Aside from vaccination, universal screening for pregnant mothers offers hope to eliminate the disease and its deadly complications, writes Nadia Badarudin
WHEN a pregnant woman has hepatitis B, there is a 90 per cent chance that the disease-- which causes liver infection, cirrhosis and liver cancer - will spread to the child.
Yet screening for the disease among pregnant mothers is not universal, which means babies who could have otherwise been prevented from being infected end up suffering from the disease.
The diagnosis of hepatitis B infection focuses on the detection of the hepatitis B surface antigen HBsAg and this screening in antenatal care in Malaysia has been implemented since 2002, but limited to mothers who are at risk of the disease.
“We’re looking into the possibility to make the screening universal; in other words, we want it to be provided to all antenatal mothers rather than selected screening,” says consultant and public health and communicable disease epidemiologist from Health Ministry’s division of disease control, Dr Anita Suleiman.
“Every child should be given the greatest chance to start a healthy life, without hepatitis B,” she says.
Dr Anita was among the four panelists speaking at the Federation of the Asia and Oceania Perinatal Societies Perinatal Forum on Universal Hepatitis B Screening in Pregnancy which was organised in conjunction with the 26th Regional Congress of the Perinatal Society of Malaysia in Ipoh, Perak on April 11 to 14.
The forum was chaired by Universiti Malaya Medical Centre head of obstetrics and gynaecology department, Professor Datuk Dr Siti Zawiah Omar.
Dr Anita says the call for universal screening in the country is in line with the World Health Organisation Global Health Sector Strategy on Viral Hepatitis B, 2016-2020.
The strategy is aimed at eliminating viral hepatitis as a public health problem by reducing new viral hepatitis infections by 90 per cent and reducing deaths to viral hepatitis by 65 percent by 2030.
“With regard to hepatitis B control in Malaysia since 1974 (where HBV screening of blood donors started), Malaysia was certified as a country which has achieved HBV control goal target of less than 1 per cent in 2011, well ahead of its 2020 global target and 2017 regional target, with the HBsAg prevalence among children of nine and 10 years at 0.3 per cent.
ELIMINATION OF MOTHER-CHILD TRANSMISSION
“In October 2018, Malaysia has been certified as having eliminated mother-to-child transmission of HIV and syphilis. And with such positive progress in hepatitis control, we’re on the right track to go for triple elimination, by adding the elimination of mother-to-child transmission of hepatitis B through universal screening,” she says.
After the one done in Sabah, Pahang, Kedah, Terengganu and Kelantan are starting on pilot projects in screening all antenatal mothers to prevent hepatitis B.
“This year, we already have one clinic in Pahang doing universal screening. And we’re waiting anxiously to see the project outcome soon,” adds Dr Anita.
The cost for universal antenatal screening is cheap as the one-off, rapid test for HBsAg costs less than RM3.
“We’ve seen children below 10 years old diagnosed with liver diseases or cancer, with mothers or grandmothers being hepatitis B carriers without them knowing about the disease.”
According to WHO, the estimated prevalence of HBV infection in children below five years old in 2015 was about 1.3 per cent, compared to about 4.7 per cent in the pre-vaccination era (the vaccine was introduced in 1982).
It says that in highly endemic areas, hepatitis B is commonly spread through perinatal transmission or from mother to child at birth, or horizontal transmission or exposure to infected blood especially from an infected child to an uninfected child during the first five years of life.
“Every year we have approximately 500,000 to 550,000 antenatal mothers in the country and with such an affordable cost, universal screening seems more beneficial.
“We already have established health systems with strong back-up in human resources and domestic financing. Key interventions for viral hepatitis are already in place too, so it’s just timely for the country to provide universal screening for all antenatal mothers,” says Dr Anita.
VACCINATION EQUALLY CRUCIAL
In preventing hepatitis B, vaccination is the most important intervention. The hepatitis B vaccine is 95 per cent effective in averting infection as well as the development of chronic disease and liver cancer, offering protection that lasts at least 20 years and is probably lifelong, according to WHO.
In Malaysia, the hepatitis B vaccination programme for children was introduced in 1989. As indicated in the immunisation schedule set by the Health Ministry, the Hepatitis B vaccine will be given to a child three times. As recommended by WHO, the first dose will be given within 24 hours of her birth, and the subsequent shots will be administered when she is one month old and six months old.
“It’s important for a child to get the first dose of hepatitis B vaccine within 24 hours of delivery. For the infected mother, hepatitis B immunoglobulin must be given immediately after birth to the newborn, followed by the routine vaccination.
“Observing the timing of the first dose given as well as the subsequent scheduled shots is equally important in order to ensure its effectiveness,” says Dr Anita.
Family medical consultant from Klinik Kesihatan Sandakan, Sabah Dr Zaiton Yahya says a major issue which is hampering the efforts to eliminate hepatitis B with universal screening and vaccination is the rise of the anti-vaccination group.
“We have a tough time addressing those who are against vaccination, including expectant mothers infected with hepatitis B who believe in natural birth or giving birth at home who are putting themselves at high risk,” says Dr Zaiton.
Her experience is shared by consultant paediatrician and adolescent medicine specialist Dr N. Thiyagar from the paediatric department of Hospital Sultanah Bahiyah, Alor Setar, Kedah.
“We’ve received cases of babies being admitted with an attached letter from their parents refusing any vaccination for their children or parents having their doubts on the importance of vaccination and who go for ‘alternatives’.
“Although the number is small, efforts to eliminate vaccine-preventable disease like hepatitis B may gone to waste if such rampant ignorance are not addressed accordingly,” he says.
THE BURDEN OF THE DISEASE
Hepatocellular carcinoma, the most common form of primary liver cancer, cirrhosis and chronic liver infection are some of the long-term complications resulted from hepatitis B.
Hepatitis B is a liver infection caused by the hepatitis B virus (HBV) transmitted through blood or other body fluids of an infected person.
Despite it being a vaccine-preventable disease, hepatitis B is a big issue across the globe as its prevalence puts people at risk of death as well as increases the financial burden with regards to treatment and care.
According to WHO, in 2015, an estimated 257 million people are living with hepatitis B virus infection (defined as hepatitis B surface antigen positive) and an estimated 2 per cent of the general population in Southeast Asia region is infected with the disease.
Out of the 257 million people, 22 million knew their diagnosis, with many diagnosed only when they were already suffering from advanced liver disease.
Hepatitis B also resulted in 887,000 deaths, mostly from complications including cirrhosis and hepatocellular carcinoma in the same year.