The UK Health Security Agency (UKHSA) today announced that vertical transmission of hepatitis B had been eliminated in England. The Agency said that the country had "succeeded in meeting the new World Health Organisation (WHO) targets for eliminating mother-to-child transmission of hepatitis B", thanks to universal antenatal screening and targeted infant immunisation.
Liver charities called the news "excellent".
About 25% of liver disease cases in the UK are due to hepatitis infections, particularly hepatitis B virus (HBV). Around 10% of pregnant woman with HBV infection are highly infectious, which imparts a 70% to 90% likelihood that the infection will be transmitted to the baby.
According to the Government’s Green Book on Immunisation, children infected perinatally have a 90% risk of developing chronic hepatitis B, which can evolve to potentially fatal cirrhosis and liver cancer, contrasted with rates of 20-50% in children infected aged between 1-5 years, and 5% or less of previously healthy people infected as adults. Hence the WHO's focus on scaling up hepatitis B vaccination coverage in infant immunisation programmes, with the expunction of viral hepatitis as the "overarching vision".
Antenatal Screening and Targeted Post-Exposure Immunisation
The UKHSA said that HBV vertical transmission was "one of the most common routes of infection globally" and noted that all pregnant women in England have been offered an antenatal blood test for HBV, as well as HIV and syphilis, since the late 1990s.
Post-exposure immunisation can prevent the development of persistent HBV infection acquired through vertical transmission at or around the time of birth in more than 90% of these babies, provided vaccination starts no later than 24 hours after birth and is followed by further doses at 4 and 8 weeks and at 1 year of age.
Since late 2017 hepatitis B has been included in the routine childhood immunisation programme, with HepB given within the routine neonatal schedule, as part of the 6-in-1 vaccine at 8,12, and 16 weeks. In 2021, quarterly coverage for these three doses was 91-92%, exceeding the WHO target of 90%.
"Through this successful three-pronged approach, England has now met the WHO criteria for elimination of mother to child transmission," the UKHSA said. "Achieving this is a key milestone in the WHO's strategy for the overall elimination of viral hepatitis as a public health threat by 2030."
Majority of English Cases In Migrants
The Agency added that, while uptake of the childhood HBV vaccine was high, this was not the case among at-risk adults. Although the risk of hepatitis B in the UK was low, and deaths from hepatitis B and C together were less than 2 per 100,000 (below WHO targets), adult HBV immunisation "needs to increase to drive down infections".
Communities at higher risk in the UK include people who inject drugs, gay, bisexual and men who have sex with men who are having sex with multiple partners, sex workers, and people detained in prisons or immigration detention centres. However the majority of the estimated 206,000 people living with chronic hepatitis B infection in England are migrants who acquired infection overseas in endemic countries prior to arrival in the UK.
The UKHSA said that as well as the success with HBV, "progress towards eliminating hepatitis C as a public health problem by 2030 in England continues".
There is no vaccine for hepatitis C, but thanks to increased testing and curative treatments, latest estimates suggested that the number of people living with hepatitis C in the UK had declined by 47.2% since 2015, to reach 92,900 by the end of 2021.
Goal to Eliminate Hepatitis B and C by 2030
Dr Sema Mandal, deputy director for blood-borne viruses at UKHSA, said: "With the elimination of mother to child transmission of hepatitis B, very low hepatitis-related death rates, and continued reduction of chronic hepatitis C levels, we are on our way to our goal of eliminating hepatitis B and C in England by 2030.
"Testing, vaccination for hepatitis B, and curative treatments for hepatitis C, have all played a significant role in driving down these infections.
"Many people are unaware they have hepatitis because the viruses can be symptomless – meaning they aren't getting the treatments they need and are possibly passing the virus on to others without knowing."
The UKHSA continues to urge all those at risk through drug use or sexual contact, and people who have immigrated to the UK from countries where hepatitis B or C is common, "to come forward for free testing, treatment or hepatitis B vaccination".
Pamela Healy OBE, chief executive of the British Liver Trust, commented: "It is excellent news that England has met the ambitious target set by the WHO and eliminated the transmission of hepatitis B between mothers and children. The challenge now is for us to find the thousands of people living in England who have hepatitis but are completely unaware of it."
Screening in Emergency Departments Identified Unrecognised Carriers
An opt-out screening programme for HIV is currently being tested in emergency departments in areas of England with the highest diagnosed prevalence of HIV infection, and incorporates HBV and HCV testing as well. More than 250,000 HIV tests and over 100,000 HCV antibody tests were delivered between April and July 2022, resulting in identification of over 500 people with previously unknown, unrecognised, or undiagnosed blood borne virus infections.
John Stewart, director for specialised commissioning and interim director of commercial medicines at NHS England, said: "The NHS is committed to increasing early detection diagnoses of blood-borne viruses, including rolling out opt-out testing for HIV, hep C, and hep B in A&Es - building on the testing already routinely available through GPs and sexual health services across the country – and ensuring people have access to treatments and specialist support as early as possible.
"Through screening programmes and national medicines deals that give NHS patients access to the latest drugs, England is also on track to become the first country to eliminate hepatitis C, which will be a landmark international achievement in public health."
Rachel Halford, CEO of the Hepatitis C Trust, commented: "Thanks to Government investment in an innovative elimination programme for hepatitis C, we are within reach of eliminating the virus before 2030 in England. To stay on track to reach this goal, we are in need of a hepatitis strategy to ensure that we are able to reach every at risk population in the country, save more lives, and maintain the elimination of both hepatitis C and B once reached.
"Treatment for hepatitis C has never been easier and 95% of people are able to clear the virus after just a few months of taking medication."