Delayed introduction of the birth dose of Hepatitis B vaccine in EPI programs in East Africa: a missed opportunity for combating vertical transmission of Hepatitis B

Impact of a performance monitoring intervention on the timeliness of Hepatitis B birth dose vaccination in the Gambia: a controlled interrupted time series analysis

INTRODUCTION

The Hepatitis B virus that can cause liver cancer is highly prevalent in the Gambia, with one in ten babies at risk of infection from their mothers. Timely hepatitis B birth dose administration to protect babies is very low in The Gambia. Our study assessed whether 1) a timeliness monitoring intervention resulted in hepatitis B birth dose timeliness improvements overall, and 2) the intervention impacted differentially among health facilities with different pre-intervention performances.

METHODS

We used a controlled interrupted time series design including 16 intervention health facilities and 13 matched controls monitored from February 2019 to December 2020. The intervention comprised a monthly hepatitis B timeliness performance indicator sent to health workers via SMS and subsequent performance plotting on a chart. Analysis was done on the total sample and stratified by pre-intervention performance trend.

RESULTS

Overall, birth dose timeliness improved in the intervention compared to control health facilities. This intervention impact was, however, dependent on pre-intervention health facility performance, with large impact among poorly performing facilities, and with uncertain moderate and weak impacts among moderately and strongly performing facilities, respectively.

CONCLUSION

The implementation of a novel hepatitis B vaccination timeliness monitoring system in health facilities led to overall improvements in both immediate timeliness rate and trend, and was especially helpful in poorly performing health facilities. These findings highlight the overall effectiveness of the intervention in a low-income setting, and also its usefulness to aid facilities in greatest need of improvement.

Dynamics of Hepatitis B infection prevention practices among pregnant women attending antenatal care at Lubaga Hospital Kampala, Uganda using the constructs of information-motivation-behavioural skills model

BACKGROUND

Hepatitis B virus (HBV) infection is considered a significant global public health challenge with infectivity as well as estimated potential for transmission more than 50 to 100 times that of HIV. Over time, numerous empirical studies have shown that majority of HBV-related yearly global deaths are secondary to carcinoma of the liver. It is also known that HBV infected Women have the potential to transmit the infection vertically to their infants during pregnancy. This accounts for the WHO reported 3.16% prevalence among children less than 5 years of age in Uganda. This study assessed the predictors of HBV infection prevention practices among eligible consenting pregnant women using Lubaga health facility for antenatal care (ANC).

METHODS

A cross-sectional descriptive study employing quantitative data collection based on the constructs of IMB model was used to capture data on the study variables among 385 randomly selected eligible pregnant women attending antenatal care at Lubaga hospital between September 2020 and October 2020. Data derived from the quantitative instrument was analysed by data reduction and transformation to summaries of descriptive statistics using (SPSS version 26) and regression analysis was performed to establish characteristics of the association between the variables with significance level set as (p < 0.05). Chi-square goodness-of-fit test was employed for significant differences in the proportion of dichotomous responses.

RESULTS

The findings showed that more than half of the respondents (59%) were between the ages of 18 and 28 and majority of them (42.3%) had secondary education. Furthermore, an average but inadequate knowledge ([Formula: see text] 5.97 ± 6.61; B = 0.57; p < .001), positive perception ([Formula: see text] 17.10 ± 18.31; B = 0.97; p = .014) and good behavioural skills ([Formula: see text] 12.39 ± 13.37; B = 0.56; p < .001) for adopting prevention practices all statistically predicted the averagely acceptable level of prevention practices ([Formula: see text] 15.03 ± 16.20) among the study respondents as measured on rating scales of 12, 33, 21 and 30 respectively.

CONCLUSION AND RECOMMENDATION

There were observed gaps in their knowledge about some basic features of the infection like transmission and risk factors as well as some misperceptions about vaccination despite the relatively average score level for both, which is likely to influence their prevention behaviours and predispose them to the risk of the infection if actions are not taken. Therefore, personalized health education is needed during antenatal visits and subsequent health campaign in order to inform better prevention practices among this vulnerable population group.

Enduring Challenges despite Progress in Preventing Mother-to-Child Transmission of Hepatitis B Virus in Angola

Sub-Saharan Africa has one of the highest rates of hepatitis B virus (HBV) infection globally, with an incidence of 1.5 million and 0.8 million yearly deaths, which drives synergistic efforts towards its elimination. To assess the risk of mother-to-child transmission of HBV infection, a cross-sectional study was conducted on 1012 pregnant women in Angola to investigate HBV serological and molecular profiles. The prevalence of HBV was 8.7% (n = 88), with hepatitis B core IgM antibody (anti-HBc IgM) positivity identified in 12.8%, hepatitis B "e" antigen (HBeAg) positivity in 30%, and HBV DNA ≥ 200,000 IU/mL in 28.2%. Family tracking studied 44 children, of which 11 (25%) received at least two doses of the hepatitis B vaccine. HBV was detected in 10/44 (22.7%) children, with vaccination reported in one infected child. Further testing identified anti-HBc IgM positivity in 3/10 (30%), HBeAg positivity in 55%, and both seromarkers in 20%. The results revealed the importance of antenatal HBV screening, antiviral prophylaxis for mothers with high viral loads or HBeAg positivity, and timely first-dose hepatitis B vaccines in newborns. Anti-HBc IgM positivity among pregnant women and children highlights prophylactic measures worth considering, including antenatal hepatitis B vaccination and catch-up vaccination to young children.

The impact of the timely birth dose vaccine on the global elimination of hepatitis B

In 2016 the World Health Organization set the goal of eliminating hepatitis B globally by 2030. Horizontal transmission has been greatly reduced in most countries by scaling up coverage of the infant HBV vaccine series, and vertical transmission is therefore becoming increasingly dominant. Here we show that scaling up timely hepatitis B birth dose vaccination to 90% of new-borns in 110 low- and middle-income countries by 2030 could prevent 710,000 (580,000 to 890,000) deaths in the 2020 to 2030 birth cohorts compared to status quo, with the greatest benefits in Africa. Maintaining this could lead to elimination by 2030 in the Americas, but not before 2059 in Africa. Drops in coverage due to disruptions in 2020 may lead to 15,000 additional deaths, mostly in South-East Asia and the Western Pacific. Delays in planned scale-up could lead to an additional 580,000 deaths globally in the 2020 to 2030 birth cohorts.

Hepatitis and tuberculosis testing are much less common than HIV testing among adults in Kisumu, Kenya: results from a cross-sectional assessment

Background

Kenya has a high burden of HIV, viral hepatitis, and tuberculosis. Screening is necessary for early diagnosis and treatment, which reduces morbidity and mortality across all three illnesses. We evaluated testing uptake for HIV, viral hepatitis, and tuberculosis in Kisumu, Kenya.

Methods

Cross-sectional data from adults aged 18–35 years who enrolled in a prospective HIV incidence cohort study from February 2017 to May 2018 were analyzed. A questionnaire was administered to each participant at screening for study eligibility to collect behavioral characteristics and to assess prior testing practices. Among participants without a history of previously-diagnosed HIV, multivariable robust Poisson regression was used to estimate prevalence ratios (PRs) and 95% confidence intervals (CIs) for factors potentially associated with HIV testing in the 12 months prior to enrollment. A hierarchical model was used to test for differential access to testing due to spatial location.

Results

Of 671 participants, 52 (7.7%) were living with HIV, 308 (45.9%) were female, and the median age was 24 (interquartile range 21–28) years. Among 651 (97.0%) who had ever been tested for HIV, 400 (61.2%) reported HIV testing in the past 6 months, 129 (19.7%) in the past 6–12 months, and 125 (19.1%) more than one year prior to enrollment. Any prior testing for viral hepatitis was reported by 8 (1.2%) participants and for tuberculosis by 51 (7.6%). In unadjusted models, HIV testing in the past year was more common among females (PR 1.08 [95% CI 1.01, 1.17]) and participants with secondary education or higher (PR 1.10 [95% CI 1.02, 1.19]). In the multivariable model, only secondary education or higher was associated with recent HIV testing (adjusted PR 1.10 [95% CI 1.02, 1.20]). Hierarchical models showed no geographic differences in HIV testing across Kisumu subcounties.

Conclusions

Prior HIV testing was common among study participants and most had been tested within the past year but testing for tuberculosis and viral hepatitis was far less common. HIV testing gaps exist for males and those with lower levels of education. HIV testing infrastructure could be leveraged to increase access to testing for other endemic infectious diseases.

Hepatitis B birth dose vaccination for newborns in Uganda: A qualitative inquiry on pregnant women's perceptions, barriers and preferences

BACKGROUND

Sub-Saharan Africa continues with very low hepatitis B (HBV) birth dose vaccination coverage. To guide policy on HBV vaccine for newborns, we explored perceptions, barriers and preferences of pregnant women regarding HBV and the HBV birth dose vaccination.

METHODS

We conducted eight focus groups discussions (FGDs) among 70 pregnant women, stratified by rural-urban residence, age and education level, using a structured focus group discussion guide to explore birth dose awareness, perceptions, barriers and preferences. Data were transcribed, coded and analysed using framework analysis.

RESULTS

Perceptions related to HBV and liver cancer causes and prevention were diverse; most FGD participants did not perceive illnesses as distinctly different. Older women-groups, both urban and rural, had never heard about HBV, but were aware of liver cancer, viewing the disease as fatal. No FGD participants were aware of HBV birth dose. Concerns included vaccine safety, its availability to women who deliver outside the health system and mistrust in health-care worker (HCWs) when handling newborns. Rural-dwelling groups perceived absence of HBV services, while FGDs with young participants believed vaccine side-effects hampered birth dose planning. Most women-groups preferred (i) oral to injectable vaccines; (ii) receiving birth dose education during antenatal, to media-based education; (iii) that newborns receive the birth dose immediately after delivery in the mother's presence.

CONCLUSION

Although the birth dose is acceptable among pregnant women, planners need to continuously engage them as key stakeholders during planning to address concerns, in order to raise confidence, maximize uptake and strengthen HBV eradication efforts.

Seroprevalence of Hepatitis B Virus and Associated Factors Among Pregnant Women Attending Antenatal Care in Public Health Facilities in Jigjiga Town, Eastern Ethiopia

Background

Hepatitis B virus (HBV) remains a major global public health problem affecting millions of people across the world. The risk of developing a chronic hepatitis B virus infection is affected by the age at the time of acquiring infection. For instance, around 95% of these infections are acquired during the perinatal period. Although evidences indicate the wider effects of hepatitis B virus and its negative consequences, there are limited studies and a scarcity of data in Eastern Ethiopia. Therefore, this study was aimed at determining seroprevalence of HBV and associated factors among pregnant women attending antenatal care in the public health facilities of Jigjiga town, Eastern Ethiopia, from March 4 to April 4, 2019.

Methods

A facility-based cross-sectional study was employed among pregnant women in the public health facilities of Jigjiga town, Eastern Ethiopia. A total of 589 pregnant women were enrolled in the study using a systematic sampling technique. Data were collected using a pretested interviewer administered questionnaire. Five milliliters of venous blood samples was collected and tested for HBV using ELISA diagnostic test. The collected data were entered in to Epidata version 3.1 and exported to SPSS version 20 for statistical analysis. Descriptive statistics was carried out using frequency tables and summary measures. Multivariable analysis was done to identify the true effects of the selected predictor variables on the outcome variable after controlling for possible confounders. Statistical significance was declared at p-value <0.05.

Results

Overall, 8.5% (95% CI: 6.5–10.7) of the study participants were seropositive for HBsAg. Having any surgical history [AOR = 3.41, 95% CI (1.26–9.24)], family history of HBV [AOR = 4.96, 95% CI (2.11–10.60)], history of sharing sharps [AOR = 2.78, 95% CI (1.13–6.83)] and having multiple sexual partners [AOR = 6.12, 95% CI (2.12–17.64)] were significant predictors of HBV infection.

Conclusion

The seroprevalence of HBV was relatively high in this study area. Having a history of surgery, family history of hepatitis, history of sharing sharps and multiple sexual partners were significantly associated with HBV infection. Therefore, health information dissemination and awareness creation on mode of transmission of HBV are very crucial.

Prevalence of hepatitis B virus infection and associated risk factors among pregnant women attending antenatal clinic in Mulago Hospital, Uganda: a cross-sectional study

AIM

To determine the prevalence and factors associated with hepatitis B virus infection among pregnant women attending antenatal clinic in Mulago Hospital.

DESIGN

Cross-sectional observational study.

SETTING

Mulago National Referral Hospital, Uganda, antenatal clinic.

PARTICIPANTS

We randomly selected 340 pregnant women attending their first antenatal visit at Mulago Hospital antenatal clinic.

PRIMARY OUTCOME

Hepatitis B surface antigen positivity.

RESULTS

We recruited 340 participants, with a mean age of 27±5.7 years, and a median gravidity of 3. The prevalence of hepatitis B virus infection among pregnant women attending the antenatal clinic in Mulago Hospital, in our study, was 2.9% (95% CI 1.58% to 5.40%, n=10). Factors positively associated with hepatitis B virus infection were: marital status (adjusted OR (aOR)=11.37, p=0.002), having a hepatitis B positive family member (aOR=49.52, p<0.001) and having had a blood or body fluid splash to mucous membranes from a hepatitis B positive patient (aOR=61.69, p=0.015). Other factors such as age, socioeconomic status, number of sexual partners, HIV serostatus, piercing of ears and history of blood transfusion were not significantly associated with hepatitis B virus infection in this study.

CONCLUSION

The prevalence of hepatitis B virus infection among pregnant women attending antenatal clinic in Mulago Hospital was of intermediate endemicity. We found that marital status, having a hepatitis B positive family member at home and having had a blood or body fluid splash to mucous membranes from a hepatitis B positive patient were independently associated with hepatitis B infection. Factors such as age, HIV status, history of blood transfusion, piercing of ears and social status were not associated with hepatitis B status in this study.

Correlates of hepatitis B awareness and disease-specific knowledge among pregnant women in Northern and Central Uganda: a cross-sectional study

Introduction

Countries in sub-Saharan Africa with a high hepatitis B burden also have limited resources to identify underlying drivers of disease among key at-risk populations. To improve prioritization and strengthen prevention of mother to child transmission of HBV, it is imperative to understand disease awareness, knowledge and related factors among pregnant women.

Objectives

This study assessed HBV disease awareness, knowledge and related factors among pregnant women in public health facilities in two regions with diverse HBV disease epidemiology.

Methods

From October 2016 through December 2017, a random sample of 455 pregnant women attending antenatal clinics were surveyed to assess HBV awareness, knowledge and associated factors. Participants responded to an 18-item questionnaire with themes on HBV awareness, knowledge of disease signs and symptoms, transmission, prevention and misconceptions about the disease. Results were analysed in STATA (version 14.0).

Results

Of 455 participants enrolled, about two thirds reported having heard about HBV disease. By region, nearly half (47%) of participants from the central region, compared to only 16% from the north, reported that they had never heard of HBV. Region of residence had a moderating effect on the education- HBV awareness relationship. Only 162/455 (36%) of participants had adequate HBV knowledge. More than half 256/455 (56%) and 242/455 (53%) were not knowledgeable about horizontal and mother to child HBV transmission, respectively. About two thirds 298/455 (66%) and 281/455 (62%) believed HBV was spread via sharing of utensils and mosquito bites respectively. In multiple regression analysis, residing in the north, (PR=1.91(1.53 -2.38), p < 0.001) compared to central region and having a secondary education (PR=1.87(1.37 -2.55), p < 0.001) compared to primary were statistically significantly related to being knowledgeable about HBV.

Conclusion

We demonstrated marked regional differences in HBV disease awareness and knowledge in this high HBV prevalence setting. However, most pregnant women displayed unacceptably low HBV knowledge and a significant proportion still hold misconceptions about HBV. Interventions to improve HBV prevention through antenatal education will need to be tailored to existing differences in comprehensive HBV knowledge.

Elimination of Vertical Transmission of Hepatitis B in Africa: A Review of Available Tools and New Opportunities

PURPOSE

This review article focuses on preventing vertical transmission of hepatitis B virus (HBV) among pregnant women living in sub-Saharan Africa (SSA), where disease is endemic and the estimated maternal HBV seroprevalence is >8%. Available interventions that have been studied in low- and middle-income countries are compared in terms of efficacy and effectiveness in clinical practice. Global disease-elimination targets, barriers to HBV-prevention efforts, and critical research gaps are discussed.

METHODS

A PubMed literature search in February 2018 identified relevant studies of interventions to reduce or prevent the transmission of HBV during pregnancy or in the peripartum period. Studies that focused on interventions that are currently available or could be made available in SSA were included. Trials conducted in SSA and other low-income countries were prioritized, although studies of interventions in middle- and high-income countries were included.

FINDINGS

Among 127 studies and reports included in the review, 60 included data from SSA. The most cost-effective intervention to reduce HBV infection rates in SSA is timely birth-dose vaccination followed by completion of the 3-dose infant-vaccination series. The identification and treatment of pregnant women with elevated HBV viral load to further reduce the risk for vertical transmission in SSA show promise, but efficacy and tolerability trials in Africa are lacking.

IMPLICATIONS

Scale-up of currently available tools is required to reach HBV disease-elimination goals in SSA. Many countries in SSA are in the process of rolling out national birth-dose vaccination campaigns; this roll out provides an opportunity to evaluate and improve processes in order to expand coverage. Early antenatal care, promotion of facility deliveries, and increased awareness of HBV prevention are also key components of prevention success. Future studies in SSA should identity an HBV-prevention package that is effective, well tolerated, and feasible and can be administered in the antenatal clinic and tailored to vertical-transmission risk.