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Identification

The infection caused by Hepatitis B virus (HBV) is called Hepatitis B. The infection is acute, subsequently it may evolve towards healing or chronicling [1]Cernescu C. Virusologie medicală. Editura Medicală; 2008 [2]***. HBV – FAQs for Health Professionals | Division of Viral Hepatitis | CDC. Centers for Disease Control and Prevention. 2016 ..

  • Acute hepatitis B is characterized by the presence of viral replication markers and more or less noisy symptoms [3]./Cernescu C. Virusologie medicală. Editura Medicală; 2008 [4]Cholongitas E, Tziomalos K, Pipili C. Management of patients with hepatitis B in special populations. World J Gastroenterol. Baishideng Publishing ...continue.

The markers of the viral replication are: DNA/HBV and HBeAg [7]Pyrsopoulos NT, Reddy KR, Talavera F, Anand BS. Hepatitis B. Gastroenterology. mai 2017.. The risk of developing chronic hepatitis with HBV after acute hepatitis varies inversely in proportion to age: Chronic infection occurs in 90% of infants infected at birth; 20-50% of children infected from 1 to 5 years and 1-10% in infected adolescents and adults [8]. Cholongitas E, Tziomalos K, Pipili C. Management of patients with hepatitis B in special populations. World J Gastroenterol. Baishideng Publishing ...continue [9]*** WHO | Hepatitis B. World Health Organization; 2017./... An estimated rate of up to 25% of people with chronic hepatitis B will die prematurely due to cirrhosis or hepatic carcinoma (cancer) [10]..***. WHO | Hepatitis B. World Health Organization; 2017.. Worldwide, approximately 80% of hepatocellular cancer cases are caused by HBV [11] Heymann DL. Manual de management al bolilor transmisibile. CDC. 2012.

 

In adult

A small fraction of acute hepatitis B can be clinically recognized because only 30-50% of infected adults are symptomatic [12]*** WHO | Hepatitis B. World Health Organization; 2017.!. [13].. Pyrsopoulos NT, Reddy KR, Talavera F, Anand BS. Hepatitis B. Gastroenterology. mai 2017.. In those with clinical manifestations the onset is insidious with:

 

In pregnant women

  • Hepatitis B is often asymptomatic and is discovered as a result of routine tests, for any other purpose [17] Ayoub WS, Cohen E. Hepatitis B Management in the Pregnant Patient: An Update. J Clin Transl Hepatol. Xia & He Publishing Limited. 28 septembrie ...continue.
  • In infected pregnant women, the disease does not take more severe forms than in the general population [18] Ayoub WS, Cohen E. Hepatitis B Management in the Pregnant Patient: An Update. J Clin Transl Hepatol. Xia & He Publishing Limited. 28 septembrie ...continue [19] Stewart RD, Sheffield JS. Hepatitis B Vaccination in Pregnancy in the United States. Vaccines. Multidisciplinary Digital Publishing Institute. 8 mai ...continue.
  • Some authors state that in pregnant patients with chronic hepatitis B, the infection has no repercussions on the fetus, and the pregnancy would not affect the evolution of the infection [20] *Cholongitas E, Tziomalos K, Pipili C. Management of patients with hepatitis B in special populations. World J Gastroenterol. Baishideng Publishing ...continue..
  • If complications such as decompensated cirrhosis occur, fertility decreases as a result of hormonal disorders and there may be a number of complications:
  • Gestational hypertension,
  • Premature birth,
  • Fetal growth restriction,
  • In some cases the fetus may die [21] Ayoub WS, Cohen E. Hepatitis B Management in the Pregnant Patient: An Update. J Clin Transl Hepatol. Xia & He Publishing Limited. 28 septembrie ...continue [22] Gentile I, Borgia G. Vertical transmission of hepatitis B virus: challenges and solutions. Int J Womens Health. Dove Press. 2014;6:605-11...

 

In the newborn from mother infected with hepatitis B

 

Screening of pregnant women

The screening of the pregnant woman for the detection of Hepatitis B is very important. It must be done as early as possible, from the first visit to the gynecologist [27] Cholongitas E, Tziomalos K, Pipili C. Management of patients with hepatitis B in special populations. World J Gastroenterol. Baishideng Publishing ...continue [28] Yogeswaran K, Fung SK. Chronic hepatitis B in pregnancy: unique challenges and opportunities. Korean J Hepatol. Korean Association for the Study of ...continue.

Screening in the case of newborn

 

Nota Bene. In this document, the laboratory diagnosis was not treated in the hepatitis B virus infection (HBV), but there were several elements related to pregnancy and newborn. For the complete diagnosis of this infection, those interested will be addressed to infectious physicians, epidemiology doctors or other physicians with competences in this area.

 

The infectious agent

Hepatitis B virus belongs to the Hepadnaviridae family [38] Song JE, Kim DY. Diagnosis of hepatitis B. Ann Transl Med. AME Publications; septembrie 2016;4(18):338. .*.. It’s a double stranded DNA virus, tire [39] Pyrsopoulos NT, Reddy KR, Talavera F, Anand BS. Hepatitis B. Gastroenterology. mai 2017.!*.. The rate of chronic HBV infection in adults is about 5%, instead the newborn rate is much higher, around 90% [40] Gentile I, Borgia G. Vertical transmission of hepatitis B virus: challenges and solutions. Int J Womens Health. Dove Press. 2014;6:605-11.*.. [41] Fourati S, Pawlotsky J-M. Recent advances in understanding and diagnosing hepatitis B virus infection. F1000Research. 6 septembrie 2016;5:2243... HBV is currently classified in 8 main genotypes, from A to H [42] Pyrsopoulos NT, Reddy KR, Talavera F, Anand BS. Hepatitis B. Gastroenterology. mai 2017.;!|.. The severity of the infection is different for each genotype [43] Cernescu C. Virusologie medicală. Editura Medicală; 2008*).

 

Incidence and prevalence

Worldwide approximately 240 million individuals have chronic hepatitis B [44]***. WHO | Hepatitis B. World Health Organization; 2017! . The main complications of the infection are cirrhosis and hepatocellular carcinoma [45] Fourati S, Pawlotsky J-M. Recent advances in understanding and diagnosing hepatitis B virus infection. F1000Research. 6 septembrie 2016;5:2243.,... As a result of these complications, approximately 600,000 deaths are recorded annually [46] Fourati S, Pawlotsky J-M. Recent advances in understanding and diagnosing hepatitis B virus infection. F1000Research. 6 septembrie 2016;5:2243.,.\..

In countries with increased endemicity (the prevalence of HBsAg is over 8%), and most cases occur at the age of infants and toddlers [47] Heymann DL. Manual de management al bolilor transmisibile. CDC. 2012 *-*.

In 2014 in Romania were registered 247 cases of acute infection and 19 chronic infection. A decrease in the total number of cases compared to previous years (2013-302 cases, 2012-361 cases) is observed [48] ***. Hepatitis B – Annual Epidemiological Report 2016. European Centre for Disease Prevention and Control. 2017. . In Europe in 2014, a total of 22,442 cases were reported, with an average incidence of 4.2 to 100,000 inhabitants, ranging from 0.1 in Romania to 17.3 in Sweden [49] *** Hepatitis B – Annual Epidemiological Report 2016. European Centre for Disease Prevention and Control. 2017./|. . The rate of chronic infections increased from 5.7 to 100,000 inhabitants in 2006 to 9.8 in 2014 [50] *** Hepatitis B – Annual Epidemiological Report 2016. European Centre for Disease Prevention and Control. 2017..!` . This data originated from official reporting data.

 

Source

The man is the only source [51] Pyrsopoulos NT, Reddy KR, Talavera F, Anand BS. Hepatitis B. Gastroenterology. mai 2017.{..

 

Method of transmission

HBV is highly contagious [52] Transmission/Exposure – Hepatitis B FAQs for the Public | Division of Viral Hepatitis | CDC. Centers Dis Control Prev. 2016... HBV can survive outside the body for 7 days while remaining infectious [53] ***. HBV – FAQs for Health Professionals | Division of Viral Hepatitis | CDC. Centers for Disease Control and Prevention. 2016.[ . [54].. Transmission/Exposure – Hepatitis B FAQs for the Public | Division of Viral Hepatitis | CDC. Centers Dis Control Prev. 2016.. HBV is very resistant to storage, to boiling, to disinfectants [55] ***Cernescu C. Virusologie medicală. Editura Medicală; 2008..

The infection is transmitted percutaneously or at the level of the mucous membranes by exposing them to infectious fluids of the body

Thus the main ways of transmitting HBV infection are:

Vertical transmission (perinatal)

Vertical transmission is the route of transmission from the mother to the fetus.

It can take place in three moments:

Vertical transmission is defined as the presence of viral HBsAg or DNA in the first 6-12 months of life, to a newborn from a mother infected with HBV [67] Gentile I et al. Vertical transmission of hepatitis B virus: challenges and solutions. Int J Womens Health. Dove Press. 2014;6:605-11... Important risk factors in the transmission of infection to the fetus are increased viral DNA serum levels, above 108 copies/ml, and positive Ag HBe to the mother [68] Gentile I et al. Vertical transmission of hepatitis B virus: challenges and solutions. Int J Womens Health. Dove Press. 2014;6:605-11.:/. [69]Yi P et al. Management of mother-to-child transmission of hepatitis B virus: Propositions and challenges. J Clin Virol. aprilie 2016;77:32-9. [70] Yogeswaran K, Fung SK. Chronic hepatitis B … and opportunities. Korean J Hepatol. Korean Association for the Study of the Liver; martie ...continue.

In pregnant women infected with HBV:

  • Transplacental transmission is responsible for one-fifth of the neonatal infection cases.
  • Transmission during childbirth occurs especially if infected mothers have HBsAg and HBeAg positive (70%) compared to those with positive HBsAg and negative HBeAg (10%).
  • Postnatal transmission can be achieved by breastfeeding, through milk or exposure to bleeding rags around the nipple [71] Yogeswaran K, Fung SK. Chronic hepatitis B in pregnancy: unique challenges and opportunities. Korean J Hepatol. Korean Association for the Study of ...continue [72] Transmission/Exposure – Hepatitis B FAQs for the Public | Division of Viral Hepatitis | CDC. Centers Dis Control Prev. 2016.[/] ..

If the immunoprophylaxis (vaccination) is not carried out, the transmission of the infection by a pregnant woman with positive  Ag HBs in the newborn occurs in 10-20% of cases [73] Stewart RD, Sheffield JS. Hepatitis B Vaccination in Pregnancy in the United States. Vaccines. Multidisciplinary Digital Publishing Institute. 8 mai ...continue.

The transmission rate increases significantly, up to 90%:

  • In the case of pregnant women with positive Ag HBs and positive Ag HBe;
  • If pregnant develops acute hepatitis in the 3rd trimester of pregnancy [74] Stewart RD, Sheffield JS. Hepatitis B Vaccination in Pregnancy in the United States. Vaccines. Multidisciplinary Digital Publishing Institute. 8 mai ...continue.

Risk groups

Persons who:

 

Incubation period

The incubation period varies between 45-180 days (average period 60-90 days) [79]Cernescu C. Virusologie medicală. Editura Medicală; 2008.~` [80]Heymann DL. Manual de management al bolilor transmisibile. CDC. 2012`!.

 

Infectiousness Period

All persons who are positive for HBsAg have infectious potential. Infectiousness in people with chronic hepatitis vary:

 

Prophylaxis

 

Vaccination

The best way to prevent hepatitis B is vaccination [82] Pyrsopoulos NT, Reddy KR, Talavera F, Anand BS. Hepatitis B. Gastroenterology. mai 2017.$. [83] Stewart RD, Sheffield JS. Hepatitis B Vaccination in Pregnancy in the United States. Vaccines. Multidisciplinary Digital Publishing Institute. 8 mai ...continue. In Romania vaccination against hepatitis B is part of the national vaccination scheme. The hepatitis B vaccine is given in 3 doses, the first in the first 24 hours after birth [84]^*Cernescu C. Virusologie medicală. Editura Medicală; 2008..

 

Vaccination of pregnant women

  • Pregnancy is not a contraindication for vaccination against hepatitis B [85] Stewart RD, Sheffield JS. Hepatitis B Vaccination in Pregnancy in the United States. Vaccines. Multidisciplinary Digital Publishing Institute. 8 mai ...continue.

Vaccination of the newborn

  • It is essential in preventing the transmission of infection from the mother.
  • Vaccination may be associated with the administration of immunoglobulins against hepatitis B (HBIg), in the case of children from mothers with positive serology for HBsAg and HBeAg.
  • The first dose of vaccine and HBIg should be carried out within the first 24 hours after birth.
  • The vaccination scheme should be supplemented by two more doses, 2 months and 6 months after birth [86] Yi P, Chen R, Huang Y, Zhou R-R, Fan X-G. Management of mother-to-child transmission of hepatitis B virus: Propositions and challenges. J Clin ...continue [87] Voiculescu M. How far we are towards eradication of HBV infection. J Gastrointest Liver Dis. 1 decembrie 2015;24(4):473-9./!..
  • The current infant vaccination scheme in Romania includes boosters at 2, 4 and 11 months after Primo-vaccination in the first 24 hours after birth.
  • There are several types of conditioning vaccine: Monovaccine, Bivaccin, Tetravaccin and pentavaccin, validated vaccines that are part of the national immunization schemes.
  • Immunity after vaccination may persist until 5-15 years after correctly done vaccination [88] Cholongitas E, Tziomalos K, Pipili C. Management of patients with hepatitis B in special populations. World J Gastroenterol. Baishideng Publishing ...continue [89] Stewart RD, Sheffield JS. Hepatitis B Vaccination in Pregnancy in the United States. Vaccines. Multidisciplinary Digital Publishing Institute. 8 mai ...continue..

In literature there are cases where the applied vaccine to the adult did not generate antibodies in protective titer or even did not generate detectable antibodies [90] Heymann DL. Manual de management al bolilor transmisibile. CDC. 2012\.\.

 

Administration of HBIG (Immunoglobulins against hepatitis B)

  • Children born from positive HBsAg mothers, in addition to the vaccine, must receive 0.5 ml intramuscularly HBIG within 12 hours of birth; the first dose of the vaccine is given at the same time as HBIG, but in different places, the second and third doses of the vaccine are given in Romania at 2, respectively 4 months of life.
  • It is recommended to test infants for HBsAg and anti HBs antibodies to 9-15 months of life for monitoring the effectiveness/inefficiency of prophylaxis.
  • Children with positive antiHBs antibodies and negative HBsAg are protected no longer require revaccination.
  • Children with negative antiHBs antibodies and positive HBsAg require revaccination [91] Stewart RD, Sheffield JS. Hepatitis B Vaccination in Pregnancy in the United States. Vaccines. Multidisciplinary Digital Publishing Institute. 8 mai ...continue [92] Gentile I, Borgia G. Vertical transmission of hepatitis B virus: challenges and solutions. Int J Womens Health. Dove Press. 2014;6:605-11. ;.;.. [93] .* ***. Perinatal Transmission | HBV | Division of Viral Hepatitis | CDC. Centers for Disease Control and Prevention. 2016.. [94] Yogeswaran K, Fung SK. Chronic hepatitis B in pregnancy: unique challenges and opportunities. Korean J Hepatol. Korean Association for the Study of ...continue.

 

Birth to HBV infected woman

  • Children born of positive HBsAg mothers, in addition to the vaccine, will receive 0.5 ml of HBIG, intramuscularly, within 12 hours of birth; the first dose of the vaccine is given at the same time as HBIG, but in different places, the second and third doses of the vaccine are given in Romania at 2, respectively 4 months of life with booster to 11 months of life.
  • It is recommended to test infants for HBsAg and anti-HBs antibodies at 9-15 months of life for monitoring the effectiveness/inefficiency of prophylaxis.
  • Children with positive anti-HBs antibodies and negative HBsAg are protected no longer require revaccination.
  • Children with negative antiHBs antibodies and positive HBsAg require revaccination [95] Stewart RD, Sheffield JS. Hepatitis B Vaccination in Pregnancy in the United States. Vaccines. Multidisciplinary Digital Publishing Institute. 8 mai ...continue [96] Gentile I, Borgia G. Vertical transmission of hepatitis B virus: challenges and solutions. Int J Womens Health. Dove Press. 2014;6:605-11.;.;.. [97] ***. Perinatal Transmission | HBV | Division of Viral Hepatitis | CDC. Centers for Disease Control and Prevention. 2016. .*.. [98] Yogeswaran K, Fung SK. Chronic hepatitis B in pregnancy: unique challenges and opportunities. Korean J Hepatol. Korean Association for the Study of ...continue.

 

Breast-feeding

Breastfeeding is not, in theory, a risk factor for transmitting infection, especially if there are no lesions in the nipple.

However, by analyzing the benefit/risk ratio, it is considered that it is better for patients with hepatitis B not to breastfeed [99] Gentile I, Borgia G. Vertical transmission of hepatitis B virus: challenges and solutions. Int J Womens Health. Dove Press. 2014;6:605-11. |` . [100]***. Perinatal Transmission | HBV | Division of Viral Hepatitis | CDC. Centers for Disease Control and Prevention. 2016.|.,. [101] Transmission/Exposure – Hepatitis B FAQs for the Public | Division of Viral Hepatitis | CDC. Centers Dis Control Prev. 2016..`|'..

 

Sexual Contact Infectant Entry 3

After sexual contact with a person with acute HBV infection, hepatitis B vaccine should be administered together with a HBIG dose of 5 ml within 14 days of infectant contact [102] Cholongitas E, Tziomalos K, Pipili C. Management of patients with hepatitis B in special populations. World J Gastroenterol. Baishideng Publishing ...continue [103] Song JE, Kim DY. Diagnosis of hepatitis B. Ann Transl Med. AME Publications; septembrie 2016;4(18):338. \;~. [104] Fourati S, Pawlotsky J-M. Recent advances in understanding and diagnosing hepatitis B virus infection. F1000Research. 6 septembrie 2016;5:2243. ./.. .

 

Bibliography

  1. Virology C. Medical. Medical publishing house; 2008.
  2. ***. HBV-FAQs for Health professionals | Division of Viral Hepatitis | Cdc. Centers for Disease Control and Prevention. 2016. Retrieved from: https://www.cdc.gov/hepatitis/hbv/hbvfaq.htm
  3. Cholongitas E, Tziomalos K, Josh C. Management of patients with hepatitis B in particular populations. World J Gastroenterol. Baishideng Publishing Group Inc; 14 February 2015; 21 (6): 1738-48. Retrieved from: http://www.ncbi.nlm.nih.gov/pubmed/25684938
  4. ***. WHO | Hepatitis B. World Health Organization; 2017. Retrieved from: http://www.who.int/mediacentre/factsheets/fs204/en/
  5. Pyrsopoulos NT, Reddy KR, Talavera F, Anand BS. Hepatitis B. Gastroenterology. May 2017. Retrieved from: http://emedicine.medscape.com/article/177632-overview
  6. Heymann DL. Management Manual of infectious diseases. CDC. 2012
  7. Song JE, Kim DY. Diagnosis of hepatitis B. Ann Transl Med. AME Publications; September 2016;4(18):338. Retrieved from: http://www.ncbi.nlm.nih.gov/pubmed/27761442
  8. Ayoub WS, Cohen E. Hepatitis B Management in the Pregnant Patient: An Update. J Clin Transl Hepatol. Xia & He Publishing Limited. 28 September 2016;4(3):241-7. Retrieved from: http://www.ncbi.nlm.nih.gov/pubmed/27777892
  9. Stewart RD, Sheffield JS. Hepatitis B Vaccination in Pregnancy in the United States. Vaccines. Multidisciplinary Digital Publishing Institute. 8 mai 2013;1(2):167-73. Retrieved from: http://www.ncbi.nlm.nih.gov/pubmed/26343965
  10. Gentile I, Borgia G. Vertical transmission of hepatitis B virus: challenges and solutions. Int J Womens Health. Dove Press. 2014;6:605-11. Retrieved from: http://www.ncbi.nlm.nih.gov/pubmed/24966696
  11. ***. Perinatal Transmission | HBV | Division of Viral Hepatitis | CDC. Centers for Disease Control and Prevention. 2016. Retrieved from: https://www.cdc.gov/hepatitis/hbv/perinatalxmtn.htm
  12. Yi P, Chen R, Huang Y, Zhou R-R, Fan X-G. Management of mother-to-child transmission of hepatitis B virus: Propositions and challenges. J Clin Virol. April 2016;77:32-9. Retrieved from: http://www.ncbi.nlm.nih.gov/pubmed/26895227
  13. Yogeswaran K, Fung SK. Chronic hepatitis B in pregnancy: unique challenges and opportunities. Korean J Hepatol. Korean Association for the Study of the Liver; March 2011;17(1):1-8. Retrieved from: http://www.ncbi.nlm.nih.gov/pubmed/21494071
  14. Liang S, Lo Y, Lin H, Al. E. Seroprevalence of viral hepatitis and infectious complications among human immunodeficiency virus-infected injection drug users at a referral hospital. J Microbiol Immunol Infect. 2008;41(3):200-8.
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  16. ***. Hepatitis B – Annual Epidemiological Report 2016. European Centre for Disease Prevention and Control. 2017. Retrieved from: https://ecdc.europa.eu/en/publications-data/hepatitis-b-annual-epidemiological-report-2016-2014-data
  17. Transmission/Exposure – Hepatitis B FAQs for the Public | Division of Viral Hepatitis | CDC. Centers Dis Control Prev. 2016. Retrieved from: https://www.cdc.gov/hepatitis/hbv/bfaq.htm#transmission
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About Corneliu Zaharia


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