Toward a generation free of hepatitis B: Why preventing infection in infants can’t wait

Hepatitis B (HBV) is an incurable liver infection that can lead to severe health consequences including liver failure and liver cancer. It is a silent killer – most people do not experience any symptoms when they get infected and children in particular are less able to fight off infection.

New data from the World Health Organization (WHO) highlights that globally over 296 million people have chronic HBV and over 820,000 people died from HBV-related causes in 2019, despite the availability of an effective vaccine and suppressive antiviral treatment. New HBV infections are also on the rise, with 1.5 million new infections in 2019, of which 66 percent were in Africa.

Vertical transmission – the passing of disease from mother to infant immediately before or after birth – is the most common and deadliest form of transmission, with approximately 90 percent of children infected in their first year of life developing chronic HBV infection. Up to a quarter of these infants will die prematurely from HBV-related causes.

At CHAI, we are focused on eliminating vertical transmission, which accounts for over 50 percent of the global burden of HBV.

Clearly, preventing vertical transmission of HBV should be a global priority but we are just as far from achieving an HBV free generation as we were in 2015 when the World Health Assembly member states committed to eliminating the virus. Appropriately, this year’s World Hepatitis Day theme is “Hepatitis Can’t Wait”, conveying the urgency of efforts needed to eliminate hepatitis as a public health threat by 2030.

At CHAI, we are focused on eliminating vertical transmission, which accounts for over 50 percent of the global burden of HBV. We must act now to prevent infants from being infected if we plan to move toward a generation free of the virus in the next 10 years.

Missed opportunities have life-impacting effects

While there is no cure for HBV, it is preventable with vaccination. Administering three to four doses of the HBV vaccine, with the first dose administered within 24 hours of birth (HepB birth dose), is highly effective at interrupting transmission of the virus from mother to baby.

Nevertheless, global coverage of HepB birth dose is low, especially in the highest-burden region of Africa, where less than 10 percent of newborns receive the vaccine. Lack of financial support to introduce HepB birth dose, coupled with difficulties reaching children within 24 hours of birth, especially in areas where births tend to occur at home or in the community, contribute to low coverage.

To address this, in 2019, the board of Gavi, The Vaccine Alliance, formally approved support for the HepB birth dose for new vaccine introduction in low- and middle-income countries, but as with so much else over the last year and a half, investment has been delayed because of COVID-19.

Pandemic-related disruptions of HBV immunization, including HepB birth dose, coupled with the slow general recovery of vaccination programs, suggests an additional 5.3 million children born in the next 10 years will contract HBV – a million of whom will die from related complications.

Kick-starting Gavi’s commitment to introduce HepB birth dose, along with other approaches to curb new HBV infections, will be critical to regaining the momentum lost during the pandemic.

New approaches to ending vertical transmission of HBV that overlap with HIV

In July 2020, the WHO released new guidelines to reduce vertical transmission of HBV. The guidelines recommend pregnant women with high HBV viral loads receive tenofovir (TDF) prophylaxis from the 28th week of pregnancy until at least birth. This recommendation is in addition to the three-dose hepatitis B vaccination in all infants and helps prevent transmission during pregnancy and delivery.

These guidelines provide significant opportunities to integrate HBV prevention into existing health programs, including those addressing HIV and other STIs, maternal, newborn, and reproductive health. TDF is already the backbone of HIV treatment and HIV and HBV viral load testing can both be done on the same diagnostic platforms. This means that diagnostic platforms commonly used for hepatitis testing and systems for TDF procurement already have a large global footprint in part due to their use in HIV programs.

Despite this, the upcoming second edition of CHAI’s Hepatitis Market Report highlights that the price paid by HBV programs and patients for TDF is more than six times higher in some countries than the price accessed by HIV programs for the same medicine (more than US$200 per patient per year compared to less than US$32 per year). Similarly, while supplier global pricing agreements for HIV viral load testing also apply to HBV, many countries are still not accessing this pricing.

Cambodia is starting to scale up interventions for elimination of HBV vertical transmission

Cambodia is demonstrating that programs to eliminate vertical transmission of HIV and syphilis could be leveraged as cost-effective platforms for elimination of HBV vertical transmission.

Though Cambodia has a high burden of HBV, with a four percent seroprevalence among pregnant women, the country is on the path to addressing this burden, thanks to strong antenatal care structures, a backbone of dual elimination of HIV and syphilis, and a high rate of HepB birth dose vaccination.

Integrating services for pregnant women and their babies reduces time required to provide care by 32% for pregnant women.

Cambodia is starting to integrate HBV into its existing elimination of vertical transmission program, which already includes screening for HIV and syphilis. The program design for pregnant women includes HBV screening, further diagnosis in women who screen positive, TDF therapy when needed, and HepB birth dose for all infants. The program prioritizes access, offering services at health centers, maternity wards, and hospital HBV units.

Coordinating and integrating services for pregnant women and their babies help to maximize their effectiveness, efficiency, and sustainability. A study conducted in Cambodia highlighted that providing integrated services for elimination of vertical transmission of HIV, HBV, and syphilis reduces the total time required to provide care by 19 percent for health workers and by 32 percent for pregnant women.

“Continued strong political commitment for triple elimination, strengthened integrated maternal and child health services, strengthened interdepartmental coordination, and sustained financing will be key to Cambodia’s continued progress towards its HBV elimination of vertical transmission goals” said Dr. Kim Rattana, Director of Cambodia’s National Maternal and Child Health Center.

Despite the challenges that COVID-19 has presented, the response to the pandemic also provides an opportunity to foster greater innovation across communicable and non-communicable disease programs, underscoring the need to integrate disease-specific responses wherever it makes sense for increased efficiencies and effectiveness. Advancing elimination of vertical transmission of HBV and achieving an HBV-free generation will require resilient health systems that promote differentiated service delivery, including approaches for integrating services, such as Cambodia’s triple elimination program.

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