COLDA 2024

Hepatitis B virus (HBV) infection is a significant global public health issue, with an estimated 254 million people living with HBV. Among them, approximately 65 million women of childbearing age are chronically infected. Although the global rate of new HBV infections has declined, it remains high, especially in the WHO African Region, which accounts for 63% of new infections, translating to around 771,000 new cases annually. Alarmingly, only 18% of newborns in this region receive the critical hepatitis B birth-dose vaccination.

Viral hepatitis is a leading cause of increasing mortality worldwide, with deaths rising from 1.1 million in 2019 to 1.3 million in 2022, of which 83% are due to hepatitis B. The burden of chronic hepatitis B is largely attributed to MTCT, where early infection increases the risk of chronic disease progression to complications like cirrhosis and liver cancer.

Sub-Saharan Africa remains a high-endemic area, with HBV transmission primarily occurring from mother to child. However, data on pregnant women infected with HBV is insufficient. Studies indicate that the prevalence of HBV among pregnant women is approximately 8% in West Africa and 5-7% in Central, Eastern, and Southern Africa.

To prevent MTCT, WHO recommends administering a birth-dose vaccine, screening pregnant women, and providing antiviral treatment with tenofovir disoproxyl fumarate (TDF) for women with a high viral load (≥200,000 IU/ml) or a positive HBV e antigen (HBeAg) test. Yet, in sub-Saharan Africa, less than 1% of pregnant women are screened and treated with TDF when eligible.
Several challenges must be addressed to enhance PMTCT efforts, including:

• Raising awareness about the asymptomatic nature of HBV, which remains undetected in 80% of cases.
• Improving access to free screening tests to increase global screening rates, which stood at just 4.2% in 2022.
• Ensuring early prenatal care to start treatment timely.
• Enhancing access to viral load testing or alternatives to identify women for treatment in the third trimester.
• Expanding the availability of affordable or free TDF to improve the treatment initiation rate, which was only 0.2% globally in 2022.
• Ensuring timely sero-vaccination of newborns within the first 24 hours of life, followed by the full course of the Expanded Programme on Immunization (EPI) doses.

Vaccination remains the cornerstone of the fight against MTCT of hepatitis B. Its effectiveness in preventing vertical transmission has been proven in several African studies, showing over 95% effectiveness against chronic HBsAg carriage and over 80% effectiveness against all HBV infections. Significant global public health successes have been achieved, such as reducing the prevalence of HBV among children under five from 4.7% in 2000 to 1.3% in 2015. However, Africa still reports the highest prevalence of chronic HBV in this age group.

As of 2020, only 14 African countries have introduced universal hepatitis B birth-dose vaccination, and by 2022, five out of 12 focus countries had included the birth dose in their national immunization programs. Despite this, vaccination coverage remains the lowest globally, with only 18% of infants receiving the birth dose within the first 24 hours.

Urgent expansion of access to effective interventions is crucial to save lives and prevent future generations from HBV-related infections, cancer, and deaths. The global health sector strategies for HIV, HBV, and sexually transmitted infections (STIs) for 2022-2030 aim for triple elimination, allowing the fight against HBV to benefit from advances in HIV and STI prevention.

The 2024 WHO recommendations broaden the treatment criteria for pregnant women with HBV, both for PMTCT and their individual health. However, implementing these recommendations in Africa requires addressing the aforementioned challenges. While progress has been made, it remains insufficient. Continued awareness and action are essential, underscoring SOLDA's commitment to communication for behavior change.