PMTCT

Preventing Hepatitis B Transmission from Infected Mothers to Newborns

Introduction

Hepatitis B is a major global health problem. Worldwide, approximately 254 million people are living with chronic hepatitis B. About 1.1 million people die each year from complications related to hepatitis B, with liver cirrhosis and liver cancer being major causes of death. Around 60% of liver cancer worldwide is related to hepatitis B. Liver cancer is the third reason for most cancer-related deaths worldwide.

Hepatitis B infection often occurs during childhood in countries where the virus is common. Transmission from an infected mother to her newborn is one of the most important routes of hepatitis B transmission. Preventing mother-to-child transmission is therefore a major part of hepatitis B prevention worldwide.

Newborn infection can be prevented by giving the baby the hepatitis B vaccine at birth and, when indicated, hepatitis B immune globulin (HBIG).

However, vaccination of newborns alone is not enough to eliminate all mother-to-child transmission by 2030. Pregnant women with hepatitis B who have high levels of the virus may also need antiviral treatment during pregnancy to further reduce the risk of transmission.

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Hepatitis B During Pregnancy

The prevalence of hepatitis B during pregnancy varies according to how common the virus is in the general population of each country. It may also vary between different population groups within the same country. The risk of transmission from mother to child depends partly on the mother's level of viral activity (HBeAg). If the mother is HBeAg-positive, the risk of transmission to the newborn can be approximately 70%–90% without appropriate preventive measures. Even when the mother is HBeAg-negative, transmission can still occur and the risk of transmission remains at 10–20%.

Newborns who become infected with hepatitis B at birth or during the first six months of life have a very high risk of developing chronic hepatitis B. Around 85–90% of these newborns may develop chronic hepatitis.

Chronic infection can remain for many years and may eventually lead to:

  • Liver cirrhosis
  • Liver cancer
  • Liver failure

An infected mother can also transmit the virus to future children.

Mother-to-Child Transmission of Hepatitis B

Hepatitis B can potentially be transmitted from mother to child:

  • Before birth
  • During childbirth
  • After birth

Transmission before birth through the placenta is possible but is less common than transmission around the time of delivery. Hepatitis B is generally not transmitted through breast milk. However, if the mother's nipples are cracked, bleeding, or infected, blood exposure could potentially create a risk. Such situations should be discussed with a healthcare professional.

Preventing Mother-to-Child Transmission of Hepatitis B

To prevent transmission of hepatitis B between mother to child, every pregnant woman should be tested for hepatitis B and soon after birth the child should be vaccinated or given immune globulin. This is the main way in which transmission can be prevented. According to World Health Organization guidelines, neonatal immunization is essential in countries where the prevalence of Hepatitis B exceeds 2%. Infants born to mothers infected with Hepatitis B must receive the first dose of the vaccine within 24 hours of birth, followed by two or three additional doses. If the mother HBeAg tests return positive, Hepatitis B immunoglobulin (HBIG) must be administered alongside the first vaccine dose within 24 hours of birth. This approach can prevent Hepatitis B infection in 85% to 90% of newborns. According to new data from the World Health Organization, if a pregnant woman with Hepatitis B has a viral load (DNA level) exceeding 20,000 IU/ml, she should be treated with Tenofovir from the 28th week of pregnancy until delivery to control the virus; additionally, the infant must receive the Hepatitis B vaccine and immunoglobulin according to standard protocols.

Mother-to-Child Transmission of Hepatitis B: The Bangladesh Perspective

Bangladesh has a population of more than 170 million people. It's the tenth most densely populated country in the world and 49.42% of its population is women and the birth rate is at around 2.06. About 40% of the total population of Bangladesh is comprised of children and around 62% of the people of Bangladesh live in rural areas, and hepatitis B remains an important public health concern. Approximately 4% of the population is estimated to have hepatitis B, placing Bangladesh in an intermediate-prevalence category. A significant number of pregnant women in Bangladesh are therefore living with hepatitis B. In Bangladesh, the Hepatitis B vaccine has been administered alongside the DPT vaccine at six weeks of age under the EPI schedule since the 2003–2005 period. The World Health Organization recommends that newborns receive a hepatitis B birth dose as soon as possible after birth, preferably within 24 hours. Countries that have achieved major success in controlling hepatitis B have incorporated the birth dose into their national hepatitis B prevention strategies.

Barriers to Hepatitis B Birth-Dose Vaccination in Bangladesh

Several challenges make universal birth-dose vaccination difficult:

  • More than half of Bangladesh's population lives in rural areas, where many births occur at home or in rural health facilities.
  • Rural health facilities may have limited supplies of hepatitis B vaccine and HBIG. Access to hepatitis B testing is also limited in some areas.
  • A substantial proportion (48.2%) of births occurs at home and may be assisted by traditional birth attendants.
  • Traditional birth attendants may have limited formal education and limited access to training in infection prevention and safe childbirth practices.
  • Many pregnant women have limited awareness of viral hepatitis and how it can be prevented.
  • Providing the hepatitis B vaccine immediately after birth may be possible in some hospitals and clinics but is much more difficult during home deliveries.
  • Vaccine availability and maintaining the required cold chain can be challenging in remote areas.
  • Vaccine hesitancy and misinformation can create additional barriers.
  • The cost and availability of vaccines and HBIG may limit access.
  • Reliable national data on hepatitis B among pregnant women are limited.
  • The absence of comprehensive national policies and guidelines for preventing mother-to-child transmission has also been a major challenge.

How Can These Barriers Be Overcome?

1. Every pregnant woman should be offered hepatitis B testing. Women who test positive should receive appropriate further evaluation, including HBV DNA and HBeAg testing when indicated, and antiviral treatment when recommended.

2. Public awareness programs should focus on women through:

  • Educational institutions
  • Workplaces
  • Women's organizations
  • Community programs
  • Public media

3. Obstetricians and gynecologists can play an important role in:

  • Screening pregnant women
  • Educating mothers about hepatitis B
  • Explaining ways to prevent transmission
  • Guiding appropriate use of hepatitis B vaccine and HBIG

4. Maternity hospitals and clinics should have reliable cold-chain systems. Hepatitis B vaccine and HBIG should be stored and transported according to recommended temperature requirements, generally +2°C to +8°C for hepatitis B vaccine.

5. Hepatitis B vaccine and HBIG should be available where deliveries take place, particularly in rural and underserved areas. Reliable data on hepatitis B among pregnant women are also needed for effective planning.

6. The government should develop and implement national policies for preventing mother-to-child transmission of hepatitis B. A birth dose of hepatitis B vaccine should be incorporated effectively into the national immunization strategy.

Conclusion

  • Preventing hepatitis B transmission from pregnant mothers to their newborns is one of the most important strategies for controlling hepatitis B.
  • Countries with a high prevalence of hepatitis B have achieved major progress by implementing effective birth-dose vaccination programs.
  • Several countries in Southeast Asia (SEAR) have incorporated hepatitis B birth-dose vaccination into their national viral hepatitis control strategies, while others are working toward doing so.
  • Bangladesh still faces challenges in implementing universal birth-dose vaccination.
  • The National Liver Foundation of Bangladesh has recommended that the Government of the People's Republic of Bangladesh include the hepatitis B birth dose in the national vaccination schedule.
  • The World Hepatitis Alliance's (WHA) president has also emphasized the importance of preventing mother-to-child transmission of hepatitis B and called on countries around the world to take action during his World Hepatitis Day speech in 2020.
  • The World Health Organization (WHO) has highlighted prevention of mother-to-child transmission as an important part of global hepatitis B elimination efforts. Effective prevention of mother-to-child transmission, combined with vaccination, testing, appropriate antiviral treatment, and long-term monitoring, can play a major role in achieving the goal of eliminating viral hepatitis as a public health threat by 2030.