Moving toward the goal of eliminating hepatitis B as a public health threat in China

Viral hepatitis is one of the leading causes of death from infectious diseases worldwide. As the most prevalent type of viral hepatitis, hepatitis B and its related diseases pose a major threat to human health. The latest report from the World Health Organization (WHO) has demonstrated that approximately 254 million people are living with hepatitis B in 2022, which results in an estimated 1.1 million deaths globally, accounting for 83% of all deaths due to viral hepatitis (1). In order to alleviate the heavy disease burden, the WHO has set an ambitious goal to eliminate viral hepatitis as a public health threat across the globe by the year 2030. Concerted and urgent global efforts are imperative to prevent new infections of hepatitis B virus (HBV) and safeguard lives from HBV-related liver diseases.

China is one of countries with a high prevalence of HBV infection, representing approximately one-third of the global burden of hepatitis B and experiencing more than 0.4 million HBV-related deaths annually (2,3). In response to this formidable challenge, China has been adopting a comprehensive strategy to combat hepatitis B. The review authored by Yan et al. emphasizes the steady and significant progress China has made in fighting against HBV infection over the past 30 years (4). Data from the latest national HBV serological survey shows that the prevalence of hepatitis B surface antigen (HBsAg) in the general Chinese population had declined to 5.86% in 2020, down from 9.72% in 1992 and 7.18% in 2006. Additionally, the HBsAg seroprevalence in children under 5 years old has further decreased, from 0.32% in 2014 to 0.30 % in 2020 (5). These notable advancements demonstrate that China continues to be on track towards the goal of eliminating viral hepatitis set by the WHO.

As the saying goes, “an ounce of prevention is worth a pound of cure”. This is particularly true when evaluating that the successful implementation of vaccination programs stands as the bedrock of China’s current strides in controlling HBV. Low prevalence of HBV among children aged under 5 years demonstrates the effectiveness of prohibiting vertical transmission. Since 1992, China has incorporated the hepatitis B vaccine (HepB) into its Expanded Program of Immunization, and further extended free HBV vaccination in 2005. China has consistently maintained vaccination coverage for three doses of HepB above 90% since 2005, and for the timely birth dose (TBD) of HepB above 90% since 2007 (6). By 2015, these figures had reached 99.6% for three doses and 95.6% for TBD (7), successfully meeting the service coverage target of 90% set by the WHO. Additionally, the comprehensive management for HBsAg-positive pregnant women also plays a fundamental role in preventing vertical transmission. Since 2010, universal HBsAg screening for pregnant women has been an integral part of the national integrated prevention of mother-to-child transmission (iPMTCT) program, and those who are HBsAg-positive can receive antiviral prophylaxis during pregnancy to minimize the risk of mother-to-child transmission (MTCT). Furthermore, infants born to HBsAg-positive mothers will receive hepatitis B immunoglobulin free of charge within 24 hours of birth. These tremendous efforts have led to a significant reduction in the MTCT rate among HBsAg-positive mothers to 0.23% (8), surpassing the WHO’s recommended target of 2%.

The prevalence of HBsAg among women of childbearing age had dropped from 8.18% in 1992 to 5.87% in 2020, as pointed out by Yan et al. (4). Notably, the HBsAg prevalence among females aged 15–19 years, who are anticipated to enter their peak fertility period within the next 5 years, has declined to below 1%. Based on the current levels of prevention interventions, China is projected to meet the WHO’s 2030 target of reducing HBsAg prevalence to below 0.1% among children under 5 years old by the year 2029 (9).

Despite evident progress, China still has a considerable gap to bridge in achieving the goal of overcoming the threat of hepatitis B. Given the large number of people infected with HBV in our nation, despite a continuous decline in the prevalence of HBsAg across the general population, China still bears a relatively heavy burden of hepatitis B. There were 75 million HBV-infected individuals by 2020, among which 19% had chronic hepatitis B, 1% developed cirrhosis, and 0.2% progressed to liver cancer (5). It is alarming to note that as many as 40.22% of HBsAg-positive individuals are not aware of their infection because they have not been tested, and a mere 17.33% of patients who fulfill the criteria for antiviral therapy have actually undergone the treatment (5). These proportions remain markedly lower than the targets established by the WHO, which aim for a diagnosis rate of 90% and a treatment coverage of 80%.

Testing is the initial and pivotal step that links to the management of hepatitis B. Nowadays, China offers free HBV testing to pregnant women and blood donors, and routine hepatitis B screening is also conducted among patients scheduled for surgeries or other invasive medical procedures. These measures have enhanced the rate of detection and diagnosis for hepatitis B, especially reducing the likelihood of MTCT and blood-borne transmission of HBV. However, the development of a comprehensive strategy to broaden and intensify HBV screening remains a formidable challenge. A study has demonstrated that implementing universal screening for HBV infection in China is cost-effective, underscoring the importance and feasibility of this strategy (10). Better yet, popularizing health knowledge among some rural populations can help them understand the necessity of screening. Likewise, those not protected need to be informed that they should be vaccinated.

Antiviral treatment for patients with hepatitis B is crucial in mitigating the risk of progression to cirrhosis and liver cancer, thereby substantially reducing the deaths attributed to HBV infection (11). The 2022 edition of China’s Guidelines for the Prevention and Treatment of Chronic Hepatitis B has broadened the indications for antiviral therapy, making it applicable to a larger population of HBV-infected individuals (12). The WHO Viral Hepatitis Report 2024 shows that the prices of entecavir, tenofovir disoproxil fumarate, and tenofovir alafenamide in China are among the lowest in the world (1). Although access to antiviral therapy is increasing, treatment coverage for hepatitis B remains low in China and needs to be expanded as soon as possible, with an emphasis on improving public education, enhancing awareness, and fostering patient adherence with the treatment.

Yan et al. summarized the evolving trajectory of HBV prevalence in China (4). Our nation has demonstrated a steadfast commitment to eradicating hepatitis B by adopting comprehensive national strategies. It is commendable that China has made significant efforts to shed its “leader in liver diseases” title by investing large amounts of money in funding research, vaccines, and drug development for hepatitis B and its related diseases since 2006. However, disparities in medical resources across different regions represent a significant factor that could potentially undermine these endeavors. As we scale up HBV screening and treatment efforts, it is imperative to prioritize accessibility in primary medical facilities, especially in rural and remote areas. By optimizing the delivery of health care for hepatitis B, we can expedite our progress towards achieving the goal of eliminating hepatitis B within the foreseeable future.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, HepatoBiliary Surgery and Nutrition. The article did not undergo external peer review.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://hbsn.amegroups.com/article/view/10.21037/hbsn-2024-758/coif). The 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.

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