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Vaccination remains the most cost-effective strategy to get on track with hepatitis B elimination in resource-limited settings

Posted on by Dr. Rania Tohme, Team Lead, Global Immunization Division

Midwife providing the 5-in-1 pentavalent vaccine (diphtheria-tetanus-pertussis [DTP], hepatitis B, and Haemophilus influenzae type b) during a routine vaccination session in Myanmar

Midwife providing the 5-in-1 pentavalent vaccine (diphtheria-tetanus-pertussis [DTP], hepatitis B, and Haemophilus influenzae type b) during a routine vaccination session in Myanmar

Dr. Rania Tohme, Team Lead, Global Immunization Division, CDC
Dr. Rania Tohme, Team Lead, Global Immunization Division, CDC

In the 1990s, the Western Pacific Region had one of the highest prevalence rates of chronic hepatitis B infection in the world (>8%). As a result, in 2005, it was the first World Health Organization (WHO) Region to adopt a hepatitis B control goal through vaccination. With the financial support of GAVI (the Vaccine Alliance), countries in the region introduced hepatitis B vaccine into routine immunization, starting with a birth dose followed by 2-3 additional doses. CDC worked with WHO, Ministries of Health, and global partners to improve hepatitis B vaccination and verify the achievement of the regional hepatitis B control goal. In 2017, the Western Pacific Region was successful at decreasing the prevalence rate of chronic hepatitis B infection to less than 1% among school-aged children because of the successful implementation of hepatitis B vaccination.

The success achieved in the Western Pacific Region could be used as a lesson for other WHO Regions and countries that are experiencing a high burden of hepatitis B, most notably the African and South-East Asia Regions. Most of the countries in Africa (36 of 47) do not have a birth dose of hepatitis B vaccine in their immunization schedule despite WHO recommendation. In a recent supplement released by the Pan African Medical Journal on the future of immunization in Africa, three articles advocated for the need of hepatitis B vaccine birth dose in Africa to be able to achieve elimination. In the absence of the universal birth dose, the transmission of hepatitis B virus (HBV) infection from mother to child remains a major source of chronic liver disease when infected children become adults. Chronic HBV infection develops in 90% of infants infected before 1 year of age and contributes to over half of infections. As evidenced by efforts in Uganda, vaccinating adults, even in high-prevalence countries, has not been shown to be cost-effective in the long term because babies will keep getting infected without a birth dose and 2-3 follow-up doses.

One of the concerns with introduction of hepatitis B birth dose in resource-limited settings is cost. In fact, in most low-income countries, the birth dose costs only $0.20, which makes it one of the cheapest vaccines available. In the Western Pacific Region, even after GAVI discontinued financial support for hepatitis B vaccine birth dose, countries identified other funding opportunities because hepatitis B is a priority disease. Therefore, political commitment is needed to support introduction of hepatitis B vaccine birth dose in high-prevalence countries. One example is Myanmar, which had to discontinue hepatitis B vaccine birth dose after GAVI stopped financing. However, in 2016, Myanmar reintroduced the birth dose in health facilities using government funds because it realized the importance of addressing the high burden of hepatitis B infection in the country. Countries in Africa could also advocate for birth dose introduction given the high burden.

Babies vaccinated with birth dose at a hospital in Myanmar
Babies vaccinated with birth dose at a hospital in Myanmar

Another concern is the challenge of vaccinating children born at home or in health facilities that do not have refrigeration for vaccines. The birth dose of hepatitis B vaccine is most effective if administered within 24 hours after birth or, if not possible, within 7 days of birth at the latest. Vaccine manufacturers have not yet changed their vaccine vial labels to mention the possibility of storing the vaccine at room temperature for a specific duration (controlled temperature chain). However, evidence has shown that the hepatitis B vaccine birth dose can be stored up to one month outside refrigeration if the temperature is monitored and does not exceed 37°C. Pilot projects in several countries showed that the vaccine stored outside the cold chain was as effective as the vaccine stored in the refrigerator, and coverage with the hepatitis B vaccine birth dose increased significantly after implementing vaccination outside the cold chain. CDC supported several countries in successfully implementing use of hepatitis B vaccine birth dose outside the cold chain.

Provision of the hepatitis B vaccine birth dose relies on good coordination between the immunization program and the maternal and child health program. During my visit to Myanmar in October 2016, I was impressed by the fact that midwives are also responsible for routine vaccination. This is the perfect situation for birth dose delivery where the person who delivers the baby usually gives the vaccine. Since midwives in Myanmar were already trained in vaccination, they would not need extensive training to give the birth dose if they have access to the vaccine. In Myanmar, 64% of births occur outside hospitals but 71% of births are performed by skilled birth attendants (midwives). Therefore, using some of the strategies described above, such as using the vaccine outside the cold chain, would help reach more children with the birth dose and decrease the burden of disease in Myanmar.

A recent CDC analysis showed that hepatitis B vaccination is higher in countries that have high rates of births delivered in health facilities and high rates of skilled attendance at birth. In countries where skilled birth attendance is low, other strategies can be used. CDC supported several projects that showed the positive impact of educating community health workers, village volunteers, and pregnant women on the importance of hepatitis B vaccine birth dose. In regions where skilled personnel are lacking, administration of hepatitis B vaccine birth dose in a compact pre-filled auto-disable device (CPAD) outside the cold chain could be the solution if production is scaled up.

Personally and professionally, I am excited about contributing to the elimination of hepatitis B globally. Children everywhere deserve a healthy life free from chronic hepatitis B infection and liver cancer. At the moment, the most cost-effective approach in resource-limited settings is provision of the hepatitis B vaccine birth dose followed by 2-3 additional doses of pentavalent vaccine. Because 194 WHO Member States endorsed the adoption of the Global Health Sector Strategy on Viral Hepatitis in 2016, which calls for elimination by 2030, more efforts are needed to promote hepatitis B vaccine birth dose introduction and increase vaccination in Africa and Asia. CDC’s commitment to collaborating with global partners to eliminate hepatitis B will continue to contribute to the impact of hepatitis B vaccination, as shown in the Western Pacific Region.

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Posted on by Dr. Rania Tohme, Team Lead, Global Immunization DivisionLeave a commentTags , , , ,

Training the Future Public Health Workforce in Malawi: Field Epidemiology Training Program (FETP)

8. Malawi FETP-Frontline Cohort 2 trainees with mentors and guests during graduation ceremony: Photo courtesy: Kiran Bhurtyal, CDC

At 4:00 PM on July 12, 2016, I received an urgent email from the CDC Malawi office asking if I had any information on a typhoid outbreak in Malosa in southern Malawi. The U.S. Embassy in Malawi was planning a visit to Malosa by the Second Lady of the United States, and they had received reports of an unusually high number of typhoid cases there. Fortunately for me, one of our trainees from the Field Epidemiology Training Program (FETP) had presented on the same outbreak earlier that day during the FETP graduation ceremony.  Read More >

Posted on by Kiran Bhurtyal, CDC MalawiLeave a commentTags ,

Polio Eradication and Beyond: What the Polio Endgame Means for Public Health

Melisachew Adane

The end of polio is in sight, with fewer cases of wild polio virus being reported yearly. Today, polio is on the cusp of eradication, with cases in only a few high-risk areas of three countries—Afghanistan, Nigeria, and Pakistan. This brings the eradication effort to its final chapter, otherwise known as the polio endgame. The Read More >

Posted on by Manish Patel, MD (CAPT, USPHS)Leave a commentTags , , ,

CDC Protects People from Disease Threats and Outbreaks in the U.S. and Around the World

This blog was originally published on Global Health Council’s The Collective Voice on June 16, 2017. Opinion polls show that the Centers for Disease Control and Prevention (CDC) is one of the federal government’s most admired and trusted agencies. Since its founding in 1946, CDC’s history as America’s premier public health agency has been tightly intertwined Read More >

Posted on by Carmen Villar, MSW, Center for Global Health Deputy Director for Policy and CommunicationsLeave a comment

Keeping Kids Healthy in Sierra Leone

Even before the recent Ebola outbreak, the lack of quality healthcare was a major challenge in Sierra Leone, leading to the country suffering some of the highest maternal and child mortality rates in the world. When a major outbreak strikes, overburdened health systems struggle to take care of other critical health issues, like making sure Read More >

Posted on by Regan Rickert-Hartman and Tushar SinghLeave a comment

Rotary and CDC – Partners in Polio and Beyond

Partnerships play an integral role in CDC’s international work. Eradication and elimination initiatives for vaccine-preventable diseases serve as examples underlining the importance of public-private partnerships. Global polio eradication has been and remains a top priority for CDC. It would be only the second time in history that a human disease has been eradicated, and partners Read More >

Posted on by W. William Schluter, MD, MSPH, Director, Global Immunization DivisionLeave a commentTags , , , ,

Media Dialogues: Cultivating a Conducive Tobacco-Control Environment In Cameroon

The author, Caleb Ayong

As the communications officer for the Cameroonian Coalition for Tobacco Control (C3T), I know the importance of educating journalists and guiding them to use factually accurate information from trustworthy sources. If this does not happen, they could obtain distorted information and pass it on to the public. C3T has held media dialogues with journalists for a couple of years now. Because of the opportunities these events present to build the capacity of the media to report accurately on tobacco control, we have organized three media dialogues in 2017, with more scheduled in several regions of the country in the months ahead.  Read More >

Posted on by CALEB I. AYONG, Communications Officer, Cameroonian Coalition to Counter Tobacco (C3T)Leave a commentTags , , ,

Transforming Hypertension Treatment in Barbados

A blood pressure screening in Barbados.

While being a physician is certainly important to me, first and foremost I consider myself a native of Barbados. The people of Barbados are unique, but they share a commonality with citizens of many other countries: they struggle with a high burden of hypertension, also known as high blood pressure, and other risk factors for Read More >

Posted on by Dr. Kenneth Connell, the Preclinical Deputy Dean and a Faculty Lecturer in Clinical Pharmacology at the University of the West Indies, Medical Sciences Cave Hill Campus in BarbadosLeave a comment

Strengthening Immunization in Challenging Settings

Training cold chain mentees in solar direct drive fridges installation

Providing routine immunization services is a global public health priority to protect families and children from vaccine-preventable diseases such as polio, measles, and cholera. In South Sudan, the world’s newest country, the need is enormous. Without vaccination, children and their communities may be vulnerable to preventable but deadly and disabling diseases. From 2008 to 2012, Read More >

Posted on by CDC’s Global Immunization Division in collaboration with in-country partnersLeave a commentTags ,

Vaccines Work: Leaving No Child Behind – How Pediatricians Can Contribute to Global Vaccine Coverage

NEPAS 2017

In Nepal, pediatricians meet with a caregiver and frontline vaccinators to learn how pediatricians can more effectively advocate for vaccine access.   Today, more children are saved by vaccines than ever before, but over 19 million children are still missing out on these critical life-saving vaccines each year across the world (WHO, 2017). To put Read More >

Posted on by Guest blogger: Louis Z. Cooper, MD, FAAP, Past President, American Academy of Pediatrics2 CommentsTags , , ,
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