Progress Toward Hepatitis B Control

World Health Organization European Region, 2016-2019

Nino Khetsuriani, MD, PhD; Liudmila Mosina, MD; Pierre Van Damme, MD, PhD; Antons Mozalevskis, MD; Siddhartha Datta, MD; Rania A. Tohme, MD


Morbidity and Mortality Weekly Report. 2021;70(30):1029-1035. 

In This Article


During 2016–2019, EUR made substantial progress toward achieving hepatitis B control, resulting in validation of the first two countries (Italy and the Netherlands) and conditional validation of two other countries (Croatia and the United Kingdom). This progress is supported by a recent modeling study, which demonstrated 0.1% HBsAg seroprevalence among children aged 5 years in EUR.[3] Among the 49 countries that have not yet initiated the validation process, 17 (74%) of 23 with a universal HepB-BD policy have met the HepB3 coverage and HepB-BD coverage criteria, and six (23%) of 26 countries with a selective birth dose policy met HepB3 coverage and antenatal screening coverage targets. Eight (16%) of these 49 countries met the ≤0.5% HBsAg seroprevalence target.

To accelerate validating achievement of the regional hepatitis B control target in EUR, some countries could consider submitting available documentation for validation, whereas others still need to generate the evidence required for validation. Although conducting nationally representative hepatitis B serosurveys might be challenging, and because the COVID-19 pandemic has further challenged their implementation, hepatitis B testing can be incorporated into other nationally representative serosurveys, including COVID-19 serosurveys, where feasible.

The historic differences in HBsAg prevalence and the diversity of HepB immunization strategies across EUR necessitated a differential approach to validation of hepatitis B control depending on national prevaccine endemicity and HepB vaccination policies. Although HepB3 immunization coverage is high in most countries, it remains consistently <90% in six countries, reflecting challenges in their immunization services. Countries can address these challenges by 1) providing sufficient support to national immunization programs to strengthen immunization systems, 2) monitoring public perception toward vaccinations and developing tailored strategies to create demand for vaccination among all population groups, and 3) strengthening immunization information systems to improve quality and availability of coverage data.[6–8] The two countries in EUR with universal birth dose policy that currently do not report HepB-BD coverage (Bosnia and Herzegovina and Russia) will need to establish systems for monitoring and reporting birth dose coverage.

In countries that provide selective HepB-BD vaccination, establishing systems for continual monitoring of coverage with antenatal screening and HBsAg-positivity among pregnant women and of coverage with HepB-BD and HepB3 among exposed infants is needed to provide reliable data on seroprevalence and interventions to prevent MTCT of HBV for validation purposes. Available seroprevalence data showed a much higher prevalence of hepatitis B among foreign-born populations in several countries in EUR. Ensuring access to MTCT prevention measures for underserved populations, including immigrants, ethnic minorities, and other vulnerable groups, can help mitigate the impact of increased migration from high- and intermediate-endemicity areas on HBsAg prevalence in low-endemicity countries.[9]

The findings in this report are subject to at least three limitations. First, missing HepB-BD coverage data for Bosnia and Herzegovina and Russia prevent determining whether these countries have met the HepB-BD coverage target. Second, timely HepB-BD coverage estimates might not be accurate for countries that do not monitor timeliness of HepB-BD administration. Finally, some HBsAg seroprevalence estimates were obtained >15 years ago and might not reflect the current prevalence in cohorts eligible for vaccination.

Despite progress made during 2016–2019, achieving the 2020 hepatitis B control goal in EUR will require programmatic improvements in underperforming countries. To accelerate the validation process, most countries will need to generate additional evidence of having achieved the regional targets. Some low- and middle-income countries will require continued external support to conduct serosurveys. Further, the COVID-19 pandemic has caused disruptions in immunization services and led to delays in implementation of serosurveys. Implementing the regional guidance on interventions to mitigate the impact of COVID-19 on immunization programs can help countries maintain or improve HepB vaccination coverage and accelerate progress toward the regional goal.[10]