The global initiatives against hepatitis B virus (HBV) infection have made significant progress over the past decades, yet perinatal transmission or mother-to-child transmission (MTCT) remains the predominant route in endemic regions where universal hepatitis B vaccination program has not been actively implemented [
1]. Previous studies from different parts of the world already demonstrated that interruption of MTCT is essential to reduce individual disease burden and achieve population-level control [
2]. In this issue, Ki et al. offer one of the most comprehensive nationwide analyses to date, using 20 years of linked data from South Korea’s Perinatal Hepatitis B Prevention Program (PHBPP) [
3]. Their findings not only affirm the efficacy of established interventions but also highlight novel associations and trends that carry substantial implications for clinical practice and policy planning. As HBV elimination efforts accelerate worldwide, experiences from mature national programs may help inform future strategic directions.
The study by Ki et al. reinforces several well-established principles in the prevention of perinatal HBV transmission. South Korea’s experience, as reflected in this study, demonstrates how the integration of antiviral prophylaxis into a long-standing immunoprophylaxis program can further reduce perinatal transmission. The observed decline in MTCT rates from 3.6% in 2002–2005 to 1.3% in 2018– 2021 reflects not only the biological efficacy of interventions but also the success of system-level implementation in South Korea. These findings align with current guidelines supporting the use of antiviral treatment during late pregnancy in women with high HBV DNA levels [
4-
6]. Likewise, the observed protective effect of breastfeeding in this study, when appropriate neonatal immunoprophylaxis is administered, is in line with growing evidence and global endorsement that breastfeeding poses no additional MTCT risk [
7,
8]. In addition to the above experience from South Ko-rea, Taiwan also provides another compelling example. As the first country to introduce universal infant HBV vaccination in 1986 [
9], the HBsAg prevalence in children decreased from 10% to 1% in Taiwan [
10,
11], with parallel declines in childhood hepatocellular carcinoma (HCC) incidence [
12,
13]. Yet despite this early success, subsequent analyses revealed that most residual HCC risks in vaccinated cohorts were attributable to maternal transmission, particularly among infants born to HBeAg-positive mothers [
13]. These insights prompted the adoption of current practices like maternal antiviral prophylaxis in highly viremic mothers and infant post-vaccination serologic testing [
14].
Moreover, this study introduces findings that challenge conventional thinking in the role of cesarean section. Although most major obstetric guidelines explicitly advise against cesarean delivery solely to prevent HBV transmission [
7,
8], Ki et al. observed significantly lower MTCT rates among mothers who underwent elective cesarean section compared to those with vaginal delivery, even after adjusting for known confounders. This effect persisted in subgroup analyses stratified by HBeAg status. Though the observational nature of the study precludes causal inference, these data suggest that delivery mode may have a greater impact on HBV MTCT than previously recognized. Their findings raise important questions about the crucial role of delivery practices within HBV MTCT prevention frameworks, and the accumulating evidence warrants renewed discussion [
3,
15-
17]. In given high-risk scenarios, such as maternal high viral load with delayed or unavailable antiviral prophylaxis, elective cesarean section may deserve further consideration as a potential adjunctive strategy.
To reach the WHO target of reducing new HBV infections by 90% and achieving <0.1% HBsAg prevalence among children under five years of age by 2030 [
18], the global community should act decisively to fill the remaining gaps in perinatal prevention. This insightful study by Ki et al. provides valuable real-world data supporting a multifaceted approach that combines birth-dose vaccination, HBIG administration, maternal antiviral prophylaxis, and careful attention to delivery and feeding practices. Validated through two decades of nationwide implementation in South Korea, this model highlights the impact of aligning clinical practice with public health policy. It charts a path not only toward better outcomes but toward a future where hepatitis B is no longer passed from one generation to the next.
FOOTNOTES
-
Authors’ contributions
SC Huang: drafting of the manuscript. JH Kao: critical revision for important intellectual content.
-
Conflicts of Interest
S.-C. H. was on speaker’s bureau for Gilead Sciences. J.-H. K. has served as a consultant for Abbvie, Abbott, Gilead Sciences, Roche, and Sysmex and on speaker’s bureaus for Abbvie, Bristol-Myers Squibb, Gilead Sciences, Merck Sharp and Dohme, and Sysmex.
Abbreviations
mother-to-child transmission
Perinatal Hepatitis B Prevention Program
REFERENCES
- 1. Kao JH, Chen DS. Global control of hepatitis B virus infection. Lancet Infect Dis 2002;2:395-403.
- 2. Kao JH, Chen DS. Universal hepatitis B vaccination: killing 2 birds with 1 stone. Am J Med 2008;121:1029-1031.
- 3. Ki M, Kim BW, Baik D, Kim JH. Factors associated with hepatitis B mother-to-child transmission in a national prevention program. Clin Mol Hepatol 2025;31:1298-1315.
- 4. Sarin SK, Kumar M, Lau GK, Abbas Z, Chan HL, Chen CJ, et al. Asian-Pacific clinical practice guidelines on the management of hepatitis B: a 2015 update. Hepatol Int 2016;10:1-98.
- 5. Terrault NA, Lok ASF, McMahon BJ, Chang KM, Hwang JP, Jonas MM, et al. Update on prevention, diagnosis, and treatment of chronic hepatitis B: AASLD 2018 hepatitis B guidance. Hepatology 2018;67:1560-1599.
- 6. European Association for the Study of the Liver. EASL Clinical Practice Guidelines on the management of hepatitis B virus infection. J Hepatol 2025;83:502-583.
- 7. Badell ML, Prabhu M, Dionne J, Tita ATN, Silverman NS; SMFM Publications Committee. Society for Maternal-Fetal Medicine Consult Series #69: Hepatitis B in pregnancy: updated guidelines. Am J Obstet Gynecol 2024;230:B2-B11.
- 8. Viral Hepatitis in Pregnancy: ACOG Clinical Practice Guideline No. 6. Obstet Gynecol 2023;142:745-759.
- 9. Chen DS, Hsu NH, Sung JL, Hsu TC, Hsu ST, Kuo YT, et al. A mass vaccination program in Taiwan against hepatitis B virus infection in infants of hepatitis B surface antigen-carrier mothers. JAMA 1987;257:2597-2603.
- 10. Hsu HY, Chang MH, Chen DS, Lee CY, Sung JL. Baseline seroepidemiology of hepatitis B virus infection in children in Taipei, 1984: a study just before mass hepatitis B vaccination program in Taiwan. J Med Virol 1986;18:301-307.
- 11. Ni YH, Huang LM, Chang MH, Yen CJ, Lu CY, You SL, et al. Two decades of universal hepatitis B vaccination in taiwan: impact and implication for future strategies. Gastroenterology 2007;132:1287-1293.
- 12. Chang MH, Chen CJ, Lai MS, Hsu HM, Wu TC, Kong MS, et al. Universal hepatitis B vaccination in Taiwan and the incidence of hepatocellular carcinoma in children. Taiwan Childhood Hepatoma Study Group. N Engl J Med 1997;336:1855-1859.
- 13. Chang MH, You SL, Chen CJ, Liu CJ, Lee CM, Lin SM, et al. Decreased incidence of hepatocellular carcinoma in hepatitis B vaccinees: a 20-year follow-up study. J Natl Cancer Inst 2009;101:1348-1355.
- 14. Su WJ, Chen HL, Chen SF, Liu YL, Wang TA, Ho YC, et al. Optimization of mother-to-child hepatitis B virus prevention program: Integration of maternal screening and infant postvaccination serologic testing. Clin Infect Dis 2024;79:690-700.
- 15. Lee SD, Lo KJ, Tsai YT, Wu JC, Wu TC, Yang ZL, et al. Role of caesarean section in prevention of mother-infant transmission of hepatitis B virus. Lancet 1988;2:833-834.
- 16. Yang J, Zeng XM, Men YL, Zhao LS. Elective caesarean section versus vaginal delivery for preventing mother to child transmission of hepatitis B virus--a systematic review. Virol J 2008;5:100.
- 17. Chang MS, Gavini S, Andrade PC, McNabb-Baltar J. Caesarean section to prevent transmission of hepatitis B: a metaanalysis. Can J Gastroenterol Hepatol 2014;28:439-444.
- 18. WHO. Global health sector strategy on viral hepatitis 2016-2021. Towards ending viral hepatitis. WHO web site, <https://www.who.int/publications/i/item/WHO-HIV-2016.06>. Accessed 18 Jul 2025.
Citations
Citations to this article as recorded by
