Our countries in sub-Saharan Africa are lagging far behind the WHO target of eliminating viral hepatitis B by 2030.  What can be done to bring about an urgent and salutary awakening?

The WHO African region has been classified as a highly endemic area for viral hepatitis B. In 2022, 64.8 million people were living with the hepatitis B virus in sub-Saharan Africa, with an HBsAg-positive prevalence of 5.4% (5.4% to 18%). The healthcare system is very poor, with a very poor care cascade: only 0.2% of these people are receiving treatment. Worldwide, 9 of the 17 countries, accounting for 75% of the global HBV burden, are found in Africa. In addition, some of these patients are co-infected or superinfected with viral hepatitis D, and sometimes with HIV. Furthermore, there's the negative influence of the metabolic associated steatotic liver diseases (MASLDs) that we're seeing more and more.

Among those chronic carriers, 3.6 million children under 5 years were HBsAg-positive, prevalence 1.7%, putting them at 90% risk of cirrhosis and liver cancer if contamination occurred at birth. Mother-to-child transmission (MTCT) of HBV is one of the most frequent modes of transmission, by vertical transmission during pregnancy and at birth, and also horizontal transmission just after birth and in early childhood. Mother-to-child transmission of HBV is more frequent (70-90%) if there is a very high HBV viral load above 200,000 IU/ml, or if HBeAg-positive. HBV MTCT in Africa is 10%, but if nothing is done, by 2030, 50% of new infections will come from MTCT. Pregnant women HBV prevalence is high (Cameroon 5,4%-15,4%). As there is currently no cure for viral hepatitis B, the best approach is prevention. 

In 2016, the World Health Assembly adopted the first Global Health Sector Strategy (GHSS) on viral hepatitis aiming to eliminate viral hepatitis as a public health threat by 2030, including elimination of MTCT of HBV, with targets for reducing prevalence, especially in children, with a reduction in the number of deaths by 2030, with prevalence in children below 0.1%.

In 2016, the GHSS had also set a 2020 interim impact target of 30% reduction in new HBV infections, equivalent to an HBsAg prevalence of no more than 1% in children <5 years of age.

But the intermediate targets of 2020 and 2023 were not met. WHO AFRO region failed to reach the 2020 WHO hepatitis B elimination goals targeting prevention, diagnosis, and treatment of hepatitis B of 30% diagnosed and treated, <1% HBsAg positivity in children under 5 years, 50% timely hepatitis B birth dose coverage, and 90% full 3-dose hepatitis B vaccine coverage, with the aim of reducing new chronic HBV infections to 20 per 100,000 and mortality to 10 per 100,000.

WHO AFRO region reported from the field in 2022 <1% of pregnant women with chronic hepatitis B have been treated. Only 14 of the 47 (29%) African countries have implemented the hepatitis B birth dose vaccination with only 14% of neonates receiving timely hepatitis B birth dose coverage (while Global was 42%, on the 50% WHO target). Full 3-dose hepatitis B vaccine coverage is 82%. The status of 2020 target for reduction to <1% in chronic HBV infection among children <5ans was still 2.5% (while Global was 0.9%). So, projections for achieving targets of <0.1% HBsAg positivity in children <5 years of age by 2030 indicate that most countries globally not achieving this will be in Africa.

Senegal is the leading African country in this fight against viral hepatitis B: 78% new-borns vaccinated, 99.1% children <5 years free of hepatitis B by 2021, less than 1% contamination.

As a result, WHO issued new recommendations in 2024 for the management of patients living with HBV, and for the prevention of MTCT of hepatitis B, with systematic testing for HDV. On the other hand, the new WHO recommendation is Triple elimination (Hepatitis B, HIV, and Syphilis).

The cornerstone of preventing HBV infection is the prevention of mother-to-child transmission and early childhood acquisition. This must become a priority. So there remains a major need for action, mainly in sub-Saharan Africa.

For PMTCT, HBsAg should be tested before the 2nd trimester, and if positive, HBV viral load or HBeAg should be determined. If HBV DNA >200,000 IU/l (or HBeAg-positive, or if no test is available), start antiviral chemoprophylaxis with Tenofovir from the 2nd trimester until after delivery or longer. The new-born should be vaccinated at birth, within the first 12 hours, and the expanded programme on immunisation (EPI)  will take over from there for full 3-dose hepatitis B vaccine coverage. Anti-hepatitis B immunoglobulins can also be used if available.

Challenges to be achieved: what we can quickly and strongly recommend to all our teams in all sub-Saharan Africa countries:

• Multiple advocacy

• Raise awareness among health authorities

• We must sensitize and educate the general population, Civil Society

• Educating and raising awareness to traditional healers

• Large-scale screening and linkage to care, promote vaccination

• Free Birth Dose implementation remains a challenge

• The biggest challenge is systematic free HepB-BD Vaccine for ALL new-borns (no prenatal visits, home deliveries, in Cameroon only 59,2% of pregnant women give birth at hospital)

• We must involve nurses, hepatologists and gastroenterologists, gynaecologists, paediatricians, infectious diseases specialists, internal medicine specialists, obstetricians and midwives, general practitioners, primary healthcare workers, biologists, and pharmacists

• Expand and simplify treatment criteria for adults and adolescents

• Need for more health facilities and a government health implementation plan

• Decentralize the fight to rural areas and primary health facilities

• Patient associations

• Close collaboration with the Ministry of Health and hepatitis a focal point

• Close collaboration with all networks against hepatitis

• All partners, GAVI, and pharmaceutical industry are encouraging research.

• Collaboration with international organizations eager to support and help us:  World Health Organisation (WHO), the Global Liver Council and Global NASH Council, World Hepatitis Alliance, Hepatitis B Foundation, Society of Liver Diseases in Africa (SOLDA), CDA Foundation, Gastroenterology and Hepatology Association of Sub-Saharan Africa (GHASSA), HEPSANET Africa CDC, European Association for the Study of the Liver (EASL), American Association for Study of Liver Diseases (AASLD), Healthy Livers Healthy Lives (HLHL), and NoHep

• Carry out major actions on World Liver Day and World Hepatitis Day

A strategy of systematic vaccination of new-borns and persons at risk will allow us to hope for a significant reduction in the prevalence of HBV infection and its consequences.