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.