Preventing Hepatitis B Vertical Transmission

Hepatitis B virus continues to drive a heavy burden of chronic infection and early liver-related death among infants across the WHO African region, despite the availability of tools to prevent transmission at birth. A systematic review and meta-analysis published in Lancet Global Health estimated 172,000 cases of mother-to-child HBV transmission occurred in the region in 2022, accounting for 0.4% of all liveborn infants.¹ Pooled HBsAg prevalence among pregnant individuals reached 6.2%, and 1 in 4 chronically infected infants will die prematurely from liver cancer or other liver-related complications.¹

Raising timely birth-dose vaccination coverage to 90% could reduce vertical transmission by nearly 44%, and combining vaccination with maternal antiviral prophylaxis could lower transmission by more than 86%, though regional HepB-BD coverage remained at just 17% as of 2021.² Peyton Thompson, MD, MSCR, assistant professor of pediatric infectious diseases at UNC School of Medicine and a member of UNC's Institute for Global Health and Infectious Diseases, co-authored the analysis. In the following interview, Thompson discusses the barriers to eliminating vertical transmission of hepatitis B in the WHO African region and the investments needed to close the coverage gap.

Contagion: Your analysis found that an estimated 172,000 cases of mother-to-child hepatitis B transmission occurred in the WHO African region in 2022. What do these findings tell us about the current burden of vertical transmission, and why has this route of infection remained such a significant challenge?

Thompson: In collaboration with a group of esteemed hepatitis B experts and led by Drs. Nicholas Riches and Alexander Stockdale, I co-authored a systematic review and meta-analysis of vertical transmission of HBV in the WHO African region, which was published in Lancet Global Health in 2025.¹ An estimated 172,000 cases of vertical transmission occurred in the African region in 2022, representing 0.4% of all liveborn infants. These infants who are infected with HBV will develop lifelong chronic infection, and 1 in 4 of them will die an early death from liver cancer or other liver-related complications. The current state of HBV control in Africa is unacceptable and represents profound health inequity.

Vertical transmission of HBV is entirely preventable by combining birth-dose vaccine for babies plus antiviral prophylaxis for pregnant people, but these strategies remain inaccessible in many low-resource settings. Birth-dose vaccine has been introduced in nearly two-thirds of African countries, but overall coverage remains low at 17% due to logistical challenges in vaccine administration within 24 hours of birth. Unfortunately, birth-dose vaccine is insufficient to interrupt vertical transmission in cases of high-risk HBV (maternal viral load ≥200,000 IU/mL and/or HBeAg positivity), when antiviral prophylaxis is recommended to reduce the viral load. Maternal antiviral prophylaxis is now recommended for all HBsAg+ pregnant women in low-resource settings where viral load testing is not available, but is rarely provided. Accessibility of these life-saving and cancer-preventing resources is paramount to eliminating vertical transmission in the WHO African region.

Contagion: The study suggests that increasing hepatitis B birth-dose vaccination coverage to 90% could reduce vertical transmission by nearly 44%, while combining vaccination with maternal antiviral prophylaxis could reduce transmission by more than 86%. What are the biggest barriers to implementing these interventions across the region, and how can they be overcome?

Thompson: The barriers to timely birth-dose vaccination are complex and exist on multiple levels: policy (eg insufficient advocacy and affordability), facility (eg lack of knowledge among healthcare personnel, stock-outs, and the short window for vaccine administration) and community (eg lack of knowledge among caregivers and insufficient community health worker (CHW) engagement).³ Educational campaigns for providers and caregivers, CHW involvement, political and financial support, and innovative strategies to reach out-of-facility births are among the strategies that can improve birth-dose coverage. Strategies must be adapted to the local context to enhance implementation.

Barriers to maternal antiviral prophylaxis are related to the novelty and cost of this approach. Prophylaxis for all HBsAg+ pregnant women in low-resource settings was recommended by the WHO beginning in 2024, and so many countries have yet to adopt this strategy. Cost of tenofovir therapy hinders widespread uptake. In the Democratic Republic of Congo, a one-month course of tenofovir costs $25-30, nearly half of the average monthly income. Integration into the existing HIV framework could defray cost and implementation challenges. Ongoing education efforts for providers and patients and subsidization of prophylactic tenofovir are also necessary to overcome implementation barriers.

Contagion: You found that approximately 6.2% of pregnant women attending antenatal care were hepatitis B surface antigen-positive. How should these findings influence prenatal screening policies and maternal care practices in countries across sub-Saharan Africa?

Thompson: Indeed, the pooled HBV surface antigen (HBsAg) prevalence was 6.2% among pregnant individuals in the WHO African region. Prenatal screening for HBV is the first step in the pathway towards elimination of vertical transmission, but is still not performed in many low-resource settings. Triple screening for HIV, HBV and syphilis should co-occur prenatally, and there are now many examples of success stories using this approach.⁴

Contagion: The study concludes that eliminating mother-to-child hepatitis B transmission in the WHO African region is achievable with expanded vaccination and antiviral use. What policy changes or investments should governments and global health organizations prioritize now to reach the WHO elimination targets?

Thompson: The gap between current HepB-BD coverage (18% in the African region) and the WHO goal for elimination at 90% coverage is substantial. However, bridging this gap is possible with dedicated political will and financial investment. One solution to overcoming this gap is Gavi’s catalytic funding that provides HepB-BD free of charge (usually $0.30 per dose), alongside country-level commitment to vaccine administration and implementation.

HepB-BD needs to be coupled with maternal antiviral prophylaxis to truly reach elimination targets of <0.1% HBsAg prevalence among children <5 years old. Global health organizations and individual countries in the WHO African region must incorporate both HepB-BD and maternal antiviral prophylaxis as a packaged approach, including educational initiatives, CHW engagement, cost subsidization, and coupling of care with HIV and syphilis towards triple elimination. Elimination of vertical transmission of HBV is at our fingertips. We need to come together as a global community to make it a reality.

References
1.Riches N, Henrion MYR, MacPherson P, et al. Vertical transmission of hepatitis B virus in the WHO African region: a systematic review and meta-analysis. Lancet Glob Health. 2025;13(3):e447-e458. doi:10.1016/S2214-109X(24)00506-0

2.Kabore HJ, Li X, Alleman MM, et al. Progress toward hepatitis B control and elimination of mother-to-child transmission of hepatitis B virus — World Health Organization African Region, 2016–2021. MMWR Morb Mortal Wkly Rep. 2023;72(29):782-787.

3.Boisson A, Goel V, Yotebieng M, Parr JB, Fried B, Thompson P. Implementation Approaches for Introducing and Overcoming Barriers to Hepatitis B Birth-Dose Vaccine in sub-Saharan Africa. Glob Health Sci Pract. 2022;10(1):e2100277. Published 2022 Feb 28. doi:10.9745/GHSP-D-21-00277

4. Global Hepatitis Report 2026. WHO. Accessed August 9, 2026.
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