The unfinished success of hepatitis B control in Saudi Arabia: Concentrated burden in adult males and geographic notification hotspots in the post-vaccination era, 2019-2023

Abstract Background: Following the 1989 universal infant vaccination mandate, Saudi Arabia achieved significant reductions in Hepatitis B Virus (HBV) prevalence. The spatiotemporal dynamics of HBV notifications were performed to identify the “unfinished success” of the national elimination program. Methods: We conducted a retrospective analysis of national HBV notification data (2019–2023). Gini coefficients measured inequality while Pareto analysis identified high-concentration foci. Vaccination program impact (VPI) was estimated by comparing pediatric (0–14 years) to adult notification rates (NR). Population attributable fraction (PAF) and VPI modeled the leverage of targeted versus universal screening strategies. Results: A 75.6-fold higher NR in adults (30.24/100,000) than children (0.40/100,000; P < 0.001) was observed, with a Gini of 0.43 indicating high age-based inequality. PAF showed 98.2% of the national burden is concentrated in adults (15+ years). VPI was 98.7% [95% CI: 98.1%–99.1%], preventing an estimated 2,507 pediatric cases in 2023. The national NR exhibited a V-shaped trajectory: a 50.7% decline during the COVID-19 pandemic followed by a complete rebound by 2023, identifying the decline as a surveillance artifact. Saudi males had a 1.5-fold higher NR than females (58.45 vs. 37.93/100,000; NR Ratio = 1.54; P < 0.001). Geographically, Pareto analysis confirmed 78.5% of the burden concentrated in four regions, with Jazan as the primary hotspot (NR: 72.53). Conclusion: While infant vaccination has reached diminishing returns against the adult reservoir, we propose pivoting to a “Precision Public Health” approach, prioritizing targeted screening and linkage-to-care for Saudi adult males within identified geographic hotspots.