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Unlike HIV, tuberculosis and malaria, the trend in mortality from viral hepatitis is
increasing
HB Vaccination in Indonesia
WHO Pilot Project in Lombok Island. Indonesia was selected as the first
model of HB vaccination integrated to EPI. Reduction of HBsAg
prevalence infants from 6.2% to 1.4%
Birth-dose
Immunization
16
%
14
12
10
> 60
1–4
5–9
10 – 14
15 – 19
20 – 24
25 – 29
30 – 34
35 – 39
40 – 44
45 – 49
50 – 54
55 – 59
Age group HBsAg (+)
many provinces
• Low coverage in
WHO Target
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
0.0
100.0
ACEH 77.5
SUMATERA UTARA 76.7
SUMATERA BARAT 72.7
RIAU 67.1
JAMBI 102.4
SUMATERA SELATAN 88.6
BENGKULU 65.7
LAMPUNG 79.4
DKI JAKARTA 74.9
JAWA BARAT 99.9
JAWA TENGAH 97.4
DI YOGYAKARTA 101.2
JAWA TIMUR 98.2
KALIMANTAN BARAT 58.8
KALIMANTAN TENGAH 60.3
WHY?
WHY?
8.00
8.00
7.00
6.00
5.00
4.37
4.24
4.08
3.76
3.76
3.61
4.00
3.50
3.33
3.03
2.80
2.78
2.76
2.67
2.65
3.00
2.56
2.43
2.42
2.39
1.93
1.79
1.79
1.73
1.66
2.00
1.57
1.46
0.80
0.79
1.00
0.00
Sumbar Jambi DKI Jateng Jatim Sulsel Kalbar Sumut Bengkulu Papua NTB Jabar Sulut Total
Jakarta Barat
Bumil Nakes
WHO Global Strategy on Viral
Hepatitis (2016)
stranded DNA
DNA polymerase
Current diagnostics: all
laboratories
HBsAg – marker of infection
IgM anti-HBc – marker of recent infection
IgG anti-HBc – marker of past infection
Anti-HBs – marker of past infection, response to
vaccine
HBeAg/Anti-HBe – helps to characterise disease stage
HBV DNA – helps to characterise disease stage,
response to Rx
Interpretation of screening test for HBV
HBV Infection status:
Current infection of HBV: HBsAg+
Past/life-time exposure to HBV: anti-HBc +
Immunity against HBV: anti-HBs+
• Resolved infection (HBsAg-, anti-HBc+, anti-HBs+)
• Immune due to vaccination (HBsAg-, anti-HBc-, anti-HBs+)
L L
I I
V V
E E
R R
D D
A A
M M
A A
G G
E E
Outcome of HBV infection
Compensated
Resolution Stabilisation cirrhosis
Acute Chronic
infection hepatitis Cirrhosis Liver cancer Death
80 Chronic Infection 80
60 60
Predominantly
adult infection
in Western
40 countries 40
20 20
Symptomatic Infection
0 0
Birth 1-6 months 7-12 months 1-4 years Older Children
and Adults
Age at Infection
How HBV Is Transmitted ?
MTCT
Blood Sexual
Mother-to-child transmission
transmission
Intrauterine transmission:
Practical definition: “The detection of HBsAg or
HBV DNA in neonatal peripheral venous blood or
cord blood”.
Routes of mother-to-child HBV transmission
Postpartum transmission
Screening of
mothers:
HBsAg: at least
before the 3rd
trimester
HBeAg (for HBsAg-
positive mothers)
Viral load/HBV DNA
level (for HBsAg-
positive mothers)
PATIENT AND FAMILY EDUCATION
Prevention of MTCT: At delivery
For mothers: Caesarean section:
Still controversial:
One study: 17.5% risk reduction of MTCT when compared with
immunoprophylaxis alone
Other studies: elective caesarean section offers no benefit.
Beijing (2007-2011) from 1,409 infants born to HBsAg (+) positive mothers,
with appropriate immunoprophylaxis at birth:
• 1.4% after elective caesarean section
• 3.4% after vaginal delivery
• 4.2% after emergency caesarean section (P <0.05).
When stratified according to HBV DNA levels:
delivery mode did not affect MTCT rates for HBV DNA levels <6 log copies/
ml).
MTCT: With and Without Intervention?
MTCT in HBeAg(+) pregnant women
Passive immunization:
Hepatitis B immune globulin (HBIG): in 12 hours after birth (Provides
temporary protection for 3 to 6 months).
Treatment of mothers:
Has not been a general treatment
policy
Indications are judged by:
HBV DNA level status
HBeAg
Evidence of liver injury (by alanine aminotransferase
[ALT] level and/or liver histology).
Flowchart for treatment of HBsAg positive mothers (for low resource)
HBsAg (quantitative)
HBeAg
HBV DNA > 2x106IU/ml HBV DNA > HBV DNA > HBV DNA > 2x105IU/ml
WHO
6-7log10IU/ml 6-7log10IU/ml
e
eas
ect dis
eff dent
productivity
HCC,
s
Evi Transplant
treatment cost
eff n-evid
Out-patient visits,
ect
No
Acute hepatitis
treatment cost
Disease development: From baseline risk to disease manifestation
reversibility
Cost
Control of hepatitis should start from the mothers