The scale of the region’s burden makes these findings consequential far beyond the Western Pacific. According to the WHO’s 2026 Global Hepatitis Report, roughly 240 million people were living with chronic HBV infection worldwide in 2024, and the virus caused about 1.1 million deaths from cirrhosis and liver cancer — a 17 percent increase in HBV-related mortality since 2015. The Western Pacific alone accounted for an estimated 102 million people living with hepatitis B in 2024, and several countries that contribute disproportionately to the global toll, including China, the Philippines, Viet Nam and Indonesia, sit within the region. WHO’s elimination strategy calls for a 90 percent reduction in new infections and a 65 percent reduction in hepatitis-related deaths by 2030, compared with 2015 baselines.

Between 2015 and 2024, the modelled estimates show genuine progress on the transmission side of the ledger. Total HBV prevalence in the region fell from 5.28 percent to 4.58 percent, corresponding to a drop from about 100.8 million to 89.7 million people living with the virus. Chronic HBV incidence fell from 6.32 to 3.16 new infections per 100,000 population, and prevalence among children under five declined from 0.40 percent to 0.28 percent — although that childhood figure has plateaued since 2019, well above the WHO 2030 target of 0.1 percent. Mortality moved in the opposite direction: the HBV-related death rate rose from 22.88 to 24.70 per 100,000, with estimated annual deaths climbing from 436,363 to 484,055.

The researchers quantified country-specific trends using estimated annual percentage changes, derived from log-linear regression of modelled annual rates against calendar year. Chronic incidence was classified as declining in 22 of the 34 countries and areas, with the steepest falls in Japan (an EAPC of −19.24 percent per year) and the Republic of Korea (−15.66 percent). Mortality, by contrast, was classified as increasing in 31 of 34 countries and areas, spanning every analytical subregion the team examined: East Asia, Southeast Asia, Australasia and the Pacific Island Countries and Territories. Japan (−3.09 percent per year) and New Zealand (−1.37 percent) were the only exceptions. The Marshall Islands recorded the sharpest mortality increase at 6.44 percent per year, followed by Tonga and Cambodia at 3.97 percent each.

Underlying the regional averages is striking heterogeneity. Among children under five, prevalence in 2024 had fallen to 0.08 percent in China, 0.03 percent in the Republic of Korea, 0.01 percent in Japan, 0.06 percent in Australia and 0.02 percent in New Zealand — all meeting the 2030 elimination target of 0.1 percent or lower. Yet in Papua New Guinea, under-five prevalence rose 24.61 percent over the decade to reach 2.38 percent, and increases were also recorded in New Caledonia, Samoa and Vanuatu. Ten other Pacific countries and territories still had childhood prevalence above 1 percent in 2024. Total prevalence rose only in the Marshall Islands (+22.73 percent) and Tuvalu (+1.49 percent), but the range across the region was enormous, from 0.73 percent in Japan to 9.16 percent in Tonga.

The statistical relationship between incidence and mortality trends was, notably, only modest. Country-level estimated annual percentage changes for chronic incidence and mortality were positively correlated (Pearson r = 0.39), and incidence trends explained just 15.2 percent of the between-country variation in mortality trends. That weak coupling reinforces the study’s central methodological message: the two indicators measure temporally distinct dimensions of elimination. Chronic HBV infection progresses over decades to decompensated cirrhosis and hepatocellular carcinoma — which accounts for roughly 80 percent of primary liver cancers globally — so today’s deaths largely reflect infections acquired long before recent vaccination gains. The authors caution that their ecological design cannot determine whether rising mortality reflects population ageing, the accumulated legacy of longstanding infection, gaps in diagnosis and treatment, or changes in how deaths are recorded.

Vaccination coverage, the backbone of HBV prevention, remained comparatively high regionally but varied dramatically between countries. Three-dose infant vaccination coverage stayed above 90 percent across most of the study period, but birth-dose coverage — the most critical intervention for preventing mother-to-child transmission — hovered around 80 percent, short of the 2030 target of 90 percent or more. In 2024, birth-dose coverage ranged from 99.65 percent in Tuvalu down to 26.20 percent in Papua New Guinea, where three-dose coverage had also fallen to 39.84 percent. Fiji’s birth-dose coverage collapsed from 99 percent in 2020 to 39.12 percent in 2024, and declines in three-dose coverage were seen in the Cook Islands and Samoa. Japan and New Zealand, which run targeted rather than universal birth-dose programmes, register low nominal birth-dose coverage for that reason rather than programme failure.

Exploratory analyses found no robust statistical association between national vaccination coverage levels, or changes in coverage, and changes in childhood infection or chronic incidence after adjustment for multiple comparisons — a result the authors stress does not challenge established vaccine effectiveness, but instead highlights the limits of contemporary coverage figures as proxies for cumulative prevention performance. Progress towards WHO milestones was similarly uneven: by 2024, only Australia (3.70 deaths per 100,000) had reached the 2030 mortality target of 4 per 100,000, with Japan and French Polynesia the only others below the 2025 interim threshold of 7 per 100,000. Neither the study’s subregional grouping nor an alternative World Bank income classification explained much of the observed heterogeneity, pointing instead to country-specific programme gaps such as those documented in Papua New Guinea, where out-of-facility births, cold-chain constraints and vaccine availability impede timely birth-dose delivery.

The implications are stark for elimination strategy. In China, despite dramatic reductions in childhood infection, an estimated 75 million people remain chronically infected with substantial diagnosis and treatment gaps, and infection is increasingly concentrated in older cohorts. As vaccination programmes mature, the authors argue, near-term reductions in cirrhosis and liver cancer will depend less on preventing new infections and more on clinical management of people already living with the virus — expanding testing, linking patients to care, widening access to antiviral therapy, and surveillance for liver cancer, in line with WHO’s 2024 treatment guidelines. Elimination monitoring, they conclude, should treat transmission, care-cascade performance and mortality as complementary but distinct outcomes, supported by better age-specific mortality data and simplified diagnostics such as point-of-care HBV DNA testing in settings with limited laboratory capacity.

The study also carries important caveats for interpretation. Its estimates derive from a single dynamic modelling framework rather than independent surveillance, uncertainty intervals were unavailable for incidence, mortality and liver-outcome measures, and some Pacific island settings share identical model-derived trajectories because regional comparators were used where local data were sparse. Residual autocorrelation was evident in many mortality models, meaning conventional confidence intervals may appear more precise than the underlying data warrant. The authors did include sensitivity analyses addressing influential observations, shared trajectories, departures from log-linearity and alternative country classifications, and the core finding — diverging incidence and mortality trajectories — held throughout. Even with those caveats, the message for the region that bears nearly half the world’s hepatitis B burden is difficult to escape: falling infection counts alone will not deliver elimination by 2030 without a parallel, and urgently scaled, assault on the disease burden carried by tens of millions already infected.

Subject of Research: Trends and disparities in hepatitis B virus burden and progress toward WHO elimination targets across the Western Pacific Region from 2015 to 2024.

Article Title: Trends and disparities in hepatitis B burden in the Western Pacific Region, 2015–2024: a subregional analysis using modelled data

Article References: Maung, H. T., Ghrabi, M. A., Morishita, F., Hubraj Yadav, R. P., Giang Tran, H. T., & Izumi, K. (2026). Trends and disparities in hepatitis B burden in the Western Pacific Region, 2015–2024: a subregional analysis using modelled data. The Lancet Regional Health – Western Pacific, 75, Article 101991. https://doi.org/10.1016/j.lanwpc.2026.101991

Image Credits: AI Generated

DOI: Not provided

Keywords: hepatitis B, Western Pacific Region, viral hepatitis, HBV mortality, vaccination, birth dose, epidemiology, elimination targets, cirrhosis, hepatocellular carcinoma, Polaris Observatory, public health

To build the picture, the investigators combined a systematic search of PubMed and Embase—updating a previously validated global strategy to cover the period from January 2001 to November 2025—with structured narrative reviews led by expert authors in each of 13 representative countries: China, Hong Kong SAR, Japan, and the Republic of Korea in East Asia; Indonesia, Malaysia, the Philippines, Singapore, and Thailand in Southeast Asia; and Australia, Fiji, New Zealand, and the Solomon Islands in Oceania. Incidence studies were eligible only if they reported population-representative rates of diabetes-related lower-extremity amputations or foot disease hospitalizations using international diagnostic definitions, distinguishing major amputations proximal to the ankle from minor amputations through or distal to it. The team calculated trends using compound annual growth rates and supplemented incidence data with validated national prevalence estimates covering 31 countries and territories. System capacity—the actual state of guidelines, models of care, barriers, innovations, research, and policy—was independently scored on a four-point scale across six domains aligned with the WHO Global Diabetes Compact, with inter-rater agreement rated as substantial.

The burden findings expose a region of stark internal contradictions. At the regional level, median amputation incidence—2.2 per 1,000 person-years with diabetes for all amputations—was actually slightly lower than the global median of 2.5, with major amputations falling faster in the Western Pacific (−6.1% per year) than globally (−3.7%). But hospitalizations tell a grimmer story: median regional hospitalization rates exceeded global figures for every foot disease category measured, including infection (6.8 versus 5.1 per 1,000 person-years), ulcer (5.2 versus 4.3), peripheral artery disease (3.9 versus just 0.7), and all foot disease hospitalizations combined (16.6 versus 12.2). Prevalence followed a similar pattern. While regional diabetes prevalence of 11.3% closely mirrored the global 11.1%, foot disease prevalence of 2.9% was substantially above the global 1.9%, driven largely by neuropathy without ulceration or amputation (2.5% versus 1.5% worldwide). In multivariate regression analyses, national diabetes prevalence was positively and strongly associated with overall foot disease prevalence, neuropathy, and ulceration, but only the Oceania sub-region was independently associated with amputation prevalence.

That geographic fingerprint is the review’s most striking finding. Oceania recorded the highest rates of nearly everything: median major amputation incidence of 1.1 per 1,000 person-years, minor amputations at 2.9, all amputations at 3.9, and all foot disease hospitalizations at 24.8—more than double East Asia’s 10.5. Oceanian countries also showed the greatest between-country variation, with overall foot disease prevalence differing by up to 9.7-fold and ulcer prevalence by 15-fold across the sub-region. Trend directions were equally polarized: in East Asia, amputation and hospitalization rates were falling across the board, with major amputations declining 7.2% annually and peripheral artery disease hospitalizations dropping 9.0%; in Oceania, nearly every rate was climbing, with ulcer, infection, and peripheral artery disease hospitalizations rising 2.7%, 3.5%, and 4.1% per year respectively. The Pacific Island nations of Fiji and the Solomon Islands fared worst of all, facing limited podiatry and vascular surgery workforces, scarce basic supplies such as dressings, footwear, and prostheses, poor public awareness, and profound geographic isolation.

The system-capacity assessment helps explain these disparities—and offers clues to solutions. On guidelines, the regional median score of 2 reflected that most countries had at least partially adapted international recommendations, led by China and the Republic of Korea, which adapted International Working Group on the Diabetic Foot guidelines with endorsement from major professional bodies, and Australia, which systematically adapted the guidelines and built implementation tools including pathways and screening instruments. Models of care varied widely: Singapore emerged as the region’s benchmark, with specialist multidisciplinary foot teams integrated across primary, secondary, and tertiary levels of care that have demonstrably reduced major amputations, while Hong Kong, Japan, Indonesia, and the Philippines relied mainly on hospital-based services, and Pacific Island nations offered little beyond general surgical care. Barriers remained the weakest domain regionally, scored at just 1 out of 3, reflecting a chronic shortage of skilled foot disease clinicians, fragmented referral pathways, limited training options, and low public awareness—even in well-resourced Australia and New Zealand, where rural communities and Indigenous Peoples experience documented inequities in access and outcomes.

Future-facing capacity showed similar gaps. Innovation activity, scored at a median of 1, ranged from Australia’s suite of national programs—a foot disease registry, multidisciplinary team accreditation, a national wound dressing program, and region-wide telehealth—to pilot telehealth services in Indonesia and Thailand with inconsistent uptake. Research activity was even more uneven, with Southeast Asia scoring highest thanks to multi-centre epidemiological and health services work in Malaysia, Singapore, and Thailand, while China rapidly became a world leader in publication output and the Republic of Korea ran industry-funded trials of cell-based therapies and smart technologies. Policy development lagged furthest: most countries held aspirational statements rather than implemented mandates, though Thailand’s Ministry of Health has legislated foot screening requirements and care reimbursement, and New Zealand has mandated quality standards for diabetes care while building equity-focused registries. The authors’ ecological analysis hinted at a critical association—countries and sub-regions with stronger care systems appeared to carry lower disease burdens.

From these findings, the team distilled eight consensus recommendations aimed squarely at the WHO Global Diabetes Compact’s call for countries to monitor multidisciplinary care access and amputation rates as national quality indicators. Each country, they argue, should establish a dedicated national foot disease organization; develop culturally responsive national strategies, guidelines, and multidisciplinary care standards; build systems to monitor amputation and hospitalization rates; and create national registries tracking who gets screened and who reaches multidisciplinary teams. They further call on countries to share successful innovations across borders and consider forming a Western Pacific or sub-regional alliance of national organizations—citing existing networks such as D-Foot International’s Western Pacific arm and the Asia Pacific Association for Diabetes Limb Problems as potential vehicles. Proven models worth exporting, the authors suggest, include Australia’s accreditation system, the Republic of Korea’s nationwide registry, Singapore’s integrated services, and Thailand’s government-mandated screening and reimbursement.

The recommendations carry substantial economic as well as humanitarian weight. Large cost-effectiveness analyses cited in the review indicate that many severe foot disease outcomes are preventable, with earlier, higher-quality community care improving quality of life while generating considerable savings for health systems. The authors emphasize that surveillance must extend beyond hospital walls, proposing that registries routinely capture outpatient outcomes such as time to multidisciplinary team presentation, ulcer healing rates, recurrence, mortality, quality of life, and patient-reported measures, alongside intervention details like offloading treatments and antibiotic regimens. They also caution against over-reading traditional metrics: while rising minor amputation rates have sometimes been interpreted as evidence of better care—reflecting earlier intervention that spares limbs—global evidence shows that well-implemented systems achieve simultaneous declines in both minor and major amputations, hospitalizations, and costs.

The review is candid about its limitations. Most incidence studies came from high-income countries, some carried risk of bias, nearly all hospitalization and amputation data predate 2020, and the system-capacity scores rest on expert narrative assessment of 13 representative rather than all countries. Aggregated national data cannot capture within-country differences in remoteness, ethnicity, or culture—and the authors specifically flag that Indigenous Peoples’ knowledge and community structures, fundamental to health in the region, remain under-recognized in national data and strategies. They also raise an emerging threat: climate change. Many Western Pacific nations sit in equatorial zones where heat and humidity damage the skin of the foot, promoting maceration, ulceration, and infection; rising temperatures, sustained humidity, and more frequent extreme weather events may worsen these risks while simultaneously disrupting wound care supply chains, specialist access, and transport.

For a region that already shoulders the world’s largest diabetes and foot disease burden, the message is unambiguous. The Western Pacific’s comparatively low amputation rates—largely a credit to East Asian health systems—should not obscure disproportionately high rates of ulcers, infections, and hospitalizations, or the fact that in Oceania nearly every indicator is worsening. The tools to reverse the tide exist, are already working in pockets of the region, and, the authors argue, can be adapted and scaled if nations commit to the organizational infrastructure, registries, workforce strategies, and cross-border collaboration their eight recommendations demand.