Hepatitis B immunoglobulin during pregnancy for prevention of mother‐to‐child transmission of hepatitis B virus New
Hepatitis is a viral infection of the liver. It is mainly transmitted between people through contact with infected blood, frequently from mother to baby in‐utero. Hepatitis B poses significant risk to the fetus and up to 85% of infants infected by their mothers at birth develop chronic hepatitis B virus (HBV) infection. Hepatitis B immunoglobulin (HBIG) is a purified solution of human immunoglobulin that could be administered to the mother, newborn, or both. HBIG offers protection against HBV infection when administered to pregnant women who test positive for hepatitis B envelope antigen (HBeAg) or hepatitis B surface antigen (HBsAg), or both. When HBIG is administered to pregnant women, the antibodies passively diffuse across the placenta to the child. This materno‐fetal diffusion is maximal during the third trimester of pregnancy. Up to 1% to 9% infants born to HBV‐carrying mothers still have HBV infection despite the newborn receiving HBIG plus active HBV vaccine in the immediate neonatal period. This suggests that additional intervention such as HBIG administration to the mother during the antenatal period could be beneficial to reduce the transmission rate in utero.Objectives
To determine the benefits and harms of hepatitis B immunoglobulin (HBIG) administration to pregnant women during their third trimester of pregnancy for the prevention of mother‐to‐child transmission of hepatitis B virus infection.Search methods
We searched the The Cochrane Hepato‐Biliary Group Controlled Trials Register, CENTRAL, MEDLINE Ovid, Embase Ovid, Science Citation Index Expanded (Web of Science), SCOPUS, African Journals OnLine, and INDEX MEDICUS up to June 2016. We searched ClinicalTrials.gov and portal of the WHO International Clinical Trials Registry Platform (ICTRP) in December 2016.Selection criteria
We included randomised clinical trials comparing HBIG versus placebo or no intervention in pregnant women with HBV.Data collection and analysis
Two authors extracted data independently. We analysed dichotomous outcome data using risk ratio (RR) and continuous outcome data using mean difference (MD) with 95% confidence intervals (CI). For meta‐analyses, we used a fixed‐effect model and a random‐effects model, along with an assessment of heterogeneity. If there were statistically significant discrepancies in the results, we reported the more conservative point estimate. If the two estimates were equal, we used the estimate with the widest CI as our main result. We assessed bias control using the Cochrane Hepato‐Biliary Group suggested bias risk domains and risk of random errors using Trial Sequential Analysis (TSA). We assessed the quality of the evidence using GRADE.Main results
All 36 included trials originated from China and were at overall high risk of bias. The trials included 6044 pregnant women who were HBsAg, HBeAg, or hepatitis B virus DNA (HBV‐DNA) positive. Only seven trials reported inclusion of HBeAg‐positive mothers. All 36 trials compared HBIG versus no intervention. None of the trials used placebo.
Most of the trials assessed HBIG 100 IU (two trials) and HBIG 200 IU (31 trials). The timing of administration of HBIG varied; 30 trials administered three doses of HBIG 200 IU at 28, 32, and 36 weeks of pregnancy. None of the trials reported all‐cause mortality or other serious adverse events in the mothers or babies. Serological signs of hepatitis B infection of the newborns were reported as HBsAg, HBeAg, and HBV‐DNA positive results at end of follow‐up. Twenty‐nine trials reported HBsAg status in newborns (median 1.2 months of follow‐up after birth; range 0 to 12 months); seven trials reported HBeAg status (median 1.1 months of follow‐up after birth; range 0 to 12 months); and 16 trials reported HBV‐DNA status (median 1.2 months of follow‐up; range 0 to 12 months). HBIG reduced mother‐to‐child transmission (MTCT) of HBsAg when compared with no intervention (179/2769 (6%) with HBIG versus 537/2541 (21%) with no intervention; RR 0.30, TSA‐adjusted CI 0.20 to 0.52; I2 = 36%; 29 trials; 5310 participants; very low quality evidence). HBV‐DNA reduced MTCT of HBsAg (104/1112 (9%) with HBV‐DNA versus 382/1018 (38%) with no intervention; RR 0.25, TSA‐adjusted CI 0.22 to 0.27; I2 = 84%; 16 trials; 2130 participants; low quality evidence). TSA supported both results. Meta‐analysis showed that maternal HBIG did not decrease HBeAg in newborns compared with no intervention (184/889 (21%) with HBIG versus 232/875 (27%) with no intervention; RR 0.68, TSA‐adjusted CI 0.04 to 6.37; I2 = 90%; 7 trials; 1764 participants; very low quality evidence). TSA could neither support nor refute this observation as data were too sparse. None of the trials reported adverse events of the immunoglobulins on the newborns, presence of local and systemic adverse events on the mothers, or cost‐effectiveness of treatment.Authors' conclusions
Due to very low to low quality evidence found in this review, we are uncertain of the effect of benefit of antenatal HBIG administration to the HBV‐infected mothers on newborn outcomes, such as HBsAg, HBV‐DNA, and HBeAg compared with no intervention. The results of the effects of HBIG on HBsAg and HBeAg are surrogate outcomes (raising risk of indirectness), and we need to be critical while interpreting the findings. We found no data on newborn mortality or maternal mortality or both, or other serious adverse events. Well‐designed randomised clinical trials are needed to determine the benefits and harms of HBIG versus placebo in prevention of MTCT of HBV.
Ahizechukwu C Eke, George U Eleje, Uzoamaka A Eke, Yun Xia, Jiao Liu
Plain language summary
Hepatitis B immunoglobulin (HBIG) during pregnancy for the prevention of mother‐to‐child transmission of hepatitis B virus (HBV)
Review question We aimed to review the evidence for benefits and harms of HBIG injection to pregnant women during their last three months of pregnancy versus no treatment for the prevention of mother‐to‐child transmission of HBV infection.
Background Hepatitis is a virus that infects the liver. When an infection goes on for a long time, it is said to be 'chronic'. It can cause damage to the liver and may cause liver failure and cancer.
Hepatitis B is mainly passed between people through contact with infected blood, but frequently from mother to baby in the womb. Hepatitis B is widespread in Africa and Asia, and when acquired during pregnancy, the infection poses serious risks to the unborn baby. Usually there are no symptoms in the early stages of infection. However, up to 85% of infants infected by their mothers at birth develop chronic HBV infection.
HBIG is a substance made from human blood that is used to prevent the child from getting HBV infection from the mother. When HBIG is given to pregnant women who have HBV, the high levels of antibodies (proteins produced by the immune system) to the virus pass easily across the placenta to the child to protect against HBV infection. This works best during the last third of pregnancy.
We searched for evidence on 22 December 2016.
Study funding sources
Four clinical trials were sponsored by a pharmaceutical company, or a group with a financial (or other) interest in the study results.
After searching the medical literature for relevant trials, we identified 36 clinical trials that recruited 6044 pregnant women with signs of HBV infection. All trials originated from China. All trials and trial results were at high risks of bias, which makes potential overestimation of benefits and underestimation of harms more likely.
The studies assessed only hepatitis B surface antigen (HBsAg) (proteins on the surface of the HBV that cause immune system of the body to make antibodies when exposed to HBV), hepatitis B virus DNA (HBV‐DNA) (self‐dividing material of the HBV which carries its genetic information), and hepatitis B envelope antigen (HBeAg) (blood proteins that shows that the virus is still active in the liver) status in newborns. There was no information about the effects of HBIG on death from all causes (newborn or mother), antibodies to hepatitis B core antigen (proteins made by the immune system which bind to HBV and cause them to be destroyed), cost‐effectiveness of HBIG, and side effects.
Antenatal (before birth) HBIG might have an effect on preventing mother‐to‐child transmission of HBV as more treated babies than non‐treated babies had no HBsAg or HBV‐DNA; however, both results could have been affected by the way the trials were conducted and were at high risk of bias. The authors could draw no conclusions about the side effects of HBIG for pregnant women with HBV infection. Well‐designed clinical trials with low risks of bias are needed to establish the benefits and harms of HBIG compared with no treatment in pregnant women with HBV.
Quality of the evidence
Due to the very low to low quality evidence in this review, we do not know if antenatal HBIG administration has an effect on the proportion of newborns with HBsAg and HBV‐DNA compared with no treatment. We could draw no conclusions about death of newborns or mothers as we found no data.
Ahizechukwu C Eke, George U Eleje, Uzoamaka A Eke, Yun Xia, Jiao Liu
Implications for practice
Due to the very low to low quality evidence found in this review, we are uncertain of the effect of benefit of repeated antenatal hepatitis B immunoglobulin (HBIG) administration to the hepatitis B virus (HBV)‐infected mothers on newborn outcomes, such as hepatitis B surface antigen (HBsAg), hepatitis B virus DNA (HBV‐DNA), and hepatitis B envelope antigen (HBeAg) compared with no intervention. The median follow‐up of the infants after birth was too short, just above one month. No conclusions could be drawn about maternal or newborn mortality or both, or other serious adverse events as there were no data for these outcomes. The results of the effects of HBIG on HBsAg and HBeAg were surrogate outcomes (raising risk of indirectness), and we need to be critical while interpreting the findings. Additionally, the results could be influenced by systematic errors because all the included trials were at high risk of bias, and outcomes were associated with sparse data and significant heterogeneity.
Implications for research
Future high‐quality placebo‐controlled randomised clinical trials with sufficient follow‐up of the infants to six months or one year and with low risk of selective reporting bias are needed. Such trials need to consider different doses and timings of HBIG to be used in pregnancy. Further trials may also be needed to determine the effective serum concentration of HBIG including the effects of HBIG versus placebo on all‐cause mortality and other serious adverse events of the newborn and mothers, and presence of local and systemic non‐serious adverse events of the mothers and neonates (with and without antiviral therapy) for the prevention of mother‐to‐child transmission of hepatitis B virus. Such trials ought to be designed according to the SPIRIT guidelines (www.spirit‐statement.org/) and reported according to the CONSORT guidelines (www.consort‐statement.org).Get full text at The Cochrane Library
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