Hepatitis B Control in South-East Asia, 2016–2019: Four Countries Reach the Goal

In 2015, an estimated 40 million people in the World Health Organization's South-East Asia Region were living with chronic hepatitis B virus (HBV) infection, and 285,000 died that year of its complications: cirrhosis and liver cancer. Most chronic infections begin in infancy, passed from mother to baby at birth or picked up in early childhood. A report by Hardeep S. Sandhu of CDC, with WHO and Thai colleagues, tracks the region's progress against it from 2016 to 2019.

The plan

WHO recommends that every infant get at least three doses of hepatitis B vaccine (HepB3), including a timely birth dose (HepB-BD) within 24 hours of birth. In 2016 the region endorsed a control goal: HBV surface antigen (HBsAg) prevalence of 1% or less among children aged 5 and older by 2020, in line with WHO's global viral hepatitis strategy. Its 2016–2020 vaccine action plan set four strategies:

1. at least 90% coverage with three doses;
2. a timely birth dose;
3. catch-up vaccination of older children;
4. vaccination of high-risk adults and health care workers.

The region's 11 countries are Bangladesh, Bhutan, Burma, India, Indonesia, Maldives, Nepal, North Korea, Sri Lanka, Thailand and Timor-Leste, home to about 2 billion people.

Progress, 2016–2019

• By 2016, all 11 countries gave at least three HepB doses in their national schedules, and eight also gave a universal birth dose.
• Regional three-dose coverage rose from 89% to 91%; birth-dose coverage from 34% to 54%.
• In 2019, nine countries reached at least 90% three-dose coverage — all but Indonesia and Timor-Leste — and three of the eight birth-dose countries reached at least 90% birth-dose coverage.

WHO–UNICEF estimates. For Maldives and Thailand, district figures are for atolls and provinces. Source: CDC, MMWR.

Hepatitis B vaccination coverage in the region. Credit: CDC, MMWR.

Verifying control

Infected children usually have no symptoms but can develop cirrhosis and liver cancer as adults, so success is measured with blood surveys of children aged 5 and older. In 2019 the region set up an expert panel of eight independent specialists to verify each country's status. Two conditions had to be met:

1. a nationally representative survey showing HBsAg prevalence of 1% or less among children 5 and older born after universal infant vaccination began;
2. birth-dose (where given) and three-dose coverage of at least 90% nationally and 80% in every district for the previous five years.

A modeling study estimated that hepatitis B vaccination prevented about 16 million chronic infections and 2.5 million deaths over the lifetimes of children born in the region from 1992 to 2015.

The gaps

• Districts. In India and Indonesia, which together account for 83% of the region's births, fewer than 80% of districts reached 80% three-dose coverage. Nepal met the national target but only 69% of its districts did. Tactics that have worked elsewhere: online vaccination registries, mapping high-risk areas to find missed children, checking vaccination at school entry, giving free vaccine to private providers, and tackling hesitancy through communication and social mobilization, along with catch-up campaigns.
• Birth doses. Delivering babies in health facilities raises timely birth-dose coverage when paired with trained staff, vaccine in delivery wards, standing orders and skilled birth attendants. Almost 80% of births in India happen in facilities, but many without a skilled attendant, and India's timely birth-dose coverage in 2019 was just 56%. Indonesia and Timor-Leste let midwives and traditional birth attendants use a compact, prefilled, auto-disable injection device, and Indonesia uses it outside the cold chain for home births in remote areas. India's open-vial policy cut vaccine waste and helped coverage. Prenatal education, pairing the birth dose with newborn care, and community health workers reporting recent births also help.
• Surveys. Maldives, North Korea and Sri Lanka already meet the coverage conditions and need only surveys. Surveys in India and Indonesia would show where to focus.
• Mothers. Where no birth dose is given, screening pregnant women and giving exposed newborns the birth dose plus hepatitis B immune globulin would prevent infections at birth.

Burma, India, Indonesia and Timor-Leste were unlikely to reach the goal by the end of 2020, and the COVID-19 pandemic was pushing childhood vaccination rates down worldwide.

Limitations

Estimates of target populations may be inaccurate, skewing coverage figures, and some surveys were not fully representative or relied on less-sensitive rapid field tests.

Sources

Based on Sandhu HS, Roesel S, Sharifuzzaman M, Chunsuttiwat S, Tohme RA, "Progress Toward Hepatitis B Control — South-East Asia Region, 2016–2019," MMWR, Centers for Disease Control and Prevention; a work of the United States government in the public domain.