Hepatitis B: vaccination programmes in Europe — an update

doi:10.1016/S0264-410X(00)00457-6

Vaccine

Volume 19, Issues 17–19, 21 March 2001, Pages 2375-2379

https://doi.org/10.1016/S0264-410X(00)00457-6 Get rights and content

Abstract

In the eight years since the Global Advisory Group of the Expanded Program on Immunisation set 1997 as the target for integrating hepatitis B (HB) vaccination into national immunisation programs world-wide, more than 116 countries have included HB vaccine as part of their routine infant or adolescent immunisation programs. Meanwhile, many countries have performed economic evaluation studies, while others have initiated sero-epidemiological studies to generate input data for burden of disease calculation. These studies have indicated that epidemiological and economic arguments cannot be used to delay the implementation of universal hepatitis B vaccination. Some countries have improved their surveillance system and included viral hepatitis in the surveillance programs. Other have put hepatitis B vaccination on the political agenda. By the year 2000, following countries of the WHO European Region (51 countries) have implemented a universal hepatitis B immunisation programme: Andorra, Albania, Austria, Belarus, Belgium, Bulgaria, Estonia, France, Germany, Greece, Italy, Israel, Kazakhstan, Kyrgyzstan, Latvia, Lithuania, Luxembourg, Malta, Moldova, Monaco, Poland, Portugal, parts of the Russian Federation, Romania, Slovakia, Slovenia, San Marino, Spain, Switzerland, Turkey and Uzbekistan. The Netherlands and some other European countries are seriously studying the issues or are making budgetary provisions for introduction of HB vaccine into their vaccination programme. Most of the European countries, which now use the vaccine routinely, have started with adolescent or infant immunisation. Belgium (1999), France (1994) and Italy (1991) have begun with both adolescent and infant HB immunisation. France continues since 1st October 1998 with the infant immunisation programme only. The rewards of effective implementation of the programmes in these countries are becoming apparent; and their success offers an exemplary model for other countries. The deadline was 1997. Globally, work still remains to be done to support and implement interventions that will bring us closer to the WHO goal and to control, eliminate and eradicate hepatitis B in the coming generations at large. If all the 145 million infants born in 1991 had been vaccinated in this way, the number of chronic carriers would have been reduced by 7.5 million, and 1.8 million deaths prevented.

Introduction

Hepatitis B is a major public health problem and remains an important infection in the community despite the availability of safe and effective vaccines for almost 20 years.

Since hepatitis B infection is largely a-symptomatic, with possible long-term complications occurring after many years, it has not received the attention it deserves. The failure of the high risk immunisation strategy and a better understanding of the burden of disease of hepatitis B, have caused a profound re-evaluation of the current vaccination strategies.

Government delegates to the World Health Assembly agreed in May 1992 that all countries should integrate hepatitis B vaccination into their national immunisation programmes by 1997.

In western Europe, some very low endemicity countries (carrier rate <0.5%) remain unconvinced that the burden of hepatitis B disease warrants the expense of universal infant or adolescent hepatitis B vaccination: hepatitis B is viewed as a limited public health problem, that does not justify additional expenses on the health care budget. For these countries, there is a need to show irrefutably how the efficiency of a universal programme compares with that of a targeted programme.

Epidemiological data in low-endemicity regions emphasise the necessity for action: it appears that 30–40% of carriers in industrialised countries have acquired their hepatitis B infection before the age of 5 [1]. Risk group vaccination policy will have no impact on these infections and won't be able to control further transmission from this young carrier pool. In addition, the increasing number of immigrants from high to intermediate endemicity regions strongly contribute to this new dynamics of hepatitis B transmission in the low endemicity countries.

Economic evaluations showing that universal hepatitis B vaccination is relatively cost-effective in low-endemic countries (compared with other healthcare interventions), indicate that control of hepatitis B by universal immunisation is attainable [2].

Section snippets

Situation in the WHO European region in 2000: an update

In 1993, four countries had implemented universal immunisation programmes against hepatitis B in the WHO European region: Bulgaria, Italy, Israel and Spain.

In Italy in 1991, a law was issued, which established mandatory immunisation of neonates and 12-year-old adolescents (law issued 27th May 1991) [3]. The latter are to be immunised only during the first 12 years of application of the law; after this period only infants will continue to be vaccinated. Compliance with vaccination in infants was

Survey

In the first part of 2000, a postal survey was conducted among the 51 EPI (Expanded Programme on Immunisation) managers from the WHO European region to update the information on hepatitis B vaccination policies in Europe and on the hepatitis B epidemiology. Information was sought on types of surveillance systems in place, incidence of acute symptomatic infections and availability of data on seroprevalence and vaccination policies.

Table 1 summarises the preliminary information from this survey.

Future challenges

Important challenges for the coming decade include: sustaining the already existing vaccination programmes; increasing vaccine coverage; ensuring that all countries are able to maintain a sustainable supply of vaccine; and monitoring currently implemented vaccination programmes [14]. Programmes should be evaluated and monitored to ensure that they are performing well. Evaluation of programmes should be a component of the initial programme development. The information gained should be used to

Conclusion

The rewards of effective implementation of universal programmes are becoming apparent in terms of reduction in incidence of acute HB infections, reduction in carrier rate in immunised cohorts and reduction in HCC and related mortality. These success stories offer an exemplary model for other countries.

In Europe, as well as in the rest of the world, work still remains to be done to support and implement interventions that will bring us closer to the WHO goal and to control hepatitis B in the

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The present study demonstrates substantial impact of hepatitis B vaccine introduction on reducing HBV infections in Tajikistan. To achieve further progress in hepatitis B control, Tajikistan should maintain high routine coverage with hepatitis B vaccine, including birth dose.
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Hepatitis B: vaccination programmes in Europe — an update

Abstract

Introduction

Section snippets

Situation in the WHO European region in 2000: an update

Survey

Future challenges

Conclusion

Lancet

Vaccine

Vaccine

Continuing risk for hepatitis B virus transmission among children born in the United States to Southeast Asian children in Louisiana

Pediatrics

Implementation in Italy of a universal vaccination programme against hepatitis B

Vaccine

Implementing universal vaccination programmes: Spain

Vaccine