

RESULTS

Variation in maternal infectivity results in higher average risk of breastfeeding-related transmission in the early stages of breastfeeding than in the late stages, even in the absence of a direct relationship between transmission risk and the age of the child. However, the available data were unable to resolve the quantitative importance of this mechanism.

CONCLUSIONS

Our model has helped identify a previously unrecognized determinant of the timing of breastfeeding-related HIV transmission, which may have adverse implications for the effectiveness of certain interventions to reduce mother-to-child HIV transmission such as maternal antiretroviral therapy in breastfeeding populations and the early cessation of breastfeeding.

Number of pregnancies, outcome expectancies, and social norms among HIV-infected young women

In this descriptive study, researchers examined pregnancies, sexually transmitted diseases (STDs), and sexual behaviors among 67 HIV-infected young women, as well as the women's outcome expectancies and peer and partner norms regarding pregnancy. Many of the women (69%) had been pregnant; 42% had been pregnant at least once since learning their HIV status, with 71% choosing to carry to term, resulting in 25% (N = 5) of the babies infected. The women had positive outcome expectancies related to pregnancy, which were significantly correlated with peer and partner social norms. Lack of knowledge regarding infant transmission, high rates of STDs, and inconsistent condom use all indicate a need for improved intervention regarding pregnancy and decision-making. Suggestions for better methods of providing information to HIV+ young women are provided.

The early natural history of vertically transmitted HIV-1 infection in African children from Durban, South Africa

Forty-eight children with vertically transmitted HIV-1 infection and 93 uninfected infants were followed up at regular intervals from birth for a mean of 26 months. They were examined physically, growth and development were assessed and illnesses recorded. Seventy per cent of infected infants were symptomatic by 6 months. Relative risks in the infected infants were highest for lymphadenopathy (4.56; CI 2.7-7.7), failure to thrive (4.48; 2.57-7.81), and neurological abnormalities (3.32; 1.9-5.58). The most frequent findings were diarrhoea (78%), pneumonia (76%) and lymphadenopathy (70%). Thrush and pneumonia occurred early but declined over time, whereas diarrhoea and neurological abnormalities occurred later and increased in frequency. A diagnosis of AIDS was made in 44% of infected infants by 12 months of age. Mortality in infected infants was 35.4%, and 76% of deaths occurred within the 1st year. About two-thirds of HIV-infected infants survived into early childhood. In South African children with vertically acquired HIV-1 infection the onset of disease is early and deterioration to AIDS and death are rapid. Infected infants can be easily recognized clinically, the majority by 6 months of age.

V3 sequence diversity of HIV-1 subtype E in infected mothers and their infants

To elucidate genetic characteristics of HIV-1 subtype E involved in vertical transmission, V3 regions of HIV-1 subtype E isolated from 17 infected mothers (M1-M17) and their infants (I1-I17) at 1 month after birth were sequenced after cloned into pCRII vectors. At least three clones of each sample were collected. All mothers were asymptomatic and had been infected through a heterosexual route. Nine infants (I9-I17) showed mild symptomatic and immunosuppression within the first year of life. The interpatient nucleotide distance of mothers and infants in this group (0.065+/-0.008) were of greater diversity than those of a nonimmunosuppression group (0.039+/-0.006) by a significant amount (Fischer's exact test, p = .003). The substitution with asparagine (N) at threonine (T) at position 13 and aspartic acid (D) at position 29 of the V3 sequence were significantly associated with nonimmunosuppression in the first year of life (F-test, p = 0.003). Either a single or multiple viral variants could transmit from mothers to their infants.

Update on vertical HIV transmission

OBJECTIVE

To describe the factors that contribute to vertical transmission of human immunodeficiency virus (HIV) and review means of decreasing the risk of transmission.

STUDY DESIGN

Medline search of the international English-language literature pertaining to HIV in pregnancy from 1989 to the present. Special emphasis was placed on articles published in the last three years related to vertical transmission as well as to antepartum, intrapartum and postpartum management to reduce transmission.

RESULTS

High levels of maternal viral load and more advanced maternal disease are associated with a greater risk of vertical transmission of HIV. Antepartum and intrapartum maternal treatment with zidovudine and postpartum neonatal zidovudine treatment decreases the risk of transmission by two-thirds, at least in patients with earlier stages of the disease. Breast-feeding is a source of postpartum HIV transmission and may double the total transmission rate.

CONCLUSION

Zidovudine should be used in pregnancy to decrease the viral load and reduce transmission of HIV to the fetus. Other antiviral agents should be used during pregnancy if indicated, although current information is lacking about their effects on the fetus and any potential benefits in decreasing vertical transmission of HIV. Breast-feeding should be avoided.

Vertical transmission of HTLV-I/II: a review

The vertical transmission of the human T-cell lymphotropic virus type I (HTLV-I) occurs predominantly through breast-feeding. Since some bottle-fed children born to carrier mothers still remain seropositive with a frequency that varies from 3.3% to 12.8%, an alternative pathway of vertical transmission must be considered. The prevalence rate of vertical transmission observed in Japan varied from 15% to 25% in different surveys. In Brazil there is no evaluation of this form of transmission until now. However, it is known that in Salvador, Bahia, 0.7% to 0.88% of pregnant women of low socio-economic class are HTLV-I carriers. Furthermore the occurrence of many cases of adult T-cell leukemia/lymphoma and of four cases of infective dermatitis in Salvador, diseases directly linked to the vertical transmission of HTLV-I, indicates the importance of this route of infection among us. Through prenatal screening for HTLV-I and the refraining from breast-feeding a reduction of approximately 80% of vertical transmission has been observed in Japan. We suggest that in Brazil serologic screening for HTLV-I infection must be done for selected groups in the prenatal care: pregnant women from endemic areas, Japanese immigrants or Japanese descendents, intravenous drug users (IDU) or women whose partners are IDU, Human immunodeficiency virus carriers, pregnant women with promiscuous sexual behavior and pregnant women that have received blood transfusions in areas where blood donors screening is not performed. There are in the literature few reports demonstrating the vertical transmission of HTLV-II.

Mother-to-child transmission of HIV

The first children with HIV-1 infection were described in 1983. As of 1998, the global HIV epidemic is having a profound impact on the health and survival of children. Almost all HIV infections among young children are due to vertical transmission, and the intrapartum period appears to provide us with a crucial window of opportunity for prevention. Postnatal transmission through breastfeeding also contributes an estimated one third to one half of vertical transmission worldwide. Carefully conducted epidemiologic studies are elucidating the immunologic, virologic, and behavioral factors affecting the risk of HIV-1 transmission from mother to infant and the natural history of HIV disease in perinatally infected children. Transmission of HIV-1 is influenced by many factors, and a high maternal viral load is insufficient to fully explain vertical transmission of HIV-1. Pediatricians and other providers should counsel HIV-infected women about the means available to decrease the risk of HIV transmission to the infant. However, the majority of HIV-infected children are born in the developing world, and a crucial challenge is to identify safe and effective interventions that are feasible in those countries with the most significant HIV burden.

Seroprevalence and mother-to-infant transmission of hepatitis C in asymptomatic Egyptian women

OBJECTIVES

In this study, we sought to determine (1) the prevalence of hepatitis C virus (HCV) RNA, or its antibodies, in a healthy parturient Egyptian population and (2) the risk of mother-to-infant transmission in this population.

METHOD

The serum of 499 pregnant Egyptian women was tested for anti-HCV with ELISA-3 and for HCV RNA by polymerase chain reaction (PCR). Neonatal cord blood and infant blood were similarly tested for anti-HCV and HCV RNA.

RESULTS

Recombinant immunoblot assay (RIBA) detected anti-HCV in 65/499 (13%) women; of these, 20/65 (31%) were PCR-positive. The total number of babies born was 499. Of the original group, 97 mothers and infants (HCV-negative) were lost to follow up and were excluded. Sixty-five anti-HCV-positive infants were born vaginally to the 65 anti-HCV-positive mothers, of which twenty (31%) corresponding mothers and babies were also positive for HCV RNA. Of these twenty babies, three died of hepatocellular disease by six months of age; sixteen developed chronic liver disease; the remaining nine remained asymptomatic but were serologically and PCR-positive. The mother-to-infant transmission rate was significantly increased (5%; P < 0.0001). Of the seropositive children, 45/65 (69%; P < 0.0001) seroreverted by eighteen months of age.

CONCLUSION

There is a high prevalence of anti-HCV in healthy pregnant Egyptian women and vertical transmission is a major risk for chronic HCV carriers.

Maternal placental infection with Plasmodium falciparum and malaria morbidity during the first 2 years of life

In areas endemic for malaria, pregnant women frequently present with a placenta that has been parasitized by Plasmodium falciparum, an infection associated with a reduction in the birth weight of the offspring. However, the impact of placental infection on malaria-related morbidity during the infant's first years of life has not been investigated. Between 1993 and 1995, 197 children in southern Cameroon were followed weekly clinically and monthly parasitologically. The dates of first positive blood smear and the evolution of the parasite prevalence rates were compared between infants born to mothers presenting with (n = 42) and without (n = 155) P. falciparum infection of the placenta. Infants born to placenta-infected mothers were more likely to develop a malaria infection between 4 and 6 months of age; then the difference progressively disappeared. Similarly, parasite prevalence rates were higher in placenta-infected infants from 5 to 8 months of age. Thus, malarial infection of the placenta seems to result in a higher susceptibility of infants to the parasite. This was not related to maternally transmitted antibodies, as specific antibody levels were similar in both groups of infants. A better understanding of the involved mechanisms may have important implications for the development of malaria control strategies.

Early-onset neonatal sepsis in Pakistan: a case control study of risk factors in a birth cohort

We prospectively evaluated risk factors for early-onset neonatal (EON) sepsis in a case-control study among inborn patients at the Aga Khan University Medical Centre in Karachi between 1990-1993. A total of 38 cases with blood culture proven bacterial sepsis were identified within 72 hr of birth (prevalence 5.6 of 1000 live births) and matched with two consecutive gender matched births with no complications. The most common isolates were Staphylococcus aureus (18%), group B Streptococci (13%), and Klebsiella pneumoniae (13%). Univariate analysis of maternal risk factors revealed a significant association between maternal urinary tract infection (UTI) (odds ratio [OR]20, 95% confidence interval [CI]2.4-166.9), maternal pyrexia (P < 0.0001), vaginal discharge (P < 0.05), vaginal examinations during labor (P = 0.03), and EON sepsis. The infected newborns also had significantly lower apgar scores at birth (P < 0.0001) and a significantly greater number were intubated at birth (Fisher's exact test P = 0.04). Infected newborn infants were transferred out of the labor room earlier than noninfected controls and significantly fewer received exclusive breastfeeds (OR 0.33, 95% CI 0.1-0.8). Our data suggest the possibility that both vertical transmission from the mother as well as postnatal acquisition of infection from the environment may be of importance in the pathogenesis of EON sepsis in Karachi. Preventive measures should focus at recognition of high-risk infants, strict asepsis during labor, and early institution of exclusive breastfeeding.

Chlamydial and gonococcal cervicitis in HIV-seropositive and HIV-seronegative pregnant women in Bangkok: prevalence, risk factors, and relation to perinatal HIV transmission

OBJECTIVES

To determine the prevalence and risk factors associated with cervicitis caused by Chlamydia trachomatis and Neisseria gonorrhoeae in human immunodeficiency virus (HIV) type 1-seropositive and HIV-seronegative pregnant women in Bangkok, and the relation to perinatal HIV transmission.

METHODS

As part of a multicenter perinatal HIV transmission study in an antenatal population with 2% HIV seroprevalence, endocervical swabs obtained at mid-pregnancy from a consecutive sample of 222 HIV-seropositive and 219 HIV-seronegative pregnant women at two large hospitals in Bangkok were tested for the presence of C. trachomatis and N. gonorrhoeae by DNA hybridization probe (Gen-Probe). Clinical risk factors and DNA probe results were analyzed in relation to the women's and newborns' HIV infection status.

RESULTS

The prevalence of C. trachomatis was 16.2% in HIV-seropositive pregnant women and 9.1% in HIV-seronegative pregnant women (P = 0.03). The prevalence of N. gonorrhoeae was 2.7% in HIV-seropositive pregnant women and 1.4% in HIV-seronegative pregnant women (P = 0.5). The overall population prevalence estimate was 9.2% for C. trachomatis and 1.4% for N. gonorrhoeae. Women with gonococcal infection were more likely to be positive for C. trachomatis (RR(MH) = 5.2, P < 0.01). Young age (<21 years) and primigravid status were associated with C. trachomatis infection among HIV-seropositive women; history of multiple sex partners (>1) were associated with C. trachomatis infection among HIV-seronegative women. For HIV-seropositive women, primigravida status also was associated with C. trachomatis infection. The perinatal HIV transmission rates were similar for those with and without C. trachomatis (24.1% and 23.2%, P = 0.9) and among those with and without N. gonorrhoeae (20% and 23.5%, P = 1.0).

CONCLUSIONS

Among pregnant women in Bangkok, C. trachomatis infection was considerably more common than N. gonorrhoeae infection and was associated with HIV infection, young age and first pregnancy (HIV-seropositive women), and multiple partners (HIV-seronegative women). Our data do not suggest an association between perinatal HIV transmission and maternal C. trachomatis or N. gonorrhoeae infection identified and treated during pregnancy. The high prevalence of C. trachomatis found using a test not readily available in Thailand emphasizes the need for improved, inexpensive ways to screen for and diagnose these sexually transmitted infections in developing countries.

Effect of zidovudine treatment in late pregnancy on HIV-1 in utero transmission

In Thailand, the prevalence of paediatric HIV-1 infection has increased rapidly through vertical transmission. According to the ACTG 076 trial regimen, zidovudine treatment in HIV-infected pregnancy can reduce vertical transmission. However, this treatment is complex and costly. It is not applicable for developing countries. We conducted a study to evaluate the effect of zidovudine treatment in late pregnancy on HIV-1 in utero transmission. Fifty cases of asymptomatic HIV-1 infected-women were voluntarily enrolled to the study. Zidovudine 250 mg orally twice a day was given to these patients from gestational age 36 weeks until labour. The newborns were evaluated at birth by a neonatologist and peripheral blood was tested for HIV genome by PCR technique within 48 hours of birth. The study revealed that no HIV genome was detected from the peripheral blood of newborns. It is suggested that zidovudine treatment in late pregnancy could reduce HIV-1 in utero transmission.

Hepatitis B virus, human immunodeficiency virus type-1, and syphilis among women attending prenatal clinics in Belize, Central America

Women and their infants may benefit from therapeutic interventions when hepatitis B, human immunodeficiency virus (HIV), or syphilis are detected during the prenatal period. We initiated hepatitis B and HIV screening of women attending prenatal clinics in Belize. Risk factor assessment information for hepatitis B infection and demographic data were determined by interview. Of 543 evaluable women, 81 (14.9%) were seropositive for hepatitis B core antibody (anti-HBc); one woman had asymptomatic hepatitis B surface antigenemia. Antibodies to HIV-1 were detected in one woman. Reactive syphilis serologies were detected in 15 (2.8%) women. Anti-HBc seroprevalence varied by district (range 3.1-43.5%) and by ethnicity (range 0.0-40.9%). Significant identified risks for anti-HBc seropositivity from univariate analyses included being of the Garifuna ethnic group, residence or birth in the Stann Creek or Toledo districts, a reactive syphilis serology, a household size of eight or greater, and five or more lifetime sexual partners. Multivariate analyses identified ethnicity and a reactive rapid plasma reagin as the best predictors of anti-HBc seropositivity. Highly variable differences in anti-HBc prevalence by district may permit the targeting of limited public health resources for education, screening, and prevention programs.

Paediatric HIV infection

By the year 2000 there will be six million pregnant women and five to ten million children infected with HIV-1. Intervention strategies have been planned and in some instances already started. A timely and cost-effective strategy needs to take into account that most HIV-1 infected individuals reside in developing countries. Further studies are needed on immunological and virological factors affecting HIV-1 transmission from mother to child, on differential disease progression in affected children, and on transient infection.

HIV infections in obstetrics and gynaecology

Thirteen women were discovered to be positive for human immunodeficiency virus (HIV) infection during pregnancy at the Port Moresby General Hospital from 1988 to 1995; of these, eight were diagnosed in the first half of 1995. Risk testing for HIV status is unlikely to discover more than 20% of HIV-positive antenatal patients because risk factors target intravenous drug users and the sexual behaviour of men. Pregnancy does not seem to have a major impact on the progress of HIV disease, but could be detrimental particularly in the later stages of the disease. Especially in developing countries, where HIV-positive patients are more likely to be of poor nutritional status and burdened with a number of other infections, there is a higher risk of preterm labour, small-for-dates babies and chorioamnionitis in pregnancy. The risk of vertical transmission is increased when viral loads are high, the general maternal condition is poor and delivery is preterm. Rates in Papua New Guinea appear to be following the higher rates which have been reported from Africa. Gynaecological conditions found in association with HIV infection, including pelvic inflammatory disease, vulvovaginal candidiasis and cervical neoplasia, may be resistant to treatment and tend to recur. Contraception for HIV-positive women may be more important to them than prevention of viral transmission; Depo-Provera and tubal ligation have special benefits in this regard. HIV infection in association with psychiatric disturbance might be an indication for termination of pregnancy.