Progress Toward Hepatitis B Control and Elimination of Mother-to-Child Transmission of Hepatitis B Virus — World Health Organization African Region, 2016–2021

Hyacinte J. Kabore, DDS1; Xi Li, MD2; Mary M. Alleman, PhD2; Casimir M. Manzengo, MD3; Mutale Mumba, MD4; Joseph Biey, MD5; Gilson Paluku, MD6; Ado M. Bwaka, MD1,5; Benido Impouma, MD, PhD7; Rania A. Tohme, MD2 (View author affiliations)

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Summary

What is already known about this topic?

In 2019, the World Health Organization African Region (AFR) accounted for 66% of all new chronic hepatitis B virus (HBV) infections. Chronic HBV infection is the leading causes of cirrhosis and liver cancer.

What is added by this report?

By 2021, all 47 AFR countries provided 3 doses of hepatitis B vaccine (HepB3) to infants, and 14 (30%) provided a birth dose (HepB-BD). By December 2021, 16 (34%) countries achieved ≥90% HepB3 coverage; two (4%) achieved ≥90% timely HepB-BD coverage. Four countries achieved hepatitis B control; none achieved elimination of mother-to-child transmission (EMTCT).

What are the implications for public health practice?

Introduction of HepB-BD, improving HepB3 and HepB-BD coverage, and monitoring implementation of EMTCT interventions are essential to accelerating progress toward hepatitis B control and EMTCT in AFR.

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Abstract

Chronic hepatitis B virus (HBV) infection is one of the leading causes of cirrhosis and liver cancer. In 2019, approximately 1.5 million persons newly acquired chronic HBV infection; among these, 990,000 (66%) were in the World Health Organization (WHO) African Region (AFR). Most chronic HBV infections are acquired through mother-to-child transmission (MTCT) or during early childhood, and approximately two thirds of these infections occur in AFR. In 2016, the World Health Assembly endorsed the goal of elimination of mother-to-child transmission (EMTCT) of HBV, documented by ≥90% coverage with both a timely hepatitis B vaccine (HepB) birth dose (HepB-BD) and 3 infant doses of HepB (HepB3), and ≤0.1% hepatitis B surface antigen (HBsAg) seroprevalence among children aged ≤5 years. In 2016, the WHO African Regional Committee endorsed targets for a 30% reduction in incidence (≤2% HBsAg seroprevalence in children aged ≤5 years) and ≥90% HepB3 coverage by 2020. By 2021, all 47 countries in the region provided HepB3 to infants beginning at age 6 weeks, and 14 countries (30%) provided HepB-BD. By December 2021, 16 (34%) countries achieved ≥90% HepB3 coverage, and only two (4%) achieved ≥90% timely HepB-BD coverage. Eight countries (17%) conducted nationwide serosurveys among children born after the introduction of HepB to assess HBsAg seroprevalence: six countries had achieved ≤2% seroprevalence, but none had achieved ≤0.1% seroprevalence among children. The development of immunization recovery plans following the COVID-19 pandemic provides an opportunity to accelerate progress toward hepatitis B control and EMTCT, including introducing HepB-BD and increasing coverage with timely HepB-BD and HepB3 vaccination. Representative HBsAg serosurveys among children and a regional verification body for EMTCT of HBV will be needed to monitor progress.

Introduction

In 2019, approximately 1.5 million persons newly acquired chronic hepatitis B virus (HBV) infection; among these, 990,000 (66%) were in the World Health Organization (WHO) African Region (AFR)* (1). Because most chronic HBV infections are acquired through mother-to-child transmission (MTCT) or during early childhood (2), WHO recommends that all newborns receive a dose of hepatitis B vaccine (HepB) within 24 hours of birth (hepatitis B vaccine birth dose [HepB-BD]) followed by 2 or 3 doses of HepB during the first year of life (2). In 2016, the World Health Assembly endorsed the goal of eliminating viral hepatitis as a public health threat by 2030, including the elimination of mother-to-child transmission (EMTCT) of HBV, documented by demonstration of ≥90% coverage with both a timely§ HepB-BD and 3 doses of HepB (HepB3), and ≤0.1% hepatitis B surface antigen (HBsAg) seroprevalence among children aged ≤5 years (3). In 2016, the WHO African Regional Committee endorsed two targets for hepatitis B control: 1) 30% reduction in incidence (equating to HBsAg prevalence of ≤2% in children aged ≤5 years), and 2) ≥90% HepB3 coverage by 2020. In 2021, AFR countries endorsed a call to develop strategies for elimination of MTCT of HBV, including increasing HepB-BD and HepB3 coverage and improving access to antenatal care and quality delivery services (4,5). This report describes progress made during 2016–2021 to achieve hepatitis B control and elimination of MTCT of HBV in AFR.

Methods

Information on country immunization activities was obtained by review of administrative** or official†† HepB coverage data reported to WHO and UNICEF that generate annual country vaccination coverage estimates. To identify HBsAg seroprevalence surveys conducted in AFR, a MEDLINE literature review was conducted using the following search criteria (Afro country names), and (“hepatitis B” OR “HBV”) AND (2016/10/01:3000/12/31[Date – Publication]) AND (survey OR serosurvey OR serosurveillance OR seroepidemiology OR prevalence OR seroprevalence). Population-based surveys including the Population based HIV Impact Assessment (PHIA) surveys and Demographic Health Survey (DHS) were also used. This activity was reviewed by CDC and was conducted with applicable federal laws and CDC policy.§§

Results

Immunization Activities

By 2014, all 47 countries in AFR had introduced HepB3 infant vaccination (Table 1). By December 2021, 14 (30%) countries provided HepB-BD, eight (57%) of which were in the West subregion.¶¶ Although 10 countries had introduced HepB-BD before 2016, only four (Benin, Côte d’Ivoire, Equatorial Guinea, and Senegal) introduced HepB-BD during 2016–2021. During this period, regional HepB3 coverage ranged from 75% in 2019 to 71% in 2021. Eighteen (38%) countries reached ≥90% HepB3 coverage in 2016; this number peaked at 20 (43%) in 2018; by 2021, the number of countries with ≥90% HepB3 coverage had declined to 16 (34%); nine of these countries were in the East and South subregions. Regional HepB-BD coverage increased from 10% in 2016 to 17% in 2021. During 2016–2021, Algeria and Cabo Verde reached HepB-BD coverage of ≥90%, and Namibia and Senegal achieved ≥50% coverage.

HBsAg Seroprevalence Surveys

Because most chronic HBV infections (particularly those among young children) are asymptomatic, the impact of hepatitis B vaccination is usually measured by HBsAg seroprevalence among children born after the introduction of HepB, usually those aged ≤5 years*** (3,6). During 2016–2021, HBsAg seroprevalence surveys among children were conducted at national or regional levels in eight (17%) countries. Among children of various age ranges surveyed in Ethiopia, Mauritania, Rwanda, Sierra Leone, Uganda, and Zambia, HBsAg seroprevalence was ≤2%. Prevalence among children aged ≤5 years measured in the Democratic Republic of the Congo, Ethiopia, Mauritania, Nigeria, and Sierra Leone ranged from 0.7% (Mauritania) to 4.5% (Nigeria) (Table 2). No country achieved ≤0.1% HBsAg seroprevalence among children. Modeling studies estimated a HBsAg seroprevalence of 2.5% (95% CI = 1.7–4.0) among children aged ≤5 years in AFR, accounting for more than two thirds (4.3 million, approximately 69%) of all infected children worldwide (1).

HBsAg seroprevalence among women of reproductive age or pregnant women provides an estimate of the risk for MTCT of HBV. Data from population-based HBsAg surveys among women of reproductive age or from screening of pregnant women available from 11 countries showed HBsAg seroprevalences ranging from 1.2% (Rwanda) to 9.8% (Sierra Leone) (Table 2).

Elimination of Mother-to-Child Transmission of HBV

By December 2021, although 21 (45%) AFR countries had developed a plan for EMTCT of HIV, syphilis, and HBV, only six countries††† reported having implemented the EMTCT guidelines for routine HBsAg testing of pregnant women, provision of antiviral medications to eligible (HBsAg-seropositive) women,§§§ and administration of HepB-BD to newborns. As of December 2021, ≥90% of pregnant women in 29 (62%) AFR countries had at least one antenatal care visit (Table 3). Data from the most recent nationwide surveys showed that in 37 (79%) countries, approximately one half of women gave birth in health care facilities, and in 23 (49%) countries, ≥80% of women delivered in a health facility (Table 1). To acknowledge progress toward EMTCT of HBV in countries with high endemicity, WHO developed a certification mechanism for the path to elimination of MTCT of HBV, using three tiers (bronze, silver, and gold) indicating increasing levels of progress¶¶¶ (6). Based on HepB immunization interventions in 2021, Botswana might be eligible for the bronze tier, three countries (Namibia, Sao Tome and Principe, and Senegal) might be eligible for the silver tier, and two countries (Algeria and Cabo Verde) might be eligible for the gold tier certification (Table 1) (Table 3).

Discussion

All 47 AFR countries have had HepB in their infant immunization schedule since 2014, and 16 (34%) have achieved ≥90% HepB3 coverage for ≥2 years, including four countries that documented <2% HBsAg seroprevalence in children, consistent with hepatitis B control. The COVID-19 pandemic led to disruptions in immunization services,**** resulting in fewer AFR countries attaining ≥90% HepB3 coverage, declining from a peak of 20 (43%) in 2018 to 16 (34%) in 2021. Strategies to recover and strengthen immunization programs such as catch-up vaccination campaigns, could help ensure that all eligible children who missed HepB vaccination receive the recommended doses (7).

Fewer than one third (30%, 14) of countries had introduced HepB-BD by 2021, and just two countries achieved ≥90% HepB-BD coverage. Scaling up HepB-BD introduction and coverage is critical to eliminating MTCT of HBV and preventing subsequent liver disease and associated mortality. During 2016–2021, four countries in AFR introduced HepB-BD which, in addition to increasing HepB-BD coverage in two of these countries (Nigeria and Senegal), resulted in an increase in regional HepB-BD coverage from 10% to 17%. However, in 2021, almost 33 million newborns in AFR did not receive timely HepB-BD. (Table 1) Based on modeled estimates, maintaining current HepB3 coverage and increasing HepB-BD coverage to ≥90% in all countries in the region could avert 554,318 HBV-related deaths among 2020–2030 birth cohorts (8). Among the 33 countries that did not have HepB-BD as part of their routine immunization schedules in 2021, two (Burkina Faso and Uganda) introduced it in 2022. Among the remaining 31 countries,†††† 13§§§§ plan to introduce HepB-BD by 2025.¶¶¶¶ However, achieving the regional target of 35 countries by 2025 (5) would require six to seven countries to introduce HepB-BD each year. Following introduction, delivery in health facilities by skilled workers was shown to be significantly correlated with timely HepB-BD administration (9). Promoting and enabling delivery in health facilities, training health care workers, and integrating HepB-BD vaccination into newborn care, are essential to increasing timely HepB-BD coverage in AFR.

In addition to providing timely HepB-BD and HepB3, the identification of pregnant women with HBV infection and provision of antiviral medications for those who are eligible for treatment would further advance EMTCT of HBV (9,10). However, as of 2021, only 17 (36%) AFR countries had national policies for antenatal HBsAg testing and treatment, and nationally representative serosurveys in AFR were uncommon. HBsAg seroprevalence surveys would help document progress and guide policy decisions regarding hepatitis B control and elimination in the region.

Limitations

The findings in this report are subject to at least two limitations. First, HepB-BD coverage data were not consistently reported by five countries,***** which might have resulted in the underestimation of overall HepB-BD regional coverage. Second, assessment of hepatitis B control and EMTCT is challenging in countries that have introduced HepB-BD and achieved high coverage with HepB3, because nationally representative seroprevalence surveys to estimate the prevalence of HBV infection among children are lacking in those countries.

Implications for Public Health Practice

Establishing a regional verification mechanism for hepatitis B control and EMTCT of HBV could elevate the profile of elimination initiatives in AFR. Scaling up the introduction of HepB-BD and strategies to increase timely HepB-BD and HepB3 coverage would accelerate the reduction of preventable hepatitis B–associated morbidity and mortality and progress toward 2030 hepatitis B elimination goals.

Acknowledgments

Reggis Katsande, Vaccine-Preventable Disease Unit, World Health Organization Regional Office for Africa, Brazzaville, Republic of the Congo.

Corresponding author: Hyacinte J. Kabore, hkabore@cdc.gov.


1Vaccine-Preventable Disease Unit, World Health Organization Regional Office for Africa, Brazzaville, Republic of the Congo; 2Global Immunization Division, Global Health Center, CDC; 3HIV, Tuberculosis, Hepatitis Unit, Inter-country Support Team, World Health Organization, Libreville, Gabon; 4Vaccine Preventable Diseases Unit, World Health Organization Inter-country Support Team – East and South, Harare, Zimbabwe; 5Vaccine Preventable Diseases Unit, World Health Organization Inter-country Support Team – West, Ouagadougou, Burkina Faso; 6Vaccine Preventable Diseases Unit, World Health Organization Inter-country Support Team – Central, Libreville, Gabon; 7Universal Health Coverage/Communicable & Non-Communicable Diseases, World Health Organization Regional Office for Africa, Brazzaville, Republic of the Congo.

All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.


* The African Region, one of the six WHO regions, with a population of approximately 1.2 billion persons, includes 47 countries. https://www.afro.who.int/countries

Depending on the country’s immunization schedule.

§ Administration of a dose within 24 hours of birth.

HBsAg seropositivity is an indicator of chronic HBV infection.

** Administrative vaccination coverage data are derived from the country’s immunization registry system. The coverage is calculated by dividing the total number of doses administered by the estimated target population for vaccination.

†† Official vaccination coverage estimates are reported by national authorities based on administrative data, immunization coverage surveys, and reports.

§§ 45 C.F.R. part 46, 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d); 5 U.S.C. Sect. 552a; 44 U.S.C. Sect. 3501 et seq.

¶¶ AFR is organized into three functional subregions: Central subregion (Angola, Burundi, Cameroon, Central African Republic, Chad, Democratic Republic of the Congo, Equatorial Guinea, Gabon, Republic of the Congo, and Sao Tome and Principe); East and South subregion (Botswana, Comoros, Eritrea, Eswatini, Ethiopia, Kenya, Lesotho, Madagascar, Malawi, Mauritius, Mozambique, Namibia, Rwanda, Seychelles, South Africa, South Sudan, Uganda, United Republic of Tanzania, Zambia, and Zimbabwe) and West subregion (Algeria, Benin, Burkina Faso, Cabo Verde, Côte d’Ivoire, The Gambia, Ghana, Guinea, Guinea-Bissau, Liberia, Mali, Mauritania, Niger, Nigeria, Senegal, Sierra Leone, and Togo).

*** HBsAg seroprevalence can be measured among children aged 1 year, 5 years, or 1–5 years, according to existing country surveillance and data collection practices. For regions and countries with a long history of high hepatitis B vaccination coverage and those that already conduct school-based serosurveys, serosurveys might be conducted in children aged >5 years. https://www.who.int/publications/i/item/9789240039360

††† Angola, Cabo Verde, Equatorial Guinea, Mozambique, Namibia, and Sao Tome and Principe.

§§§ Pregnant women who received positive HBsAg test results and had an HBV DNA ≥5.3 log10 IU/mL (≥200,000 IU/mL) or received a positive HBsAg antigen test result are recommended by WHO to receive antiviral prophylaxis to prevent MTCT of HBV. https://apps.who.int/iris/bitstream/handle/10665/333391/9789240002708-eng.pdf

¶¶¶ Bronze tier: 1) ≥90% HepB3 infant vaccination coverage, and 2) implementation of universal timely HepB-BD policy for ≥2 years. Silver tier: 1) ≥90% HepB3 infant vaccination coverage, 2) ≥50% universal timely HepB-BD coverage, and 3) availability of antenatal HBsAg testing in the public sector for ≥2 years. Gold tier: 1) ≥90% HepB3 infant vaccination coverage, 2) ≥90% universal timely HepB-BD coverage, and 3) >30% antenatal HBsAg testing coverage for ≥2 years. https://www.who.int/publications/i/item/9789240039360

**** https://www.who.int/publications/i/item/WHO-2019-nCoV-EHS_continuity-survey-2022.1

†††† Burundi, Cameroon, Central African Republic, Chad, Comoros, Democratic Republic of the Congo, Eritrea, Eswatini, Ethiopia, Gabon, Ghana, Guinea, Guinea-Bissau, Kenya, Lesotho, Liberia, Madagascar, Malawi, Mali, Mozambique, Niger, Republic of the Congo, Rwanda, Seychelles, Sierra Leone, South Africa, South Sudan, Togo, United Republic of Tanzania, Zambia, and Zimbabwe.

§§§§ Burundi, Cameroon, Comoros, Eritrea, Ghana, Lesotho, Madagascar, Niger, Seychelle, Sierra Leone, South Africa, Togo, and Zimbabwe.

¶¶¶¶ Obtained from workshop reports on National Immunization Plan; meetings were held during September–October 2022.

***** Angola, Botswana, Equatorial Guinea, The Gambia, and Mauritania.

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TABLE 1. Year of hepatitis B vaccine introduction, hepatitis B vaccination schedule and estimated coverage* with the third vaccine dose, a timely administered hepatitis B vaccine birth dose, and rates of institutional delivery, by country — World Health Organization African Region, 2016–2021Return to your place in the text
Region, country Year of introduction HepB Schedule HepB3 coverage, % Timely HepB-BD coverage, % Rates of institutional delivery, % (most recent source and year)
HepB HepBD 2016 2017 2018 2019 2020 2021 2016 2017 2018 2019 2020 2021
Central subregion
Angola 2006 2015 B, 2, 4, 6 mos 55 52 59 53 47 41 NR NR NR NR NR NR 45.6 (DHS 2015–2016)
Burundi 2004 6, 10, 14 wks 94 91 90 93 93 94 NA NA NA NA NA NA 83.9 (DHS 2016–2017)
Cameroon 2005 6, 10, 14 wks 75 74 67 67 69 69 NA NA NA NA NA NA 67.0 (DHS 2018)
Central African Republic 2003 6, 10, 14 wks 42 42 42 42 42 42 NA NA NA NA NA NA 58.3 (MICS 2018–2019)
Chad 2003 6, 10, 14 wks 41 41 46 50 52 58 NA NA NA NA NA NA 27.2 (MICS 2019)
Democratic Republic of the Congo 2003 6, 10, 14 wks 70 71 71 73 70 65 NA NA NA NA NA NA 81.5 (MICS 2017–2018)
Equatorial Guinea 2003 2018 B, 6, 10, 14 wks, 18 mos 53 53 53 53 53 53 NA NA NA NR NR NR 67.3 (DHS 2011)
Gabon 2003 6, 10, 14 wks 75 75 70 70 63 75 NA NA NA NA NA NA 90.2 (DHS 2012)
Republic of the Congo 2003 8, 12, 16 wks 71 69 75 79 73 77 NA NA NA NA NA NA 91.5 (MICS 2014–2015)
Sao Tome and Principe 2003 2010§ B, 6, 10, 14 wks 96 95 95 95 96 97 NA NA NA 95 82 69 95.4 (MICS 2019)
East and South subregion
Botswana 1994 1998 B, 2, 3, 4 mos 95 95 95 95 95 95 NR NR NR NR NR NR 99.7 (Other NS 2015)
Comoros 2003 6, 10, 14 wks 91 91 91 91 87 85 NA NA NA NA NA NA 76.1 (DHS–MICS 2012)
Eritrea 2002 6, 10, 14 wks 95 95 95 95 95 95 NA NA NA NA NA NA 33.7 (Other NS 2010)
Eswatini 1996 6, 10, 14 wks 90 90 90 90 83 77 NA NA NA NA NA NA 87.7 (MICS 2014)
Ethiopia 2007 6, 10, 14 wks 66 68 68 68 71 65 NA NA NA NA NA NA 47.5 (DHS (Mini) 2019)
Kenya 2001 6, 10, 14 wks 89 82 92 91 91 91 NA NA NA NA NA NA 61.2 (DHS 2014)
Lesotho 2003 6, 10, 14 wks 87 87 87 87 87 87 NA NA NA NA NA NA 89.4 (MICS 2018)
Madagascar 2002 6, 10, 14 wks 68 65 65 68 66 55 NA NA NA NA NA NA 38.7 (MICS 2018)
Malawi 2002 6, 10, 14 wks 84 88 92 95 90 93 NA NA NA NA NA NA 96.7 (MICS 2019–2020)
Mauritius 1996 1996§ R, 6, 10, 14 wks, 18 mos 72 96 97 97 93 92 NA NA NA NA NA NA 98.4 (MoH 2003)
Mozambique 2001 6, 10, 14 wks 88 88 88 88 79 61 NA NA NA NA NA NA 54.8 (DHS 2011)
Namibia 2009 2014 B, 6, 10, 14 wks 85 88 89 87 93 93 85 81 76 81 86 86 87.4 (DHS 2013)
Rwanda 2002 6, 10, 14 wks 98 98 97 98 91 88 NA NA NA NA NA NA 93.1 (DHS 2019–2020)
Seychelles 1996 3, 4, 5 mos 96 97 99 99 97 94 NA NA NA NA NA NA NR
South Africa 1995 6, 10, 14 wks, 18 mos 85 84 82 85 84 86 NA NA NA NA NA NA 95.9 (DHS 2016)
South Sudan 2014 6, 10, 14 wks 45 47 49 49 49 49 NA NA NA NA NA NA 11.5 (SHHS 2010)
Tanzania 2002 6, 10, 14 wks 92 90 89 89 86 81 NA NA NA NA NA NA 62.6 (DHS 2015–2016)
Uganda 2002 6, 10, 14 wks 93 94 93 93 89 91 NA NA NA NA NA NA 73.4 (DHS 2016)
Zambia 2005 6, 10, 14 wks 95 94 90 88 84 91 NA NA NA NA NA NA 83.8 (DHS 2018–2019)
Zimbabwe 1994 6, 10, 14 wks 90 89 89 90 86 86 NA NA NA NA NA NA 85.5 (MICS 2019)
West subregion
Algeria 2001 2001 B, 2, 4, 12 mos 91 91 91 91 91 91 99 99 99 99 99 99 98.6 (MICS 2018–2019)
Benin 2002 2020 B, 6, 10, 14 wks 76 76 76 76 72 76 NA NA NA NA 21 71 83.9 (DHS 2017–2018)
Burkina Faso 2006 8, 12, 16 wks 91 91 91 91 91 91 NA NA NA NA NA NA 82.2 (Other NS 2015)
Cabo Verde 2002 2002 B, 2, 4, 6, 18 mos 96 97 99 97 94 94 96 96 97 96 96 96 97.0 (IDSR 2018)**
Côte d’Ivoire 2003 2019 B, 6, 10, 14 wks 87 83 84 81 75 76 NA NA NA 9 62 66 69.8 (MICS 2016)
The Gambia 1995 1999 B, 2, 3, 4 mos 95 92 93 88 86 82 NR NR NR NR NR 25 83.7 (DHS 2019–2020)
Ghana 2002 6, 10, 14 wks 93 99 97 97 94 98 NA NA NA NA NA NA 77.9 (MICS 2017–2018)
Guinea 2006 6, 10, 14 wks 47 45 47 47 47 47 NA NA NA NA NA NA 52.6 (DHS 2018)
Guinea-Bissau 2008 6, 10, 14 wks 85 79 82 78 74 67 NA NA NA NA NA NA 50.4 (MICS 2018–2019)
Liberia 2008 6, 10, 14 wks 73 80 80 70 65 66 NA NA NA NA NA NA 79.8 (DHS 2019–2020)
Mali 2002 6, 10, 14 wks 76 77 77 77 70 77 NA NA NA NA NA NA 66.8 (DHS 2018)
Mauritania 2005 2013 B, 6, 10, 14 wks 74 76 77 80 72 68 NR NR NR NR NR NR 69.3 (MICS 2015)
Niger 2008 6, 10, 14 wks 80 85 79 81 81 82 NA NA NA NA NA NA 44.3 (ENAFEME 2021)**
Nigeria 2004 2004 B, 6, 10, 14 wks 53 55 55 56 56 56 30 30 41 52 52 52 39.4 (DHS 2018)
Senegal 2004 2016 B, 6, 10, 14 wks 93 93 92 96 92 86 62 76 81 85 86 78 80.3 (DHS 2019)
Sierra Leone 2007 6, 10, 14 wks 84 90 93 95 91 92 NA NA NA NA NA NA 83.4 (DHS 2019)
Togo 2008 6, 10, 14 wks 82 83 81 84 82 83 NA NA NA NA NA NA 80.0 (MICS 2017)
African Region 73 74 74 75 73 71 10 10 12 15 16 17

Abbreviations: B = birth; DHS = demographic health survey; ENAFEME = Enquête Nationale sur la Fécondité et la Mortalité des Enfants de Moins de 5 Ans; HepB = hepatitis B vaccine; HepB-BD = birth dose of monovalent hepatitis B vaccine; HepB3 = third dose of hepatitis B–containing vaccine; IDSR = integrated disease surveillance and response; MICS = multiple indicator cluster survey; MoH = Ministry of Health; NR = not reported; NS = national survey; R = restricted HepB-BD; SHHS = South Sudan Household Health Survey.
* WHO-UNICEF Estimates of National Immunization Coverage. https://immunizationdata.who.int/pages/coverage/HEPB.html
Timely receipt of HepB-BD is defined as administration of 1 dose of HepB within 24 hours of birth.
§ During 2010 to 2018: HepB-BD was selectively given to newborns of mothers who have received a positive HBV? surface antigen test result; in 2019, the country switched to universal HepB-BD vaccination of all newborns.
Restricted HepB-BD given only to children born to mothers with hepatitis B.
** Preliminary data.

TABLE 2. Hepatitis B virus surface antigen seroprevalence based on population-based serosurveys among children and women of reproductive age or pregnant women during antenatal screening in selected countries — World Health Organization African Region, 2016–2021Return to your place in the text
Survey group, Country Year of most recent data (source) Geographic area Age group No. of persons tested HBsAg prevalence, % (95% CI)
Children born after HepB introduction
Democratic Republic of the Congo* 2013–2014 (DHS) Nationwide 0−5 yrs 277 2.20 (0.3−4.1)
Ethiopia 2017–2018 (PHIA) Nationwide (Urban) 0−14 yrs§ 4,729 1.48 (NR)
5−9 yrs 539 3.34 (NR)
10−14 yrs 655 3.05 (NR)
Mauritania 2019–2021 (DHS) Nationwide 1−4 yrs 2,642 0.70 (NR)
5−9 yrs 3,447 0.40 (NR)
10−14 yrs 2,939 2.40 (NR)
Nigeria** 2018 (NAIIS) Nationwide 2−4 yrs 2,968 4.50 (3.6−5.6)
5−9 yrs 3,620 6.60 (5.5−7.9)
2−9 yrs 6,588 5.80 (5.0−6.6)
Rwanda†† 2018–2019 (PHIA) Nationwide 10−14 yrs 869 0.00 (NR)
Sierra Leone§§ 2018 (Household-based survey) 3 of 5 provinces 4−30 mos 1,889 1.30 (0.8−2.0)
5−9 yrs 2,025 1.60 (1.1−2.3)
Uganda¶¶ 2016–2017 (PHIA) Nationwide 0−14 yrs 10,345 0.60 (NR)
Zambia*** 2016 (PHIA) Nationwide 0−14 yrs††† 8,015 1.30 (NR)
Women of reproductive age
Burkina Faso§§§ 2010–2011 (DHS) Nationwide 15−49 yrs 8,056 7.80 (7.1−8.6)
Cameroon¶¶¶ 2017–2018 (PHIA) Nationwide 15−49 yrs 1,058 6.00 (NR)
Democratic Republic of the Congo* 2013–2014 (DHS) Nationwide 15−59 yrs 368 3.80 (NR)
Kenya**** 2018–2019 (PHIA) Nationwide 15−49 yrs 1,652 2.70 (NR)
Mauritania 2019–2021 (DHS) Nationwide 15−49 yrs 4,420 6.40 (NR)
Nigeria** 2018 (NAIIS) Nationwide 15−49 yrs 8,682 6.10 (5.1−7.0)
Rwanda†† 2018–2019 (PHIA) Nationwide 15−49 yrs 1,813 1.20 (NR)
Sierra Leone§§ 2018 (Household based survey) 3 of 5 provinces 15−49 yrs 1,776 9.80 (8.1−11.7)
Tanzania†††† 2016–2017 (PHIA) Nationwide 15−49 yrs 615 3.70 (NR)
Uganda¶¶ 2016–2017 (PHIA) Nationwide 15−49 yrs 1,4716 3.10 (NR)
Zambia*** 2016 (PHIA) Nationwide 15−59 yrs 1,0973 4.10 (NR)
Antenatal screening of pregnant women
Nigeria§§§§ 2019 (ANC screening in HIV facilities) Nationwide (34 of 36 states) NA 200,473 3.94 (NR)

Abbreviations: ANC = antenatal care; DHS = demographic and health survey; HBsAg = hepatitis B virus surface antigen; HepB = hepatitis B vaccine; HIV = human immunodeficiency
virus; NA = not applicable; NAIIS = Nigeria HIV/AIDS Indicator and Impact Survey; NR = not reported; PHIA = population-based HIV impact assessment survey.
* https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6609197/pdf/tpmd180883.pdf
https://onlinelibrary.wiley.com/doi/full/10.1111/hiv.13457
§ Includes children and adolescents aged 11–13 years born before HepB introduction.
https://dhsprogram.com/pubs/pdf/FR373/FR373.pdf
** https://global-hepatitis.com/wp-content/uploads/2023/04/GHS2023-Abstract-Book-ONLINE_4.pdf?utm_source=mobile+app&utm_medium=link&utm_campaign=abstract-book (abstract no. 047)
†† https://phia.icap.columbia.edu/wp-content/uploads/2020/11/RPHIA-Final-Report_Web.pdf
§§ https://www.sciencedirect.com/science/article/pii/S0264410X22003607
¶¶ https://phia.icap.columbia.edu/wp-content/uploads/2020/02/UPHIA_Final_Report_Revise_07.11.2019_Final_for-web.pdf
*** https://phia.icap.columbia.edu/wp-content/uploads/2019/03/ZAMPHIA-Final-Report__2.26.19.pdf
††† Includes children and adolescents aged 11–14 years born before the introduction of HepB.
§§§ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6239015/
¶¶¶ https://phia.icap.columbia.edu/wp-content/uploads/2021/09/53059-CAMPHIA-Report_EN_WEB_August1.pdf
**** https://phia.icap.columbia.edu/kenya-final-report-2018/
†††† https://phia.icap.columbia.edu/wp-content/uploads/2020/02/FINAL_THIS-2016-2017_Final-Report__06.21.19_for-web_TS.pdf
§§§§ https://pubmed.ncbi.nlm.nih.gov/34387113/

TABLE 3. Policies and interventions to prevent mother-to-child transmission of hepatitis B virus and tier eligibility* for the path to elimination of mother-to-child transmission of hepatitis B virus — World Health Organization African Region, 2021Return to your place in the text
Policies and interventions No. (%) of countries with policy or intervention present or not present
Present Not present
National strategic plan for viral hepatitis 21 (45) 26 (55)
National plan for triple elimination of HIV, syphilis, and hepatitis B§ 21 (45) 26 (55)
National guidelines for antenatal HBsAg testing and maternal treatment, 17 (36) 30 (64)
ANC1 coverage ≥90%**,†† 29 (62) 16 (34)
HepB-BD coverage ≥90%§§ 2 (4) 45 (96)
HepB-BD coverage ≥50%§§ 6 (13) 41 (87)
HepB3 coverage ≥90%§§ 16 (34) 31 (66)
Eligibility for bronze tier for path to elimination of MTCT of HBV *,§§ 1 (2)
Eligibility for silver tier for path to elimination of MTCT of HBV *,§§ 3 (6)
Eligibility for gold tier for path to elimination of MTCT of HBV *,§§ 2 (4)

Abbreviations: ANC1 = at least 1 antenatal care visit; HBsAg = hepatitis B surface antigen; HBV = hepatitis B virus; HepB-BD = birth dose of monovalent hepatitis B vaccine; HepB3 = three doses of a hepatitis B containing vaccine; MTCT = mother-to-child transmission; WHO = World Health Organization.
* Eligibility for tier certification on the path to elimination of MTCT of HBV is based on immunization interventions. Bronze tier: 1) ≥90% coverage of HepB3 infant vaccination, and 2) implementation of universal timely HepB-BD policy. Silver tier: ≥90% coverage of HepB3 infant vaccination, 2) ≥50% coverage of universal timely HepB-BD, and 3) availability of antenatal HBsAg testing in the public sector. Gold tier: 1) ≥90% coverage of HepB3 infant vaccination, 2) ≥90% coverage of universal timely HepB-BD, and 3) >30% coverage of antenatal HBsAg testing. Indicators for each tier should be achieved for ≥2 years. https://www.who.int/publications/i/item/9789240039360
https://www.afro.who.int/publications/viral-hepatitis-scorecard-2021-african-region
§ All 21 priority countries reported by WHO regional office: Angola, Botswana, Burundi, Cameroun, Chad, Côte d’Ivoire, Democratic Republic of the Congo, Eswatini, Ethiopia, Ghana, Kenya, Lesotho, Malawi, Mozambique, Namibia, Nigeria, Uganda, South Africa, Tanzania, Zambia, and Zimbabwe.
Included in national testing and treatment guidelines.
** https://data.unicef.org/resources/dataset/maternal-newborn-health/
†† Data are not available for two (4%) countries (Mauritius and Seychelles).
§§ WHO-UNICEF estimates. https://immunizationdata.who.int/pages/coverage/HEPB.html


Suggested citation for this article: Kabore HJ, Li X, Alleman MM, et al. Progress Toward Hepatitis B Control and Elimination of Mother-to-Child Transmission of Hepatitis B Virus — World Health Organization African Region, 2016–2021. MMWR Morb Mortal Wkly Rep 2023;72:782–787. DOI: http://dx.doi.org/10.15585/mmwr.mm7229a2.

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