POLICY BRIEF

OCTOBER 2012

A newborn baby in the health center of Guna, Madhya Pradesh, India. 2007 Anil Gulati, Courtesy of Photoshare

Protection against hepatitis B starts at birth

Chris Morgan, Priya Mannava
Centre for International Health, Burnet Institute

An opportunity to increase provision of postnatal care within the first 24 hours

The World Health Organization (WHO) estimates that more than 240 million individuals are chronically infected with the hepatitis B virus (HBV) and at risk of serious illness and death, mainly from liver cirrhosis and hepatocellular carcinoma, with 500-700,000 deaths each year.1 More than 80% of HBV-related deaths are due to infection acquired during birth or early childhood. Birth and early childhood are the most common periods for transmission of the HBV in highly endemic regions, including many countries in Asia and the Pacific, and could account for more than one-third of chronic infections in other regions. It is vital that early infection with hepatitis B virus is prevented.

The importance of timely vaccination at birth

To prevent early childhood infection, the WHO recommends that 'all infants should receive their first dose of hepatitis B vaccine as soon as possible after birth, preferably within 24 hours,' even in countries where the virus is not endemic.2 Birth dose is effective in preventing 85% of HBV transmission from an infected mother to her child. Delaying the birth dose will still have some effect, but the vaccines efficacy in prevention of perinatal transmission declines after the first day of life. Reaching newborns with vaccination is not straightforward: less than half of all countries have a national policy to administer hepatitis B vaccine at birth and only 27% of newborns received the vaccine at the recommended time.1

Hepatitis B is a significant global health issue Chronic hepatitis B infection can lead to liver disease and liver cancer, which is one of the most common types of cancer death globally. An estimated 30% of the worlds population has been infected with the virus, and approximately 240 million people are living with a chronic infection. Less than five percent of chronic infections are acquired as adults. The virus is transmitted through exposure to infectious blood, semen, and other body fluids. The hepatitis B virus is transmitted the same way as the human immunodeficiency virus (HIV); however, it is 50 to 100 times more infectious than HIV. Persons with chronic infection are often asymptomatic and may not be aware that they are infected. Vaccination is the most effective way to prevent hepatitis B virus infection.

Evidence-based national policy for hepatitis B vaccination

HBV vaccination should be a part of every countrys immunization program, including timely first dose within 24 hours of birth and 2 or 3 subsequent doses. National policy which mandates that all newborns are vaccinated with the birth dose, and which defines birth dose as within 24 hours of birth, is associated with high coverage.

KNOWLEDGE HUBS FOR HEALTH STRENGTHENING HEALTH SYSTEMS THROUGH EVIDENCE IN ASIA AND THE PACIFIC

Integrating birth dose hepatitis B vaccination with postnatal care for mothers and newborns

There is a real opportunity for immunization and maternal and newborn health programs to work together to improve outcomes. The need for timely vaccination may provide additional programmatic drive to reach mothers and newborns with health care in the first 24 hours, a critical period when 60% of maternal deaths and 32% of neonatal deaths occur.3 Most national plans for improved maternal and newborn survival include increasing skilled attendance at birth, preferably in well-supported health facilities, which is also critical to improved birth dose coverage. For babies born in health facilities, standing orders and consistent staff training in the importance of timely HBV vaccination will increase coverage. Birth dose HBV vaccination should be part of essential postnatal care that also addresses issues of hygiene, warmth, nutrition (especially breastfeeding) and early response to infections or other complications. In settings with low rates of childbirth in health facilities current WHO/UNICEF guidelines on community-based postnatal care recommend that a home visit should take place within 24 hours of a home birth. A systematic review of home visits by community health workers estimated they are associated with a 38% reduction in the risk of newborn death, in difficult settings.4 HBV vaccination is not commonly part of postnatal home visits, but medical technologies, including vaccine storage outside the cold chain and Uniject, make this possible even in difficult settings: Because HBV vaccine is more heat stable than other vaccines, it can be kept outside of standard coldchain refrigeration for up to 30 days, with appropriate precautions.5 Uniject is a compact, pre-filled injection device that is simpler to use than standard needles and syringes. Uniject can be safely used by trained and supervised community health care providers, including those who may not be suited to giving other vaccine injections.

Key messages

Birth and early childhood are critical periods to prevent transmission of the hepatitis B virus. Globally, there are an estimated 500-700,000 deaths from hepatitis B each year, 80% of which are from chronic infection acquired during birth and early childhood. Hepatitis B vaccination is recommended as part of every countrys immunization program, including timely first dose within 24 hours of birth. Scaling up postnatal care is important for mothers and newborns in all countries. Now that birth dose HBV vaccination is also recommended in all settings, there is an opportunity to exploit the synergy of both programs, aiming to reach families in this critical stage of life.

References 1 World Health Organization. Prevention and control of viral hepatitis infection: framework for global action, 2012. 2 World Health Organization. Hepatitis B vaccines. WHO Position Paper. Weekly Epidemiological Record, 2009, 84(40):405420. 3 World Health Organization. WHO Technical Consultation on Postpartum and Postnatal Care, 2010. 4 Siddhartha Gogia & Harshpal Singh Sachdev. Home visits by community health workers to prevent neonatal deaths in developing countries: a systematic review. Bulletin of the World Health Organization 2010; 88:658666B. 5 World Health Organization. Introduction of hepatitis B vaccine into childhood immunization services: Management guidelines, including information for health workers and parents, 2001. Further information and guidelines are available: Generic guidance on implementing new and underutilized vaccines is available on the WHO website: http://www.who.int/ Practices for improving coverage of the hepatitis B vaccine birth dose: a systematic review. Monograph for World Health Organization, Immunization Vaccines and Biologicals, Expanded Programme on Immunization. WHO/IVB/EPI, publication pending (approved April 2012) Acknowledgements Practices for improving coverage of the hepatitis B vaccine birth dose collates the evidence for practices proven effective in increasing coverage with timely birth-dose vaccination. The review was done by Compass: the Womens and Childrens Health Knowledge Hub, working in partnership with Burnet Institute, the Victorian Infectious Diseases Reference Laboratory and the WHOs Department of Immunization, Vaccines and Biologicals. The authors gratefully acknowledge the contributions of Ben Cowie and Kylie Carville (of VIDRL) and Tony Stewart (of the Burnet Institute) as well as expert reviews by WHO. In preparing this policy brief the authors acknowledge editorial advice of Jane Hawtin, Compass: Womens and Childrens Health Knowledge Hub. For further information regarding this policy brief please contact: Chris Morgan cmorgan@burnet.edu.au Compass: Women's and Children's Health Knowledge Hub is a partnership between the Burnet Institute, Menzies School of Health Research and the Centre for International Child Health, University of Melbourne. The Knowledge Hubs for Health are an Australian Agency for International Development (AusAID) initiative that aims to build knowledge, evidence and expertise and inform health policy dialogue relevant to Asia and the Pacific. www.wchknowledgehub.com.au

Scaling up postnatal care is important for mothers and newborns in all countries. Now that birth dose HBV vaccination is also recommended in all settings, there is an opportunity to exploit the synergy of both programs, aiming to reach families in this critical stage of life. A comprehensive review of effective practices for increasing birth-dose vaccination, and integrating this with postnatal care, was conducted by the authors for the WHO's Expanded Programme on Immunization.

This research has been funded by AusAID. The views represented are not necessarily those of AusAID or the Australian Government

KNOWLEDGE HUBS FOR HEALTH STRENGTHENING HEALTH SYSTEMS THROUGH EVIDENCE KNOWLEDGE HUBS FOR HEALTH IN ASIA AND THE PACIFIC KNOWLEDGE HUBS FOR HEALTH