2024 latest report on hepatitis B virus epidemiology in China: current status, changing trajectory, and challenges

Introduction

Hepatitis B virus (HBV) infection is a major public health problem worldwide and among the most prevalent causes of liver cirrhosis, liver cancer, and viral hepatitis-related fatalities (1). The World Health Organization (WHO) estimated that the global seroprevalence of hepatitis B surface antigen (HBsAg) is 3.2%, with 254 million individuals chronically infected with HBV and ~820,000 people succumbing to HBV-related disorders by 2024 (2). To take proactive measures towards the sustainable development goal of preventing and treating hepatitis, the WHO sanctioned the “Global Health Sector Strategy on Viral Hepatitis” in 2016, setting an objective to eliminate viral hepatitis as a public health menace by 2030, with the aim of reducing new infections by 90% and mortality by 65%. Therefore, HBV infection remains a formidable challenge leading to a significant disease burden (3).

China is facing a substantial burden of hepatitis B infection. According to a recent estimation, approximately 75 million people in China are afflicted with hepatitis B, accounting for nearly one-third of the 254 million individuals chronically infected with HBV worldwide (4-6). From 1970 to 1992, owing to loopholes in domains such as injection and blood transfusion management, there was an explosive increase in HBV carriers in China. With the incorporation of the hepatitis B vaccine into planned immunization management, utilization of immunoglobulins, advancement of medical technology, and continuous enhancement of people’s awareness regarding HBV, the number of chronic hepatitis B (CHB) infections in China significantly declined. From 1992 to 2020, health officials in China conducted four nationally representative serological surveys to monitor and evaluate national HBV prevention and control circumstances (4,7). The latest HBV Epidemic Status survey was conducted in 31 provinces (cities and autonomous regions) across the country in 2020 (4), initiated by the “13th Five-Year Plan” for Infectious Diseases. This survey encompassed 91,896 individuals, and the latest national HBV serological survey results were disclosed for 2024 (4). Additionally, based on a previous report from 2016 to 2020, the WHO officially released the latest Global Hepatitis Report 2024, which is the first comprehensive report integrating the epidemiology of viral hepatitis, covering the scope of services provided, and offering data on improved actions (5).

Overall, the prevalence of HBsAg among the general population in China and children aged 1–4 years has decreased significantly. The prevalence of HBsAg among the general population of China is 5.86% (75 million), which is higher than the global average of 3.2%. Among the survey participants, approximately 58.78% of those aged ≥15 years and older who were infected with hepatitis B were aware of their infection status, which was higher than the previous estimate. Additionally, 17% of the respondents with known indications for antiviral therapy were administered it, while the corresponding global data were only 13% (2,4).

The latest data on the HBV prevalence in China holds significant value for both national and global efforts to eliminate the burden of hepatitis. It highlights the remarkable achievements made in hepatitis prevention and control in China over the past few decades and underscores the ongoing challenges in the fight against hepatitis. We systematically analyzed the current status and evolving trends of hepatitis prevention and control in China by integrating data from recent national surveys, the Chinese Center for Disease Control and Prevention, and the WHO reports (4-6). By summarizing the progress and disparities in hepatitis B elimination efforts over the past 30 years, we identified the key difficulties impacting current prevention and control measures. This review provides crucial data to support future planning for major infectious disease control, the establishment of national key research programs, and the implementation of hepatitis elimination strategies.

Steady decrease in HBsAg prevalence among the general population in China

Over the past 30 years, the prevalence of HBsAg among the general population of China has been steadily declining. The latest national serum survey in 2020 indicated that the current prevalence in China is 5.86%, representing a 39.9% decrease compared with that in 1992 (8) (Figure 1). Specifically, the most significant decline was among children under five years of age, exceeding 96% from 1992 to 2020 and dropping from 9.67% to 0.30%. HBV was once highly endemic (HBsAg prevalence ≥8%) in China, with serosurveys in 1992 revealing a 9.72% prevalence of HBsAg (8). China implemented comprehensive strategies to prevent HBV transmission, including immunization, promotion of safe injection practices, blood donation screening, and surveillance. China transitioned to a higher intermediate endemic area for HBV infection (HBsAg prevalence, 5–7.99%) (7,9). National surveys have shown a decrease in the prevalence of HBsAg in the general Chinese population, from 9.72% in 1992 to 7.18% in 2006. International studies have estimated 79–86 million cases of chronic HBV infections in China (10).

Figure 1 Trends in HBsAg prevalence in China (1992–2020), stratified by age (<5, 5–14, 15–29, and ≥30 years). Data from the fourth national serological survey, 2020 (4). CI, confidence interval; HBsAg, hepatitis B surface antigen.

Nevertheless, the latest national survey conducted in 2020 revised these data; ~75 million cases of chronic HBV infection exist in China. According to recent international model estimations, the prevalence of HBsAg in China is expected to reach approximately 5.0% by 2024, approaching the level of a lower-intermediate endemic area (10) (Figure 2).

Figure 2 Global prevalence of HBsAg across different regions, 2024. Data from Polaris database of HBsAg prevalence global distribution (6). HBsAg, hepatitis B surface antigen.

Furthermore, a meta-analysis of HBV infections in China from 1973 to 2021 revealed that the seroprevalence of HBsAg varied among the major regions/territories of China (Figure 3). All patients, except those in Hong Kong witnessed a decline in HBsAg seroprevalence (11). Further, North China shows the lowest HBsAg seroprevalence [2.5%, 95% confidence interval (CI): 2.2–2.8%] among six regions in China. Decline in HBsAg seroprevalence was observed at the provincial level during this period, although at different magnitudes. Overall HBsAg seroprevalence varied more than 3.5-fold at the provincial level, with the highest prevalence observed in Tibet and the lowest seroprevalence observed in Beijing and Shanxi. The disequilibrium in HBV infection rates across Chinese mainland may be predominantly explained by the differential coverage and initiation time of HBV vaccination among regions (12). The HBV infection rate was higher in Taiwan and Hong Kong than that in Chinese mainland, which might be mainly due to the high historical prevalence of HBV infection, despite excellent vaccination coverage (10,13-15).

Figure 3 HBsAg prevalence among the major regions/territories of China, 2006–2021. Data from meta-analysis for HBsAg seroprevalence in the general population in China (11). HBsAg, hepatitis B surface antigen.

Nationwide meta-analyses and annual percentage change (APC) analyses have also revealed a significant decline in HBsAg seroprevalence in both men (from 8.8% in 1973–1992 to 4.6% in 2006–2021) and women (from 6.3% in 1973–1992 to 3.9% in 2006–2021). The HBsAg seroprevalence was significantly higher in men than in women (Figure 4). However, the rate of decline was twice as fast in men as in women during the study period (APC: −3.90 vs. −1.82), thereby reducing sex-specific differences over time. Similarly, both rural and urban populations exhibited significant declines in HBsAg seroprevalence, with a stronger trend observed in urban areas (APC =−4.34, 95% CI: −4.74 to −3.93) compared to rural areas (APC =−3.01, 95% CI: −3.78 to −2.24) (Figure 4). The urban-rural disparity might be attributed to the relatively scarce medical resources in the rural areas of our country. Therefore, all aspects, including the government, healthcare providers, and communities, should make joint efforts to curb HBV transmission in rural populations.

Figure 4 Gender and rural-urban disparities in HBsAg prevalence, 2006–2021. Data from meta-analysis for HBsAg seroprevalence in the general population in China (11). HBsAg, hepatitis B surface antigen.

Additionally, variations in HBsAg seroprevalence trends by age were examined, revealing declines across most age groups, including individuals aged <5 years, 5–14 years, 15–29 years, and ≥30 years (4,11) (Figure 1). Over the past four decades, there has been a 7.7% annual decrease in HBsAg seroprevalence in children aged <5 years, reflecting the success of China’s immunization strategy. Notably, there was an increase in HBV prevalence among persons ≥60 years, reflecting long-lasting infection acquired in early childhood (16). For older adults aged >60 years, all were born before 1960, that is, 20–30 years before the initiation of HBV vaccination. In addition to the absence of preventive measures at that time, the high prevalence of HBV infection is expected to have contributed to the elevated HBV seroprevalence in older birth cohorts (11).

According to a 2024 WHO hepatitis report, the global prevalence of HBV infection will be 3.2% (254 million cases) in 2022 (5). China is situated in the Western Pacific Region, where the prevalence rate of HBV was the second highest worldwide at 5.0% (96.8 million cases), surpassed only by the African Region with a rate of 5.8% (64.7 million cases) (Figure 1) (2). The WHO estimated that the prevalence of HBsAg in China in 2022 would be approximately 5.6%, constituting 31.5% of the global rate and 82.2% of that in the Asia-Pacific region. These outcomes were comparable to those of a survey in China (4). Although the prevalence rate of HBsAg in China has declined significantly, due to the large number of the HBV-infected population infected with the HBV, there still exists a relatively heavy disease burden.

Goal of HBV transmission elimination in China

China’s strategies for the prevention of HBV transmission focus on neonatal vaccination, elimination of mother-to-child transmission (MTCT) and blood-borne transmission. In regions where hepatitis B is prevalent, including China, MTCT during childbirth is the primary source of chronic HBV infection, which is estimated to contribute to 30–50% of new cases (17). The WHO Global Health Sector Strategy on Viral Hepatitis aims to eliminate hepatitis B as a public health threat by 2030, with a reduction in the prevalence of HBsAg positivity to below 0.1% in children aged 5 years (18,19).

First of all, hepatitis B vaccination is the most effective method for preventing HBV infection. China initiated a universal infant hepatitis B vaccination (HepB) program in 1992, recommending a timely birth dose (TBD) of HepB and a full 3-dose regimen. In 2005, the government began providing free Hep B vaccination services to all newborns. To reduce the MTCT rate of HBV further, China launched a program for the Triple Elimination of MTCT for human immunodeficiency virus (HIV), syphilis, and HBV (PMTCT) in 2011. This program-free routine prenatal screening program for HBsAg prescribes additional antiviral drugs to HBsAg-positive women during pregnancy. The PMTCT program also ensures free hepatitis B immunoglobulin (HBIG) for all infants born to HBsAg-positive women (20).

Owing to these efforts, in China, coverage rates for three-dose HepB have increased from 30.0% in 1992 to 99.6% in 2020, while TBD coverage from 22.2% to 95.6% during the same period (21) (Figure 5). Compared to the most recent global data, only 85% of infants received three doses of HepB before 1 year of age, 46% received TBD coverage, and 14% received HBIG along with the full vaccination regimen (2). According to the latest 2020 nationwide seroprevalence survey, the prevalence of HBsAg in children has decreased significantly from 9.67% in 1992 to 0.30% in 2020 nationwide seroprevalence survey (4). In the meanwhile, the global HBsAg prevalence among children aged 5 years or younger was estimated to be 0.7% (95% CI: 0.6–1.0%), corresponding to 5.6 million (95% CI: 4.5–7.8) children with HBV infection (2). Consequently, the HBsAg prevalence among children under 5 years of age in China is lower than the global average but still above the global goal of <0.1% by 2030. This demonstrates China’s significant efforts and accomplishments in hepatitis B prevention through immunization programs.

Figure 5 HBV vaccination coverage in China during 2004–2022 period, including timely birth dose of HepB and the full 3-dose regime. Data from WHO and the UNICEF database based on national vaccination progress reports (http://apps.who.int/gho/data/node.main.A824?lang=en) (22). HBV, hepatitis B virus; HepB, hepatitis B vaccination; TBD, timely birth dose; WHO, World Health Organization; UNICEF, United Nations International Children’s Emergency Fund.

Prevention of MTCT of HBV in China is also manifested in the comprehensive management of HBsAg-positive women of childbearing age. The prevalence of HBsAg among Chinese women aged 15–49 years in their childbearing years significantly decreased from 8.18% in 1992 to 6.61% in 2006, and further decreased to 5.87% in 2020. Stratified age analysis revealed that the prevalence of HBsAg among women at peak childbearing ages (20–29 and 30–39 years old) decreased to 2.83% and 5.89%, respectively, representing a reduction of 65.02% and 27.91%, respectively, compared to that in 1992. Furthermore, for women aged between 15 and 19 years who will enter the highest fertility age within the next 5 years, HBsAg prevalence has been reduced to <1% (4).

A real-world study (the SHIELD program) involving 30,109 pregnant women in China demonstrated that the overall nationwide MTCT rate (vertical transmission in pregnant women with HBV infection) was as low as 0.23% (23). Among HBV infected pregnant women, those with hepatitis B e-antigen (HBeAg) typically exhibit elevated HBV DNA levels and significantly higher MTCT rates (24-26). In 2020, 12.73% of HBsAg-positive women of childbearing age tested positive for HBeAg, representing a decrease from the proportion observed in 2006 (23.50%) (25,27,28). Initiating oral antiviral therapy during the second or third trimester of pregnancy in women with high HBV DNA levels can reduce the MTCT of HBV (29). Finally, the SHIELD program indicated that with comprehensive management, including passive and active immunoprophylaxis of infants and antiviral prophylaxis of mothers, the HBV MTCT rate decreased to 0.16% in hospitals and 0.03% in community settings (23).

In addition, ensuring blood and injection safety plays a critical role in cutting off the bloodborne transmission of HBV. Since 2015, China has achieved 100% coverage of HBV nucleic acid testing for donations at blood banks. To ensure safe injections in health facilities, China has officially prohibited the reuse of disposable sterile medical devices in healthcare settings since 2000, and all reusable injection equipment had been eliminated in 2010 (30). Also, the government provides clean syringes to injection drug users to reduce HBV transmission via contaminated injection paraphernalia. Between 2014 and 2021, each injection drug user received approximately 240 clean needles per year (31). By the end of 2021, there were 578 needle exchange sites across 11 provinces. Therefore, a significant reduction in HBV transmission through blood has been witnessed.

Lack of timely diagnosis and standard treatment is the primary challenge in hepatitis B prevention

Timely diagnosis and standardized treatment are crucial strategies for reducing HBV-related mortality, and their deficiency is the primary challenge in HBV prevention. WHO has set a target for HBV diagnosis and antiviral treatment rates to reach 90% and 80% respectively by 2030. However, in 2023, the Polaris Observatory Collaborators estimated that among 257.5 million HBsAg positive individuals worldwide, only 36.0 million will be diagnosed, and only 6.8 million of the estimated 83.3 million eligible for treatment will receive antiviral treatment (2). The diagnostic rate in China is slightly higher than that globally, with 58.78% of individuals with positive HBsAg already aware of their status through screening or testing prior to the survey (4). Among those who were aware of their HBV infection status, 38.25% had indications for antiviral treatment, whereas only 17.33% had received it (4).

It is estimated that at least 30 million HBsAg-positive individuals in China are still unaware of their infection status; thus, they are unable to receive standardized diagnosis and treatment. Additionally, ~14 million individuals in need of antiviral treatment for HBV have not received intervention (4). The estimated Chinese HBV testing rate in the 2020 survey data has not yet reached the WHO target, but is significantly higher than the global average at that time and exceeds previous estimates of 20–36% (4,30). Moreover, the Chinese government mandates that medical institutions screen for hepatitis B in all pregnant women during antenatal care and in patients undergoing surgery, hospitalization, hemodialysis, or invasive diagnosis and treatment. Free hepatitis B screening for pregnant women and blood donors as well as a significant increase in the number of surgeries among inpatients (from 14.0 million in 2002 to 50.8 million in 2016) have greatly improved the detection and diagnosis of HBV infection (32).

Current antiviral drugs can suppress HBV replication and reduce liver disease progression, which is necessary for most patients with CHB. These include entecavir (ETV), tenofovir disoproxil fumarate (TDF), and tenofovir alafenamide fumarate (TAF) (33). Since 2005, the guidelines for the prevention and treatment of CHB in China have undergone five editions: the 2005, 2010, 2015, and 2019 editions, and the latest 2022 edition. The latest 2022 guidelines have expanded the scope of HBV antiviral therapy compared to 2019, potentially increasing the number of individuals requiring antiviral therapy in China to more than the previously estimated 17 million (34). The 2024 version of the WHO Hepatitis B Prevention and Treatment Guidelines also includes expanding the population eligible for treatment as an important revision, aiming to enable at least 50% of HBsAg-positive individuals to receive antiviral treatment (35). However, there are differences in treatment thresholds between the Chinese and WHO guidelines, particularly regarding whether patients with HBV DNA <2,000 IU/mL and aged >30 years need to initiate antiviral therapy.

Achieving coverage for HBV diagnosis and treatment remains a challenging target, both in China and globally. According to our country’s latest guideline, it is estimated that nearly 95% of patients with detectable HBV DNA are eligible for antiviral treatment (36). By incorporating the WHO guideline recommendations, CHB patient treatment coverage can be further increased by lowering AST to platelet ratio index (APRI) diagnostic thresholds and alanine aminotransferase (ALT) treatment thresholds, potentially expanding China’s CHB patient treatment coverage rate (37).

Spectrum of liver disease due to hepatitis B has changed in recent 3 decades

A major concern associated with chronic HBV infection lies in its potential long-term complications, with approximately 15–40% of patients at risk of developing liver cirrhosis, hepatocellular carcinoma (HCC), liver transplantation (LT), and HBV-related death (38). The 2020 national serological survey on HBV was the first to incorporate research into the liver disease status of a population positive for HBsAg. Among individuals aged ≥15 with positive HBsAg, the weighted proportions of carriers (with no evidence of liver damage), CHB (with liver enzyme abnormalities), cirrhosis, and suspected HCC were 78.03%, 19.63%, 0.84%, and 0.15% respectively (4).

The annual reduction in the prevalence of HBV infection has also influenced the spectrum of HBV-related liver diseases. The age-standardized incidence rate (ASIR) and age-standardized DALY rate (ASDR) were used to quantify the disease burden of HBV infection. Based on data from the Global Burden of Diseases Study 2019 (GBD 2019), the ASIRs for global acute hepatitis, cirrhosis, other chronic liver diseases, and liver cancer decreased from 1990 to 2019 (39). A similar trend has been observed in China. Enhanced vaccination coverage and the accessibility of highly effective nucleos(t)ide analogs have contributed to the gradual decline in the ASIR of HBV-associated diseases in China [APC, −2.3 (−2.4 to 2.1)] (40). For instance, the ASIR of acute hepatitis B in China dropped from 2,699.35/100,000 in 1990 to 1,384.26/100,000 in 2019, representing a 48.7% reduction. Similarly, there has been a decline in the ASIRs and ASDRs for HBV-related liver cancers over the recent 30 years (40). Among other liver diseases that cause liver cancer, ASIRs and ASDRs have remained stable in alcohol-related liver cancer and have increased in metabolic dysfunction-associated steatotic liver disease (MASLD) (41,42).

According to the 2024 WHO Global Hepatitis Report, an estimated 1.3 million people will die from viral hepatitis in 2022, which is a communicable disease with increasing mortality. Among them, hepatitis B was responsible for 1.1 million. Although China has effectively prevented perinatal HBV infections, the burden of previous chronic HBV infections remains high in the general population. National surveys in China have consistently indicated a decline in the prevalence of HBsAg among individuals over 50 years of age, reflecting excess or premature deaths due to HBV cirrhosis and HCC, which is consistent with the aging of the HBsAg-positive population and the natural history of HBV infection. In China, HBV-related liver diseases account for over 30% of the global HBV mortality, with 0.308 million deaths per year.

From 1990 to 2019, the net drift of incidence and mortality was −2.3% (−2.4–2.2%) and −5.6% (−5.8–5.3%) per year, respectively, for HBV-associated diseases (40), indicating a rapid decrease in incidence and mortality in China. In 2019, the number of HBV-associated deaths was ~162,000, among which liver cancer caused the highest mortality rate (5.8 per 100,000), followed by cirrhosis [2.2 per 100,000 for HBV, 2.3 per 100,000 for hepatitis C virus (HCV)] and acute hepatitis (<1 per 100,000 for HBV or HCV). Deaths from various liver diseases caused by hepatitis B decreased from 1990 to 2019 by 74.83%, 34.71%, and 23.34% for acute hepatitis, cirrhosis, other chronic liver diseases, and liver cancer, respectively (43). Specifically, alcohol use was regarded to be associated with the deaths of HBV-related cirrhosis and other chronic liver diseases, with a large proportion (57.9%) of mortality among those patients being attributable to alcohol use (40,44).

Challenges and future directions of HBV control in China

Although China has made significant progress in interrupting the transmission of HBV, the burden of HBV-related diseases remains substantial (Table 1). While the HBsAg prevalence in the general population has decreased to 5.86%, a nearly 20% reduction compared to the previous survey, it remains relatively high globally, slightly above the 5.0% prevalence rate in the Western Pacific region. Due to China’s large population, approximately one-third of the world’s HBV carriers are in China, contributing to a considerable remaining disease burden. The global Hepatitis Policy Index (HPI) trends from 2019 to 2023 indicate that there is still significant room for improvement in China’s HBV elimination policy (46). Furthermore, the prevalence of HBsAg among middle-aged and elderly individuals shows an upward trend. In particular, for individuals aged over 60 years, all were born prior to 1960, 20–30 years before the initiation of the HBV vaccination program. The lack of preventive measures at that time, coupled with the high prevalence of HBV infection, likely contributed to the elevated HBV seroprevalence in older birth cohorts (11).

As mentioned above, less than 60% of the HBsAg patients are aware of their infectious status and less than 20% receive interventions in China. Considering the current disease burden of HBV infection, future efforts should prioritize diagnosis and antiviral therapy. First, it is crucial to enhance screening strategies, improve early accessibility, and increase HBV diagnosis rates. A 2022 study on the cost-effectiveness of universal screening for chronic HBV infection in China concluded that a five-test universal screening strategy for individuals aged 18–70 years, to be implemented within the next decade, represents the optimal approach for China and could prevent 3.46 million liver-related deaths (47). For the antiviral treatment, both guidelines and consensuses on HBV prevention in China and globally have expanded the indications recently. Another Modeling shows that implementing a universal treatment strategy for HBsAg-positive individuals has the highest cost-effectiveness (48).

Additionally, for chronic HBV carriers, significant challenges persist in attaining the targets to reduce mortality. In 2019, hepatitis B-related liver diseases led to 162,000 deaths in China, with over 98% attributable to cirrhosis and other chronic liver diseases caused by hepatitis B (26.04%) and liver cancer caused by hepatitis B (72.18%) (43). The GBD data revealed that HBV accounted for 68% of cirrhosis cases and 65% of HCC cases in China, whereas the corresponding figures were 42% and 56% globally (49). Although a downward trend in the mortality of liver disease caused by HBV has been observed, HBV is still a major cause of liver disease-related mortality in China and many other countries such as India and Nigeria (40,43,50). For HBV-related complications such as HCC, regular monitoring is critical for early detection and treatment, which are significant in improving patient survival (51). On the other hand, for individuals who are positive for HBV DNA, one of the ideal therapeutic goals is to achieve clinical cure (also referred to as functional cure). Antiviral treatment should be initiated as early as possible to minimize inflammation and fibrosis, thereby reducing the incidence of end-stage liver disease. Previous studies have shown that the proportion of patients achieving clinical cure of hepatitis B after long-term treatment remains below 10%. However, China’s recent combination therapy strategy has successfully raised the HBV clinical cure rate to over 30% for the first time (52). Over the next decade, achieving functional cure for CHB patients remains a major challenge for the international medical community, and new drug targets and therapeutic strategies need further development.

Last but not least, there are still regional disparities in HBV screening and treatment. Therefore, through resource decentralization, establishing community-based, population-wide HBV screening, referral systems, and standardized treatment will contribute to the construction of a more comprehensive hepatitis B prevention and control system. In addition, national drug price negotiations and collective procurement significantly reduce the cost of antiviral medications, thereby increasing treatment accessibility. For instance, the monthly cost of TDF has decreased from 1,500 CNY to below 10 CNY after collective procurement. This initiative helps reduce the disparities in HBV control across different geographic regions, urban and rural areas, and social-economic groups.

In conclusion, over the past three decades, China has made remarkable progress in controlling HBV infection through comprehensive strategies, particularly universal vaccination programs. However, significant challenges remain in achieving WHO’s 2030 HBV elimination targets. Future efforts should focus on expanding screening strategies, improving treatment accessibility, and addressing regional healthcare disparities to achieve the elimination goals.

Acknowledgments

Funding: This work was supported by grants from the National High-Level Hospital Clinical Research Funding (No. 2022-PUMCH-B-034 to Y.M.), Chinese Academy of Medical Sciences Initiative for Innovative Medicine (No. 2021-I2M-1-058 to Y.M.), National Natural Science Foundation of China (No. 32271470 to H.Y., 82300754 to L.S.), Beijing-Tianjin-Hebei Basic Research Cooperation Special Project (No. 22JCZXJC00200 to Y.M.).

Footnote

Peer Review File: Available at https://hbsn.amegroups.com/article/view/10.21037/hbsn-2024-754/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://hbsn.amegroups.com/article/view/10.21037/hbsn-2024-754/coif). H.Y. and S.D. serve as the unpaid editorial board members of HepatoBiliary Surgery and Nutrition. Y.M. serves as the Editor-in-Chief of HepatoBiliary Surgery and Nutrition. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Dusheiko G, Agarwal K. Delineating the global challenges of hepatitis B virus infection. Lancet Gastroenterol Hepatol 2018;3:372-3. [Crossref] [PubMed]
2. Global prevalence, cascade of care, and prophylaxis coverage of hepatitis B in 2022: a modelling study. Lancet Gastroenterol Hepatol 2023;8:879-907. [Crossref] [PubMed]
3. Manne V, Gochanour E, Kowdley KV. Current perspectives into the evaluation and management of hepatitis B: a review. Hepatobiliary Surg Nutr 2019;8:361-9. [Crossref] [PubMed]
4. Hui Z, Yu W, Fuzhen W, et al. New progress in HBV control and the cascade of health care for people living with HBV in China: evidence from the fourth national serological survey, 2020. Lancet Reg Health West Pac 2024;51:101193. [Crossref] [PubMed]
5. WHO. Global Hepatitis Report 2024 1st ed. Geneva: World Health Organization; 2024. Available online: https://www.who.int/publications/b/68511
6. Chinese Center for Disease Control and Prevention. National Epidemic Situation of Notifiable Infectious Diseases in 2023. 2024. Available online: https://www.chinacdc.cn/jksj/jksj01/202410/t20241010_301346.html
7. Cui F, Shen L, Li L, et al. Prevention of Chronic Hepatitis B after 3 Decades of Escalating Vaccination Policy, China. Emerg Infect Dis 2017;23:765-72. [Crossref] [PubMed]
8. Schweitzer A, Horn J, Mikolajczyk RT, et al. Estimations of worldwide prevalence of chronic hepatitis B virus infection: a systematic review of data published between 1965 and 2013. Lancet 2015;386:1546-55. [Crossref] [PubMed]
9. Liu J, Zhang S, Wang Q, et al. Seroepidemiology of hepatitis B virus infection in 2 million men aged 21-49 years in rural China: a population-based, cross-sectional study. Lancet Infect Dis 2016;16:80-6. [Crossref] [PubMed]
10. Global prevalence, treatment, and prevention of hepatitis B virus infection in 2016: a modelling study. Lancet Gastroenterol Hepatol 2018;3:383-403. [Crossref] [PubMed]
11. Liu Z, Lin C, Mao X, et al. Changing prevalence of chronic hepatitis B virus infection in China between 1973 and 2021: a systematic literature review and meta-analysis of 3740 studies and 231 million people. Gut 2023;72:2354-63. [Crossref] [PubMed]
12. Department of Disease Control, Ministry of Health. Chinese Academy of Preventive Medicine. National EPI vaccination and hepatitis B vaccine coverage rate and the related factors: Results from the 1999 nationwide survey. Chinese Journal of Vaccines and Immunization 2000;6:193-7.
13. Allain JP, Opare-Sem O. Screening and diagnosis of HBV in low-income and middle-income countries. Nat Rev Gastroenterol Hepatol 2016;13:643-53. [Crossref] [PubMed]
14. Lin CL, Kao JH. Perspectives and control of hepatitis B virus infection in Taiwan. J Formos Med Assoc 2015;114:901-9. [Crossref] [PubMed]
15. Liu KSH, Seto WK, Lau EHY, et al. A Territorywide Prevalence Study on Blood-Borne and Enteric Viral Hepatitis in Hong Kong. J Infect Dis 2019;219:1924-33. [Crossref] [PubMed]
16. Tang LSY, Covert E, Wilson E, et al. Chronic Hepatitis B Infection: A Review. JAMA 2018;319:1802-13. [Crossref] [PubMed]
17. Xu Y, Liu H, Wang Y, et al. The next step in controlling HBV in China. BMJ 2013;347:f4503. [Crossref] [PubMed]
18. Cooke GS, Andrieux-Meyer I, Applegate TL, et al. Accelerating the elimination of viral hepatitis: a Lancet Gastroenterology & Hepatology Commission. Lancet Gastroenterol Hepatol 2019;4:135-84 Erratum in Lancet Gastroenterol Hepatol 2019;4:e4. [Crossref] [PubMed]
19. Global health sector strategy on viral hepatitis 2016-2021. Towards ending viral hepatitis [cited 2024 Nov 25]. Available online: https://www.who.int/publications/i/item/WHO-HIV-2016.06
20. General Office of the State Council. Prevention of AIDS, Syphilis and Hepatitis B Hepatitis B Mother-to-Child Transmission Implementation Programme. [cited 2024 Nov 23]. Available online: https://www.gov.cn/zwgk/2011-02/24/content_1809480.htm
21. The 2017 China health statistics yearbook. Beijing: China Union Medical University Press; 2017.
22. WHO. Global Health Observatory data repository. [cited 2024 Dec 18]. Available online: https://apps.who.int/gho/data/node.main.A824?lang=en
23. Yin X, Wang W, Chen H, et al. Real-world implementation of a multilevel interventions program to prevent mother-to-child transmission of HBV in China. Nat Med 2024;30:455-62. [Crossref] [PubMed]
24. Lu Y, Song Y, Zhai X, et al. Maternal hepatitis B e antigen can be an indicator for antiviral prophylaxis of perinatal transmission of hepatitis B virus. Emerg Microbes Infect 2021;10:555-64. [Crossref] [PubMed]
25. Hou J, Cui F, Ding Y, et al. Management Algorithm for Interrupting Mother-to-Child Transmission of Hepatitis B Virus. Clin Gastroenterol Hepatol 2019;17:1929-1936.e1. [Crossref] [PubMed]
26. Yin X, Han G, Zhang H, et al. A Real-world Prospective Study of Mother-to-child Transmission of HBV in China Using a Mobile Health Application (Shield 01). J Clin Transl Hepatol 2020;8:1-8. [Crossref] [PubMed]
27. WHO. Prevention of mother-to-child transmission of hepatitis B virus: Guidelines on antiviral prophylaxis in pregnancy [cited 2024 Nov 25]. Available online: https://www.who.int/publications/i/item/978-92-4-000270-8
28. Chen HL, Zha ML, Cai JY, et al. Maternal viral load and hepatitis B virus mother-to-child transmission risk: A systematic review and meta-analysis. Hepatol Res 2018;48:788-801. [Crossref] [PubMed]
29. Pan CQ, Duan Z, Dai E, et al. Tenofovir to Prevent Hepatitis B Transmission in Mothers with High Viral Load. N Engl J Med 2016;374:2324-34. [Crossref] [PubMed]
30. Liu J, Liang W, Jing W, et al. Countdown to 2030: eliminating hepatitis B disease, China. Bull World Health Organ 2019;97:230-8. [Crossref] [PubMed]
31. Tian ML, Xu J, Luo W. Analysis of the current status of needle and syringe exchange programmes for injecting drug users in China. Zhonghua Liu Xing Bing Xue Za Zhi 2022;43:1907-11. [Crossref] [PubMed]
32. Zheng H, Zhang G, Wang F, et al. Self-motivated medical care-seeking behaviors and disease progression in a community-based cohort of chronic hepatitis B virus-infected patients in China. BMC Public Health 2019;19:901. [Crossref] [PubMed]
33. Hou J, Wang G, Wang F, et al. Guideline of Prevention and Treatment for Chronic Hepatitis B (2015 Update). J Clin Transl Hepatol 2017;5:297-318. [Crossref] [PubMed]
34. You H, Wang F, Li T, et al. Guidelines for the Prevention and Treatment of Chronic Hepatitis B (version 2022). J Clin Transl Hepatol 2023;11:1425-42. [Crossref] [PubMed]
35. WHO. Guidelines for the prevention, diagnosis, care and treatment for people with chronic hepatitis B infection [cited 2024 Nov 25]. Available online: https://www.who.int/publications/i/item/9789240090903
36. Zhang M, Kong Y, Xu X, et al. "Treat-all" Strategy for Patients with Chronic Hepatitis B Virus Infection in China: Are We There Yet?. J Clin Transl Hepatol 2024;12:589-93. [Crossref] [PubMed]
37. Wang BQ, Shan S, Kong YY, et al. Comparison of the population covered by the 2024 version of the WHO’s hepatitis B prevention and treatment guidelines and the Chinese antiviral treatment guidelines. Zhonghua Gan Zang Bing Za Zhi 2024;32:525-31. [Crossref] [PubMed]
38. Abara WE, Qaseem A, Schillie S, et al. Hepatitis B Vaccination, Screening, and Linkage to Care: Best Practice Advice From the American College of Physicians and the Centers for Disease Control and Prevention. Ann Intern Med 2017;167:794-804. [Crossref] [PubMed]
39. Cao G, Jing W, Liu J, et al. Countdown on hepatitis B elimination by 2030: the global burden of liver disease related to hepatitis B and association with socioeconomic status. Hepatol Int 2022;16:1282-96. [Crossref] [PubMed]
40. Yue T, Zhang Q, Cai T, et al. Trends in the disease burden of HBV and HCV infection in China from 1990-2019. Int J Infect Dis 2022;122:476-85. [Crossref] [PubMed]
41. Tan EY, Danpanichkul P, Yong JN, et al. Liver cancer in 2021: Global burden of disease study. J Hepatol 2024; [Epub ahead of print]. [Crossref]
42. Testino G, Caputo F. Alcohol-related liver disease. Hepatobiliary Surg Nutr 2024;13:347-51. [Crossref] [PubMed]
43. Cao G, Liu J, Liu M. Trends in mortality of liver disease due to hepatitis B in China from 1990 to 2019: findings from the Global Burden of Disease Study. Chin Med J (Engl) 2022;135:2049-55. [Crossref] [PubMed]
44. Marti-Aguado D, Vilar-Gomez E. Impact of low alcohol consumption in the natural history of cirrhosis. Hepatobiliary Surg Nutr 2024;13:161-4. [Crossref] [PubMed]
45. Institute for Health Metrics and Evaluation [cited 2024 Dec 8]. Global health data results tool. Available online: https://vizhub.healthdata.org/gbd-results
46. Cooke GS, Flower B, Cunningham E, et al. Progress towards elimination of viral hepatitis: a Lancet Gastroenterology & Hepatology Commission update. Lancet Gastroenterol Hepatol 2024;9:346-65. [Crossref] [PubMed]
47. Su S, Wong WC, Zou Z, et al. Cost-effectiveness of universal screening for chronic hepatitis B virus infection in China: an economic evaluation. Lancet Glob Health 2022;10:e278-87. [Crossref] [PubMed]
48. Zhang S, Wang C, Liu B, et al. Cost-effectiveness of expanded antiviral treatment for chronic hepatitis B virus infection in China: an economic evaluation. Lancet Reg Health West Pac 2023;35:100738. [Crossref] [PubMed]
49. Alberts CJ, Clifford GM, Georges D, et al. Worldwide prevalence of hepatitis B virus and hepatitis C virus among patients with cirrhosis at country, region, and global levels: a systematic review. Lancet Gastroenterol Hepatol 2022;7:724-35. [Crossref] [PubMed]
50. Devarbhavi H, Asrani SK, Arab JP, et al. Global burden of liver disease: 2023 update. J Hepatol 2023;79:516-37. [Crossref] [PubMed]
51. Zeng H, Cao M, Xia C, et al. Publisher Correction: Performance and effectiveness of hepatocellular carcinoma screening in individuals with HBsAg seropositivity in China: a multicenter prospective study. Nat Cancer 2023;4:1396. [Crossref] [PubMed]
52. Hou J, Zhang W, Xie Q, et al. Xalnesiran with or without an Immunomodulator in Chronic Hepatitis B. N Engl J Med 2024;391:2098-109. [Crossref] [PubMed]