Children in the UK and seven other European countries should be universally vaccinated against hepatitis B to eliminate the major public-health impact of this disease, according to a Review published in the June issue of The Lancet Infectious Diseases.

Infection with hepatitis B causes between 500 000 and 1·2 million deaths per year worldwide, with around 22 000 of these deaths occurring across Europe. Hepatitis B is also the leading cause of liver cancer. Dr Jane Zuckerman, Academic Centre for Travel Medicine and Vaccines, Royal Free and University College Medical School, London, UK and colleagues reviewed vaccination policies in the UK, Ireland, Finland, Iceland, the Netherlands, Norway, Sweden, and Denmark.

They say: "Over 12 years ago, WHO recommended that universal childhood hepatitis B vaccination be implemented globally. Despite this, Denmark, Finland, Iceland, Ireland, the Netherlands, Norway, Sweden, and the UK adopt an 'at-risk' strategy."

"At-risk" vaccination programmes mean only those people at the highest risk of contracting the disease, e.g. immigrant communities, are vaccinated.

The authors add: "Although all eight countries are classed as having low endemicity, factors such as increased travel and integration of immigrant communities are increasing the number of 'at-risk' individuals in these countries."

Under-reporting of hepatitis B cases is a problem, even in industrialised countries. The authors say: "The annual incidence of hepatitis B in England is reported to be 600 cases. However, over the past four years, the true incidence is thought to have been nearer 6000 cases, mainly because of immigration of hepatitis B-positive individuals from areas of high endemicity."

The Review also examines the role of drug users, short- and long-haul travellers, and tattoos and body piercing.

The authors say that the advantages of a universal vaccination programme include that it is the most effective means of reducing the global burden of a particular disease. It also protects children before they are at risk of infection, and vaccines available today can immunise individuals for life with no need for additional booster vaccinations. Disadvantages include cost-effectiveness in countries of low endemicity and concerns about adding another vaccine into the childhood vaccination programme.

The advantages of the "at-risk" strategy are that an immediate impact within the target group can be obtained, with low cost in countries with low endemicity. Disadvantages include leaving the general population at risk, the difficulties in properly identifying at risk groups and the social stigma of being defined "at-risk."

The authors conclude that on the basis of current experience and evidence, the UK, Ireland, Finland, Iceland, the Netherlands, Norway, Sweden, and Denmark should all adopt a universal vaccination policy.

They say: "Global hepatitis B universal vaccination is ultimately the only way to eliminate HBV transmission and new cases of hepatitis B. Indeed, global efforts to control and prevent hepatitis B are of crucial importance and it is the responsibility of each country worldwide to play its part."

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