Strategies to increase timely uptake of hepatitis B vaccine birth dose
Authors: Fuqiang Cui
Journal: The Lancet Global Health (2020)

WHO estimates that, in 2015, 900 000 people died due to hepatitis B virus infection,1WHOGlobal hepatitis report. World Health Organization, Geneva2017Google Scholar with most infections acquired at birth, and that more than 1 million children younger than 5 years developed chronic hepatitis B infection.1WHOGlobal hepatitis report. World Health Organization, Geneva2017Google Scholar Hepatitis B prevalence was high in countries with a low coverage of hepatitis B vaccine birth dose.1WHOGlobal hepatitis report. World Health Organization, Geneva2017Google Scholar WHO recommends storage of hepatitis B vaccine in a traditional cold chain (+2°C to +8°C). However, in remote rural areas where many births occur at home, this practice could be a barrier to achieving high coverage of birth dose vaccination.2Scott N Palmer A Morgan C et al.Cost-effectiveness of the controlled temperature chain for the hepatitis B virus birth dose vaccine in various global settings: a modelling study.Lancet Glob Health. 2018; 6: e659-e667Summary Full Text Full Text PDF PubMed Scopus (16) Google Scholar In addition, a 2017 study3Rao R Schreiber B Lee BY Immunization supply chains: why they matter and how they are changing.Vaccine. 2017; 352103Crossref Scopus (10) Google Scholar showed that accidental freezing can occur in low-income and middle-income countries (LMICs). Therefore, WHO recommends that vaccines should be licensed for use in a controlled temperature chain (CTC), enabling vaccine products to be in ambient temperatures for a specified duration under monitored conditions.4WHOMeeting of the Strategic Advisory Group of Experts on immunization, October 2016–conclusions and recommendations.Wkly Epidemiol Rec. 2016; 91: 561-582PubMed Google Scholar The 69th World Health Assembly set a target to eliminate viral hepatitis as a public health threat by 2030,5WHOWHO global health sector strategy on viral hepatitis. World Health Organization, Geneva2016Google Scholar requiring a reduction of hepatitis B prevalence to less than 0·1% in children younger than 5 years. This target can be achieved through universal immunisation of infants and other interventions to prevent mother-to-child transmission against hepatitis B virus. In their modelling and cost-optimisation study in The Lancet Global Health, Christopher Seaman and colleagues6Seaman CP Morgan C Howell J et al.Use of controlled temperature chain and compact prefilled auto-disable devices to reach 2030 hepatitis B birth dose vaccination targets in LMICs: a modelling and cost-optimisation study.Lancet Glob Health. 2020; 8: e931-e941Google Scholar estimate that the use of CTC plus compact prefilled auto-disable (CPAD) devices to achieve 90% coverage in LMICs would avert 36·3 million disability-adjusted life-years (DALYs; IQR 24·1–49·3) across each cohort's lifetime and cost an annual minimum of US$687·5 million. They estimate that would be cost-saving in five of the six Global Burden of Disease regions containing LMICs because of averted disease costs, with the cost per DALY averted being less than $83·27 otherwise. This study addresses two key issues, showing first the importance of timely hepatitis B birth dose vaccination for achieving the 2030 target, and second that CTC plus CPAD could be a cost-effective strategy by which to achieve it. However, the study does not consider the cost or impact from the demand side (eg, market demand and community awareness) or the supply side (eg, personnel and other operational costs). More importantly, it does not address the issue of home birth, which is believed to be one of the biggest contributors to missed birth dose of hepatitis B vaccine.7Cui F Liang X Gong X et al.Preventing hepatitis B though universal vaccination: reduction of inequalities through the GAVI China project.Vaccine. 2013; 31: J29-J35Crossref PubMed Scopus (23) Google Scholar Furthermore, because the findings are based on modelling rather than on real-world data, quantitative validation of the model is impossible. Given the evidence that the heat stability of the hepatitis B vaccine and the ease of administration of CPADs could improve birth dose coverage in a cost-effective way, the first issue to consider is whether there is a market for such a vaccine.8Petit D Tevi-Benissan C Woodring J Hennessey K Kahn A-L Countries' interest in a hepatitis B vaccine licensed for the controlled temperature chain; survey results from African and Western Pacific regions.Vaccine. 2017; 35: 6866-6871Crossref PubMed Scopus (6) Google Scholar Second, regulatory authorities must license a vaccine for CTC use. Currently, seven WHO-prequalified hepatitis B vaccines exist, none of which are licensed for use in a CTC.9Controlled Temperature Chain Working GroupControlled temperature chain: strategic roadmap for priority vaccines 2017–2020. World Health Organization, Geneva2017Google Scholar The currently low supply of CPADs must also be increased, should CTC and CPADs be prioritised by the currently ongoing Vaccine Innovation Prioritisation Strategy co-led by WHO and Gavi, the Vaccine Alliance (GAVI).10Pagliusi S Che Y Dong S The art of partnerships for vaccines.Vaccine. 2019; 37: 5909-5919Crossref Scopus (3) Google Scholar Third, WHO and GAVI need to support LMICs to implement tailored policies to reach vulnerable populations. Efforts need to be focused on increasing hepatitis B vaccine coverage to meet the 2030 target, particularly in difficult-to-reach areas where vaccine accessibility is a concern. GAVI's decision to fund birth dose introduction in LMICs will make an important difference in achieving these objectives. Fourth, countries should be aware that integration with other interventions is essential when the health-care system is severely hampered by the shortage of human resources, service delivery, and other challenges.8Petit D Tevi-Benissan C Woodring J Hennessey K Kahn A-L Countries' interest in a hepatitis B vaccine licensed for the controlled temperature chain; survey results from African and Western Pacific regions.Vaccine. 2017; 35: 6866-6871Crossref PubMed Scopus (6) Google Scholar Moreover, increasing awareness at the country level about the potential benefits of timely hepatitis B birth dose vaccination, institutional delivery, and adopting a CTC approach where needed will be key to boosting interest in and the eventual uptake of birth dose vaccination, for infants born in hospital and at home, which will in turn improve coverage and equity. In conclusion, timely hepatitis B birth dose vaccination coverage of 90% is unlikely to be reached under current protocols. CTC plus CPAD vaccine strategies present cost-effective solutions to overcoming barriers to coverage. Interventions should be implemented from both the supply and the demand side, and countries must use the most appropriate strategies for their varied scenarios. Furthermore, proper supervision and monitoring of the CTC plus CPAD vaccine in place will be needed to ensure vaccine safety. I report funding from Peking University Health Science Center (grant BMU20170607) and the National Key Science and Technology Research on Infections Diseases (grant 2018ZX10721202). Use of controlled temperature chain and compact prefilled auto-disable devices to reach 2030 hepatitis B birth dose vaccination targets in LMICs: a modelling and cost-optimisation studyHepatitis B birth dose coverage of 90% is unlikely to be reached under current protocols. CTC and CPAD vaccine strategies present cost-effective solutions to overcome coverage barriers. Full-Text PDF Open Access