Epidemiology of Hepatitis B and C in Republic of Indonesia

Seroconversion among children with HBsAg-positive mothers in Indonesia and factors affecting the anti-HBs titers

Background and aim

Around 2% of newborns are at risk of hepatitis B virus (HBV) infection from their mothers. To prevent this, infants born to HBsAg-positive mothers are given hepatitis B immune globulin (HBIG) and hepatitis B (HB) vaccine as immunoprophylaxis. This study aims to investigate the efficacy of immunoprophylaxis in infants born to HBsAg-positive mothers and the contributing factors.

Methods

The study was conducted on a group of 87 children, ranging from nine months to under 36 months, born to HBsAg-positive mothers and received immunoprophylaxis within 24 h after birth followed by a national immunization schedule at the Community Health Center (CHC) in three administrative cities of DKI Jakarta. We measured the levels of HBsAg and anti-HBs, and utilized ordinal logistic regression models to identify factors that influence the anti-HBs titers after vaccination.

Results

Out of 87 children, only one child had positive HBsAg results. The data showed that 88.5% of the children had seroprotection with anti-HBs levels ≥10 mIU/mL. Additionally, 48.3% of the children had a high protective response with anti-HBs levels ≥100 mIU/mL, while 11.5% had a non-protective response. Children under one year of age, with a family history of HBV carriers, and who received five doses of the HB vaccine exhibited higher levels of anti-HBs titer category with adjusted OR 3.9 (95%CI: 1.3-11.6), 5.3 (95%CI: 1.1-27.4), and 8.3 (95%CI: 2-34.8), respectively.

Conclusion

The administration of HBIG and HB vaccine successfully prevented vertical transmission, resulting in a high seroprotection rate.

The effectiveness of hepatitis B vaccine in toddlers based on the five-year period national basic health research (Riskesdas 2007, 2013 and 2018) in Indonesia

Background

Hepatitis B is a viral infection that has a high prevalence in Indonesia. The Ministry of Health of Indonesia has conducted a national vaccination program for hepatitis B. In order to evaluate the success of the hepatitis B vaccination in Indonesia, a community study based on basic health research (Riskesdas) was performed nationwide since 2007 for five year period in 2007, 2013, and 2018.

Methods

Further statistical analysis was performed specifically for the children under 59 months old (toddlers) immunized in both urban and rural areas in 2007, 2013, and 2018 based on certain characteristics by examining antibodies against HBsAg (anti-HBs), IgG antibodies against the core antigen (HBcAb), surface antigen (HBsAg) of hepatitis B virus (HBV). The data obtained from the data management laboratory of Ministry of Health, Indonesia, was analyzed with Bivariate analysis with continuity correction chi-square or Pearson chi-square using Stata software version 16.

Results

This study showed an increase in hepatitis B coverage of complete immunization (30% in 2007, 60.3% in 2013, and 57% in 2018), which was also influenced by mothers' level of education (Pearson chi-square , p ¡ 0.05) and access to health service points within 30 minutes (OR = 1.3-2.8, p ¡ 0.05). The trend of the percentage of immune status (anti-HBs) was increased (41.8% in 2007; 56.1% in 2013; and 79.1% in 2018). The higher anti-HBs was found in complete hepatitis B immunization status (OR = 1.5-2, p ¡ 0.05) and in good nutritional status (p ¡ 0.05). However, the anti-HBs was found decreased with increasing age (p ¡ 0.05). The trend of positive HBcAb (exposure to HBV infection) showed a decrease gradually of almost ten times from 2007 (8.6%-13.5%) compared to 2013 (2.6%-11.1%) and 2018 (1.1%-2%). Urban areas were at higher risk of hepatitis B exposure (OR = 1.4-2.2) than rural areas (OR = 0.37-0.80). The HBsAg data were only available in 2013 and 2018. Riskesdas data analysis showed the prevalence of hepatitis B (HBsAg) was lower in complete immunization status than that in incomplete one (p ¡ 0.05), but with an increase from 3.9% (2013) to 9.3% (2018), possibly due to inappropriate implementation of birth dose immunization or a vaccine-escape mutant from the HBV variants.

Conclusions

The effectiveness of hepatitis B vaccine obtained from the three Riskesdas periods in Indonesia showed an improvement, with an increase in immune status, reduced exposure to HBV and a lower prevalence of hepatitis B in children with complete vaccination. However, there is still an increase in hepatitis B infection, especially in urban areas. Therefore, a long-term evaluation of immunization coverage especially ensuring that the initial dose of immunization was given within the first 24 h of birth, HBsAg and HBcAb, nutritional status, genomic surveillance of HBV, and other aspects of program quality evaluation are needed to ensure that elimination efforts have been implemented properly.

Host Factors in the Natural History of Chronic Hepatitis B: Role of Genetic Determinants

BACKGROUND

The host immune system plays an important role in hepatitis B virus (HBV) infection manifestation. Genetic polymorphisms of several inflammatory cytokines, including TNF-α and IL-10, have been associated with chronic hepatitis B (CHB) progression, although with contradicting results. CHB progression can be categorized into four phases, immune tolerance (IT), immune clearance (IC), low/no replicative (LR), and e-negative hepatitis (ENH), with HBeAg seroconversion as an important milestone. Here, we determined the association of TNF-α (rs1800629) and IL-10 (rs1800896 and rs1800872) SNPs in the context of CHB natural history progression, particularly to HBeAg seroconversion, in Indonesian CHB patients.

METHODS

A total of 287 subjects were recruited and categorized into distinct CHB phases based on HBeAg, viral load, and ALT levels. TNF-α and IL-10 SNPs were determined using PCR-RFLP and confirmed with direct sequencing. The association between SNP genotypes with CHB dynamics was determined using logistic regression presented as odds ratio (OR) with 95% CI.

RESULTS

No significant association was found between IL-10 -592A/C polymorphism and progression of IT and IC to LR, IT and IC to ENH, and LR to ENH phases in all the gene models. IL-10 rs1800896 and TNF-α rs1800629 could not be analyzed using logistic regression. Subjects' age (≥40 years old) was significantly associated with IT and IC to LR (OR: 2.191, 95% CI 1.067-4.578, P = 0.034), IT and IC to ENH (OR: 7.460, 95% CI 3.316-18.310, P < 0.001), and LR to ENH (OR: 5.252, 95% CI 2.010-14.858, P = 0.001). Male gender was associated with LR to ENH (OR: 4.077, 95% CI 1.605-11.023, P = 0.004).

CONCLUSIONS

Age and male gender were associated with CHB phase progression instead of the TNF-α and IL-10 polymorphisms. It would be beneficial to study not only the effect of host determinants but also the viral factor to understand the mechanisms of CHB phase progression.

Association Between Serum IL-6, IL-10, IL-12, and IL-23 Levels and Severity of Liver Cirrhosis

Background

Liver cirrhosis contributes to high liver-related mortality globally. Systemic inflammation mediated by immune cells contributes to the progression of liver cirrhosis. Growing evidence shows that several pro- and anti-inflammatory cytokines might have an important role in liver cirrhosis.

Objective

To evaluate the association between serum IL-6, IL-10, IL-12, and IL-23 levels and severity of liver cirrhosis.

Methods

This observational study was carried out at the Department of Internal Medicine, Universitas Sumatera Utara, Indonesia from March 2018 to August 2019. The severity of liver cirrhosis was assessed by using the Child-Pugh score. IL-6, IL-10, IL-12, and IL-23 levels, hepatitis and renal function were measured in all study subjects. Independent t-test and Mann-Whitney tests were conducted to observe differences between groups.

Results

A total of 78 liver cirrhosis patients were enrolled, mean age was 50.6±11.4. Median serum IL-6, IL-10, IL-12, and IL-23 levels were 24.5(2.6-46.4)pg/ml, 2.1(0.4-9.3)pg/ml, 3.5(1.4-20.8)pg/ml and 20.3(9.2-218)pg/ml, respectively. A higher IL-6 level was associated with more severe liver cirrhosis (p=0.001) and the presence of hepatic encephalopathy (p=0.018). Higher IL-23 level was found in patients with no hepatic encephalopathy (p=0.049). There was no association between serum cytokines levels and hepatitis viral infection status.

Conclusion

IL-6 is associated with the severity of liver cirrhosis.

Acute Kidney Injury and Jaundice in a Patient With Concurrent Severe Malaria and Acute Exacerbation of Hepatitis B

Patients chronically infected with hepatitis B virus (HBV) may travel to areas with high endemicity of malaria. The overlap between malaria and HBV infection can be clinically severe and present a diagnostic challenge as both diseases manifest similar symptoms. This case describes a fatal case of a 43-year-old man with chronic HBV infected with Plasmodium falciparum malaria that presents as acute kidney injury (AKI) and jaundice following a trip to malaria-endemic region. Despite administering antimalarial and 6 courses of renal replacement therapy, the patient’s clinical condition did not improve, leading to septic shock, multi-organ dysfunction, and eventually, death. AKI and jaundice are commonly seen in severe P. falciparum malaria, as well as acute exacerbation of chronic HBV. This case emphasizes the importance to consider malarial screening when evaluating sick returning travelers, even in those with underlying chronic HBV. Given the severity of coinfection, prompt identification of this overlap can avert the rapid deterioration of severe malaria by early administration of intravenous artesunate and renal replacement therapy.

Knowledge Gaps in Understanding the Etiology of Anemia in Indonesian Adolescents

BACKGROUND

Anemia is a public health problem among adolescents in Indonesia. Strategies to prevent or treat anemia should be tailored to local conditions, taking into account its specific etiology and prevalence in a given setting and population group.

OBJECTIVE

This review aims to (1) identify and synthesize the current knowledge on the etiology of anemia among adolescents in Indonesia, (2) reveal knowledge gaps in this area, and (3) suggest directions for future research and programmatic work.

METHODS

We systematically searched PubMed, Web of Science, Scopus, Medline, and WorldCat databases for peer-reviewed journal articles to identify which etiological factors were related to anemia among Indonesian adolescents. Research papers were reviewed and included in the review according to inclusion criteria.

RESULTS

Of 13 studies, 8 showed that anemia was associated with iron deficiency; 4 are suggestive of vitamin A deficiency; and 2 of folic acid deficiency. Five studies underscore different etiological determinants for anemia, such as malaria, protein and energy malnutrition, vitamin B2 deficiency, calcium, and vitamin C deficiency. Based on these findings, we developed a framework on knowledge gaps on the etiology of anemia among adolescents in Indonesia, divided in 3 levels of knowledge: (1) significant knowledge gaps, (2) knowledge gaps, and (3) established knowledge.

CONCLUSIONS

The knowledge gaps around the etiology of anemia among Indonesian adolescents are significant. Our framework emphasizes the need for further research across all etiological factors, namely inadequate nutritional intake and absorption, genetic hemoglobin disorders, infection and inflammation, and menstrual disorders.

Genotype Distribution of Vitamin D Receptor Polymorphisms among Indonesian Patients with Chronic Hepatitis B

Background

Chronic hepatitis B is a necro-inflammatory of the liver parenchyma caused by hepatitis B virus (HBV) infection leading to liver cirrhosis and hepatocellular carcinoma (HCC). Genetic variants including single nucleotide polymorphisms (SNPs) within genes regulating immune response may contribute to the progression of chronic hepatitis B (CHB) infection. This study aimed to examine the genotype distribution of vitamin D receptor (VDR) polymorphism among patients with CHB infection and to study its association with the development of cirrhosis and hepatoma.

Methods

This cross-sectional study analysed 75 CHB patients, consisting of 36 CHB patients without cirrhosis, 25 CHB patients with cirrhosis, and 14 CHB patients with hepatoma. VDR polymorphism was examined using the Amplification Refractory Mutation System Polymerase Chain Reaction (ARMS-PCR) method.

Results

Alanine aminotransferase (ALT) and alpha fetoprotein (AFP) levels did not show any significant differences between study groups, but albumin levels in CHB patients with cirrhosis and hepatoma were significantly lower than CHB patients without cirrhosis (p< 0.05). In contrast, the bilirubin levels in CHB patients with cirrhosis was higher than in CHB patients' cirrhosis. The most common genotypes of VDR polymorphisms were Ff (57.3%), TT (72%), aa (48%) and bb (74.7%) for Fok1, Taq1, Apa1 and Bsm1 respectively. There was no significant different in the genotype distribution of VDR polymorphism between CHB patients without cirrhosis and CHB with cirrhosis or hepatoma.

Conclusion

This study suggest that VDR gene polymorphism may not contribute to the progression of CHB infection.

The High Prevalence of Negative Hepatitis B Surface Antibody (Anti-HBs) among Pregnant Women in Bandung, Indonesia: A Community-Based Study

BACKGROUND

Hepatitis B virus (HBV) infection is a disease that creates a high global burden by affecting approximately 3.5% of the total world population. The main transmission of this disease is from mother to child (MTCT). HBV vaccination program was already initiated in Indonesia in 1987. However, after three decades, the HBV infection prevalence stays stagnant. This study aimed to explore the seroprevalence of HBV markers and the attributable risk factors of pregnant women at risk of transmitting HBV to their offspring.

METHOD

A cross-sectional study was conducted on pregnant women from primary midwifery and obstetric clinics across Bandung, Indonesia, to assess the HBsAg, anti-HBc, and anti-HBs serological markers. Questionnaire-based interviews were used to obtain the sociodemographic determinants. Logistic regression was applied to assess the association of each determinant factor to positive HBsAg or negative anti-HBs as a dependent variable, which was then reported as odds ratios (OR).

RESULTS

A total of 196 subjects were recruited with 12/196 (6.1%) of them were positive HBsAg. After exclusions of those with positive HBsAg and anti-HBc, 24/175 (13.7%) women were isolated as positive anti-HBs, leaving 151/175 (86.3%) women with negative anti-HBs who were susceptible to HBV infection. Low body mass index (BMI) less than 18.5 kg/m² was a risk factor for positive HBsAg with OR = 5.850 (95% CI 1.466-23.34), p = 0.012. Nevertheless, no significant determinant factor was associated with negative anti-HBs.

CONCLUSION

Most pregnant women in Bandung, Indonesia, are susceptible to HBV infection, as marked by the negative anti-HBs status.

Liver diseases in the Asia-Pacific region: a Lancet Gastroenterology & Hepatology Commission

The Asia-Pacific region is home to more than half of the global population and accounted for 62·6% of global deaths due to liver diseases in 2015. 54·3% of global deaths due to cirrhosis, 72·7% of global deaths due to hepatocellular carcinoma, and more than two-thirds of the global burden of acute viral hepatitis occurred in this region in 2015. Chronic hepatitis B virus (HBV) infection caused more than half of the deaths due to cirrhosis in the region, followed by alcohol consumption (20·8%), non-alcoholic fatty liver disease (NAFLD; 12·1%), and chronic infection with hepatitis C virus (HCV; 15·7%). In 2015, HBV accounted for about half the cases of hepatocellular carcinoma in the region. Preventive strategies for viral hepatitis-related liver disease include increasing access to clean drinking water and sanitation. HBV vaccination programmes for neonates have been implemented by all countries, although birth-dose coverage is extremely suboptimal in some. Availability of screening tests for blood and tissue, donor recall policies, and harm reduction strategies are in their initial stages in most countries. Many governments have put HBV and HCV drugs on their essential medicines lists and the availability of generic versions of these drugs has reduced costs. Efforts to eliminate viral hepatitis as a public health threat, together with the rapid increase in per-capita alcohol consumption in countries and the epidemic of obesity, are expected to change the spectrum of liver diseases in the Asia-Pacific region in the near future. The increasing burden of alcohol-related liver diseases can be contained through government policies to limit consumption and promote less harmful patterns of alcohol use, which are in place in some countries but need to be enforced more strictly. Steps are needed to control obesity and NAFLD, including policies to promote healthy lifestyles and regulate the food industry. Inadequate infrastructure and insufficient health-care personnel trained in liver diseases are issues that also need to be addressed in the Asia-Pacific region. The policy response of most governments to liver diseases has thus far been inadequate and poorly funded. There must be a renewed focus on prevention, early detection, timely referral, and research into the best means to introduce and improve health interventions to reduce the burden of liver diseases in the Asia-Pacific region.

An expert review on the use of tenofovir alafenamide for the treatment of chronic hepatitis B virus infection in Asia

Asia has intermediate-to-high prevalence and high morbidity of hepatitis B virus (HBV) infection. The use of guideline-recommended nucleos(t)ide analogs with high barrier to resistance, such as entecavir (ETV), tenofovir disoproxil fumarate (TDF), and tenofovir alafenamide (TAF), is one of the key interventions for curbing HBV infection and associated morbidity in Asia. However, there are some challenges to the use of ETV and TDF; while ETV is associated with high resistance in lamivudine (LAM)-exposed (especially LAM-refractory) patients; bone and renal safety issues are a major concern with TDF. Hence, a panel of twenty-eight expert hepatologists from Asia convened, reviewed the literature, and developed the current expert opinion-based review article for the use of TAF in the resource-constrained settings in Asia. This article provides a comprehensive review of two large, phase 3, double-blind, randomized controlled trials of TAF versus TDF in HBeAg-negative (study 0108) and HBeAg-positive (study 0110) chronic HBV patients (> 70% Asians). These studies revealed as follows: (1) non-inferiority for the proportion of patients who had HBV DNA < 29 IU/mL; (2) significantly high rate of normalization of alanine aminotransferase levels; (3) no incidence of resistance; and (4) significantly better bone and renal safety, with TAF vs. TDF up to 144 weeks. Considering the benefits of TAF, the expert panel proposed recommendations for optimizing the use of TAF in Asia, along with guidance on specific patient groups at risk of renal or bone disease suitable for TAF therapy. The guidance provided in this article may help clinicians optimize the use of TAF in Asia.

Comparative efficacy of sofosbuvir-ribavirin versus sofosbuvir-daclatasvir for treatment of chronic hepatitis C in an area with limited NS5A inhibitor availability

INTRODUCTION

Sofosbuvir (SOF) and daclatasvir (DCV) regimens are recommended for all genotypes of hepatitis C virus (HCV) infection. However, DCV accessibility is still low in several low- and middle-income countries. Ribavirin (RBV) is more affordable and has been known for chronic HCV treatment along with SOF or interferon. The aim of this study was to assess the efficacy of SOF + RBV and SOF + DCV regimens for treatment of chronic HCV in Indonesia.

METHODS

We conducted a retrospective study among patients with chronic HCV who were treated with SOF. Data on SOV + RBV were collected from 2015 to 2016, while those on SOF + DCV were collected from 2016 to 2017. The baseline characteristics were recorded from the medical record unit in Cipto Mangunkusumo General Hospital, Jakarta, Indonesia. The primary outcome was the achievement of sustained virological response at 12 weeks (SVR12).

RESULTS

Of 309 patients, 64.4% (199/309) had genotype 1 infections, 29.8% (92/309) had cirrhosis, and 4.9% (15/309) had co-infection with human immunodeficiency virus (HIV). At the end of treatment (EOT), 99.3% (136/137) patients in the SOF + RBV group and 99.4% (164/165) in SOF + DCV group had no detectable viral load. The criterion for SVR12 was met in 90.8% (109/120) patients in SOF + RBV regimen and 98.2% (108/110) in SOF + DCV regimen. Among patients with cirrhosis, 84.4% (38/45) patients and 100% (27/27) achieved SVR12 in the SOF + RBV and SOF + DCV groups, respectively.

CONCLUSION

SOF + DCV regimen had higher SVR rates compared to SOF + RBV regimen (p = 0.034). However, both the regimens showed an impressive outcome, with overall SVR12 rates above 90%, irrespective of presence of cirrhosis and HCV genotype. In non-structural protein 5A inhibitor limited setting, SOF + RBV regimen still can be used as treatment for HCV infection, particularly in non-cirrhotic patients.

Comparison of ARIMA and GM(1,1) models for prediction of hepatitis B in China

Background

Hepatitis B virus (HBV) infection is a major public health threat in China for China has a hepatitis B prevalence of more than one million people in 2017 year. Disease incidence prediction may help hepatitis B prevention and control. This study intends to build and compare 2 forecasting models for hepatitis B incidence in China.

Methods

Autoregressive integrated moving average (ARIMA) model and grey model GM(1,1) were adopted to fit the monthly incidence of hepatitis B in China from March 2010 to October 2017. The fitting and forecasting performances of the 2 models were evaluated. The better one was adopted to predict the incidence from November 2017 to March 2018. Database was built by Excel 2016 and statistical analysis was completed using R 3.4.3 software.

Results

Descriptive analysis showed that the incidence of hepatitis B in China has seasonal variation and has shown a downward trend from 2010 to 2017. We selected the ARIMA (3,1,1) (0,1,2)₁₂ model among all the ARIMA models for it has the lowest AIC value. Model expression of GM (1,1) was X⁽¹⁾ (k + 1) = 3386876.7478e^0.0249k − 3289206.7428. The root mean square error (RMSE), mean absolute error (MAE) and mean absolute percentage error (MAPE) of ARIMA(3,1,1)(0,1,2)₁₂ model were lower than GM(1,1) model on fitting part and forecasting part. According to the forecast results, the incidence may have a slight fluctuation during the following months.

Conclusions

The ARIMA model showed better hepatitis B fitting and forecasting performance than GM(1,1) model. It is a potential decision supportive tool for controlling hepatitis B in China before a predictive hepatitis B outbreak.

Seroepidemiology of HBV infection among health-care workers in South Sulawesi, Indonesia

BACKGROUND

Hepatitis B virus (HBV) infection is a world health problem with an estimated 257 million chronically infected people. Indonesia, with 7.1% prevalence of hepatitis B surface antigen (HBsAg), is classified as a moderately endemic country. Healthcare workers (HCWs) are at high occupational risk for HBV infection and potentially becoming transmitters for further infections. In Indonesia, the extent of hepatitis B among HCWs and specific control strategy are not available. This study evaluated the seroprevalence of HBV infection and associated risk factors in HCWs from four areas in South Sulawesi, Indonesia.

METHODS

A total of 467 HCWs (median age 28 years, male/female 89/378) were recruited. All HCWs were classified into three age groups (< 20-29, 30-39, and ≥ 40 years old), three work types (administration, non-intervention, and intervention), and three service periods (< 5, 5-9, and ≥ 10 years). Data on socio-demographic characteristics and risk factors were obtained by questionnaire and serum samples were tested for HBV markers (HBsAg, its antibody [anti-HBs], and antibody to core antigen [anti-HBc]. Chi-square or Fisher's exact test was used to determine differences in categorical variables, while risk factors were reported as odds ratios (OR).

RESULTS

The prevalence of current HBV infection (HBsAg+), exposure to HBV (anti-HBc+), and immunity to HBV (anti-HBs+) was 6.2, 19.2, and 26.1%, respectively. Two thirds (66.17%) of all HCWs did not express any of HBV markers. In relation to the age groups, intervention work-type, and service period of HCWs, increasing trends were observed in the exposure to HBV (p < 0.001, p < 0.001, and p < 0.010, respectively) and the immunity to HBV by natural infection (HBsAg-, anti-HBc+, anti-HBs+) (p = 0.004, p < 0.001, and p < 0.010, respectively). Needlestick injury contributed the highest risk factor (OR = 1.71; 95% CI: 1.05-2.77; p = 0.029) for infection acquisition, which mostly occurred in the intervention group (p = 0.046).

CONCLUSION

Exposure to HBV showed significant association with HCWs' age, work type, and service period. Needlestick injury was the highest risk factor for the acquisition of HBV, with highest events in the intervention work-type. Two thirds of HCWs were still susceptible to HBV infection. Intervention strategies at the national level are required to mount prevention, control, and management of HBV infection in HCWs.

Hepatitis B Virus Infection among Health Care Workers in Indonesia

Hepatitis B virus (HBV) infection is a global health problem with an estimated 257 million chronically infected people. Indonesia is a moderately hepatitis B-endemic country with 7.1% prevalence of hepatitis surface antigen (HBsAg). This infection is considered as an important occupational hazard among health care workers (HCWs), who may become further transmitters of this infection. The extent of hepatitis B among HCWs and specific control strategy are not available in Indonesia. A study was done on 644 HCWs, who were categorized into administration, nonintervention, and intervention groups. The prevalence of HBsAg, antibody to HBV core antigen (anti-HBc), and antibody to HBsAg (anti-HBs) was 4.7, 18.5, and 36.7% respectively, while 57.3% were negative for all seromarkers, indicating susceptibility to this infection. Increasing trend with age was observed in the exposure to infection (anti-HBc) (p <0.001) and the marker of resolved infection (HBsAg-, anti-HBc+, anti-HBs+) (p = 0.004), suggesting accumulated exposure to HBV infection by increasing age. Rising trend of exposure rate was also observed across the administration, nonintervention, and intervention groups (p < 0.001). By length of service period, significant escalation of exposure (p = 0.010) and resolved infection (p < 0.001) were also observed, suggesting increasing occupational risk to HBV infection. There is an urgent need to safeguard the HCWs with hepatitis B vaccination and provide continuing education at various health care setups. The establishment of a national policy and a roadmap for effective and efficient intervention is required for the prevention, diagnosis, postexposure management, and treatment of HBV infection in this special population.

How to cite this article: Muljono DH, Wijayadi T, Sjahril R. Hepatitis B Virus Infection among Health Care Workers in Indonesia. Euroasian J Hepato-Gastroenterol 2018;8(1):88-92.