Editor’s Note:HBV infection remains a significant public health issue worldwide, with about 1.5 million new infections annually. As of 2019, there were 46.5 million children and adolescents globally suffering from HBV-related chronic liver diseases. At the first National Conference on Clinical Diagnosis and Treatment of Viral Hepatitis in Children and the release of the Expert Consensus on Prevention and Treatment of Chronic Hepatitis B in Children, Professor Hongmei Xu from the Department of Infectious Diseases at the Children’s Hospital of Chongqing Medical University shared strategies for early diagnosis and treatment of chronic hepatitis B in children.
China was once a high-prevalence area for HBV infection, which poses a severe threat to public health through its progression to end-stage liver disease and hepatocellular carcinoma (HCC). Since 1992, China has implemented universal hepatitis B vaccination within 24 hours of birth, HBV immunoglobulin injection within 24 hours for newborns from HBV carrier mothers, and antiviral treatment for pregnant women with HBV infection in the late stages of pregnancy. These measures have successfully prevented the majority of child infections, although a small number still acquire the infection in utero or due to failures in the immunoprophylaxis program. As of 2019, there are approximately 23 million children and adolescents who are carriers of HBV in China, with 980,000 new infections reported in 2021.
It was previously believed that child HBV carriers were in an immune-tolerant phase, characterized by positive HBsAg, positive HBeAg, high levels of serum HBV DNA, but often “normal” or mildly/intermittently elevated ALT levels, and typically normal liver histology, suggesting no need for treatment. This notion has led to a lack of attention to infected children, who, despite mostly showing no clear symptoms or signs during infancy and childhood, can still become a reserve group for adult hepatitis B. Some children may experience disease progression, leading to liver failure, cirrhosis, and cancer, or develop extra-hepatic chronic diseases (such as HBV-related nephritis, thrombocytopenic purpura).
A study involving liver tissue examinations of 278 children with chronic hepatitis B (CHB) showed that 32.7% had mild fibrosis, 47.5% had moderate fibrosis, and 8.3% had cirrhosis. Another study revealed that despite normal ALT levels in children, 89.4% had some degree of inflammation or fibrosis upon liver biopsy. Further research indicated that 0.01%–0.03% of children develop HCC during childhood, with an annual incidence of 0.32‰.
Recent clinical studies indicate that children have a high response rate to antiviral treatment during this period, particularly when treatment is initiated at a young age, which is a crucial factor in achieving clinical cure. Additionally, numerous studies on CHB children in the immune clearance phase confirm that antiviral treatment can also achieve clinical cure, with earlier treatment initiation correlating with higher cure rates. One study showed that antiviral treatment for children with HBeAg-positive chronic HBV infection is safe, with an HBeAg seroconversion rate of over 22% and an HBsAg clearance rate of over 17%, suggesting that young age (1–7 years) is a major factor influencing cure. Another study indicated cure rates exceeding 40% in the 1–7 year age group, reaching up to 60% in the 1–3 year group. Research from our hospital shows that antiviral treatment is more effective in children aged 1-5 years than in those aged 5-16 years. Therefore, initiating antiviral treatment in young children as early as possible is beneficial for clinical cure.
To further reduce the HBV infection rate and its harm in China, under the leadership of Academician Fusheng Wang, dozens of experts from the Chinese Medical Association’s Infectious Diseases, Hepatology, and Pediatrics branches have formulated the “Expert Consensus on the Prevention and Treatment of Chronic Hepatitis B in Children.” This consensus offers 18 recommendations, playing a crucial role in the prevention and treatment of HBV infection in children. The main contents are summarized as follows:
1. Prevention is paramount:
(1) Further promote hepatitis B vaccination.
For newborns without HBV-infected mothers, vaccinate within 24 hours of birth using the 0-1-6 schedule. A full three-dose vaccination results in an antibody seroconversion rate of 97%–100%.
(2) Block mother-to-child transmission.
For HBV-infected mothers and their newborns, take the following steps: (i) Start antiviral treatment with TDF or TAF during the 24–28 weeks of pregnancy to treat HBV; (ii) Inject HBIG 100IU into newborns within 12 hours after birth; (iii) Vaccinate newborns within 12 hours after birth at different sites; (iv) Conduct serological testing for hepatitis B 1–2 months after the second vaccine dose to detect early infant infections.
2. Early detection of HBV infections in children, increasing the detection rate of pediatric hepatitis B markers.
3. Early antiviral treatment for infected children is essential to delay disease progression and reduce the burden of liver disease in China. The current antiviral regimens are maturing, and pediatric infectious disease doctors in China have accumulated substantial experience in treating pediatric hepatitis B, with good accessibility to antiviral medications. This provides support for early treatment of pediatric hepatitis B. Treatment options include interferon (subcutaneous injection) or nucleos(t)ide analogues (oral), with regimens being either monotherapy or combined treatment. Interferon treatment duration is 1-2 years for effective cases, while nucleos(t)ide analogues are used for longer periods. For HBeAg positive CHB patients, stopping medication after HBV DNA levels are below the detection limit and after HBeAg serological conversion, especially if HBsAg<100 IU/mL, can reduce the risk of relapse post-treatment, with treatment lasting several years. During treatment, monitoring of antiviral effects and side effects is necessary, and for those using nucleos(t)ide analogues, monitoring for viral resistance is also required. More experience is needed for combined treatments.
In summary, the prevention and early treatment of chronic hepatitis B in children will greatly reduce the HBV infection rate among Chinese children, decrease the occurrence of cirrhosis and HCC in childhood and particularly in adulthood, and enhance the health level of the population.
