Hepatitis B virus infection is a global problem, affecting mostly people living in developing countries. However, it has been estimated that 2 billion people globally have been exposed to the virus. Whilst 300 million persons have the chronic forms of the liver disease the virus causes, about half a million deaths per year from complications of HBV are recorded.
Mother to child transmission of hepatitis B virus has been found to fuel the endemicity of HBV in developing countries.
Interventions such as availability of an effective vaccine for HBV have led to significant declines in chronic complications of HBV, but the uptake of vaccination programmes has been relatively varied across countries.
Integration of interventions that target mother to child transmission of HBV needs to be simplified in order to enable those practicing in resources that are limited to ensure successful implementation of programmes that seek to eliminate hepatitis B in years to come.
Mother-to-child transmission of hepatitis B commonly occurs at birth.
The role of programmes targetting prevention of transmission of hepatitis B virus infection in the control and final elimination of hepatitis B by 2030 must include activities that ensure integrated plans to curb the transmission of HBV from mothers to their children.
In this blog, I have set out 17 practical, simple steps that will advise health facilities to successfully implement prevention of mother to child transmission of HBV.
Mother to child transmission of hepatitis B is one of the commonest modes of transmission of this deadly disease
The risk a mother has, to transmit hepatitis B virus to her baby is highest if the mother has any of the following: HBeAg +ve, HBV viral load above 200,000IU/mL, Child does not have a first dose HBV vaccine within 12hrs of birth, and Non availability of Hepatitis B immune globulin
To ensure the risk of transmission is reduced, test all mothers (in endemic regions) for HBsAg at their first antenatal visit (to book their pregnancy)
If mother is found to be positive to HBsAg, perform additional tests to determine the relative risk of transmission of HBV to her baby – includes HBV DNA, HBeAg and Liver Chemistry (ALT)
If HBeAg is positive, or abnormal ALT elevation and or HBV DNA is >200,000IU/mL, start antiviral treatment from week 28
If mother has a low HBV DNA (viral load) in their first 13 weeks of pregnancy, then repeat viral load at weeks 26 – 28 – and treat as suggested above
Mothers without evidence of hepatitis B infection or exposure (negative for anti-HBs and anti-HBc) should be vaccinated
Mothers that come to deliver and who did not have antenatal care and whose status have not been determined previously should be tested for HBsAg at the time of delivery (and baby managed as will be advised below)
Provide passive-active immunisation to the infant (baby at birth) – includes hepatitis B immune globulin (HBIG) and HBV vaccine
Tenofovir is considered the safest drug to use in pregnancy as it is considered the safest, relative to other agents, as well as the fact that HBV resistance to it is lowest
Women who start tenofovir during pregnancy for the purpose of preventing mother to child transmission may stop antiviral therapy immediately after delivery
Stopping antiviral therapy is particularly necessary if they want to breastfeed
Some liver specialists, together with the obstetricians may prefer continuing treatment for 4 to 12 weeks post-partum (after delivery)
ALT should be monitored 3-4 months (if baseline was abnormal) after cessation of treatment
If the pregnant mother was already deemed to have need for treatment as per adult recommendations, then treatment does not need to stop. It should be continued, and the patient put in the pool of follow up by their liver specialist
HBV transmission is not common when the mother breast feeds her baby (especially, if the baby received the birth dose vaccine and completed the series). But if there is suspected nipple injury, and risk of bleeding from the breast, then formula feed is recommended
If there is unavailability of HBIG, then going ahead with HBV vaccine for the baby is not optional