Viral hepatitis is a descriptive medical term for liver infection caused by hepatitis viruses of which the most significant in Ghana is hepatitis B virus. The infections caused by hepatitis B virus (and hepatitis C virus) are of grave importance because they can persist beyond six months and lead to chronic (long term) infection of the liver, aptly called chronic hepatitis B (or C as the case may be). The age at which exposure to infection occurs is the single most important predictor of whether the liver gets chronically infected or not. Infected newborns, infants, and children under five generally are disadvantaged due to their immature body defence system which is too weak to clear the virus. Thus they have very high chance of developing chronic infection of the liver (chronic hepatitis B) once they get infected. Nine out of ten hepatitis B-infected newborns and infants develop chronic infection, compared to one out of ten hepatitis B-infected adults. Most of those infected do not usually show signs of sudden onset (acute) illness and yet they will progress to develop chronic infection of the liver. From this point, up to a third of chronically infected livers will develop abnormal changes in the normally soft liver tissue (due to scarring) and in some cases, also develop liver cancer, all over a short space of fifteen to thirty years.
Chronic hepatitis B infection in children is therefore a time-bomb which can prematurely end the lives of about one third of those affected. The irreversible damage leading to death progresses as these children grow into adolescence and adulthood, with few of them or their parents knowing about this danger. This is the period for formal education and skill acquisition to become part of the productive labour force. It is evident therefore that chronic hepatitis B secretly undermines the gains made by society in ensuring child survival from common childhood killer diseases. Health staff who work to ensure children survive are hardly aware of the dangers the child faces from chronic hepatitis B as he or she grows, unless there is some indication to test for hepatitis B. Usually there is none.
Ghana has had a high chronic hepatitis B burden over the years. In the 1990s, when no vaccine was routinely deployed, the burden was estimated to be 17.1% of the general population. This declined to 10.5% in 2015 after the Ministry of Health introduced routine hepatitis B- containing pentavalent vaccine for children at 6, 10 and 14 weeks of life. Significantly part of the 6.6 percentage point decline in general population prevalence between 1990 and 2015 is attributable to pentavalent vaccination over the 13-year period from 2002 to 2015. This vaccine has helped to prevent new infections, especially those due to child-to-child transmission of the virus. With better targeting of vaccination through efforts to reach every district and every child, and attainment of high national coverage beyond 98% for several years now, there has also been a corresponding decline from 10.5% in 2015 to 9.1% in 2019 in general population prevalence. The recorded declines in disease burden are accompanied by declining death rates from the disease. This means although more people are surviving the disease by living longer, the general picture is one of decline in disease burden. This reduction in chronic hepatitis B burden is largely accounted for by significant reduction in new chronic hepatitis B cases among children and adolescents, who are main beneficiaries of routine vaccination.
For a disease that can be eliminated, the current prevalence of 9.1% (that is affecting 2.8 million Ghanaians, is still high: being above 8%, this indicates persisting vertical transmission. Further significant decline is possible when newborns are immunized against its transmission from mothers to children, and its early transmission in the first six weeks of life. The tool for enabling newborns to fight against the virus at birth or during early days of life till six weeks when pentavalent vaccination is received is the hepatitis B birth dose vaccine. This is a monovalent vaccine that protects against only hepatitis B, as against the pentavalent which protects against five diseases including hepatitis B. Hepatitis B birth dose vaccination is most effective when given during the first 24 hours of birth, the so-called timely birth dose. Timely birth dose is highly protective and when given to all newborns, it will result in drastic reduction of vertical transmission and early childhood infection. Together with additional three doses of pentavalent vaccines (already being given), it results in infants who are fully protected against hepatitis B, usually for life. These doses supply 98–100% protection against infection. This initial vaccination series aims to establish a strong and long-lasting immune response. Although the level of immunity can gradually decline over time, current recommendations generally do not include routine booster shots for healthy individuals who completed the series.
Hepatitis B birth dose is beneficial for all newborns, whether the mother is known to be infected or not, as newborns to mothers without infection also stand the risk of early childhood transmission of infection from handlers and unsafe procedures. This is the universal hepatitis B birth dose which Ghana seeks to implement. Is it better to treat incurable liver disease than prevent it? Most reasonable people will choose prevention as birth dose vaccination is highly cost-effective, taking away future healthcare costs to treat hepatitis-related liver disease and cancer.
From latter part of this year 2025, a future hepatitis B-free Ghana looms into view, thanks to government of Ghana and its partners, especially GAVI. This desirable future is attainable when few or no new infections arise while existing older cases are cured (if cure becomes reality) or die out eventually. However, potential challenges impeding access to effective vaccination exist even if the vaccine and infrastructure for vaccine delivery are available. Leaders in the health sector are to anticipate these and develop strategies to overcome them.
Nationally, about 78% of births in Ghana take place at a health facility, with an estimated 11.2% of these births taking place in the private health maternities. The rest 22% are delivered outside health facilities.
The first challenge is ensuring all public facility births are vaccinated within 24 hours. This will depend on the awareness and enthusiasm of midwives, and acceptance of the crucial role of being the first vaccinators of newborns as part of essential newborn care, just like they administer Vitamin K to all newborns to prevent bleeding disorders. The requirement for timely birth dose vaccination makes this vaccine a little different from oral polio and BCG vaccine against TB which can also be given at birth but come with more laxity than hepatitis B birth dose. Thus a different approach altogether is required. If public sector fails this responsibility to maximize birth dose vaccination of children born under their care, a hepatitis B-free future will become elusive and a mirage.
The second challenge is ensuring all private hospital/clinic maternity births are vaccinated within 24hours. The level of integration between the private and public sectors and how public goods like vaccines are allocated between these sectors as well as private sector willingness to be accountable are crucial. Acceptance by private midwives (and facility owners) to comply with public sector rules of fee-free and timely vaccination and the documentation responsibilities that go with it will go a long way in maximizing birth dose vaccination of children born under their care. A less desired scenario is private sector midwives notifying public sector nurse vaccinators (community health nurses) to come over to vaccinate each newborn within 24 hours. A successful interplay between these sectors can ensure all facility births receive timely birth dose. Anything else will undermine the realization of the desired future-a hepatitis B-free Ghana.
A third challenge is to ensure most out of facility births receive timely birth dose. This requires a lot of innovation from community health officers, working together with traditional birth attendants, community volunteers, and families of the newborn. A successful approach can compensate for untimely birth doses given to facility births through lack of coordination and other factors. Staff motivation, effective communication and surveillance are required. Ultimately, health system improvements that ensure all births are attended at health facilities will be good for timely birth dose administration.
Pregnant women have been highly motivated to undertake HIV testing in pregnancy once they know the results would benefit their child when born. Similar counseling can be used for hepatitis. Maternal motivation at the personal level and from within nuclear and extended family set up and the entire community will empower mothers to demand that their newborns receive a timely birth dose. A lot of education on the vaccine, its benefits, safety profile and pro-active management of any side-effects as well as active management of misinformation and disinformation will be needed for this to happen. Hepatitis B birth dose vaccine champions and the media using multi-modal communication can help to raise large scale public awareness in a short time.
What advantages does birth dose vaccination for hepatitis B bring? It brings on board a safe and effective prevention of chronic hepatitis B and consequent liver damage or cancer that can arise after 15-30 years. It reinforces the common wisdom of prevention being better and cheaper than cure.
The benefits of Hepatitis B vaccination significantly outweigh the risks of potential side effects. Most newborns receiving the birth dose hepatitis B vaccine experience no significant side effects. The vaccine is injected directly into a thigh muscle. The injection itself is usually quick and causes minimal pain. Local reactions are the most common side effects-typically manifesting as pain, redness, swelling, or tenderness at the injection site. These reactions usually appear within the first 24 to 48 hours after vaccination and generally resolve within a few days without any specific intervention. Systemic reactions, affecting the entire body, are less frequent and can include fever, irritability, fatigue, loss of appetite, and occasionally vomiting or diarrhea. These symptoms are typically mild and self-limiting, resolving within 1-2 days.
In conclusion, we appeal to all Ghanaians to support this vaccination and actively address bottlenecks that will deny a timely dose to any newborn. It’s time to carry the good news and discuss it at any opportunity to ensure awareness and high level acceptance. A hepatitis B -free future looms for all of us, can we grab it?
By Hepatitis Foundation of Ghana & National Viral Hepatitis Control Programme
