Dear Editor,
We appreciate the editorial by Dr. Choi et al. [
1] on our recent study regarding mother-to-child transmission (MTCT) of hepatitis B virus (HBV) and the importance of preventive strategies in pregnancy [
2]. As highlighted in the editorial, preventing MTCT remains a crucial component in the global effort to eliminate HBV infection, and the implementation of comprehensive preventive measures has significantly reduced transmission rates over recent decades.
While the Korean Perinatal Hepatitis B Prevention Program (PHBPP) has demonstrated remarkable success in reducing MTCT rates, we acknowledge the editorial’s important observation regarding the absence of maternal HBV DNA testing in this current program. This limitation, noted both in our study and in the program itself, represents a significant opportunity for improvement in identifying higher-risk cases that would benefit from additional interventions.
In addition to the points raised in the editorial, we would like to highlight that despite robust evidence supporting the effectiveness of antiviral prophylaxis during pregnancy (antiviral prophylaxis) in preventing MTCT, the antiviral prescription rate for HBsAg-positive pregnant women in Korea was as low as 17.8% in 2021. Furthermore, among those who received any antiviral prescription, only approximately 50% received it following the guidelines of recommended timing for initiation and discontinuation [
3]. This observation, combined with the current lack of HBV DNA testing in PHBPP, suggests a critical need to enhance our prevention strategy through more active identification of higher-risk candidates for antiviral prophylaxis and improving adherence to the guidelines.
We strongly agree with several key points raised in the editorial, particularly regarding the importance of systematic screening during pregnancy and the value of antiviral prophylaxis for higher-risk pregnant women [
4]. However, we would like to provide additional perspectives on two specif-ic aspects of HBV management during pregnancy and the postpartum period.
First, regarding cesarean section (C-section), we would like to respectfully offer a more nuanced perspective based on our study findings. While the editorial correctly emphasizes the importance of appropriate peripartum prophylaxis, our research demonstrated lower MTCT risk with C-section (1.9%) compared to vaginal deliver y (2.6%). Importantly, we observed differential outcomes between elective and emergency C-sections, with elective C-sections (1.7%) showing lower MTCT rates compared to emergency procedures (2.2%). This finding suggests that the timing and circumstances of C-section may be crucial factors in MTCT prevention.
Our study found that the association between C-section and lower MTCT rates was observed regardless of maternal HBeAg status. However, it’s important to note that this difference was primarily evident in mothers who did not receive antiviral prescriptions. In the subgroup of mothers who received antiviral prescription, we did not observe significant differences in MTCT rates between C-section and vaginal delivery. While our study did not include HBV DNA measurements, which the 2025 European Association for the Study of the Liver guidelines emphasize as an important factor (particularly the threshold of 200,000 IU/mL) [
5], our findings contribute to the understanding of delivery mode in MTCT risk, especially in settings where antiviral prophylaxis is not utilized.
The potential mechanism, as suggested by Pan et al. [
6], may involve reduced exposure to contaminated maternal body fluids during elective C-section performed before labor onset. Given that C-section carries its risks for maternal morbidity, delivery method decisions should be carefully individualized, taking into account multiple factors including maternal HBV DNA level (HBeAg status), availability of antiviral prophylaxis, the timing of C-section (elective vs. emergency), and the overall risk-benefit balance for both mother and infant. Notably, our results suggest that antiviral prophylaxis may mitigate any differences in MTCT risk between delivery methods.
Second, concerning breastfeeding safety, recent evidence suggests a more nuanced understanding than previously held. The immediate protection provided by hepatitis B immunoglobulin (HBIG), lasting 3–6 months post-birth [
7], coupled with the progressive development of vaccine-induced immunity, creates a robust protective environment for the infant. Importantly, the oral route is not considered a mode of HBV transmission, as maternal blood potentially ingested through cracked nipples during breastfeeding undergoes viral inactivation due to gastric acidity and proteolytic effects of digestive enzymes, including pepsin [
8-
11]. The theoretical risk of transmission through cracked nipples requires both nipple and infant’s oral mucosa damage to occur simultaneously, a rare combination. Notably, the 2022 American Academy of Pediatrics guidelines [
12] have removed specific warnings about cracked nipples in HBVpositive mothers, reflecting this updated understanding of transmission risks.
Moving forward, while the current Korean PHBPP effectively implements infant-focused interventions, including HBIG administration, HBV vaccination series with birth dose, and post-vaccination serologic testing, we propose expanding the program to include maternal interventions to further enhance MTCT prevention.
Key strategic additions should include:
1. Integration of maternal HBV DNA testing into the standard PHBPP protocol
• This would enable the identification of higher-risk mothers requiring additional interventions
• Allow for the timely implementation of preventive measures
2. Implementation of antiviral prophylaxis for eligible pregnant women
• Particularly crucial for mothers with high viral loads
• Demonstrated effectiveness in reducing perinatal transmission risk
These maternal-focused expansions to the existing infant-centered Korean PHBPP would create a more comprehensive prevention strategy, potentially achieving even higher rates of MTCT prevention than the current protocol alone. We believe that strengthened collaboration between clinical practice and public health policy sectors will be es-sential in implementing these enhanced preventive strategies, ultimately leading to better outcomes for both mothers and infants in our shared mission to eliminate HBV infection.
FOOTNOTES
-
Authors’ contribution
Drafting of manuscript and critical review of manuscript: Both authors.
-
Acknowledgements
This work was mainly supported by the Korea Disease Control and Prevention Agency under grant No. 2022-10- 013, and partially by the National Cancer Center, Korea under grant No. NCC-2310710 and SK bioscience under grant No. CMC 5-2023-D0731-00002.
-
Conflicts of Interest
The authors have no conflicts to disclose.
Abbreviations
antiviral prophylaxis during pregnancy
hepatitis B envelope antigen
hepatitis B immunoglobulin
hepatitis B surface antigen
mother-to-child transmission
perinatal hepatitis B prevention program
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- 9. Martinsen TC, Fossmark R, Waldum HL. The phylogeny and biological function of gastric juice-microbiological consequences of removing gastric acid. Int J Mol Sci 2019;20:6031.
- 10. LiverWELL Incorporating HEPATITIS VICTORIA, Australia. Hepatitis B Transmission. LiverWELL web site <https://liverwell.org.au/liver-conditions/hepatitis-b/transmission/>. Accessed 10 Jul 2025.
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Citations
Citations to this article as recorded by
- Reply to correspondence on “Factors associated with hepatitis B mother-to-child transmission in a national prevention program”
Eunho Choi, Ji Hoon Kim, Young-Sun Lee
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