Progress Toward Hepatitis B Control and Elimination of Mother-to-Child Transmission of Hepatitis B Virus — World Health Organization African Region, 2016–2021

Hyacinte J. Kabore, DDS1; Xi Li, MD2; Mary M. Alleman, PhD2; Casimir M. Manzengo, MD3; Mutale Mumba, MD4; Joseph Biey, MD5; Gilson Paluku, MD6; Ado M. Bwaka, MD1,5; Benido Impouma, MD, PhD7; Rania A. Tohme, MD2 (

Summary

What is already known about this topic?

In 2019, the World Health Organization African Region (AFR) accounted for 66% of all new chronic hepatitis B virus (HBV) infections. Chronic HBV infection is the leading causes of cirrhosis and liver cancer.

What is added by this report?

By 2021, all 47 AFR countries provided 3 doses of hepatitis B vaccine (HepB3) to infants, and 14 (30%) provided a birth dose (HepB-BD). By December 2021, 16 (34%) countries achieved ≥90% HepB3 coverage; two (4%) achieved ≥90% timely HepB-BD coverage. Four countries achieved hepatitis B control; none achieved elimination of mother-to-child transmission (EMTCT).

What are the implications for public health practice?

Introduction of HepB-BD, improving HepB3 and HepB-BD coverage, and monitoring implementation of EMTCT interventions are essential to accelerating progress toward hepatitis B control and EMTCT in AFR.

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Abstract

Chronic hepatitis B virus (HBV) infection is one of the leading causes of cirrhosis and liver cancer. In 2019, approximately 1.5 million persons newly acquired chronic HBV infection; among these, 990,000 (66%) were in the World Health Organization (WHO) African Region (AFR). Most chronic HBV infections are acquired through mother-to-child transmission (MTCT) or during early childhood, and approximately two thirds of these infections occur in AFR. In 2016, the World Health Assembly endorsed the goal of elimination of mother-to-child transmission (EMTCT) of HBV, documented by ≥90% coverage with both a timely hepatitis B vaccine (HepB) birth dose (HepB-BD) and 3 infant doses of HepB (HepB3), and ≤0.1% hepatitis B surface antigen (HBsAg) seroprevalence among children aged ≤5 years. In 2016, the WHO African Regional Committee endorsed targets for a 30% reduction in incidence (≤2% HBsAg seroprevalence in children aged ≤5 years) and ≥90% HepB3 coverage by 2020. By 2021, all 47 countries in the region provided HepB3 to infants beginning at age 6 weeks, and 14 countries (30%) provided HepB-BD. By December 2021, 16 (34%) countries achieved ≥90% HepB3 coverage, and only two (4%) achieved ≥90% timely HepB-BD coverage. Eight countries (17%) conducted nationwide serosurveys among children born after the introduction of HepB to assess HBsAg seroprevalence: six countries had achieved ≤2% seroprevalence, but none had achieved ≤0.1% seroprevalence among children. The development of immunization recovery plans following the COVID-19 pandemic provides an opportunity to accelerate progress toward hepatitis B control and EMTCT, including introducing HepB-BD and increasing coverage with timely HepB-BD and HepB3 vaccination. Representative HBsAg serosurveys among children and a regional verification body for EMTCT of HBV will be needed to monitor progress.

Introduction

In 2019, approximately 1.5 million persons newly acquired chronic hepatitis B virus (HBV) infection; among these, 990,000 (66%) were in the World Health Organization (WHO) African Region (AFR)* (1). Because most chronic HBV infections are acquired through mother-to-child transmission (MTCT) or during early childhood (2), WHO recommends that all newborns receive a dose of hepatitis B vaccine (HepB) within 24 hours of birth (hepatitis B vaccine birth dose [HepB-BD]) followed by 2 or 3 doses† of HepB during the first year of life (2). In 2016, the World Health Assembly endorsed the goal of eliminating viral hepatitis as a public health threat by 2030, including the elimination of mother-to-child transmission (EMTCT) of HBV, documented by demonstration of ≥90% coverage with both a timely§ HepB-BD and 3 doses of HepB (HepB3), and ≤0.1% hepatitis B surface antigen (HBsAg)¶ seroprevalence among children aged ≤5 years (3). In 2016, the WHO African Regional Committee endorsed two targets for hepatitis B control: 1) 30% reduction in incidence (equating to HBsAg prevalence of ≤2% in children aged ≤5 years), and 2) ≥90% HepB3 coverage by 2020. In 2021, AFR countries endorsed a call to develop strategies for elimination of MTCT of HBV, including increasing HepB-BD and HepB3 coverage and improving access to antenatal care and quality delivery services (4,5). This report describes progress made during 2016–2021 to achieve hepatitis B control and elimination of MTCT of HBV in AFR.

Methods

Information on country immunization activities was obtained by review of administrative** or official†† HepB coverage data reported to WHO and UNICEF that generate annual country vaccination coverage estimates. To identify HBsAg seroprevalence surveys conducted in AFR, a MEDLINE literature review was conducted using the following search criteria (Afro country names), and (“hepatitis B” OR “HBV”) AND (2016/10/01:3000/12/31[Date – Publication]) AND (survey OR serosurvey OR serosurveillance OR seroepidemiology OR prevalence OR seroprevalence). Population-based surveys including the Population based HIV Impact Assessment (PHIA) surveys and Demographic Health Survey (DHS) were also used. This activity was reviewed by CDC and was conducted with applicable federal laws and CDC policy.§§

Immunization Activities

By 2014, all 47 countries in AFR had introduced HepB3 infant vaccination (

HBsAg Seroprevalence Surveys

Because most chronic HBV infections (particularly those among young children) are asymptomatic, the impact of hepatitis B vaccination is usually measured by HBsAg seroprevalence among children born after the introduction of HepB, usually those aged ≤5 years*** (3,6). During 2016–2021, HBsAg seroprevalence surveys among children were conducted at national or regional levels in eight (17%) countries. Among children of various age ranges surveyed in Ethiopia, Mauritania, Rwanda, Sierra Leone, Uganda, and Zambia, HBsAg seroprevalence was ≤2%. Prevalence among children aged ≤5 years measured in the Democratic Republic of the Congo, Ethiopia, Mauritania, Nigeria, and Sierra Leone ranged from 0.7% (Mauritania) to 4.5% (Nigeria) (

HBsAg seroprevalence among women of reproductive age or pregnant women provides an estimate of the risk for MTCT of HBV. Data from population-based HBsAg surveys among women of reproductive age or from screening of pregnant women available from 11 countries showed HBsAg seroprevalences ranging from 1.2% (Rwanda) to 9.8% (Sierra Leone) (Table 2).

Elimination of Mother-to-Child Transmission of HBV

By December 2021, although 21 (45%) AFR countries had developed a plan for EMTCT of HIV, syphilis, and HBV, only six countries††† reported having implemented the EMTCT guidelines for routine HBsAg testing of pregnant women, provision of antiviral medications to eligible (HBsAg-seropositive) women,§§§ and administration of HepB-BD to newborns. As of December 2021, ≥90% of pregnant women in 29 (62%) AFR countries had at least one antenatal care visit (

Discussion

All 47 AFR countries have had HepB in their infant immunization schedule since 2014, and 16 (34%) have achieved ≥90% HepB3 coverage for ≥2 years, including four countries that documented 7).

Fewer than one third (30%, 14) of countries had introduced HepB-BD by 2021, and just two countries achieved ≥90% HepB-BD coverage. Scaling up HepB-BD introduction and coverage is critical to eliminating MTCT of HBV and preventing subsequent liver disease and associated mortality. During 2016–2021, four countries in AFR introduced HepB-BD which, in addition to increasing HepB-BD coverage in two of these countries (Nigeria and Senegal), resulted in an increase in regional HepB-BD coverage from 10% to 17%. However, in 2021, almost 33 million newborns in AFR did not receive timely HepB-BD. (Table 1) Based on modeled estimates, maintaining current HepB3 coverage and increasing HepB-BD coverage to ≥90% in all countries in the region could avert 554,318 HBV-related deaths among 2020–2030 birth cohorts (8). Among the 33 countries that did not have HepB-BD as part of their routine immunization schedules in 2021, two (Burkina Faso and Uganda) introduced it in 2022. Among the remaining 31 countries,†††† 13§§§§ plan to introduce HepB-BD by 2025.¶¶¶¶ However, achieving the regional target of 35 countries by 2025 (5) would require six to seven countries to introduce HepB-BD each year. Following introduction, delivery in health facilities by skilled workers was shown to be significantly correlated with timely HepB-BD administration (9). Promoting and enabling delivery in health facilities, training health care workers, and integrating HepB-BD vaccination into newborn care, are essential to increasing timely HepB-BD coverage in AFR.

In addition to providing timely HepB-BD and HepB3, the identification of pregnant women with HBV infection and provision of antiviral medications for those who are eligible for treatment would further advance EMTCT of HBV (9,10). However, as of 2021, only 17 (36%) AFR countries had national policies for antenatal HBsAg testing and treatment, and nationally representative serosurveys in AFR were uncommon. HBsAg seroprevalence surveys would help document progress and guide policy decisions regarding hepatitis B control and elimination in the region.

Limitations

The findings in this report are subject to at least two limitations. First, HepB-BD coverage data were not consistently reported by five countries,***** which might have resulted in the underestimation of overall HepB-BD regional coverage. Second, assessment of hepatitis B control and EMTCT is challenging in countries that have introduced HepB-BD and achieved high coverage with HepB3, because nationally representative seroprevalence surveys to estimate the prevalence of HBV infection among children are lacking in those countries.

Implications for Public Health Practice

Establishing a regional verification mechanism for hepatitis B control and EMTCT of HBV could elevate the profile of elimination initiatives in AFR. Scaling up the introduction of HepB-BD and strategies to increase timely HepB-BD and HepB3 coverage would accelerate the reduction of preventable hepatitis B–associated morbidity and mortality and progress toward 2030 hepatitis B elimination goals.

Acknowledgments

Reggis Katsande, Vaccine-Preventable Disease Unit, World Health Organization Regional Office for Africa, Brazzaville, Republic of the Congo.

Corresponding author: Hyacinte J. Kabore, hkabore@cdc.gov.

1Vaccine-Preventable Disease Unit, World Health Organization Regional Office for Africa, Brazzaville, Republic of the Congo; 2Global Immunization Division, Global Health Center, CDC; 3HIV, Tuberculosis, Hepatitis Unit, Inter-country Support Team, World Health Organization, Libreville, Gabon; 4Vaccine Preventable Diseases Unit, World Health Organization Inter-country Support Team – East and South, Harare, Zimbabwe; 5Vaccine Preventable Diseases Unit, World Health Organization Inter-country Support Team – West, Ouagadougou, Burkina Faso; 6Vaccine Preventable Diseases Unit, World Health Organization Inter-country Support Team – Central, Libreville, Gabon; 7Universal Health Coverage/Communicable & Non-Communicable Diseases, World Health Organization Regional Office for Africa, Brazzaville, Republic of the Congo.

All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

• The African Region, one of the six WHO regions, with a population of approximately 1.2 billion persons, includes 47 countries. https://www.afro.who.int/countries

† Depending on the country’s immunization schedule.

§ Administration of a dose within 24 hours of birth.

¶ HBsAg seropositivity is an indicator of chronic HBV infection.

** Administrative vaccination coverage data are derived from the country’s immunization registry system. The coverage is calculated by dividing the total number of doses administered by the estimated target population for vaccination.

†† Official vaccination coverage estimates are reported by national authorities based on administrative data, immunization coverage surveys, and reports.

§§ 45 C.F.R. part 46, 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d); 5 U.S.C. Sect. 552a; 44 U.S.C. Sect. 3501 et seq.

¶¶ AFR is organized into three functional subregions: Central subregion (Angola, Burundi, Cameroon, Central African Republic, Chad, Democratic Republic of the Congo, Equatorial Guinea, Gabon, Republic of the Congo, and Sao Tome and Principe); East and South subregion (Botswana, Comoros, Eritrea, Eswatini, Ethiopia, Kenya, Lesotho, Madagascar, Malawi, Mauritius, Mozambique, Namibia, Rwanda, Seychelles, South Africa, South Sudan, Uganda, United Republic of Tanzania, Zambia, and Zimbabwe) and West subregion (Algeria, Benin, Burkina Faso, Cabo Verde, Côte d’Ivoire, The Gambia, Ghana, Guinea, Guinea-Bissau, Liberia, Mali, Mauritania, Niger, Nigeria, Senegal, Sierra Leone, and Togo).

*** HBsAg seroprevalence can be measured among children aged 1 year, 5 years, or 1–5 years, according to existing country surveillance and data collection practices. For regions and countries with a long history of high hepatitis B vaccination coverage and those that already conduct school-based serosurveys, serosurveys might be conducted in children aged >5 years. https://www.who.int/publications/i/item/9789240039360

††† Angola, Cabo Verde, Equatorial Guinea, Mozambique, Namibia, and Sao Tome and Principe.

§§§ Pregnant women who received positive HBsAg test results and had an HBV DNA ≥5.3 log10 IU/mL (≥200,000 IU/mL) or received a positive HBsAg antigen test result are recommended by WHO to receive antiviral prophylaxis to prevent MTCT of HBV. https://apps.who.int/iris/bitstream/handle/10665/333391/9789240002708-eng.pdf

¶¶¶ Bronze tier: 1) ≥90% HepB3 infant vaccination coverage, and 2) implementation of universal timely HepB-BD policy for ≥2 years. Silver tier: 1) ≥90% HepB3 infant vaccination coverage, 2) ≥50% universal timely HepB-BD coverage, and 3) availability of antenatal HBsAg testing in the public sector for ≥2 years. Gold tier: 1) ≥90% HepB3 infant vaccination coverage, 2) ≥90% universal timely HepB-BD coverage, and 3) >30% antenatal HBsAg testing coverage for ≥2 years. https://www.who.int/publications/i/item/9789240039360

**** https://www.who.int/publications/i/item/WHO-2019-nCoV-EHS_continuity-survey-2022.1

†††† Burundi, Cameroon, Central African Republic, Chad, Comoros, Democratic Republic of the Congo, Eritrea, Eswatini, Ethiopia, Gabon, Ghana, Guinea, Guinea-Bissau, Kenya, Lesotho, Liberia, Madagascar, Malawi, Mali, Mozambique, Niger, Republic of the Congo, Rwanda, Seychelles, Sierra Leone, South Africa, South Sudan, Togo, United Republic of Tanzania, Zambia, and Zimbabwe.

§§§§ Burundi, Cameroon, Comoros, Eritrea, Ghana, Lesotho, Madagascar, Niger, Seychelle, Sierra Leone, South Africa, Togo, and Zimbabwe.

¶¶¶¶ Obtained from workshop reports on National Immunization Plan; meetings were held during September–October 2022.

***** Angola, Botswana, Equatorial Guinea, The Gambia, and Mauritania.

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• WHO-UNICEF Estimates of National Immunization Coverage. https://immunizationdata.who.int/pages/coverage/HEPB.html
  † Timely receipt of HepB-BD is defined as administration of 1 dose of HepB within 24 hours of birth.
  § During 2010 to 2018: HepB-BD was selectively given to newborns of mothers who have received a positive HBV? surface antigen test result; in 2019, the country switched to universal HepB-BD vaccination of all newborns.
  ¶ Restricted HepB-BD given only to children born to mothers with hepatitis B.
  ** Preliminary data.

virus; NA = not applicable; NAIIS = Nigeria HIV/AIDS Indicator and Impact Survey; NR = not reported; PHIA = population-based HIV impact assessment survey.

• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6609197/pdf/tpmd180883.pdf
  † https://onlinelibrary.wiley.com/doi/full/10.1111/hiv.13457
  § Includes children and adolescents aged 11–13 years born before HepB introduction.
  ¶ https://dhsprogram.com/pubs/pdf/FR373/FR373.pdf
  ** https://global-hepatitis.com/wp-content/uploads/2023/04/GHS2023-Abstract-Book-ONLINE_4.pdf?utm_source=mobile+app&utm_medium=link&utm_campaign=abstract-book (abstract no. 047)
  †† https://phia.icap.columbia.edu/wp-content/uploads/2020/11/RPHIA-Final-Report_Web.pdf
  §§ https://www.sciencedirect.com/science/article/pii/S0264410X22003607
  ¶¶ https://phia.icap.columbia.edu/wp-content/uploads/2020/02/UPHIA_Final_Report_Revise_07.11.2019_Final_for-web.pdf
  *** https://phia.icap.columbia.edu/wp-content/uploads/2019/03/ZAMPHIA-Final-Report__2.26.19.pdf
  ††† Includes children and adolescents aged 11–14 years born before the introduction of HepB.
  §§§ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6239015/
  ¶¶¶ https://phia.icap.columbia.edu/wp-content/uploads/2021/09/53059-CAMPHIA-Report_EN_WEB_August1.pdf
  **** https://phia.icap.columbia.edu/kenya-final-report-2018/
  †††† https://phia.icap.columbia.edu/wp-content/uploads/2020/02/FINAL_THIS-2016-2017_Final-Report__06.21.19_for-web_TS.pdf
  §§§§ https://pubmed.ncbi.nlm.nih.gov/34387113/

• Eligibility for tier certification on the path to elimination of MTCT of HBV is based on immunization interventions. Bronze tier: 1) ≥90% coverage of HepB3 infant vaccination, and 2) implementation of universal timely HepB-BD policy. Silver tier: ≥90% coverage of HepB3 infant vaccination, 2) ≥50% coverage of universal timely HepB-BD, and 3) availability of antenatal HBsAg testing in the public sector. Gold tier: 1) ≥90% coverage of HepB3 infant vaccination, 2) ≥90% coverage of universal timely HepB-BD, and 3) >30% coverage of antenatal HBsAg testing. Indicators for each tier should be achieved for ≥2 years. https://www.who.int/publications/i/item/9789240039360
  † https://www.afro.who.int/publications/viral-hepatitis-scorecard-2021-african-region
  § All 21 priority countries reported by WHO regional office: Angola, Botswana, Burundi, Cameroun, Chad, Côte d’Ivoire, Democratic Republic of the Congo, Eswatini, Ethiopia, Ghana, Kenya, Lesotho, Malawi, Mozambique, Namibia, Nigeria, Uganda, South Africa, Tanzania, Zambia, and Zimbabwe.
  ¶ Included in national testing and treatment guidelines.
  ** https://data.unicef.org/resources/dataset/maternal-newborn-health/
  †† Data are not available for two (4%) countries (Mauritius and Seychelles).
  §§ WHO-UNICEF estimates. https://immunizationdata.who.int/pages/coverage/HEPB.html

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