Since the discovery, substantial improvement in the understanding of hepatitis B virus (HBV) virology, host immune response, and natural course, combined with the advent of effective vaccine and antiviral drugs, has led to better control for chronic HBV infection, as well elaborated and demonstrated in the chapters in this book. In particular, 183 countries have implemented vaccination program as of 2013 [1]. The estimated global population with chronic HBV infection has decreased from 350 million to 240 million in the most recent estimate in 2012 [2]. In addition, potent nucleos(t)ide analogs (NUC) with high genetic barrier to drug resistance are able to maintain long-term HBV suppression, improve liver histology, reverse hepatic fibrosis, and reduce hepatocellular carcinoma (HCC). However, there are challenges ahead to achieve eradication of HBV.

First, the most important and critical challenge is the economic or financial problem. According to 2013 data of gross national income (GNI) per capita [3], the majority of high intermediate and high HBsAg prevalence countries have low-income economies. Conceivably, the infrastructure of the healthcare system is not satisfactory in many of these countries. For example, only 81 % of the infants received 3 doses of vaccine and only 93 of the 183 countries with nationwide HBV vaccination program for infants introduced the birth dose with a coverage rate estimated to be 38 % globally and only 11 % in the African region [1]. Even in a country like Taiwan where complete vaccine coverage was 97 %, the HBsAg carrier rate still remains at 0.5 % in the vaccinated population. Thus, nonsatisfactory outcome of incomplete vaccination is predictable. Reduction of vaccine price and international technical or financial support had greatly extended the HBV vaccination program in early years. Since universal HBV vaccination is the most important and effective step towards HBV eradication, further support to extend and enhance (birth dose) vaccination program is needed to reduce HBV infection and its adverse sequelae including HCC. Another important issue in the prevention of vertical transmission is the need for hepatitis B immune globulins (HBIG) administration in the newborns to maximize the prophylactic effect of vaccination, and the need for NUC administration during the third trimester of pregnancy in women with high viral load (see Chap. 19). These strategies have to face practical issues in terms of cost for both HBIG and NUCs and continuous supply for HBIG.

Second, there are large number of existing HBsAg carriers worldwide. Most patients with chronic hepatitis B or compensated cirrhosis have few or no symptoms; therefore persons with chronic HBV infection largely remain undiagnosed. It was estimated that only as low as 35 % of the chronically infected Asian-American adults were aware that they were infected. In Taiwan, a country with high HBsAg prevalence and HCC incidence, a 2005 estimate showed that only 46 % of the adults living with chronic HBV infection were aware that they were infected in spite of active campaign activity through media and public education since 1980s [4]. A recent survey in nearly 10,000 Greek adults showed that 47 % had never been tested for serum HBsAg and only 32.4 % of the diagnosed hepatitis B patients had ever been treated [5]. Since chronic HBV infection is now amenable to treatment, the importance of active screening programs to identify unrecognized victims of chronic HBV infection for appropriate monitoring and timely interventions is obvious. Lack of disease awareness or understanding of the disease and fear of stigmatization in society among patients are associated with inappropriate health-seeking behavior or poor patient adherence to therapy. Lack of disease awareness among governments and healthcare practitioners are also obstacles to the proper management of HBV disease. Lack of awareness among government officials results in lack of screening programs and inadequate reimbursement. Lack of adequate education and awareness among heath-care providers is obviously an even more serious problem because adequate explanation, counseling and individualized assessment are essential for successful anti-HBV therapy. In addition, lack of specialists and state-of-the-art laboratory assays are also problems in some countries. Even if the government and society are well aware of the problems, costs of screening, monitoring and therapy may be well beyond their threshold of willingness to pay. These factors not only are responsible for the low diagnostic rate of HBV, but also for the low treatment rate among diagnosed patients (4 % in Asia versus 20 % in the USA, 17–28 % in Europe, and 8 % in Japan) [4]. These contrasting figures reflect the difference in the level of development or income of the countries and also clearly indicate that lack of economic resources is the main obstacle to proper management of HBV. Obviously, to enhance awareness campaigns, active screening programs and other effective public policy responses such as national action plans need to be developed [6].