Hepatitis B control among children in the Eastern Mediterranean Region of the World Health Organization

doi:10.1016/j.vaccine.2016.03.063

Vaccine

Volume 34, Issue 21, 5 May 2016, Pages 2403-2409

https://doi.org/10.1016/j.vaccine.2016.03.063 Get rights and content

Abstract

In the pre-vaccination era, the prevalence of chronic hepatitis B virus (HBV) infection in the World Health Organization (WHO) Eastern Mediterranean Region (EMR) ranged from two to seven percent in a total population of over 580 million people. Mortality estimates place cirrhosis among the top ten causes of years of life lost in the EMR. The region has made notable achievements, improving coverage from only 6% in 1992, when WHO recommended hepatitis B vaccination of all infants, to 83% in 2014. Member states adopted a hepatitis B control target in 2009 to reduce chronic hepatitis B virus infection prevalence to less than one percent among children aged <5 years by 2015. This report reviews progress toward achievement, challenges faced, and the next steps forward of hepatitis B control among children in the EMR.

Section snippets

Background

Two billion persons have been infected with hepatitis B virus (HBV) worldwide, and >350 million have chronic infection [1]. Globally, in 2010, over 700,000 deaths were attributed to HBV infection: >340,000 from liver cancer, >312,000 from cirrhosis and >132,000 from acute infection [2]. Low and middle-income countries bear the majority of the burden of hepatitis B-related liver cancer deaths [3].

The World Health Organization (WHO) estimates that more than four million people are infected yearly

Methods

EMR member states and Palestine annually report vaccination coverage using the WHO/UNICEF Joint Reporting Form (JRF) [7]. Methodology used by the WHO and UNICEF working group to derive coverage estimates from JRF data, vaccine coverage surveys and consultation with national authorities has been previously published [8]. Vaccination coverage data reported in this paper are WHO/UNICEF estimates of national immunization coverage, unless specified otherwise.

A mathematical model, developed by

Regional hepatitis B control target and strategies

In 2009, EMR member states endorsed Resolution EM/RC56/R.5 that established a regional target to reduce the prevalence of chronic HBV infection to <1% among children below five years of age by 2015. The main strategies for achieving and verifying achievement of the hepatitis B control target include: (1) reaching high hepatitis B vaccine birth dose coverage within 24 h of birth; (2) reaching high coverage of three-doses of hepatitis B vaccine; (3) completion of serological surveys of HBsAg

Status and impact of hepatitis B control

Eleven EMR countries have either completed nationally representative hepatitis B serosurveys (Oman and Sudan), are in the process of analyzing serosurveys (Egypt and Tunisia), or are in planning and development stages (Bahrain, Iran, Lebanon, Morocco, Palestine, Qatar and Saudi Arabia). Oman and Sudan have likely met the regional control target by showing that HBsAg prevalence is <1% in their target population of children. Oman conducted a nationally representative, school-based hepatitis B

Introduce universal birth dose and achieve high birth dose coverage

Low rates of health institution deliveries create challenges to introduce birth dose and to increase birth dose coverage [17]. Home births are more likely to occur in remote areas without access to an adequate cold chain. Without a cold chain, these areas do not have a continuous supply of vaccine. While outreach activities can be conducted to provide vaccine doses after birth, the urgency in the timing of birth dose precludes that solution. Birth dose vaccine needs to be available every day as

Conclusions

The significant prevalence of chronic HBV infection in countries of the WHO Eastern Mediterranean Region and the burden of resultant cirrhosis, liver cancer and death have made HBV control a public health priority. The region has responded by introducing infant hepatitis B vaccination into all national programs and by establishing a regional control target to reduce the prevalence of chronic HBV infection to less than one percent in children aged <5 years. But many challenges remain. Five of

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Comparison between a rapid diagnostic test and dried blood spot-based immunoassay for hepatitis B surface antigen testing: Performance and cost implications in a population-based serosurvey in Vietnam
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Citation Excerpt :
In these regions with high prevalence, evaluating the magnitude of HBV infection is particularly important to control the disease burden, and WHO recommends HBsAg serosurveys as a priority action (WHO, 2016, 2017b, 2017c). However, HBsAg serosurveys have not been conducted regularly (Allison et al., 2016; Breakwell et al., 2017). The accuracy of a serosurvey result is important to evaluate immunization activities, which is generally affected by various factors, such as assay formats.
This study aimed to determine the agreement between a rapid diagnostic test (RDT) and a dried blood spot (DBS)-based electrochemiluminescence immunoassay (ECLIA) of hepatitis B surface antigen and to compare the costs of conducting serosurveys using RDTs and DBS in a field setting.
A serosurvey was conducted in the South Central Coast region of Vietnam in May 2019. Participants aged 1-39 years were recruited using a four-stage random sampling method and tested for hepatitis B surface antigen using an RDT kit (Alere Determine) and a DBS-based ECLIA. The agreement between the RDT and the DBS-based ECLIA was assessed using cross-tabulation and Cohen kappa. Cost data were categorized by input (personnel, transportation, field consumables, laboratory consumables, and capital item/overhead) and survey phase (survey preparation, data/biospecimen collection, laboratory testing, and coordination).
A total of 2072 participants were analyzed. There was a 99% agreement between the RDT and the DBS-based ECLIA results, with a Cohen kappa of 0.9. The estimated cost of conducting a serosurvey by DBS was UD $75,291, whereas RDT was $53,182.
RDTs and DBS-based ECLIA provide test results with high agreements. RDTs are a better option in terms of cost, whereas the DBS-based ECLIA may be useful when evaluating multiple infectious diseases.
Moving towards hepatitis B elimination in Gulf Health Council states: From commitment to action
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Citation Excerpt :
The Gulf Health Council (GHC) states are a regional alliance of 6 Middle Eastern countries on the Arabian Peninsula that was founded in 1981 and includes Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates. Despite a number of publications on the epidemiology of HBV, there is a paucity of published works describing the HBV elimination initiative in GHC states [16–18]. This article review the progress made towards HBV elimination in the GHC states, identifies the challenges to be confronted by the National HBV control programme, highlights the lessons learnt and proposes steps towards elimination.
In 2016, the World Health Assembly adopted the hepatitis B (HB) elimination strategy that aims at ending HB by 2030. In this descriptive review we provide the progress made and challenges to achieving hepatitis B elimination by 2030 in Gulf Health Cooperated (GHC) states.
Data record from relevant online databases and reliable resources were reviewed until the end of 2017. The analysis was based on the core indicators of the WHO monitoring and evaluation framework for viral hepatitis B and the targets of the global health sector strategy by 2016‒2021.
The states introduced HB vaccination, including birth-dose for those under 5 years old, with global coverage of more than 95%, in order to prevent mother-to-child transmission of HBV. The prevalence of HB antigens declined in children under age 5 to less than 1%. However, the rate of vaccination among the most-at-risk populations remains suboptimal. All states have implemented safe blood transfusions and injection safety policies as well as universal laboratory-based surveillance for acute HB. However, surveillance for chronic HB and sequelae as well as estimation methods of morbidity and mortality to evaluate impact are not established. Similarly, harm reduction for people who inject drugs and testing and treatment policies and protocols for people with chronic HB are suboptimal.
Additional steps are required to strengthen immunisation among the most-at-risk populations, maintain high quality surveillance, use antiviral therapy to treat chronic HBV and stop unsafe injection practices for drug users. Establishing country-specific national hepatitis responses based on country priorities as well as the capacity of the home health sectors to address these needs are paramount. Achieving elimination targets will require a radical alteration in the current hepatitis response and this goal should be elevated to a higher priority in the public health arena.
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Chronic hepatitis B virus (HBV) infection occurs in 90% of infants infected perinatally but is prevented when a hepatitis B vaccine is given within 24 h of birth (HepB-BD), followed by 2–3 additional doses.
Using Spearman’s rho correlation coefficients (rho), we analyzed global and regional data to assess correlations between HepB-BD coverage, institutional delivery rates (IDR), skilled birth attendance (SBA) rates, and other potential co-variates.
Significant correlations were observed worldwide between HepB-BD and SBA rates (rho = 0.44, p < 0.001), IDR (rho = 0.42, p < 0.001), adult literacy rate (rho = 0.37, p = 0.003), total health expenditure per capita (rho = 0.24, p = 0.03) and live births (rho = −0.27, p = 0.014). HepB-BD, IDR, and SBA rates were significantly correlated in the World Health Organization African, South-East Asia and Western Pacific Regions.
Increasing IDR and SBA rates, training and supervising staff, increasing community awareness, and using HepB-BD outside the cold chain where needed would increase HepB-BD coverage and prevent chronic infections.
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ReviewHepatitis B control among children in the Eastern Mediterranean Region of the World Health Organization

Abstract

Section snippets

Background

Methods

Regional hepatitis B control target and strategies

Status and impact of hepatitis B control

Introduce universal birth dose and achieve high birth dose coverage

Conclusions

Lancet

J Hepatol

Lancet

Vaccine

Vaccine

Vaccine

Hepatitis B vaccines

Wkly Epidemiol Rec

Technical Paper. The growing threats of hepatitis B and C in the Eastern Mediterranean Region: a call for action

A mathematical model to estimate global hepatitis B disease burden and vaccination impact

Int J Epidemiol

WHO/UNICEF joint reporting form on immunization: WHO vaccine preventable diseases monitoring system

WHO and UNICEF estimates of national infant immunization coverage: methodology and processes

Bull World Health Organ

MMWR Recomm Rep

Practices to improve coverage of the hepatitis B birth dose vaccine

Documenting the impact of hepatitis B immunization: best practices for conducting a serosurvey

Review
Hepatitis B control among children in the Eastern Mediterranean Region of the World Health Organization