Early results from a randomised Chinese clinical trial have shown a possible way to make this happen. Using the medication known as maternal tenofovir disoproxil fumarate (TDF) in combination with infant vaccination against hepatitis B completely eliminated vertical transmission of the hepatitis B virus. This was the case even when the mothers had extremely high loads of hepatitis B virus in their blood.
Another exciting aspect to this trial is that there was no need to use hepatitis B immunoglobulin, something which is often used to give people a temporary immunity against hepatitis B in high-risk situations, or immediately after exposure as a form of prophylaxis. Supply of this immunoglobulin is often very limited, and so anything which reduces demand is extremely helpful.
The mothers themselves also showed dramatically lowered levels of hepatitis B in their blood at the time of birth, and there was no increase in the risk of congenital defects.
Dr Calvin Pan told an audience at The Liver Meeting, one of North America’s largest hepatology conferences, that the findings showed that use of this two-part treatment “could effectively prevent transmission, which is comparable to the current standard of care, with no safety signals.”
This sort of 100% success rate is extraordinarily rare in medical trials, and so further larger trials are now needed to confirm and extend these results.
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Hepatitis B isn’t common in young Australians because children born here are routinely immunised against it as part of the National Immunisation Program. The first of four free vaccination shots is usually given within a week of birth, with the others following at 2, 4 and 6 months of age (often in combination with other vaccinations). Babies who are born very prematurely or have a low birth weight get an additional free hepatitis B vaccine at 12 months.
If a pregnant woman has hepatitis B, she is usually given medicine to reduce the chance of passing the virus on to her baby. At birth, the baby might also get a extra injection of antibodies against hepatitis B, given within the first 12 hours, as well as the standard hepatitis B immunisation. Women who have hepatitis B can safely breastfeed unless their nipples are cracked or bleeding, as the virus can be transmitted in blood.
Hepatitis C is also rare in Australian children, due to to the fact that is is usually quite hard to transmit: it can only happen when blood containing the virus enters another person’s bloodstream. Household contact could lead to this happening, for example if a child uses a toothbrush belonging to an adult living with hepatitis C, or if they receive a needlestick injury after finding injecting equipment belonging to an adult. There is also a small risk of transmission if the mother breastfeeds with cracked or bleeding nipples.
What about the risks of transmitting viral hepatitis during pregnancy, birth or breastfeeding? In Australia, it is recommended that all pregnant women should be tested for hepatitis B and C. Testing in pregnancy allows arrangements to be made for vaccinating the newborn if the mother is found to have hepatitis B, or for precautions to be taken to prevent transmission of hepatitis C to the baby after birth. If a pregnant woman is found to have hepatitis C, plans can also be set up for her to start treatment once she is no longer breastfeeding. If hepatitis testing has not taken place for some reason, hepatitis C testing of pregnant women who are to have a planned invasive procedure — such as a Chorionic villus sampling (CVS) — has also been recommended, due to the small risk of blood-to-bloodstream hepatitis C transmission to the baby.
For hepatitis B, mother-to-child transmission can happen either in the uterus, through placental leakage, or through exposure to blood or blood-contaminated fluids at or around the time of birth. Perinatal transmission (transmission which takes place during or soon after the time of birth) is believed to account for between a third and a half of all hepatitis B infections.
If a pregnant woman is living with hepatitis C, it is actually extremely unlikely that she will pass on the virus to her child in utero: the risk is less than 5%. The greatest risk during birth is if a medical intervention is needed: for example, forceps can scratch a child’s skin, allowing blood-borne transmission. If the mother is known to have hepatitis C, then any interventions can be adjusted with this in mind to reduce risk as much as possible. Identifying women who have hepatitis C during pregnancy means that interventions that increase the risk of transmission to the baby can be avoided and effective treatments commenced after the birth or cessation of breastfeeding.
Because children with hepatitis B often don’t have symptoms, transmission between children may easily occur during play or fight through cuts and scratches.
If a child is living with viral hepatitis, what can be done? Clinical trials have recently shown that treatment of hepatitis C infection in children with the same medications used for those over the age of 18 is safe and effective, and these treatments have a cure rate of more than 97%.
Hepatitis C treatments listed on the Pharmaceutical Benefits Schedule can now be prescribed to children over three years old. However, they should be referred to a paediatrician who has experience with hepatitis C treatment, to discuss therapy options.
When children become infected with hepatitis B, some will recover from the virus within weeks or months without any medical intervention, and indeed may not even feel any effects from the infection. A majority (about 90%) of younger children who contract hepatitis B will develop chronic hepatitis B and will live with the virus long-term. This can put them at risk of liver scarring, liver failure and liver cancer in the future, so it is vital that children with chronic hepatitis B have liver and general health checks every 6-12 months depending on the advice of medical professionals. Although there is currently no cure for hepatitis B, there are some safe and effective anti-viral medicines to ameliorate its effects.
Any pregnant women or children living with viral hepatitis should be put in touch with a liver health nurse or specialist, in order to make sure that the best decisions are made for their health. It’s also extremely important to make all tests and services easily available for Aboriginal or Torres Strait women or women born overseas, as they are statistically more likely to have been exposed to viral hepatitis in the course of their lives.
If you have any concerns about your health or your child’s health, always remember to talk to your GP with any questions you might have, or you can call Hepatitis SA on 1800 437 222 or chat to us via the webchat icon at the bottom of our homepage.
Further reading:
https://www.schn.health.nsw.gov.au/fact-sheets/hepatitis-b-virus-infection-in-infants-and-children
https://www.schn.health.nsw.gov.au/fact-sheets/hepatitis-c-virus-infection-in-children
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Unlike other blood-borne viruses such as HIV and hepatitis B, the risk of a baby being infected with hepatitis C during the mother’s pregnancy or during birth is very low. Only about 5% of babies born to mothers who have hepatitis C are themselves infected by the disease.
A possible reason for this low figure is that the baby’s immune system has already destroyed the virus
before birth. A new study from researchers at Sweden’s Karolinska Institutet, published in the journal Gut, reveals clear adaptations of the uninfected babies’ immune system that may now lead the way to new treatment methods.
“The immune system of the [exposed but non-infected] babies shows similar changes to that in babies infected with hepatitis C,” explained Niklas Björkström, a doctor and researcher at the Institutet. “This could suggest that the immune cells have encountered the virus in the womb and managed to eliminate it before birth.”
The study was conducted in collaboration with a maternity hospital in Saint Petersburg, Russia. Of the 55 pregnant women participating, 40 had an active hepatitis C infection, while the others had been cured, but still tested positive for hepatitis C antibodies.
The babies born to women with an active infection were all considered exposed to the virus; despite this, only three of these 40 babies developed hepatitis C.
All the infants were monitored up to the age of 18 months through regular testing, and to increase the volume of comparable data, samples were added from 18 infants who had been infected with hepatitis C at birth.
This is particularly important research in the quest for a vaccine for hepatitis C.
The study showed that both the babies born with an infection and the babies who had been exposed to the virus by an infected mother had similar changes in their adaptive immune system, with clear adaptations of the body’s B lymphocytes, the role of which is to produce antibodies able to discover and identify alien microbes, such as viruses, bacteria and parasites.
“A possible explanation is that most babies exposed to the virus in utero manage to deal with it, which we can later see by the B lymphocytes,” said Dr Björkström. “One interesting hypothesis is that these cells can contain novel information that we can use to protect ourselves against hepatises C in the future.”
This is particularly important in the quest for a vaccine for hepatitis C. “This is why we need to continue researching,” Dr Björkström said. “We need to understand what it’ll take to obtain lasting protection against the virus. Only then can we attain the WHO goal of elimination.”
The researchers will now be investigating whether other immune cells in the infants have changed in a similar way. You can see the study here.
This article first appeared in issue 86 of the Hepatitis SA Community News.
]]>The hepatitis C virus (HCV) infects around 1per cent of the human population and is a devastating pathogen. In most people, it silently infects the liver for decades, and can cause life-threatening inflammation, scarring and even cancer. How the virus achieves this feat has long puzzled scientists.
In our latest study, published in the journal PLOS Pathogens, we found that a molecule that defends against HCV and other pathogens is weaker in humans than in our closest relative, the chimpanzee. This weakened molecule might have made it easier for some viruses, such as HCV, to infect humans and cause disease.
As humans, we are not completely defenceless against HCV. Our liver responds to infection by producing antiviral molecules called interferons. You can think of these molecules as the antiviral alarm system. Interferons are made rapidly once an invader has been spotted inside a cell. They are then released by the infected cell and begin to float across the nearby cells, sending chemical signals that warn them that a virus is near, and forcing them to defend themselves by making hundreds more antiviral molecules.
In particular, we produce what are known as lambda interferons against HCV that work well in liver cells. Strangely, one particular kind of interferon lambda, called IFNL4, is associated with a reduced chance of clearing HCV, making it easier for the virus to silently infect the liver for decades. How an antiviral molecule appears to help a virus to sustain infection over such a long time, and how this may have evolved, remains a mystery.
The long evolution of humans in Africa and our later global spread has resulted in genetically diverse populations of humans, each adapted to suit local environments and diseases. In our recent study, we searched through all the known genetic diversity of the IFNL4 gene, including that of chimpanzees, to identify whether people who carried different versions had different abilities to block viral replication. We hoped this would shine a light on the paradoxical role of IFNL4 during HCV infection.
What we found surprised us. A very rare version of IFNL4, which is only found in pygmies (hunter-gatherers from central Africa), was far better able to inhibit HCV infection in the lab. Even more surprisingly, this version had similar properties to the chimpanzee IFNL4. Nearly all humans, except this group of hunter-gatherers, produce a weaker version of IFNL4.
This more antiviral version of IFNL4, found in chimpanzees and a small pocket of Central African hunter-gatherers, was better able to turn on hundreds of antiviral molecules when it was added to cells in the lab. This heightened antiviral response was similar to what was found when we compared the genes produced in the liver in response to HCV in people and in chimpanzees. That is, chimpanzees appeared to mount a greater antiviral response to HCV than humans, turning on anti-HCV molecules and enhancing the immune response.
Chimpanzees are the only animal—other than humans—that can be infected by HCV, which is the reason they were used to study the virus and find effective antiviral drugs and vaccines. However, testing in chimpanzees is now banned.
Correlating with this stronger antiviral response is the fact that HCV infection in chimpanzees is less pronounced than in humans. Chimpanzees don’t develop serious hepatitis C. The virus appears to replicate more slowly, and it might be more difficult for HCV to gain a foothold in chimpanzees. Also, despite searching, scientists have been unable to find natural HCV infection in chimpanzees in the wild.
Our finding that very early in human evolution we evolved an antiviral molecule with a reduced ability to block viral infections, might help explain the insidious nature of HCV—and possibly other viral infections—in humans.
One remaining mystery is what evolutionary pressures drove early humans to reduce the antiviral activity of IFNL4, and why do a handful of people retain it? We may not have the answers yet, but studying the immune responses in our chimpanzee cousins in the wild, or in people who still carry the more antiviral version of IFNL4, may unlock some of the mysteries behind the role of IFNL4 in virus infection.
]]>These are the Australian National Guidelines for the Management of Healthcare Workers Living with Blood Borne Viruses and Healthcare Workers who Perform Exposure Prone Procedures at Risk of Exposure to Blood Borne Viruses.
Exposure-prone procedures (EPPs) are procedures where there is a risk of injury to the healthcare worker, with exposure of the patient’s open tissues to the blood of the health care worker. All healthcare workers who perform EPPs are required to take reasonable steps to know their blood borne virus status and to follow these guidelines.
Previously, healthcare workers living with BBVs were excluded from performing exposure-prone procedures, but these new guidelines reflect the effectiveness of current antiviral treatment for hepatitis B, hepatitis C and HIV. These changes are also consistent with those made in other countries.
Some procedures undertaken as part of medical care carry an extremely low chance of patients becoming infected with a blood-borne virus from a healthcare worker living with a BBV, even when usual infection prevention and control practices are followed. While still extremely unlikely, there are certain procedures where the healthcare workers are at a higher risk of getting a BBV from a patient and also of passing a BBV to a patient. However, when healthcare workers living with a BBV are complying with the guidelines, this risk is minimised. The guidelines also support healthcare workers to get timely testing and treatment.
A broad range of health professional groups were consulted and provided feedback during the development of the new guidelines.
No. Healthcare workers have the same right to confidentiality and access to confidential testing, counselling and treatment as the general population. The guidelines are in place so that all patients can feel confident that their procedure is being performed in a way that protects their health and safety.
To read the guidelines online, visit Communicable Diseases Network Australia, Department of Health.
]]>Among the many attempts to get people talking about it was a peculiar social media campaign in which several of the movie’s stars took up careers as amateur tattoo artists, branding each other and members of the crew with toe-faces or misspelled words so that they could always remember being involved in the making of a film that scored 26% at Rotten Tomatoes.
Actress Margot Robbie has used talk-show appearances to talk about having bought a tattoo gun on eBay and using it to tattoo the toes of her co-stars and friends, and some of them also seem to have taken it up as a hobby.
The photos show that, commendably, gloves were worn when giving the tattoos, but no information was provided about whether anyone observed other forms of blood safety. This is a problem because backyard tattooing can be a easy way to transmit blood-borne diseases like hepatitis C.
When you receive a tattoo, your skin is being pierced by a needle and injected with small amounts of ink. You need to make sure that the needle is coming out of a new, sterile package, that the tattoo artist is wearing latex gloves, and that all other tattooing equipment has been sterilized—something which is unlikely to have happened in a backyard tattooing session.
Items that come into contact with blood and cannot be sterilized (gloves, ink caps, cotton swabs, ointments, soap bottles, paper towels, etc) should be disposed of immediately after tattooing and labeled as a biohazard. Ink- or water-based products should be thrown out after they are used and should not be put back into the container they came from. Surfaces and other areas the tattoo artist used to work on should be cleaned regularly with a disinfecting cleaner.
Things to remember about backyard tattoos:
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