Paving the way towards hepatitis B virus-free generations in Africa
Authors: Olufunmilayo A Lesi, John W Ward
Journal: The Lancet Global Health (2021)

The children of Africa are in desperate need of protection from hepatitis B virus (HBV) infection. Globally, two-thirds of the estimated 1·5 million new cases of chronic HBV infection occurred in Africa in 2019.1WHOGlobal progress report on HIV, viral hepatitis and sexually transmitted infections, 2021. World Health Organization, Geneva2021https://www.who.int/publications-detail-redirect/9789240027077Date accessed: August 26, 2021Google Scholar Most of these new infections in Africa are among young children, particularly newborn babies. Of children infected at birth, 90% remain infected with a 25% risk of premature death from HBV-related liver disease, including liver cancer. Despite this risk, less than 10% of newborn babies in Africa receive a timely HBV birth-dose vaccine (ie, within 24 h of birth).2WHOGlobal guidance on criteria and processes for validation: elimination of mother-to-child transmission of HIV and syphilis. World Health Organization, Geneva2017https://www.who.int/reproductivehealth/publications/emtct-hiv-syphilis/en/Date accessed: August 20, 2021Google Scholar As a result, an estimated 4·3 million young children in Africa are currently infected with HBV. By contrast, other WHO regions have attained the 2020 Sustainable Development Goal (SDG) target of reducing HBV prevalence to less than 1% among children younger than 5 years.3WHOInterim guidance for country validation of viral hepatitis elimination. World Health Organization, Geneva2021https://apps.who.int/iris/bitstream/handle/10665/341652/9789240028395-eng.pdfDate accessed: August 26, 2021Google Scholar Reducing hepatitis B surface antigen (HBsAg) prevalence from 2·5% to 0·1% in African children is key to eliminating HBV transmission. To eliminate risks for mother-to-child transmission of HBV and prevent breakthrough HBV infections among vaccinated newborn babies, WHO recommends that a timely HBV birth-dose vaccination—preferably within 24 h of birth—should be combined with maternal HBV screening, to guide anti-viral prophylaxis for mothers with high HBV viral loads.4WHOPrevention of mother-to-child transmission of hepatitis B virus: guidelines on antiviral prophylaxis in pregnancy. World Health Organization, Geneva2020https://www.who.int/publications/i/item/978-92-4-000270-8Date accessed: May 25, 2021Google Scholar In The Lancet Global Health, Peyton Thompson and colleagues5Thompson P Morgan CE Ngimbi P et al.Arresting vertical transmission of hepatitis B virus (AVERT-HBV) in pregnant women and their neonates in the Democratic Republic of the Congo: a feasibility study.Lancet Glob Health. 2021; 9: e1600-e1609Summary Full Text Full Text PDF PubMed Scopus (5) Google Scholar examined the opportunities and challenges of delivery of this combination of three interventions to achieve HBV prevention of mother-to-child transmission in Africa. Firstly, HBV birth-dose vaccination provides the foundation on which other interventions are based.4WHOPrevention of mother-to-child transmission of hepatitis B virus: guidelines on antiviral prophylaxis in pregnancy. World Health Organization, Geneva2020https://www.who.int/publications/i/item/978-92-4-000270-8Date accessed: May 25, 2021Google Scholar Of the HBV-exposed newborn babies, only 46 (52%) of 88 infants received a timely HBV birth-dose vaccination, and coverage was poorer in children born outside the two study facilities. Inadequate supplies of the HBV vaccine and other issues limited the availability for study participants. Notably, the study only targeted HBV birth-dose vaccination to children born to HBsAg-positive mothers. WHO recommends universal timely HBV birth-dose vaccination for all newborn babies irrespective of maternal HBV status.6WHOImmunization agenda 2030: a global strategy to leave no one behind. World Health Organization, Geneva2020https://www.who.int/publications/m/item/immunization-agenda-2030-a-global-strategy-to-leave-no-one-behindDate accessed: May 26, 2021Google Scholar This recommendation is a priority in high HBV burden countries yet to reach the 2020 SDG target; however, only 14 (30%) of 47 countries in the African region have adopted policies for universal HBV birth-dose vaccination.1WHOGlobal progress report on HIV, viral hepatitis and sexually transmitted infections, 2021. World Health Organization, Geneva2021https://www.who.int/publications-detail-redirect/9789240027077Date accessed: August 26, 2021Google Scholar, 7Cooke GS Andrieux-Meyer I Applegate TL et al.Accelerating the elimination of viral hepatitis: a Lancet Gastroenterology & Hepatology Commission.Lancet Gastroenterol Hepatol. 2019; 4: 135-184Summary Full Text Full Text PDF PubMed Scopus (245) Google Scholar Thompson and colleagues' study had limitations. Their examination of the feasibility and benefits of integrated service delivery was limited by the small number of HBsAg-positive mothers (109 [2·7%] of 4016 women screened) and mothers with a high risk for perinatal transmission (ten [11%] of 91). Although the study was conducted within established HIV perinatal prevention programmes and was deemed acceptable by most participants, more data are needed regarding how integration with HIV prevention can improve shortcomings in HBV testing and adherence to HBV anti-viral prophylaxis identified in this study.7Cooke GS Andrieux-Meyer I Applegate TL et al.Accelerating the elimination of viral hepatitis: a Lancet Gastroenterology & Hepatology Commission.Lancet Gastroenterol Hepatol. 2019; 4: 135-184Summary Full Text Full Text PDF PubMed Scopus (245) Google Scholar Remarkably, only one study participant had serological evidence of tenofovir disoproxil fumarate concentrations approaching the daily dosing regimen recommended to suppress viral replication. Although we laud the merits of Thompson and colleagues' study, larger studies are needed to answer key questions in strengthening guidance for countries working towards triple elimination of HIV, HBV, and syphilis. How do we break the siloes and embrace coordinated and integrated HBV prevention of mother-to-child transmission programmes? How do we provide the appropriate technical assistance for countries to implement HBV birth-dose vaccination? Working together, immunisation and maternal and child health programmes can resolve implementation issues necessary to improve coverage with HBV birth-dose vaccination. Receiving Gavi support, which has been temporarily delayed by the COVID-19 pandemic, will allow eligible countries to accelerate implementation of universal HBV birth-dose vaccination while the Global Fund strategic support for resilient and sustainable systems for health can support and strengthen integrated prevention of mother-to-child transmission. WHO is working with various regional and partner organisations including the African Union, Coalition for Global Hepatitis Elimination, World Hepatitis Alliance, and others to support countries in setting national policies and building capacity for HBV prevention of mother-to-child transmission programmes. Expanding access to affordable HBV envelope antigen rapid tests and point-of-care HBV DNA tests will improve detection of HBV-infected mothers and delivery of care services to protect their health and the health of their newborn babies. Stimulating advocacy by civil society organisations promotes adoption of policies for HBV birth-dose vaccination and spurs integration of infant immunisation and maternal and child health programmes. The formation of public–private partnerships among private sector and non-governmental organisations provides resources for every step in the process towards HBV prevention of mother-to-child transmission. In summary, the study by Thompson and colleagues has begun building the evidence for an integrated service delivery approach of preventing perinatal HBV transmission. Indeed, the absence of HBV transmission among study participants shows the feasibility of HBV prevention of mother-to-child transmission in Africa. Guided by evidence from this study and others, governments and the global community must recognise HBV infection as an urgent health threat for African children, invest in the capacity for HBV prevention of mother-to-child transmission as a developmental priority, and ensure future generations in Africa are free of HBV infection. JWW reports participation in The Task Force for Global Health, which receives funding from Abbott, Gilead, AbbVie, Merck, Siemens, Cepheid, Roche, Pharco, and Zydus-Cadila, in addition to other donations from governmental agencies and philanthropic organisations, outside the submitted work. OAL declares no competing interests. The authors alone are responsible for the views expressed in this Comment and these views do not necessarily represent the views, decisions, or policies of the institutions with which the authors are affiliated. Copyright © 2021 This is an Open Access article published under the CC BY-NC-ND 3.0 IGO license which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. In any use of this article, there should be no suggestion that WHO endorses any specific organisation, products or services. The use of the WHO logo is not permitted. This notice should be preserved along with the article's original URL. Arresting vertical transmission of hepatitis B virus (AVERT-HBV) in pregnant women and their neonates in the Democratic Republic of the Congo: a feasibility studyAdding HBV screening and treatment of pregnant women and infant birth-dose vaccination to existing HIV prevention of mother-to-child transmission platforms is feasible in countries such as the Democratic Republic of the Congo. Birth-dose vaccination against HBV infection integrated within the current Expanded Programme on Immunisation and HIV prevention of mother-to-child transmission programme could accelerate progress toward HBV elimination in Africa. Full-Text PDF Open Access