India introduced hepatitis B vaccine in the Universal Immunisation Programme in 2002 and scaled-up nationwide in 2011. But even eight years later, the prevalence among children less than five years of age has not reduced below 1%. In contrast, Bangladesh, Bhutan, Nepal and Thailand have achieved this feat.
On September 3 this year, Bangladesh, Bhutan, Nepal and Thailand became the first four countries in the World Health Organisation’s southeast Asia region to have successfully controlled hepatitis B. The virus is said to be controlled when the disease prevalence is reduced to less than 1% among children less than five years of age.
Despite introducing hepatitis B vaccine in the Universal Immunisation Programme in 2002 and scaling-up nationwide in 2011, about one million people in India become chronically infected with the virus every year. According to the health ministry, as on February 2019, an estimated 40 million people in India are infected. Hepatitis B infection at young age becomes chronic causing over 100,000 premature deaths annually from liver cirrhosis or liver cancer.
Though hepatitis vaccine is administered concurrently with diphtheria, pertussis and tetanus (DPT) and oral polio vaccine at 6, 10 and 14 weeks, a study published in 2013 found lower coverage of hepatitis B vaccine in eight of the 10 districts surveyed. But hepatitis B coverage has witnessed an increase with the introduction of a pentavalent vaccine — diphtheria, tetanus, pertussis, hepatitis B and haemophilus influenzae type b (Hib) — on a pilot basis in Kerala and Tamil Nadu in December 2011 and national roll-out in 2014-2015.
According to the WHO, the coverage of hepatitis B third dose had reached 86% in 2015. Despite high vaccination coverage, disease prevalence in children aged less than five years has not dropped below 1%. One of the reasons for this is the sub-optimal coverage of birth dose in all infants within 24 hours of birth.
Hepatitis B birth dose was introduced in the national programme way back in 2008. The birth dose given in the first 24 hours helps prevent vertical transmission from the mother to child. The compulsion to increase birth dose to cut vertical transmission arises from two important reasons — about 70-90% newborns infected this way become chronic carriers of hepatitis B, and about 20-30% carriers in India are due to vertical transmission.
But even seven years after the health ministry approved the birth dose, its coverage has been low — 45% in 2015 and 60% in 2016 — according to a 2019 health ministry report. What is indeed puzzling is that even in the case of institutional delivery the birth dose vaccine coverage though increasing with each passing year is still low — 55% in 2015, 67% in 2016 and 76.36% in 2017. Incidentally, about 80% of all deliveries in the country are in health-care institutions. The birth dose coverage when delivery takes place outside health-care institutions is not known.
One of the reasons for the low coverage even when born in health-care facilities is the fear of wastage of vaccine when a 10-dose vial is used. Unfortunately, health-care workers are often unaware of the WHO recommendation that allows hepatitis B open vial policy. Opened vials of hepatitis B vaccine can be kept for a maximum duration of 28 days for use in other children if the vaccine meets certain conditions. There is also a need to increase awareness among public about the merits of birth dose.