Hepatitis B : Symptom I Transmission I Diagnosis I Treatment I Allopathic I Ayurvedic I Medicine I Side-effects

 

 

 

 

 

 

 

 

               
                                                                 Hepatitis B



















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Hepatitis is an inflammation of the liver, most commonly caused by a viral infection. There are five main hepatitis viruses, referred to as types A, B, C, D and E, but it can also be caused due to toxins (notably alcohol, certain medications, some industrial organic solvents and plants), other infections and autoimmune diseases.

·         Hepatitis A and E are typically caused by ingestion of contaminated food or water. Hepatitis B, C and D usually occur as a result of parenteral contact with infected body fluids. Common modes of transmission for these viruses include receipt of contaminated blood or blood products, invasive medical procedures using contaminated equipment and for hepatitis B transmission from mother to baby at birth, from family member to child, and also by sexual contact.

·         The clinical presentation of infectious hepatitis varies with the individual, as well as with the specific causative virus. Some patients may be entirely asymptomatic or only mildly symptomatic at presentation. Others may present with rapid onset of fulminant hepatic failure (FHF). The classic presentation of infectious hepatitis involves 4 phases, as follows:

Ø  Phase 1 (viral replication phase) – Patients are asymptomatic during this phase; laboratory studies demonstrate serologic and enzyme markers of hepatitis

Ø  Phase 2 (prodromal phase) – Patients experience anorexia, nausea, vomiting, alterations in taste, arthralgias, malaise, fatigue, urticaria, and pruritus, and some develop an aversion to cigarette smoke; when seen by a health care provider during this phase, patients are often diagnosed as having gastroenteritis or a viral syndrome

Ø  Phase 3 (icteric phase) – Patients may note dark urine, followed by pale-colored stools; in addition to the predominant gastrointestinal (GI) symptoms and malaise, patients become icteric and may develop right upper quadrant pain with hepatomegaly

Ø  Phase 4 (convalescent phase) – Symptoms and icterus resolve, and liver enzymes return to normal

 

v  Sign And Symptoms :

v  Acute

ü  Initial features are of nonspecific flu-like symptoms, common to almost all acute viral infections and may include malaise, muscle and joint aches, fever, nausea or vomiting, diarrhea, and headache. More specific symptoms, which can be present in acute hepatitis from any cause, are: profound loss of appetite, aversion to smoking among smokers, dark urine, yellowing of the eyes and skin (i.e., jaundice) and abdominal discomfort. Physical findings are usually minimal, apart from jaundice in a third and tender hepatomegaly (swelling of the liver) in about 10%. Some exhibit lymphadenopathy (enlarged lymph nodes, in 5%) or splenomegaly (enlargement of the spleen, in 5%).

ü  Acute viral hepatitis is more likely to be asymptomatic in younger people. Symptomatic individuals may present after convalescent stage of 7 to 10 days, with the total illness lasting 2 to 6 weeks.

ü  A small proportion of people with acute hepatitis progress to acute liver failure, in which the liver is unable to clear harmful substances from the circulation (leading to confusion and coma due to hepatic encephalopathy)  and produce blood proteins (leading to peripheral edema and bleeding). This may become life-threatening and occasionally requires a liver transplan

 v  Chronic

ü  Chronic hepatitis often leads to nonspecific symptoms such as malaise, tiredness and weakness, and often leads to no symptoms at all. It is commonly identified on blood tests performed either for screening or to evaluate nonspecific symptoms. The occurrence of jaundice indicates advanced liver damage. On physical examination there may be enlargement of the liver. WHO estimates that in 2015, 257 million people were living with chronic hepatitis B infection (defined as hepatitis B surface antigen positive).

ü  Extensive damage and scarring of liver (i.e. cirrhosis) leads to weight loss, easy bruising and bleeding tendencies, peripheral edema (swelling of the legs) and accumulation of ascites (fluid in the abdominal cavity). Eventually, cirrhosis may lead to various complications: esophageal varices (enlarged veins in the wall of the esophagus that can cause life-threatening bleeding) hepatic encephalopathy (confusion and coma) and hepatorenal syndrome (kidney dysfunction).

§  Acne, abnormal menstruation, lung scarring, inflammation of the thyroid gland and kidneys may be present in women with autoimmune hepatitis.

 v Geographical distribution:

 

 






















ü 
Hepatitis B prevalence is highest in the WHO Western Pacific Region and the WHO African Region, where 6.2% and 6.1% of the adult population is infected respectively. In the WHO Eastern Mediterranean Region, the WHO South-East Asia Region and the WHO European Region, an estimated 3.3%, 2.0% and 1.6% of the general population is infected, respectively. And in the WHO Region of the Americas, 0.7% of the population is infected.


v Lack of Knowledge About Hepatitis B Disadvantages Black Communities:


ü  Hepatitis B is known to affect Black people to a greater extent than whites in the United States. Only Asians have a higher rate. Both African American and Haitian Black communities have poor knowledge about the disease, which might limit prevention, diagnosis and treatment, researchers reported in a study published in Cancer Causes & Control.  

 

ü  These findings highlight the need for community-level, culture-specific programs that include Black communities and guide them toward earlier screening and treatment for hep B.  

                  

ü  “Essentially, if you don’t know that you have HBV, you cannot seek treatment for it, and if you develop cancer, you will likely present when the cancer is advanced and there are fewer options for treatment,” Patricia Jones, MD, of the University of Miami’s Sylvester Comprehensive Cancer Center, said in a press release. “We want to interrupt that cycle by better understanding the perspectives of the populations most affected and creating programs that address those specific needs.” 

 

ü  Of the estimated 1.4 million people with chronic hep B in the United States, only 26% are aware they carry the virus. In an earlier study, the researchers had found that despite being heavily affected by hep B, Blacks were likely to be unaware of their infection until they were diagnosed with hepatocellular carcinoma. Further, when diagnosed, African Americans were younger and further along in their disease progression than their white, Latino and Asian counterparts. 

 

ü  “When we studied patients with liver cancer in South Florida, we found that 8% of white liver cancer patients had long-term HBV infections, compared to 21% of African-American Black and 30% of Haitian liver cancer patients,” Jones said. 

 

ü  In South Florida, Jones and her colleagues recruited Black participants through email, social media, local radio, word of mouth or a hepatology clinic. Between February 2017 and February 2018, they conducted focus groups in Haitian Creole or English to determine these communities’ understanding of hep B, hepatocellular carcinoma and availability of screening.  

 

ü  They included Black men and women born in the United States or Haiti and excluded any individuals who had been diagnosed with hepatitis C or who already had cirrhosis or liver cancer. Of the 55 participants, 15 (27%) had chronic HBV infection.  

 

ü  Among the Haitian Blacks, only 42% knew about hep B. Comparatively, 78% of African Americans knew about the virus. People with chronic hep B were more knowledgeable about the virus than individuals without hep B.  

 

ü  There was little knowledge about liver cancer within the African-American community, with most believing it to be uncommon. On the other hand, cirrhosis was reported as being common, with most participants having some understanding of its causes and symptoms. 

 

ü  All participants in this group knew of at least one individual with cirrhosis and considered it to be related to heavy alcohol and drug use. This group was less aware of hep B, including its transmission route, and hepatocellular carcinoma. Many participants were under the impression that hep B was somehow related to HIV. 

 

ü  In comparison to African Americans, Haitian Blacks were better informed about cirrhosis and hep B. They knew about its symptoms and preventive vaccines. But many individuals were unaware of its transmission route and connection to hepatocellular carcinoma. Participants from this group also talked about “supernatural” causes leading to sickness—even though most acknowledged their disbelief in these long-held and firmly rooted beliefs in the community. While this group knew that hep B and HIV were different, stigma was associated with both. Those living with hep B were unlikely to reveal the information to anybody else. 

 

ü  “In two communities disproportionately affected by HBV, misconceptions about disease transmission, stigma, low health literacy and decreased access to care may limit detection for HBV,” wrote the researchers. 

 

ü  Both communities were of the opinion that distrust of medical facilities, stigma and fear might prevent members from accessing health care. Economic disadvantage and lack of education were held responsible for the higher likelihood of late-stage diagnosis of hepatocellular carcinoma among Black individuals.  

 

ü  Overall, both groups believed that a lack of access to opportunities and health care was a result of the low economic status of their communities. Moreover, these communities concurred that they are less likely to have access to the care afforded white people. Census data reaffirmed that white people are more likely to be insured in comparison with Latinos and Blacks.  

 

ü  Further, people who had been diagnosed with hep B reported having to educate themselves about the viral infection because information from their providers was lacking. “It’s critical that we, as physicians, ask how much patients understand and that we assess their understanding,” Jones said. 

ü  Through the focus group, it became apparent that more awareness of hepatitis and cirrhosis is needed across Black communities. Public service announcements via social media or more traditional institutions, educational town hall meetings and even Haitian radio would be suitable routes for hep B education. Getting community leaders involved in the dissemination of this information would help engage the community. Home-based screening or using a confidential mobile testing service would also aid in increasing access. 

ü  “The key is to understand how to work best with communities and get people to engage in education, screenings, medical care and research,” Jones said. 

ü  In conclusion, the reseachers wrote, “Culturally relevant community-based interventions are needed to increase HBV detection.”  

 

 

v Transmission:

 Ã¼  In highly endemic areas, hepatitis B is most commonly spread from mother to child at birth (perinatal transmission), or through horizontal transmission (exposure to infected blood), especially from an infected child to an uninfected child during the first 5 years of life. The development of chronic infection is very common in infants infected from their mothers or before the age of 5 years.

  §  As of 2016, 27 million people (10.5% of all people estimated to be living with hepatitis B) were aware of their infection, while 4.5 million (16.7%) of the people diagnosed were on treatment. According to latest WHO estimates, the proportion of children under five years of age chronically infected with HBV dropped to just under 1% in 2019 down from around 5% in the pre-vaccine era ranging from the 1980s to the early 2000s.

ü  Hepatitis B is also spread by needlestick injury, tattooing, piercing and exposure to infected blood and body fluids, such as saliva and, menstrual, vaginal, and seminal fluids.

ü  Sexual transmission of hepatitis B may occur, particularly in unvaccinated men who have sex with men and heterosexual persons with multiple sex partners or contact with sex workers.
Infection in adulthood leads to chronic hepatitis in less than 5% of cases, whereas infection in infancy and early childhood leads to chronic hepatitis in about 95% of cases.

v  Who is at risk of chronic disease?

ü  The likelihood that infection becomes chronic depends on the age at which a person becomes infected. Children less than 6 years of age who become infected with the hepatitis B virus are the most likely to develop chronic infections.

ü  In infants and children:

§  80–90% of infants infected during the first year of life develop chronic infections; and

§  30–50% of children infected before the age of 6 years develop chronic infections.

ü  In adults:

§  less than 5% of otherwise healthy persons who are infected as adults will develop chronic infections; and 20–30% of adults who are chronically infected will develop cirrhosis and/or liver cancer.

 

v About Virus:

ü  The hepatitis B virus can survive outside the body for at least 7 days. During this time, the virus can still cause infection if it enters the body of a person who is not protected by the vaccine. The incubation period of the hepatitis B virus is 75 days on average, but can vary from 30 to 180 days. The virus may be detected within 30 to 60 days after infection and can persist and develop into chronic hepatitis B.

  Diagnosis:

ü  It is not possible, on clinical grounds, to differentiate hepatitis B from hepatitis caused by other viral agents, hence, laboratory confirmation of the diagnosis is essential. A number of blood tests are available to diagnose and monitor people with hepatitis B. They can be used to distinguish acute and chronic infections. There are several laboratory tests that may be used in cases of known or suspected hepatitis, including:

 

§  Abdominal ultrasound

§  Autoimmune blood markers

§  Hepatitis virus serologies

§  Liver function tests

§  Liver biopsy to check for liver damage

§  Paracentesis (if fluid is in your abdomen)

§  Detection of immunoglobulin M (IgM) for hepatitis A virus (HAV) is the standard for diagnosing acute infection with HAV.

§  Detection of IgM for hepatitis B core antigen (HBcAg) in serum is required to make the diagnosis of acute hepatitis B virus (HBV) infection. Hepatitis B surface antigen (HBsAg) may be present in acute infection or in patients who are chronic carriers. Its presence in patients with symptoms of acute hepatitis strongly suggests acute HBV infection but does not rule out chronic HBV with acute superinfection by another hepatitis virus. The presence of HBsAg in the serum for 6 months or longer indicates chronic infection.

§  Hepatitis C virus (HCV) infection can be confirmed with serologic assays to detect antibody to HCV (anti-HCV) or with molecular tests for the presence of viral particles. Third-generation assays for anti-HCV are sensitive and specific and can detect such antibodies within 4-10 weeks of infection. A rapid antibody test strip has now been approved. Qualitative polymerase chain reaction (PCR) assay for presence of viral particles is the most specific test of HCV infection and may be helpful in diagnosing acute HCV infection before antibodies have developed.

§  Assays to detect IgM antibody to hepatitis D virus (HDV) do not need to be routinely performed in all patients with suspected hepatitis.

 

 

  v Treatment:

                        v Allopathic Treament:

ü  There is no specific treatment for acute hepatitis B. Therefore, care is aimed at maintaining comfort and adequate nutritional balance, including replacement of fluids lost from vomiting and diarrhoea. Most important is the avoidance of unnecessary medications . Acetaminophen/Paracetamol and medication against vomiting should not be given. You’ll have to give up things that can hurt your liver, like alcohol and acetaminophen. Check with your doctor before taking any other drugs, herbal treatments, or supplements.

ü  Chronic hepatitis B infection can be treated with medicines, including oral antiviral agents. Treatment can slow the progression of cirrhosis, reduce incidence of liver cancer and improve long term survival. Only a proportion (estimates vary from 10% to 40% depending on setting and eligibility criteria) of people with chronic hepatitis B infection will require treatment.

ü  WHO recommends the use of oral treatments - tenofovir or entecavir- as the most potent drugs to suppress hepatitis B virus. They rarely lead to drug resistance compared with other drugs, are simple to take (1 pill a day), and have few side effects, so require only limited monitoring.

§  Entecavir (Baraclude). This is the newest drug for hepatitis B. You can take it as a liquid or tablet.is off-patent. In 2017, all low- and middle-income countries could legally procure generic entecavir, but the costs and availability varied widely.

§  Tenofovir (Viread). This drug comes as a powder or tablet. If you take it, your doctor will check often to make sure it doesn’t hurt your kidneys.This drug is no longer protected by a patent anywhere in the world. The median price of WHO-prequalified generic tenofovir on the international market fell from US$ 208 per year to US$ 32 per year in 2016.

§   Lamivudine (3tc, Epivir A/F, Epivir HBV, Heptovir). It comes as a liquid or tablet you take once a day. Most people don’t have a problem with it. But if you take it for a long time, the virus might stop responding to the drug.

§  Adefovir dipivoxil (Hepsera). This drug, which you take as a tablet, works well for people who don’t respond to lamivudine. High doses can cause kidney problems.

§  Interferon alfa (Intron A, Roferon A, Sylatron). This medicine boosts your immune system. You take it as a shot for at least 6 months. It doesn’t cure the disease. It treats liver inflammation. Long-acting interferon, peginterferon alfa2a (Pegasys, Pegasys Proclick), can also help. But this drug can make you feel bad all over or depressed, and it can and zap your appetite. It also lowers your white blood cell count, which makes it harder to fight off infection.

§  Telbivudine (Tyzeka) is an antiviral medication. Resistance to this medication is common.

 

ü  In most people, however, the treatment does not cure hepatitis B infection, but only suppresses the replication of the virus. Therefore, most people who start hepatitis B treatment must continue it for life.

ü  There is still limited access to diagnosis and treatment of hepatitis B in many resource-constrained settings. In 2016, of the more than 250 million people living with HBV infection, 10.5% (27 million) were aware of their infection. Of those diagnosed, the global treatment coverage is 16.7% (4.5 million). Many people are diagnosed only when they already have advanced liver disease.

ü  Among the long-term complications of HBV infections, cirrhosis and hepatocellular carcinoma cause a large disease burden. Liver cancer progresses rapidly, and since treatment options are limited, the outcome is generally poor. In low-income settings, most people with liver cancer die within months of diagnosis. In high-income countries, surgery and chemotherapy can prolong life for up to a few years. Liver transplantation is sometimes used in people with cirrhosis in high income countries, with varying success.


v   Ayurveda Perspective & Management of Hepatitis:

 


ü  In Ayurveda, the liver is called Yakrit. Pitta is the predominant humor of the liver. Most liver disorders are aggravated conditions of Pitta.

 

ü  Excessive bile production or a blockage in the flow of bile usually indicates high pitta, which in turn affects the agni or enzyme activities responsible for absorption, digestion and metabolism.

ü  Aggravation of the Pitta causes the liver diseases such as hepatitis, cirrhosis and fatty liver.

ü  Kaamala is the term mentioned in Ayurveda to describe the wide range of liver diseases including Hepatitis. Kaamala is a disease of the Raktavaha srotas (a system which includes liver, spleen, blood vessels, and reticuloendothelial tissue) and dominant of pitta dosha. Kaamala is caused due to impairment of pitta dosha and rakta dhatu.

ü  Ayurveda describes various types of kaamala (hepatitis or jaundice) based on the stage or depth of the symptoms. They are:

§  Shakhasrita – is caused by the aggravation of all the doshas (Vata, Pitta and Kapha), and is a kind of obstructive jaundice.

§  Koshta shakhsrita – results from very high pitta derangement and considered as severe jaundice or hepatitis, difficult to cure.

§  Kumbha kamala – is a neglected or untreated stage of jaundice or hepatitis. It can become incurable if not attended immediately. It can be compared with Cirrhosis of liver.

§  Haleemaka – is an advanced or neglected stage of Paandu roga that occurs when both the vata and pitta are out of level.

§  Various herbal centre  are providing highly effective treatment for various type or Hepatitis including hepatitis B & hepatitis C. Their treatment is useful in controlling the infection & replication of the virus, preventing further damage to liver. Hepatitis B patients show better response than Hepatitis C.

 

ü  Their  treatment involves Shodana chikitsa (detoxification through Panchakarma procedures), Shamana chikitsa (Palliative researched Ayurvedic medicines) and Kayakalpa (rejuvenation).

ü  Diet restrictions, life style modifications and de-addiction are also the essential factors practiced for the best possible results.

 

v Prevention:

ü  The hepatitis B vaccine is the mainstay of hepatitis B prevention. WHO recommends that all infants receive the hepatitis B vaccine as soon as possible after birth, preferably within 24 hours – followed by two or three doses of hepatitis B vaccine at least four weeks apart to complete the series. Timely birth dose is an effective measure to reduce transmission from mother-to-child.   

ü  This marks the achievement of one of the milestone targets to eliminate viral hepatitis in the Sustainable Development Goals ─ to reach under 1% prevalence of HBV infections in children under five years of age by 2020.

ü  The scale-up of hepatitis B vaccine worldwide over the last two decades has been a great public health success story and contributed to the decrease in HBV infections among children

ü  In 2019, coverage of 3 doses of the vaccine reached 85% worldwide compared to around 30% in 2000. However, coverage of the hepatitis B vaccine birth dose remains uneven. Global coverage of the HBV birth dose, for example, is 43%, while coverage in the WHO African Region is only 6%. .

ü  The complete vaccine series induces protective antibody levels in more than 95% of infants, children and young adults. Protection lasts at least 20 years and is probably lifelong. Thus, WHO does not recommend booster vaccinations for persons who have completed the 3-dose vaccination schedule.

ü  All children and adolescents younger than 18 years and not previously vaccinated should receive the vaccine if they live in countries where there is low or intermediate endemicity. In those settings it is possible that more people in high-risk groups may acquire the infection and they should also be vaccinated. This includes:

 

§  people who frequently require blood or blood products, dialysis patients and recipients of solid organ transplantations;

§  people in prisons;

§  people who inject drugs;

§  household and sexual contacts of people with chronic HBV infection;

§  people with multiple sexual partners;

§  healthcare workers and others who may be exposed to blood and blood products through their work; and

§  travellers who have not completed their HBV series, who should be offered the vaccine before leaving for endemic areas.

ü  The vaccine has an excellent record of safety and effectiveness and the proportion of children under five years of age chronically infected with HBV dropped to just under 1% in 2019 down from around 5% in the pre-vaccine era ranging from the 1980s to the early 2000s.

ü  In addition to infant vaccination, including a timely birth dose, WHO recommends the use of antiviral prophylaxis for the prevention of hepatitis B transmission from mother-to-child. Pregnant women with high levels of HBV DNA (viral load) and/or the presence of HBeAG have an elevated risk of transmitting the virus to their child, even among infants who receive the timely birth dose and the complete hepatitis B vaccine series. As such, pregnant women with high HBV DNA levels may be eligible for antiviral prophylaxis during pregnancy to prevent perinatal HBV infection and protect their infants from contracting the disease.

ü  In addition to infant vaccination and prevention of mother-to-child-transmission, implementation of blood safety strategies, including quality-assured screening of all donated blood and blood components used for transfusion, can prevent transmission of HBV. Furthermore, safer sex practices, including minimizing the number of partners and using barrier protective measures (condoms), also protect against transmission.

WHO response :

ü  In May 2016, the World Health Assembly adopted the first "Global health sector strategy on viral hepatitis, 2016-2020". The strategy highlights the critical role of universal health coverage and sets targets that align with those of the Sustainable Development Goals. 

ü  The strategy has a vision to eliminate viral hepatitis as a public health problem. This is encapsulated in the global targets to reduce new viral hepatitis infections by 90% and reduce deaths due to viral hepatitis by 65% by 2030. Actions to be taken by countries and the WHO Secretariat to reach these targets are outlined in the strategy.

ü  To support countries in achieving the global hepatitis elimination targets under the Sustainable Development Agenda 2030, WHO is working to:

§  raise awareness, promote partnerships and mobilize resources;

§  formulate evidence-based policy and data for action;

§  increase health equities within the hepatitis response

§  prevent transmission; and

§  scale up screening, care and treatment services.

ü  In March 2015, WHO launched its first "Guidelines for the prevention, care and treatment of persons living with chronic hepatitis B infection".

ü  The recommendations include:

§  promote the use of simple, non-invasive diagnostic tests to assess the stage of liver disease and eligibility for treatment;

§  prioritize treatment for those with the most advanced liver disease and at greatest risk of mortality; and

§  recommend the preferred use of the nucleos(t)ide analogues with a high barrier to drug resistance (tenofovir and entecavir, and entecavir in children aged 2–11 years) for first- and second-line treatment.

ü  These guidelines also recommend lifelong treatment for those with cirrhosis and those with high HBV DNA and evidence of liver inflammation, and regular monitoring for those on treatment, as well as those not yet on treatment for disease progression, indications for treatment and early detection of liver cancer.

ü  In July 2020 WHO published  additional guidance on “Prevention of mother-to-child transmission of hepatitis B virus: Guidelines on  antiviral prophylaxis in pregnancy”.

ü  In addition to the series of hepatitis B vaccinations (including a first dose within 24 hours of birth), WHO now recommends that pregnant women testing positive for HBV infection (HBsAg positive) with an HBV DNA equal to or greater 200,000 IU/ml receive tenofovir prophylaxis; the preventive therapy should be provided from the 28th week of pregnancy until at least birth.

ü  Some settings have poor access to tests that quantify an individual’s HBV viral load and determine whether a pregnant woman would be eligible for preventative treatment or prophylaxis. This is especially the case in low income settings or rural areas where many antenatal care visits take place. In settings where antenatal HBV DNA testing is not available, WHO now recommends the use of HBeAg testing as an alternative to determine eligibility for tenofovir prophylaxis for the prevention of mother-to-child transmission of HBV.

ü  The hepatitis B testing and treatment of eligible pregnant women can be integrated with the prevention of mother-to-child transmission of HIV and congenital syphilis with antenatal care service. This approach is often referred to as ‘Triple elimination’ – an initiative that promotes the elimination of mother-to-child transmission of three infections: HIV, syphilis and hepatitis B virus.

ü  In addition, WHO recently published the “Progress report on HIV, viral hepatitis and sexually transmitted infections, 2019”, outlining its progress towards elimination. The report sets out global statistics on viral hepatitis B and C, the rates of new infections, the prevalence of chronic infections and mortality caused by these 2 high-burden viruses, and coverage of key interventions, all current as at the end of 2016 and 2017.

ü  Moreover, since 2011, together with national governments, partners and civil society, WHO has organized annual World Hepatitis Day campaigns (as 1 of its 9 flagship annual health campaigns) to increase awareness and understanding of viral hepatitis. The date of 28 July was chosen because it is the birthday of Nobel-prize winning scientist Dr Baruch Bloomberg, who discovered the hepatitis B virus and developed a diagnostic test and vaccine for it.

ü  For World Hepatitis Day 2020, WHO is focusing on the theme “Hepatitis-Free Future” to highlight the importance of addressing the prevention of mother-to-child transmission of HBV, launch new guidance,  and to call for increased domestic and international programming and  funding  to prevent hepatitis B mother-to-child transmission and expand access to hepatitis prevention, testing and treatment services, with a view to achieving the 2030 elimination targets

 

 

                                                                                                                            


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