Epidemiology of Hepatitis B and C in Republic of Indonesia

Abstract

Hepatitis B virus (HBV) and hepatitis C virus (HCV) infections pose serious problems in terms of public health and clinical intervention in a country with approximately 250 million people, who live in more than 17,000 islands. Efforts to combat HBV and HCV have been made through the implementation of universal infant hepatitis B immunization, blood screening, and other health promotion actions, and building epidemiological data to develop intervention strategies. A nationwide study in 2013 revealed hepatitis B surface antigen (HBsAg) prevalence of 7.1%, which indicates that Indonesia has moved from high to moderate endemicity of hepatitis B, leaving the prevalence of 9.4% in 2007. The occurrences of new hepatitis B cases still continue in early childhood period, which may root from low coverage of birth-dose hepatitis B immunization in remote islands, and the potential mother-to-child transmission of HBV from HBsAg-positive pregnant mothers. Other problems still exist including the high HBV infection rates among young adults in remote islands, the presence of occult hepatitis B, as well as the substantial prevalence of HCV infection in general population, who do not have access to diagnosis and treatment. Effective preventive and control strategies are being developed tailored to the local capacity, infrastructures, socioeconomics, and culture, as well as geographical aspects of the country.
How to cite this article: Muljono DH. Epidemiology of Hepatitis B and C in Republic of Indonesia. Euroasian J Hepato-Gastroenterol 2017;7(1):55-59.

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Epidemiology of Hepatitis B and C in Republic of Indonesia
Euroasian Journal of Hepato-Gastroenterology, January-June 2017;7(1):55-59 55
EJOHG
INTRODUCTION
Hepatitis B virus (HBV) infection is a major public health
problem. Worldwide, approximately 2 billion people have
been infected, and more than 240 million are chronic car-
riers with risk of developing progressive liver diseases,
such as cirrhosis, liver failure, and hepatocellular carci-
noma (HCC).1 The HBV infection accounts for more than
780,000 deaths each year, with HCC currently being the
fifth most frequent cancer and the second most common
cause of cancer mortality.2 The Asia Pacific region has the
largest share of HBV and hepatitis C virus (HCV) infec-
tion in the world, and 74% of global deaths from liver
cancer occur in Asia.3 In many countries in this region,
there is a lack of robust epidemiological data upon which
to develop intervention strategies.
In Indonesia, information about the prevalence of
HBV and HCV is lacking for the general population due to
several factors, including (1) inadequate disease surveil-
lance systems, with a high likelihood of underreporting
of both acute and chronic infections; (2) geographical
barriers for successful data collection in a population of
about 250 million people distributed in more than 17,000
MINI REVIEW
10.5005/jp-journals-10018-1212
Epidemiology of Hepatitis B and C in Republic of Indonesia
David H Muljono
islands; and (3) limited testing facilities for detection of
chronic HBV or HCV, leading to a large proportion of
people remaining undiagnosed.3
Most studies have been done in different areas or
groups of people with risk factors of acquiring this infec-
tion, such as blood donors, military members, and indig-
enous people in isolated areas. Between 1990 and 1997,
before the implementation of the national infant universal
hepatitis B vaccination, the prevalence rates of hepatitis B
surface antigen (HBsAg) among healthy populations in
several islands were 4 to 20.3%, categorizing Indonesia
as a country with intermediate-to-high endemicity of
hepatitis B. The HBsAg prevalence ranged between 37
and 76% in patients with liver cirrhosis, and 37 to 68%
in patients with HCC. Data on hepatitis C have also been
limited. One among the few data resulted from studies
on blood donors in 1998 showed anti-HCV prevalence of
1.5% in Java and 1.0% outside Java.4
ACTIONS TAKEN
A serious effort toward this hepatitis problem started in
1991 with a World Health Organization (WHO)-sponsored
ABSTRACT
Hepatitis B virus (HBV) and hepatitis C virus (HCV) infections pose serious problems in terms of public health
and clinical intervention in a country with approximately 250 million people, who live in more than 17,000 islands.
Efforts to combat HBV and HCV have been made through the implementation of universal infant hepatitis B
immunization, blood screening, and other health promotion actions, and building epidemiological data to develop
intervention strategies. A nationwide study in 2013 revealed hepatitis B surface antigen (HBsAg) prevalence of
7.1%, which indicates that Indonesia has moved from high to moderate endemicity of hepatitis B, leaving the
prevalence of 9.4% in 2007. The occurrences of new hepatitis B cases still continue in early childhood period,
which may root from low coverage of birth-dose hepatitis B immunization in remote islands, and the potential
mother-to-child transmission of HBV from HBsAg-positive pregnant mothers. Other problems still exist including
the high HBV infection rates among young adults in remote islands, the presence of occult hepatitis B, as well
as the substantial prevalence of HCV infection in general population, who do not have access to diagnosis
and treatment. Effective preventive and control strategies are being developed tailored to the local capacity,
infrastructures, socioeconomics, and culture, as well as geographical aspects of the country.
Keywords: Epidemiology, Hepatitis B virus, Hepatitis C virus, Indonesia.
How to cite this article: Muljono DH. Epidemiology of Hepatitis B and C in Republic of Indonesia. Euroasian
J Hepato-Gastroenterol 2017;7(1):55-59.
Source of support: Nil
Conict of interest: None
Copyright and License information: Copyright © 2017; Jaypee Brothers Medical Publishers (P) Ltd.
This work is licensed under a Creative Commons Attribution 3.0 Unported License. To view a copy of this license,
visit http://creativecommons.org/licenses/by/3.0/
Address reprint requests to: David H Muljono, Eijkman Institute for Molecular Biology, Jakarta, Indonesia. Phone: +62213917131
e-mail: davidhm@eijkman.go.id
EJOHG
Eijkman Institute for Molecular Biology, Jakarta, Republic of Indonesia; Faculty of Medicine, Universitas Hasanuddin, Makassar, Republic
of Indonesia; Sydney Medical School, University of Sydney, Australia

David H Muljono
56
universal neonatal vaccination program in Lombok
Island.5 In 1992, the Indonesian Red Cross (IRC) stepped
in to clean up the blood supply; during 1992 to 1994,
Indonesia was seen as a model for the international
community for clean blood. This effort and recent
(2010) active harm reduction measures were consid-
ered to support a decreasing incidence.6 In 1997, the
universal infant hepatitis B program was launched as a
national program, and was intensified in the year 1999,
when the administration of birthdose vaccination was
implemented, started from big islands then gradually
expanded to reach smaller islands.
May 2010 was a milestone in the history of fighting
viral hepatitis. Indonesia, Brazil, and Columbia were
cosponsoring the resolution on hepatitis at the WHO
Executive Board session in January 2010, which was
adopted by the World Health Assembly (WHA) in May
2010.7 This resolution (WHA 63.18) called for a compre-
hensive prevention of viral hepatitis by all member states,
and designated 28 July as the World Hepatitis Day.
Government’s commitment to address hepatitis was
made in 2012 by official designation of Hepatitis Control
Program within the Indonesian Ministry of Health,
secured by the issuance of the Ministerial Decree on the
National Control of Viral Hepatitis in 2015.
CURRENT SITUATION
National Data of HBV and HCV Infection
Efforts to have national-level data have been made in
2007 through a national surveillance project [Basic Health
Survey (Riskesdas)] to collect samples from 21 of 33 exist-
ing provinces. The prevalence of HBsAg, anti-hepatitis
core antibody (HBc), and anti-HBs was 9.4% (of 10,391
samples), 32.8% (of 18,867 samples), and 30.6 % (of 16,904
samples) respectively. For HCV infection, the prevalence
of anti-HCV was 0.82% (of 11,762 samples), with peak inci-
dence in the 50 to 54- and 50 to 55-year-old age groups.8
Recently, a nationwide study was conducted through
Riskesdas 2013 that covered 33 provinces. Provisional
result showed HBsAg, anti-HBc, and anti-HBs prevalence
of 7.1% (of 40,791 samples), 31.9% (of 38,312 samples), and
35.6% % (of 39,750 samples) respectively.9 It is worthy
to note that there has been a decline in the prevalence
of HBsAg (9.4% in 2007 to 7.1% in 2013), indicating that
Indonesia has moved from high to moderate endemicity
of HBV infection.
As in other countries, HBV infection has been
reduced by the universal infant hepatitis B immunization
program; nevertheless, it continues to occur during early
childhood period as shown by 5.0% prevalence of HBsAg
in the under-5 children (Graph 1). Several reasons could
be the background: (1) Uneven coverage of birthdose
vaccination, which is lower in eastern part of Indonesia,
which consists of small islands separated by sea and are
socioeconomically less developed than the islands in the
western part; and (2) high HBsAg prevalence in pregnant
mothers, which would allow vertical or mother-to-child
transmission (MTCT) of HBV infection, particularly in the
perinatal period.10,11 Anti-HBc prevalence as the evidence
of exposure to HBV showed an increasing trend by age,
suggesting the high infection rate and role of horizontal
HBV transmission in the community (Graph 2).
Another interesting finding was the presence of
bimodal age distribution of anti-HBs prevalence, which
was higher in younger age groups with low proportion
of anti-HBc frequencies, decreased to the lowest at 15 to
20 years, and increased in parallel with anti-HBc frequen-
cies (Graph 3). This finding could suggest that anti-HBs
positivity in younger age groups was gained by the
immunization given to those who were born before 1997
(i.e., the start of national infant immunization program),
Graph 1: Distribution of HBsAg-positive subjects according to age group. No signicant difference is observed
between age groups

Epidemiology of Hepatitis B and C in Republic of Indonesia
Euroasian Journal of Hepato-Gastroenterology, January-June 2017;7(1):55-59 57
EJOHG
while in the older age groups, it was obtained through
resolved infection. The declined anti-HBs frequency
with increasing age could suggest the waning anti-HBs
titers by age.
For HCV infection, anti-HCV prevalence was 1.0% (of
40,233 samples) with a peak incidence in subjects aged
60 years and older (Graph 4). The IRC notified between
8,400 and 12,100 individuals of HCV diagnosis annually
through blood donation in 2010 to 2014.12 Based on IRC
and Riskesdas data, it was estimated that there were
1,284,000 (447,000–2,047,000) viremic individuals in
2014. Total viremic infections were estimated to increase
slightly to 1,303,000 by 2023 before returning to 1,288,000
by 2030. In 2014, an estimated 9% of the viremic popu-
lation experienced cirrhosis, HCC, or liver transplant
eligibility. By 2030, this proportion was projected to
increase to 15%. The number of HCC and decompensated
cirrhosis cases was projected to increase through 2030,
when cases will number 5,300 and 19,400 respectively,
nearly doubling the 2014 values.6
HBV and HCV Infection in Specic Populations
Studies have been conducted among special popula-
tions, such as pregnant mothers and injecting drug users
(IDUs). One study in 2009 observed HBsAg prevalence
of 2.2% among 1,009 Indonesian parturient women in
Jakarta, which was markedly reduced compared with
the prevalence of 5.2% in 1985. Another study in 2014
revealed HBsAg prevalence of 6.8% (64/943) among preg-
nant women in Makassar. Of HBsAg-positive subjects, all
were HBV deoxyribonucleic acid (DNA) positive, with
15.6% having HBV DNA levels > 6.0 log10 IU/mL, which
is a recognized as threshold for MTCT.13 Other studies
reported HBsAg prevalence among pregnant mothers of
Graph 2: Distribution of anti-HBc-positive subjects according to age group. Linear-by-linear association test
shows an increasing trend of anti-HBs-positive rates with increasing age (p < 0.001)
Graph 3: Distribution of anti-HBc-positive subjects and proportion of anti-HBc frequencies according to age. Anti-HBs
distribution shows bimodal pattern, highest in 1 to 4 years, lowest in 15 to 19 years, and increased by age in parallel
with anti-HBc frequencies

David H Muljono
58
4.7% in West Java, 1.9% in Bali, and 3.4% in Mataram.4,11
This fact is of concern, because it occurs in pregnant
women who tend to be in the immune-tolerant phase of
chronic hepatitis B (CHB) with normal physical/labora-
tory examinations and high-level viremia, but unaware
of their HBsAg-positive status and can transmit the virus
to their babies.
An ongoing study on 70,000 pregnant women reveals
HBsAg prevalence of 2.76%.6 With a pregnancy rate of
5,000,000/year, approximately 150,000 pregnant mothers
in Indonesia every year have potential to transmit HBV
to their babies, of whom 95% may have CHB and become
infectious for the entire lifetime. This is of serious
concern, as screening tests for HBV in pregnant women
are not routinely performed, and antiviral treatment for
HBV-infected women has not been adopted as a preven-
tive strategy for MTCT.
Specific studies were also conducted in young adults
in Ternate and Banjarmasin representing East Indonesia.
Of 376 subjects in Ternate, HBsAg, anti-HBc, anti-HBs,
and HBV DNA prevalence was 15.7, 36.2, 24.2, and 27.9%
respectively. Of all subjects, 13.0% were HBsAg negative
with detectable HBV DNA [occult HBV infection (OBI)],
and 56.4% showed negativity for all seromarkers.14
Among 195 young adults in Banjarmasin, the prevalence
of HBsAg, anti-HBc, and anti-HBs was 4.6, 31.8, and 49.2%
respectively, while 37.9% were seronegative for all three
parameters, and 6.7% were OBI cases.15 These popula-
tions showed high hepatitis B prevalence with substantial
occurrence of OBI. High percentages of the population
were still susceptible and at risk of HBV infection, indicat-
ing the necessity to improve preventive strategy including
catch-up immunization to susceptible young adults, in
addition to the routine infant immunization program.
The HCV infection also appears as another problem.
In 2012, 2.5% of the HCV-infected population was active
IDU. This percentage was back-calculated using estimates
of 70,000 (61,901–88,320) IDU in Indonesia and an IDU
HCV prevalence of 77.3% (40–80%), based on data from
a recent survey of viral diseases among IDU. Applying
a spontaneous clearance rate of 20% suggests there were
between 22,400 and 43,680 viremic-infected IDUs.6,12
CONCLUSION
Republic of Indonesia has a substantial burden of HBV
and HCV infections. Efforts have been made and sup-
ported with increasing commitment by the government.
Current data showed that HBV level of endemicity has
decreased, entering the WHO category of intermedi-
ate endemic region. In general, epidemiological data of
HBV and HCV infection are being built, expecting to
result in increasing attention to the magnitude of the
problem of HBV and HCV infection in more areas of the
country. What is clear is that, solutions should engage
all sectors to build momentum and work with govern-
ments to develop, resource, and implement measures
that work toward elimination of viral hepatitis by 2030,
as targeted in the Global Health Sector Strategy on Viral
Hepatitis 2016 to 2021.16 To achieve this goal, there is a
need to develop national policies based on up-to-date and
reliable epidemiological evidence. Effective preventive
and control strategies have to be developed tailored to
the local capacity, infrastructures, socioeconomics, and
culture, as well as geographical aspects of the country,
by the government together with all related stake holders
including professional associations, societal participation,
with the support of communication media.
ACKNOWLEDGMENTS
The author would like to thank Dr Pretty Multiharina
Sasono PhD, Head of the Center for Biomedical Research
Graph 4: Distribution of anti-HCV-positive subjects according to age group. Anti-HCV rates are highest in the
50 to 59 and >60 year group. No signicant difference is observed between age groups

Epidemiology of Hepatitis B and C in Republic of Indonesia
Euroasian Journal of Hepato-Gastroenterology, January-June 2017;7(1):55-59 59
EJOHG
and Basic Health Technology, National Institute of Health
Research and Development, Ministry of Health; and
Ms Naning Nugrahini MSc, Head of Subdirectorate of
Hepatitis and Gastrointestinal Infection, Directorate
General of Communicable Diseases, Ministry of Health,
for providing the data and fruitful discussions.
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