In 2015, out of the estimated 15-18 million annual livebirths in China, close to 1 million infants were born to women chronically infected with Hepatitis B.
[Name withheld] was one such mother. A resident of Beijing, during her first pregnancy she learned she had hepatitis B.
She initially struggled with a sense of shame for having the virus, and was thankful no one else in her family was Hepatitis positive. She felt overwhelmed by all the conflicting information circulating among online communities.
“As a mother, I couldn’t help but feel sorry for my unborn child. In fact, I didn’t even want to have the child at first. What if he or she was forced to grow up facing the same forms of discrimination that I was experiencing?”
[Name withheld, HBV infected mother of 2, Beijing]
Infant vaccination is a core national policy in China. In 2015 both hepatitis B vaccine immunization rates and use of hepatitis B immunoglobulin for PMTCT were each more than 95%, nationally.
Nevertheless, a large national survey in 2014 found that, among children under 5 years old, the prevalence of hepatitis B was 0.32%, meaning that each year there were still new infections of 50,000 – 60,000 among infants, a tremendous burden placed on each new birth cohort.
The national integrated prevention of mother-to-child transmission programme (iPMTCT) included interventions to prevent mother-to-child transmission of HBV. But at that time, the essential package of HBV iPMTCT did not include follow-up of HBV exposed infants. That meant, despite robust scale up of the vaccination program and use of immunoglobulins for PMTCT, there was no method for knowing whether or not these at-risk infants had completed their 3-dose vaccine schedule and were protected.
Taking action
“It was my first pregnancy which brought the devastating news. I was ashamed and I felt alone. I kept asking myself, why did the virus choose me?”
[Name withheld, HBV infected mother of 2, Beijing]
In 2015, WHO China initiated discussions with national programmes and stakeholders on moving the agenda of elimination of HBV mother to child transmission towards zero new infections. The discussions were largely based on a situation analysis undertaken by the office earlier that year. As a result, the office advocated for the development of a national strategy that would:
- Evaluate the current national HBV prevention and PMTCT strategy to determine whether the strategy was working among infants at-risk (through an infant blood test after completing vaccination, the post vaccination serological test (PVST) at about 7-9 months of age).
- Strengthen the package of services of the iPMTCT program, which was focused primarily on dual elimination of mother to child transmission, and with a goal of moving towards triple elimination of mother to child transmission of HIV, syphilis and Hepatitis B. This included a provision for additional interventions such as antiviral drugs, maternal viral load testing as well as PVST.
- Generate more evidence around HBV prevention and HBV markers during pregnancy.
The country office convened meetings and technical seminars with a range of stakeholders – including government counterparts and non-governmental organizations, provided technical support to UNICEF to mobilize funding for provincial demonstration projects, and provided technical support for a public-private partnership where high risk HBV infected mothers are provided with antiviral drugs.
Impact
“I thought about it long and hard, and decided at last to give it a try, for my baby. I underwent the PMTCT at Beijing Ditan Hospital and it was a success. From being afraid to spoon-feed him out of fear of infecting him, to taking him for regular check-ups and blood test here at the hospital, the process was undoubtedly a long one, but it was worth it. My eldest just turned one and a half, and I’m expecting his little brother very soon. They are both very healthy. According to the doctor, my son’s antibody levels are great! To all hepatitis mothers out there: this isn’t just your fight, we’re all in this together.”
[Name withheld, HBV infected mother of 2, Beijing]
In early 2017, the government of China committed to the vision of triple elimination of mother to child transmission of HIV, syphilis and hepatitis B. The demonstration projects for triple elimination for HIV, syphilis and HBV in several provinces supported by UNICEF with technical support of WHO was launched in September.
The WHO funded PVST project implemented by the national immunisation program is ongoing with preliminary results available in November 2017. Early lessons from the field have triggered discussions on tightening the HBV prevention strategy and extending implementation research in this area. The public-private partnership (SHIELD HBV zero transmission) project has expanded to over 100 hospitals across the country with evaluation planned towards the end of 2017.
The catalytic work of WHO in China is contributing to the transition from dual to triple elimination of mother to child transmission. The pragmatic projects in progress are generating field evidence and changing implementation strategies to further reduce new infections of HBV among infants at risk.
Looking forward, the WPRO region is tabling the triple elimination of HIV, syphilis and Hepatitis B in the regional committee meeting in October 2017. In China, the WHO office at all levels will support national-level consultations on HBV elimination of MTCT in Beijing in November 2017 together with the iPMTCT program and China’s national immunization program and other partners