Hepatitis B vaccine birth dose coverage correlates worldwide with rates of institutional deliveries and skilled attendance at birth
Introduction
Two billion persons have been infected with hepatitis B virus (HBV) worldwide, and about 250 million are chronically infected, which increases their risk of liver cirrhosis and cancer [1], [2]. Progression to chronic infection is age-related, occurring in 90%, 30%, and 6% of those infected perinatally, in early childhood, and after age five years, respectively [1]. Administration of a hepatitis B vaccine dose within 24 h of birth (HepB-BD) followed by 2–3 additional hepatitis B vaccine (HepB) doses can prevent up to 95% of perinatal transmission of HBV [1].
Despite the availability of an effective vaccine, overall coverage with HepB-BD in 2014 was 38%; the lowest coverage was reported in the World Health Organization (WHO) African Region (10%) and the highest coverage in the WHO Western Pacific Region (80%). In 2014, up to 30 million newborns were still unvaccinated in the 96 countries that provided universal HepB-BD in the national immunization schedule [3]. This low coverage is related to challenges unique to the HepB-BD, which must be given within 24 h of birth to be most effective at preventing perinatal infections. Logistical barriers to timely HepB-BD administration can include lack of vaccine in the delivery ward, lack of cold chain for vaccine storage, and absence of skilled personnel to vaccinate children born at home [4]. Home births have been reported as important reasons for low coverage with timely HepB-BD in Cambodia and Indonesia [5], [6], while timely HepB-BD vaccination was significantly associated with institutional delivery in China [7], [8]. In 2014, global IDR and SBA rates were 65% and 73%, respectively [9]. The African and South-East Asia regions had the lowest IDR and SBA rates while the Americas, European, and Western Pacific regions had the highest rates (Fig. 1).
Nevertheless, the correlation between HepB-BD coverage and IDR or SBA rates have not been investigated globally or by WHO region. We analyzed global and regional data to assess the correlation between HepB-BD coverage, IDR, SBA rates, and other potential co-variates for all countries worldwide that include universal HepB-BD in national immunization schedules.
Section snippets
Methods
We compiled available individual country data on the latest IDR and SBA rates reported by each country [9], [10]. Since the latest IDR and SBA rates for several countries were from 2014 or earlier, we used the 2014 WHO/UNICEF (WUENIC) estimates of HepB-BD vaccination coverage for comparison purposes [9]. We also compiled country data on total number of live births, hospital density per 100,000 population [9], total health expenditure per capita, adult literacy rates, and land mass [11].
To
Results
Eighty-three (86%) of 96 countries that provided universal HepB-BD throughout 2014 were included in the analysis. Twelve (12%) countries (Australia, El Salvador, Estonia, Greece, Indonesia, Israel, Laos, Mauritania, Russian Federation, Saint Lucia, Spain and Vanuatu) were excluded because HepB-BD WUENIC coverage data were not available. Andorra was excluded because IDR and SBA data were not available. Of 83 countries analyzed, 2 (2%) were missing THE-PPP data, 8 (10%) were missing IDR, 21 (25%)
Discussion
In this paper we report significant positive correlations between HepB-BD coverage, institutional delivery rates and skilled birth attendance rates worldwide and in the WHO African, South-East Asia, and Western Pacific Regions. High rates of home births have been linked to low HepB-BD coverage in Cambodia, Indonesia, and China [5], [6], [7], and prevalence of chronic HBV infection was higher among children born at home compared to those born at large hospitals in China and Vietnam, indicating
Conflicts of interest
All authors declare that they have no conflicts of interest.
Funding
The work was supported by the Centers for Disease Control and Prevention.
Disclaimer
The findings and conclusions in this paper are those of the authors and do not necessarily represent the position of the Centers for Disease Control and Prevention
Acknowledgements
Kathleen Wannemuehler (Statistician) and Sarah Pallas (Health Economist), Centers for Disease Control and Prevention.
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