Hepatitis B treatment for all who need it an "achievable public health goal" for Malawi

Keith Alcorn
Published:
13 December 2021

Providing hepatitis B treatment for everyone who needs it in Malawi is an achievable public health goal, researchers from the Malawi-Liverpool-Wellcome Trust programme report, following community surveys in Blantyre, Malawi.

Hepatitis B treatment provision would be far less ambitious than the scale of programme required to deliver antiretroviral treatment for people with HIV in Malawi. Approximately 25,000 people in Malawi need treatment for hepatitis B, the research group estimates, based on assessments of disease status in people tested in household surveys between 2016 and 2018.

The survey also demonstrated the enormous impact of the country’s infant hepatitis B vaccination programme, which began in 2002. Comparing the prevalence of hepatitis B surface antigen in people born before and after 2002, the researchers estimate that vaccination has reduced the prevalence of chronic hepatitis B infection by up to 96%. The findings provide the first assessment of community hepatitis B vaccine impact in southern Africa.

To assess the success of the vaccination programme and the need for hepatitis B treatment, researchers associated with the Malawi-Liverpool-Wellcome Trust programme carried out a random household survey in a township in north Blantyre, Malawi’s second-largest city. The survey tested 6073 people from a population of 97,386 people. Participants had a median age of 18 years and 57% were female.

Participants were tested for hepatitis B surface antigen and vaccination status was determined from health records. One hundred and sixty participants (2.6%) tested positive for hepatitis B surface antigen (HBsAg). The age- and sex-standardised prevalence of HBsAg was 3.1% and was highest in males aged 30-39 (9%).

People who tested positive for HBsAg were subsequently followed up to test for hepatitis B treatment eligibility; 94 were available and consented to evaluation. Ninety-three agreed to test for HIV and 24 (25%) were HIV positive (seven out of 24 were newly diagnosed). Sixteen out of 17 people with HIV who were previously diagnosed were taking antiretroviral treatment containing drugs active against hepatitis B, and all had HBV DNA suppressed below 34 IU/ml.

Of the 69 people without HIV who tested positive for HBsAg, eleven had HBV DNA above 20,000 IU/ml and three had a liver stiffness measurement above 9.5kPa. Using World Health Organization, EASL and AASLD criteria for treatment, 2.9%, 5.7% and 8.7% were eligible for treatment, respectively.

Projecting the proportion eligible for treatment by EASL criteria to the entire population of Malawi (17.6 million), the researchers estimate that 25,586 people in Malawi need hepatitis B treatment.

To assess vaccination impact, the researchers used medical records to identify those vaccinated. Vaccination status information was available for 56% of children aged ten and under and 67% of children aged five and under. Ninety-seven per cent of children aged ten and under and 98% of children aged five and under had received three doses of hepatitis B vaccine and HBsAg prevalence was 0.6% among 913 children with unknown vaccination status.

HBsAg prevalence was 5.1% in adults born prior to vaccine introduction and 0.3% in children born after vaccine implementation in 2002. Comparing prevalence in those born five years prior and five years after vaccine introduction, vaccine impact was 95.9%.

The researchers say that compared to the number in need of antiretroviral treatment in Malawi, the number requiring treatment for hepatitis B is low and providing treatment would be an achievable public health goal. Malawi currently provides antiretroviral treatment to more than 800,000 people with HIV.

“The success of the vaccination programme does not abrogate responsibility to tackle the anticipated rise in adult liver disease,” the authors conclude.

Reference

Stockdale A et al. Hepatitis B vaccination and the unmet need for antiviral treatment in Blantyre, Malawi. Journal of Infectious Diseases, published online 9 November, 2021.

DOI: 10.1093/infdis/jiab562