Why is hepatitis B vaccine coverage at birth so low in many African countries?

Hepatitis B vaccine. Photo by: Larry McCormack / The Tennessean via Imagn Content Services, LLC

MANILA — More children are receiving the hepatitis B vaccine today, but coverage, especially at birth, remains uneven across regions. Coverage of the first critical dose, which the World Health Organization says should be given within 24 hours from birth, is only at 43% globally. The proportion is even lower when broken down regionally, with only 6% in the countries that are part of the WHO regional office for Africa.

In its latest estimates, WHO has found that the proportion of children under 5 years old infected with hepatitis B has dropped to below 1%, thanks in large part to the uptake of the hepatitis B vaccine worldwide as part of routine vaccinations over the last two decades.

In 2019, coverage of the WHO-recommended three vaccine doses during childhood — which protects children for at least 20 years and “probably lifelong,” according to the organization — reached 85% globally.

“Ultimately, strong political will, community engagement and partnerships are needed for the successful introduction and scale up of the hepatitis B birth dose.”

— Dr. Meg Doherty, director, WHO HIV, Hepatitis and Sexually Transmitted Infections Unit

This is a significant achievement, especially as the hepatitis B virus is most commonly spread from mother-to-child during birth and early childhood, according to WHO.

“This landmark achievement means we will dramatically reduce the number of cases of liver cancer and cirrhosis in future generations,” said WHO Director-General Tedros Adhanom Ghebreyesus in Monday’s virtual press briefing, ahead of World Hepatitis Day.

But while 14 countries in Africa have achieved a Hepatitis B Surface Antigen prevalence of less than 1% in children under 5 years old, prevalence among this age group across sub-Saharan Africa remains high at 2.53%, according to Dr. Meg Doherty, director of WHO’s HIV, Hepatitis and Sexually Transmitted Infections Unit.

“Many countries in sub-Saharan Africa do have the hepatitis birth dose vaccine as part of the infant immunization schedule; however several do not,” she said.

The hepatitis B birth dose is not part of the vaccines supported by Gavi, the Vaccine Alliance. Gavi has addressed the issue previously, noting that the decision was due to a number of factors. These include implementation challenges in administering the vaccine at birth, and its low cost per dose. The cost, at $0.20 per dose, is equal to the minimum amount countries co-finance as part of Gavi’s co-financing policy.

Under its new Vaccine Investment Strategy post-2020, Gavi is expected to provide support to countries for the introduction of hepatitis B birth dose from 2021. But the support is meant more to help countries overcome introduction barriers and strengthen immunization timepoints.

The vaccine as well as the diphtheria, pertussis and tetanus-containing booster vaccines, according to Gavi, “are inexpensive and fall below the threshold for Gavi vaccine support.”

“Globally, 109 countries are currently implementing the birth dose. More than 50 countries still need to introduce the birth dose. Gavi, as a part of [its] Vaccine Investment Strategy (VIS) announced in 2019 to include hepatitis birth dose for ~50 countries that do NOT currently have [the birth dose] and will only fund the cost of introduction (i.e. training, reprinting of vaccine cards, etc). [Countries] will still have to pay around US$0.25 to US$0.42 per dose,” Doherty told Devex by email.

There are other reasons for the low coverage related to logistics, according to Doherty. These include high numbers of out-of-facility births in low- and middle-income countries, administration of the vaccine outside the recommended 24-hour time frame, cold chain storage requirements, and the limited number of skilled birth attendants in some countries, particularly in rural or hard-to-reach areas. In sub-Saharan Africa, only around 50% of birth deliveries are done in the presence of a skilled birth attendant, she said.

This shows the continued need for innovations in vaccine delivery, use of temperature-stable vaccines, and vaccine delivery integration into national programs, such as for maternal and neonatal care, she said.

“Ultimately, strong political will, community engagement and partnerships are needed for the successful introduction and scale up of the hepatitis B birth dose,” she said.

New guidelines from WHO also recommend that pregnant women testing positive for hepatitis B virus infection receive tenofovir, an antiviral approved for HIV treatment, as prophylaxis from the 28th week of pregnancy as part of efforts to prevent mother-to-child transmission.

Disruptions to vaccination programs globally due to COVID-19 could have a serious impact on efforts in eliminating hepatitis B. A modeling study led by WHO and the Imperial College London  shows that under a worst-case scenario, a projected 5.3 million additional chronic hepatitis B infections among children born between 2020 and 2030 could occur, and 1 million additional deaths among those children.

About the author

  • Jenny Lei Ravelo

    Jenny Lei Ravelo is a Devex Senior Reporter based in Manila. She covers global health, with a particular focus on the World Health Organization, and other development and humanitarian aid trends in Asia Pacific. Prior to Devex, she wrote for ABS-CBN, one of the largest broadcasting networks in the Philippines, and was a copy editor for various international scientific journals. She received her journalism degree from the University of Santo Tomas.