Zero Hepatitis B in Children: Maldives and Sri Lanka Reach WHO Control Milestone

In a historic stride for public health, the Maldives and Sri Lanka have officially achieved the hepatitis B control goal, validated by an independent expert panel convened by the World Health Organization (WHO) in 2024. The milestone follows rigorous national seroprevalence surveys conducted by the Health Protection Agency of Maldives and the Epidemiology Unit of the Ministry of Health, Sri Lanka, with support from WHO’s South-East Asia Regional Office (SEARO). The findings mark a new era in hepatitis prevention in the region, positioning both countries alongside Bangladesh, Bhutan, Nepal, and Thailand in meeting a critical benchmark under WHO’s Global Health Sector Strategy (GHSS) on viral hepatitis. The surveys confirmed exceptionally low hepatitis B surface antigen (HBsAg) prevalence among children, well below the 1% threshold, underscoring decades of immunization investments and systems strengthening.

South-East Asia's Hepatitis Burden and Global Targets

Viral hepatitis continues to pose a dire global threat, with 1.3 million deaths recorded in 2022, including 1.1 million from hepatitis B alone. The South-East Asia Region bears a disproportionately high burden, accounting for about a quarter of global hepatitis B and C infections. Despite the existence of effective vaccines and treatments, the region struggles with low testing and treatment rates; only 10% of people living with hepatitis B are diagnosed, and fewer than 5% of them receive treatment. To combat this, the GHSS targets a 90% reduction in new infections and a 65% reduction in deaths by 2030. Within this framework, reducing HBsAg prevalence among children under five to under 1% by 2020 and under 0.1% by 2030 is seen as a critical milestone. The success of the Maldives and Sri Lanka marks significant progress toward that global ambition.

Maldives: A Textbook Case of Immunization Excellence

Maldives introduced the hepatitis B vaccine, including the timely birth dose, into its national immunization programme as early as 1993. Since then, the country has maintained consistently high coverage: birth dose rates have hovered above 97%, and the three-dose completion rate (HepB3) has surpassed 96% for over two decades. In 2023, the country conducted its first nationally representative hepatitis B serosurvey among 2,074 grade 1 students across all 21 atolls. The survey found zero HBsAg prevalence and immunization coverage of 96.3% for the birth dose and 97.4% for HepB3. These results reflect not only policy success but also high institutional birth rates and universal primary school enrollment, which provide an effective platform for vaccine delivery. The few missed birth doses were attributed mainly to children born abroad, where the vaccine was not offered at birth. Robust planning ensured the survey’s credibility, including a pilot test, quality control measures, and integration of school health screening data, especially in the Greater Malé Region, where response rates were lower. Data from health screening in 11 of the 14 selected schools confirmed high vaccination coverage, reinforcing the findings. The Maldives’ immunization history, dating back to 1960, has earned public trust, minimized dropout rates, and made it a model for disease prevention through vaccination.

Sri Lanka: Sustained Success Without a Birth Dose

Sri Lanka took a different yet equally effective path. The country introduced hepatitis B vaccination into its infant immunization schedule in 2003, administering doses at 2, 4, and 6 months. Although it does not offer the birth dose, citing historically low hepatitis B prevalence, the country has maintained near-universal HepB3 coverage since 2005. In 2023, a national school-based survey tested 2,528 grade 1 students and 1,266 pregnant women. Both groups recorded zero HBsAg prevalence, confirming the effectiveness of the existing strategy. The survey followed a highly coordinated and community-centered approach. Children were recruited with parental consent, and vaccinated status was verified using child health development records (CHDRs). Pregnant women were engaged through public health midwives, ensuring high participation. COVID-19 precautions, medical record verification, and post-survey consultations added further credibility. Despite not using the birth dose, Sri Lanka's comprehensive approach, including targeted adult vaccination for high-risk groups and rigorous blood screening protocols, has yielded exceptional results. The survey findings strengthen the case for continuing current strategies while also opening a conversation on future adjustments, such as considering birth dose introduction if maternal transmission risks are identified.

A Shared Future: Towards Triple Elimination

Both countries surpassed WHO’s performance benchmarks, including district-level HepB3 coverage above 80%, a national dropout rate between the first and third doses under 5%, and high overall immunization coverage for over five years. These achievements were unanimously endorsed by the WHO Regional Expert Panel, chaired by Dr. Supamit Chunsuttiwat. The panel encouraged ongoing annual reviews by national immunization advisory bodies to ensure the sustainability of these gains. Importantly, the success in the Maldives and Sri Lanka sets the stage for broader disease elimination efforts. Both countries, already validated for the elimination of mother-to-child transmission (EMTCT) of HIV and syphilis, are now positioned to aim for “triple elimination”, of HIV, syphilis, and hepatitis B. Achieving this goal will require integrating perinatal services, ensuring access to timely birth dose vaccination, expanding screening, and reinforcing community education. The exemplary efforts in these nations demonstrate the powerful impact of well-coordinated immunization systems, dedicated health workers, and informed communities. Their stories offer both inspiration and a practical roadmap for other countries aiming to eliminate hepatitis B as a public health threat.