China's childhood hepatitis B virus (HBV) vaccination programme is a great public health success, resulting in a prevalence of HBsAg of only 1% in children under 5 years. However, the burden of HBV infection in China is still the highest in the world, with one third of the world's 240 million people with chronic HBV living in China.¹ Nevertheless, most people with HBV infection in China are unaware that they carry the disease, making HBV infection a truly silent epidemic.²

Among the population with HBV infection in China, 28 million people require treatment, with 7 million of these being urgent because of advanced liver disease and the high risk of developing cancer.² However, less than one in 50 patients in need of treatment receive it, with the biggest barrier to treatment being affordability.² A 2016 study³ sampled 4726 cases in China and revealed that the direct medical costs alone equalled 53·06% of the patient's annual household income. Six medications have been approved for the treatment of chronic HBV, but only lamivudine is included in the Chinese national drug list.⁴ HBV-related diseases have become an important cause of poverty and continue to perpetuate the cycle between poverty and illness in China.

Beyond the heavy economic burden, the discrimination attached to HBV infection remains a major problem in China. This can range from unwillingness to hug or shake hands with people with HBV infection, to losing a job or not being hired. Ignorance about the aspects of HBV is widespread, and many people believe that HBV can be transmitted through contact or by eating together.⁵ In 2016, to implement health-related Sustainable Development Goals, the Healthy China 2030 plan was officially approved by China's Central Committee. By the end of 2017, 30 of 31 provinces, autonomous regions, and municipalities in China had also issued their local Healthy 2030 plans, and full sections of 22 of these plans can be accessed online. All the accessible plans make a statement on the control of communicable diseases. For AIDS, HIV, and tuberculosis, these plans emphasise health education, screening, diagnosis, treatment, and financial reimbursement. However, for HBV, these plans are still restricted to vaccination and prevention of mother-to-child transmission, with five plans not even mentioning the word hepatitis. The attention paid to HBV is severely inadequate.

In China, the disease burden of HBV is the highest among communicable diseases, and about 10 million people living with chronic HBV will die by 2030,² with most of these deaths being avoidable. The HBV immunisation programme is a great public health success story, but efforts to address other HBV-related problems are lagging behind. To really achieve the Healthy China 2030 goals, China should also mobilise a response to HBV on a scale similar to that of other communicable diseases, such as HIV, AIDS, and tuberculosis, including enhanced education, elimination of discrimination, enhanced screening, and the offer of affordable and effective treatment to patients.

We declare no competing interests.

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