Download Symptoms of Hepatitis B

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Running head: HEPATITIS B
HEPATITIS B
by
Sonia Donaires
Applied Research Project Paper Submitted in Partial Fulfillment Of the Requirements
For the Degree of Master in Public Health MPH 500
Concordia University Nebraska
Dr. Evelyn Davila
January 26, 2015
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Executive Summary
This is a research review about descriptive epidemiology for Hepatitis B. Hepatitis B
virus is an infections disease that is present worldwide. According to WHO, people infected for
Hepatitis B (HBV) virus are estimated 400 million with chronic infection and approximately one
million of deaths every year worldwide.
Hepatitis B is a virus (HBV). The HBV is a small DNA virus classified in the virus
family Hepadnaviridae. Once the HBV virus is inside of the liver can cause damage to the liver
cells and progress in lever cancer that can be fetal for people. Hepatitis B progression starts with
an acute infection and go into the chronic infection that can lead to cirrhosis. The cirrhosis can
lead to a liver failure or liver cancer and lead to death of the patient. Hepatitis B virus is mostly
sexually transmitted disease. Symptoms can vary from mild to severe infection. The most
important symptoms include joint pain, nausea and vomiting, weakness and fatigue and jaundice.
A preventive measurement taken against Hepatitis B is vaccination.
The prevalence of Hepatitis B varies in each country. Globally, the prevalence of
Hepatitis B was categorized as high, intermediate and low endemicity. According the CDC,
countries with low endemicity are those that belong to the developed countries and high
endemicity for developing countries. The vaccine is one of the principal factors that regulate the
morbidity and mortality in each country. Today Hepatitis B is still one of the infectious diseases
with high incidence in the world and it can be treated and prevented.
The principal sources for this research was a review of a data, tables and statistics found
in the CDC and WHO along with others projects of investigation about Hepatitis B that help me
to finalized the requirements of this research. Data about the socioeconomic factor was hard to
find especially for the United States, probably because the incidence in US is low compared with
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countries with high incidence. However, it was easy to find in cross sectional studies have done
in countries with major incidence of Hepatitis B. i.e. developing countries.
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Hepatitis B
Define the problem
The hepatitis B virus is an infectious disease present worldwide, two billion (1 out of 3
people) people have been infected with hepatitis B virus (HBV), 400 million have chronic
infection, This is a research review about descriptive epidemiology for Hepatitis B. Hepatitis B virus is an
infections disease that is present worldwide. According to WHO, people infected for Hepatitis B (HBV) virus are
estimated 400 million with chronic infection and approximately one million of deaths every year worldwide.
Hepatitis B is a virus (HBV). The HBV is a small DNA virus classified in the virus family Hepadnaviridae.
Once the HBV virus is inside of the liver can cause damage to the liver cells and progress in lever cancer that can be
fetal for people. Hepatitis B progression starts with an acute infection and go into the chronic infection that can lead
to cirrhosis. The cirrhosis can lead to a liver failure or liver cancer and lead to death of the patient. Hepatitis B virus
is mostly sexually transmitted disease. Symptoms can vary from mild to severe infection. The most important
symptoms include joint pain, nausea and vomiting, weakness and fatigue and jaundice. A preventive measurement
taken against Hepatitis B is vaccination.
The prevalence of Hepatitis B varies in each country. Globally, the prevalence of Hepatitis B was
categorized as high, intermediate and low endemicity. According the CDC, countries with low endemicity are those
that belong to the developed countries and high endemicity for developing countries. The vaccine is one of the
principal factors that regulate the morbidity and mortality in each country.
Today Hepatitis B is still one of the infectious diseases with high incidence in the world and it can be treated and
prevented.
The principal sources for this research was a review of a data, tables and statistics found in the CDC and
WHO along with others projects of investigation about Hepatitis B that help me to finalized the requirements of this
research. Data about the socioeconomic factor was hard to find especially for the United States, probably because
the incidence in US is low compared with countries with high incidence. However, it was easy to find in cross
sectional studies have done in countries with major incidence of Hepatitis B. i.e. developing countries.
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10 to 30 million will become infected each year, 600.000 die each year from HBVrelated liver disease or hepatocellular carcinoma, and approximately 2 people die each minute
from Hepatitis B. Globally, it is estimates that 5% of the populations are chronic carriers of
HBV, and nearly 25% of all carriers develop serious liver diseases such as chronic hepatitis,
cirrhosis, and primary hepatocellular carcinoma (liver cancer). HBV infection causes more
than one million deaths every year. (WHO, 2015)
According to the statistics in the United States, 12 million Americans have been infected
(1 out of 20 people) with hepatitis B virus, more than one million people are chronically infected,
up to 40,000 new people will become infected each year, 5,000 people will die each year from
hepatitis B and its complications and approximately 1 health care worker dies each day from
hepatitis B. (Hepatitis B Foundation, 2014)
Most healthy adults (90%) who are infected will recover and develop protective
antibodies against future hepatitis B infections. A small number (5-10%) will be unable to get rid
of the virus and will develop chronic infections. Unfortunately, this is not true for infants and
young children 90% of infants and up to 50% of young children infected with hepatitis B will
develop chronic infections. Therefore, vaccination is essential to protect infants and children.
Hepatitis B is 100 times more infectious than the AIDS virus, yet it can be prevented with a safe
and effective vaccine. (Hepatitis B Foundation, 2014)
Hepatitis B Virus (HBV)
Hepatitis B (HBV) is a DNA virus classified in the virus family Hepadnaviridae. Humans
are the only known natural host. HBV enters the liver via the bloodstream, and replication occurs
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only in liver tissue. Hepatities B virus has a small circular DNA genome that is partially doublestranded. HBV contains numerous antigenic components, but the three antigens related with
Hepatitis B are: HBsAg, HBcAg and HBe Ag. HBcAg is the nucleocapsid protein core of HBV.
HBcAg is not detectable in serum by conventional techniques, but it can be detected in liver
tissue of persons with acute or chronic HBV infection. HBeAg is a soluble protein, also
contained in the core of HBV. HBeAg is detected in the serum of persons with high virus titers
and indicates high infectivity. Antibody to HBsAg (anti-HBs) develops during convalescence
after acute HBV infection or following hepatitis B vaccination. The presence of anti-HBs
indicates immunity to HBV. Antibody to HBcAg (anti-HBc) indicates infection with HBV at an
undefined time in the past. IgM class antibody to HBcAg (IgM anti-HBc) indicates recent
infection with HBV. Antibody to HBeAg (anti-HBe) becomes detectable when HBeAg is lost
and is associated with low infectivity of serum. (CDC, 20015)
Hepatitis B virus (HBV) is a noncytopathic virus. The HBV virus does not cause direct
damage to liver cells. Instead, it is the immune system’s aggressive response to the virus leads to
an inflammation and damage the liver (hepatitis). Once the HBV virus inside of the liver, cause
damage to the genetic material of the liver cells produces cancer, which it can be fatal for the
human. (Hepatitis B foundation, 2014)
Transmission of Hepatitis B
The virus is transmitted by exposure to HBsAg-positive body fluids from persons who
have acute or chronic HBV infection. The highest concentrations of virus are in blood and
serous fluids; lower concentrations of virus are found in other fluids, such as saliva and
semen. Saliva can be a vehicle of transmission through bites. The hepatitis B virus can
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survive outside the body for at least 7 days. During this time, the virus can still cause
infection if it enters the body of a person who is not protected by the vaccine.
The hepatitis B virus is not spread by contaminated food or water, and cannot be
spread casually in the workplace. The incubation period of the hepatitis B virus is 75 days on
average, but can vary from 30 to 180 days. The virus may be detected 30 to 60 days after
infection and persists for variable periods of time. (WHO, 2014)
The most common ways of transmissions are:

Unprotected sexual intercourse with an infected. In the United States, the most important
route of transmission is by sexual contact, either heterosexual or homosexual, with an
infected person. Transmission occurs among men who have sex with men, possibly via
contamination from asymptomatic rectal mucosal lesions.

Using a syringe that was previously used by an infected person (most commonly happens
with drug addicts and people who inject steroids).

Having your skin perforated with unsterilized needles, as might be the case when getting a
tattoo, or being accidentally pricked.

Early childhood transmission in highly endemic areas with HBV is most commonly
spread from mother to child at birth or from person to person in early childhood.

People who work in health care are in risk of becoming infected by accident.
Symptoms of Hepatitis B
When first infected, a person can develop an acute infection that refers to the first 6
months after the individual is exposed to the hepatitis B virus. Acute HBV infection is
characterized by the presence of HBsAg and immunoglobulin M (IgM) antibody to the core
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antigen, HBcAg. During the initial phase of infection, patients are also seropositive for
HBeAg. Chronic Hepatitis B refers to the illness that occurs when the Hepatitis B virus
remains in a person’s body. Chronic infection is characterized by the persistence (>6 months)
of HBsAg (with or without concurrent HBeAg). Persistence of HBsAg is the principal marker
of risk for developing chronic liver disease and hepatocellullar carcinoma (HCC) later in life.
The presence of HBeAg indicates that the blood and body fluids of the infected individual are
highly contagious (WHO, 2015)
Over time, the infection can cause serious health problems that lead to a chronic or lifelong,
illness. Some people are able to fight the infection and clear the virus. For others, the infection
remains to a chronic or lifelong illness.
The symptoms vary from mild to severe; usually appear about one to 6 months after the person is
infected. Signs and symptoms of hepatitis B may include: abdominal pain, dark urine, fever, joint
pain, loss of appetite, nausea and vomiting, weakness and fatigue and yellowing of your skin and
the whites of your eyes (jaundice).
Treatment and Prevention of Hepatitis B
The treatment for acute hepatitis B is adequate nutritional balance, and replacement of fluids that
are lost from vomiting and diarrhea. Chronic hepatitis B requires some drugs, such as Tenofovir
and Enteravir. When it complicates with liver cancer, chemotherapy can prolong life for up to a
few years. The best prevention is the vaccines for Hepatitis B virus especially in pregnant
women for HBsAg, routine vaccination of infants, vaccination of adolescents, and vaccination of
adults at high risk for infeccion. For pediatric and adult formulations of Recombivax HB are
approved for use in any age group. (WHO, 2015)
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Morbidity and Mortality in the United States
Morbidity in US
In the United States, the morbidity in 2011 had a total of 2,890 cases of acute hepatitis B were
reported nationwide to CDC. The overall incidence rate for 2011 was 0.9 cases per 100,000
populations. The graph shown below that the number of reported of acute hepatitis B decreased
64%, from 8,036 in 2000 to 2,890 in 2011.
Source: http://www.cdc.gov/nchhstp/

In 2011, a total of 39 states submitted 39,636 reports of chronic hepatitis B to CDC.

Thirteen states agreed to publication of their NNDSS data for this report, representing
29.7% (n=11,781) of all reports of chronic hepatitis B received by CDC.

In 2011, the greatest number of reports was received from California (n=9,386),
representing 80.0% of all reports received; however, this count included both confirmed
and probable case reports.
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The range in the number of reports of chronic hepatitis B, which contained only confirmed
reports, was 22 received from Montana to 1,333 received from Pennsylvania.
Number of laboratory-confirmed, chronic hepatitis B case reports
National Notifiable Diseases Surveillance System (NNDSS), 2011
No. chronic hepatitis B
State
case reports submitted
Arizona
California
Iowa
Louisiana
Maine
55
9,386§
55
144
64
Missouri
278
Montana
22
Oregon
Pennsylvania
South Carolina
180
1,333
147
South Dakota
51
Vermont
36
Wyoming
30
Total
11,781
Source: http://www.cdc.gov/nchhstp/
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Mortality in US
The table below shows that from 2006 through 2010, hepatitis B accounted for more
deaths than hepatitis A but fewer deaths than hepatitis C. In 2010, the mortality rate for hepatitis
B was 0.5 deaths per 100,000 population (n=1,792). In 2010, the highest mortality rates by age,
race/ethnicity and sex were observed among persons aged 55–64 years (1.7 deaths per 100,000
population), Asians and Pacific Islanders (3.0 deaths per 100,000 population), and males (0.8
deaths per 100,000 population) respectively.
From 2006 through 2007, the mortality rate increased among persons aged 55–64 years,
from 1.4 deaths per 100,000 population in 2006 to 1.7 deaths per 100,000 population in 2007.
There was a slight decrease in 2008 to 1.6 deaths per 100,000 populations and then an increase
back to 1.7 deaths per 100,000 populations in 2010. (CDC, 2013)
Number and rate* of deaths with hepatitis B listed as a cause of death†, by demographic
characteristic and year — United States, 2006–2010
Demographic
characteristic
2006
2007
2008
2009
2010
No. Rate No. Rate No. Rate No. Rate No. Rate
Age
0–34
48 0.03
62 0.04
44 0.03
39 0.03
48 0.03
Group
35–44
192 0.44
184 0.43
154 0.36
143 0.34
142 0.35
45–54
527 1.22
532 1.21
533 1.20
469 1.05
448 1.00
55–64
442 1.40
546 1.67
523 1.55
547 1.57
610 1.67
65–74
270 1.43
266 1.37
271 1.35
254 1.22
296 1.36
≥75
226 1.23
225 1.21
263 1.40
245 1.30
248 1.34
(years)
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White§
Race
1,011 0.38 1,081 0.40 1,093 0.40
978 0.35
Black¶
344 1.01
359 1.03
327 0.92
320 0.87
Non-White,
350 2.12
375 2.16
368 2.05
399 2.15
non-Black**
Race/
White, non856 0.34
Ethnicity
Hispanic
Black, non356 0.94
Hispanic
136 0.43
Hispanic
Asian/Pacific
421 2.95
Islander
American
17 0.73
Indian/Alaskan
Native
Sex
Male
Female
Overall
1,256 0.85 1,345 0.88 1,315 0.85 1,267 0.80 1,316 0.81
449 0.27
470 0.28
473 0.27
430 0.24
476 0.27
1,705 0.54 1,815 0.56 1,788 0.54 1,697 0.51 1,792 0.52
* Rates for race, sex, and overall total are age-adjusted per 100,000 U.S. standard population.
†Cause of death is defined as the underlying cause of death or one of the multiple causes of death and is based on the International Classification
of Diseases, 10th Revision (ICD-10) codes B16, B17.0, B18.0, and B18.1(hepatitis B).
§Included white, non-Hispanic and white Hispanic.
¶Included black, non-Hispanic and black Hispanic.
**Included all other racial/ethnic groups.
Source: CDC. National Vital Statistics System.
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Distribution of Hepatitis B
Host Characteristics
In many low risk regions of the world, the highest incidence of HBV is seen in teenagers
and young adults. In endemic areas of Africa and Asia, most infections occur in infants and
children. In 2011, the highest rates of HBV were among persons aged 30–39 years (2.00
cases/100,000 population), and the lowest were among adolescents and children aged <19 years
(0.04 cases/100,000 population). (CDC, 2015)
Age
According to the graph in the United States, declines were observed in all age groups. In
2011, the highest rates were among persons aged 30–39 years (2.00 cases/100,000 population),
and the lowest were among adolescents and children aged <19 years (0.04 cases/100,000
population).
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Source: CDC
Gender
In 2011, the rate of HBV in the US was 1.7 times higher among males than among females (1.18
cases and 0.69 cases per 100, 000 population, respectively). Incidence of acute hepatitis B, by
sex in United States, 2000-2011. While the incidence rate of acute hepatitis B remained higher
for males than females, the gap has narrowed between 2000 and 2011. Incidence rates of acute
hepatitis B decreased for both males and females from 2000 through 2011. In 2011, the rate for
males was approximately 1.7 times higher than that for females (1.18 cases and 0.69 cases per
100, 000 population, respectively).
Source: http://www.cdc.gov/nchhstp/
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Ethnic Group
The incidence of HBV infection in the U.S. differs significantly by race and ethnicity
with the highest rates among blacks; rates are higher among Hispanics than non-Hispanics.
The graph below shows that a total of 11,500 chronic hepatitis B cases were reported by
eight sites in 2011. New York City reported the greatest number of cases (n=6,956; 60.5%)
compared with other sites. San Francisco reported the highest rate of chronic HBV infection,
with 113 cases per 100,000 populations. The percentage of male cases at the eight sites ranged
from 51% - 61%. Among the 5,155 cases for which race/ethnicity was known, Asian/Pacific
Islanders accounted for the highest number of chronic HBV cases (n=3,031, 59%) reported from
all sites. For all sites, the highest proportion of cases (n=8,088; 70.3%) was among persons aged
25–54 years. Among all cases for whom place of birth was known, those born outside the United
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States accounted for the highest number of chronic HBV cases (n=2,981) reported from all sites.
HBsAg was the most common HBV laboratory marker used to confirm a case of chronic
hepatitis B (95 %); however, HBV DNA positive test results were also reported for 72% of
cases.
Environmental Attributes
Geographical areas
The geographical distribution of the prevalence of chronic Hepatitis B virus infection in
2002, shows that the global epidemiology of HBV infection is described according to three
categories of endemiity: high, intermediate, and low. Depending on the proportion of the
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population that is seropositive for HBsAg . Countries with high endemicity are those where
HBsAg seroprevalence is greater than or equal to 8%; countries with intermediate endemicity are
those where seroprevalence is 2–7%; and those with low endemicity are those where
seroprevalence is less than 2 percent. HBsAg seroprevalence has marked geographic variations,
and the degree of HBV endemicity often correlates with the predominant mode of transmission.

Countries with high level of prevalence of Hepatitis B are: china, Indonesia, Nigeria, and
much of the rest of Asia and Africa

Countries with intermediate prevalence of hepatitis B are Southern Europe, the Middle
East, and South Asia. In Italy, Russia, and Turkey, the prevalence of chronic HBV
infection ranges from 3 to 10%.

Countries with low levels of endemicity are: Most of Central and South America.
However, the western amazon basin, including Brazil and Peru, is a highly endemic area,
with observed HNcAg seroprevalence rates greater than 10%. Many developed nations,
including the United States have low endemicity category.
Although anti-viral therapies can suppress HBV and delay liver disease progression, most
people with chronic HBV infection reside in developing countries with limited health care
resources. Thus, HBV-related HCC incidence is projected to increase for at least two decades
due to the high prevalence of chronic HBV infection throughout the world.
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Geographic Distribution of Prevalence of Hepatitis B virus infection in the world by country 2010
Source: http://www.who.int/csr/disease/hepatitis/en/.
Social and Economic Factor
The hepatitis B viruses (HBV) are major etiological factors in the occurrence of
hepatocellular carcinoma (HCC) worldwide, but most especially in developing countries where
the majority of liver cancer cases can be found. In parallel with the geographic distribution of
HCC, high levels of HBV endemicity are concentrated in the developing world. The association
between chronic infection with HBV and low social class is quite strong; socioeconomic factors
such as low educational attainment, lower social stratum, and crowded urban residence have
been reported to predict higher HBV chronic carrier prevalence in both developed and
developing countries. More importantly, the effect of poverty on HBV endemicity is clearly
evident among younger age groups, and earlier chronic HBV infection seems to increase the risk
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of development of HCC. It would appear that the striking correlation between HCC and low
socioeconomic status is largely related to the impact of poverty on the spread of HBV. (Stuver,
SO, Boschi-Pinto, C. & Trichopoulos D., n.d.)
A study of the socioeconomic factor of Hepatitis B was done in Nigeria. The finding of a
significantly higher sero-prevalence of HBV infection among patients aged 40-60 years is similar
to the reports on the age predilection for HBV infections from the country. According to these
reports, sero-prevalence of HBsAg increases with age.
According to the table shown below, the study observed that artisans had significantly higher
sero-prevalence of HBsAg compared with other occupational groups. The artisans are more
likely to have clustering of risk factors such as history of multiple unprotected sexual
intercourse. This factor among others may encourage exposure to HBV infection. In addition, the
significantly higher sero-prevalence among the artisans in this study could be a reflection of the
male predominance of artisan occupation. The reported gender epidemiological pattern of HBV
infections in the endemic areas of sub-Sahara Africa was in favor of the male sex and a rapid
decline in HBsAg titres in females.
HEPATITIS B
Socio-demographic characteristics as related to HBsAg sero-positivity
Source: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3662097/table/T2/
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Temporal variation
Secular trends in the United States
The incidence of reported hepatitis B peaked in the mid-1980s, with about 26,000 cases
reported each year. Reported cases have declined since that time, and fell below 10,000 cases for
the first time in 1996. The decline in cases during the 1980s and early 1990s is generally
attributed to reduction of transmission among men who have sex with men and injection-drug
users as a result of HIV prevention efforts.
During 1990–2004, incidence of acute hepatitis B in the United States declined 75%. The
greatest decline (94%) occurred among children and adolescents, coincident with an increase in
hepatitis B vaccine coverage. A total of 3,405 cases of hepatitis B were reported in 2009.
Hepatitis B – United States, 1978-2009
Source: http://www.cdc.gov/vaccines/pubs/pinkbook/hepb.html
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Reported cases of HBV infection represent only a fraction of cases that actually occur. In
2001, a total of 7,844 cases of acute hepatitis B were reported to CDC. Based on these reports,
CDC estimates that 22,000 acute cases of hepatitis B resulted from an estimated 78,000 new
infections. An estimated 700,000 to 1.4 million persons in the United States are chronically
infected with HBV, and an additional 5,000–8,000 persons become chronically infected each
year.
Before routine childhood hepatitis B vaccination was recommended, more than 80% of
acute HBV infections occurred among adults. Adolescents accounted for approximately 8% of
infections, and children and infants infected through perinatal transmission accounted for
approximately 4% each. Perinatal transmission accounted for a disproportionate 24% of chronic
infections.
In the United States in 2005, the highest incidence of acute hepatitis B was among adults
aged 25–45 years. Approximately 79% of persons with newly acquired hepatitis B infection are
known to engage in high-risk sexual activity or injection-drug use. Other known exposures (i.e.,
occupational, household, travel, and healthcare-related) together account for 5% of new
infections. Approximately 16% of persons deny a specific risk factor for infection.
Cyclic and Seasonal
Hepatitis B does not have cyclic fluctuations and seasonal trends, because this is an
infection disease that is related to a human behavior, style of life and is an infectious disease that
in the majority of cases is sexually transmitted.
Epidemic
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The prevalence of chronic hepatitis B infection is variable throughout the world, ranging
from < 1% in areas of low endemism up to 30% in highly endemic areas. There has been an
overall decline in the prevalence of the disease due to global infant and childhood vaccination
programs, post-exposure prophylaxis and anti-viral therapy. As a result of global vaccination
programs, many countries in Asia that once had high rates of HBV infection are now classified
as intermediate endemic areas. The variations of hepatitis b in the distributional geography are
regulated for the implementation of vaccination programs in each country. However, vaccination
programs have still not been implemented in all countries, thereby maintaining reservoirs of
infection and continued HBV transmission, especially in countries of high endemicity.
Some examples of this variation in countries in the world are:

The highest incidence of HBV in Europe is in the 25 to 44-year old age group, followed
by the 15 to 24 year-old age group. The infection is more common in males (1.33 cases
per 100,000) than females (0. 58 cases per 100,000).

In countries with intermediate to high endemicity, childhood transmission within infected
households are the most common routes of infection, whereas in low endemic areas,
intravenous drug use and sexual activity are the predominant. For example, in the
Netherlands where the prevalence rate is low, sexual transmission is the most frequent
mode of infection.

Additionally, after the introduction of dry heat sterilization in the 1970s which was
insufficient to eliminate HBV, multiple studies in Poland showed that nosocomial
infections from blood transfusions and medical procedures accounted for up to 60% of
HBV infections in adults and 80% in children. Today, strict blood screening, vaccination
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and improved sanitation practices have led to a declining trend of HBV prevalence in
most countries.

Throughout the Eastern Mediterranean region, transmission occurs through childhood
and adulthood. Risk factors associated with infection include residence in a rural
area, overcrowding, poor sanitary conditions, parenteral drug use, and exposure to blood
products, medical procedures, ear piercing and scarification.

Perinatal transmission is widely thought to be the reason for high endemicity in the
Western Pacific region. In Taiwan, an overall 30% of HBsAg positive women of
childbearing age had positive HBeAg, indicative of active replication. However, a study
from China showed that childhood horizontal transmission may be the most important
mode of infection, accounting for up to 80% of all HBV infection. Furthermore, a study
of rural sites in the Philippines suggests variable patterns of transmission in other parts of
Asia. In some villages in the Phillipines, HBsAg seroprevalence peaks in the 2 to 9-year
old age group, while other villages have relatively consistent seroprevalence peaking in
the 30 to 49-year old age groups. Regardless of the mode of infection, the Western
Pacific region continues to be a highly endemic region of HBV infection with a need for
continued prevention and treatment strategies.
Outbreaks of Hepatitis B in US
Outbreaks of hepatitis B virus (HBV) and hepatitis C virus (HCV) infection reported in
the United States during 2008-2013. Because of the long incubation period (up to 6 months) and
typically asymptomatic course of acute hepatitis B and C infection, it is likely that only a fraction
of such outbreaks that occurred have been detected, and reporting of outbreaks detected and
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investigated by state and local health departments is not required. Therefore, the numbers
reported here may greatly underestimate the number of outbreak-associated cases and the
number of at-risk persons notified for screening. 38 outbreaks of viral hepatitis related to
healthcare reported to CDC during 2008-2013; of these, 36 (94%) occurred in non-hospital
settings.
Hepatitis B (total 20 outbreaks, 162 outbreak-associated cases, >10,500 persons notified for
screening):

15 outbreaks occurred in long-term care facilities, with at least 114 outbreak-associated
cases of HBV and approximately 1,400 at- risk persons notified for screening

87% (13/15) of the outbreaks were associated with infection control breaks during assisted
monitoring of blood glucose (AMBG)

5 outbreaks occurred in other settings, one each at: a free dental clinic in school
gymnasium, an outpatient oncology clinic, a hospital surgery service, and two at pain
remediation clinics (one outbreak of HBV and one with both HBV and HCV), with 46
outbreak-associated cases of HBV and > 8,500 persons at-risk persons notified for
screening
Additional characteristics that contribute to an epidemiologic description of Hepatitis B
Some factor that contribute to the epidemiology description of Hepatitis B are:

Persons with either acute or chronic HBV infection should be considered infectious any
time that HBsAg is present in the blood. When symptoms are present in persons with
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acute HBV infection, HBsAg can be found in blood and body fluids for 1–2 months
before and after the onset of symptoms.

Although HBV infection is uncommon among adults in the general population (the
lifetime risk of infection is less than 20%), it is highly prevalent in certain groups.
Generally, the highest risk for HBV infection is associated with lifestyles, occupations, or
environments in which contact with blood from infected persons is frequent. In addition,
the prevalence of HBV markers for acute or chronic infection increases with increasing
number of years of high-risk behavior. For instance, an estimated 40% of injection-drug
users become infected with HBV after 1 year of drug use, while more than 80% are
infected after 10 years.

Vaccine nonresponse to Hepatitis Be could be another factor related to the epidemiology
of Hepatitis B. Several factors have been associated with nonresponse to hepatitis B
vaccine. These include vaccine factors (e.g., dose, schedule, injection site) and host
factors. Older age (40 years and older), male sex, obesity, smoking, and chronic illness
have been independently associated with nonresponse to hepatitis B vaccine.
Summarize any current hypotheses that have been proposed to explain the observed distribution
According to the table social and economic distribution of Hepatitis B in Nigeria, the
Bivariate analysis of socio-demographic variables as related to HBsAg sero-positivity showed
that age (χ2= 29.7, df = 2, P = 0.048) and occupation (χ2 = 47.2, df = 8, P = 0.019) were
statistically significant. The age group 40-60 years and artisans were significantly infected.
Socio-economic variables such as sex, marital status, educational attainment and socio-economic
class were not statistically significant.
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List any principal gaps in knowledge about the distribution of the health problem.
The three major risk groups: heterosexuals with contact with infected persons or multiple
partners, injection-drug users, and men who have sex with men; are not reached effectively by
targeted programs. Deterrents to immunization of these groups include lack of awareness of the
risk of disease and its consequences, lack of effective public or private sector programs, and
vaccine cost. Difficulty in gaining access to these populations is also a problem. Further, success
in providing vaccine to persons in high-risk groups has been limited because of rapid acquisition
of infection after beginning high-risk behaviors, low initial vaccine acceptance, and low rates of
completion of vaccinations. (CDC, 2012)
The decline in the rate of new HBV infections in the United States over the past two
decades is encouraging, and new oral agents for treatment are in clinical trials. However,
problems must be resolved before hepatitis B can be eradicated. One obstacle is the
unsubstantiated fear of neurologic side effects of HBV vaccines. A recent large case-control
study failed to demonstrate a connection between the recombinant vaccine and an increased risk
of multiple sclerosis, which had been suggested by earlier case reports. Another obstacle is the
current failure to offer hepatitis vaccination in STD clinics and correctional facilities, as well as
to other high-risk groups.
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Further Epidemiological Research
The greatest need for research is in accurate measurement of prevalence of HBV
infection in the United States. The current estimates are primarily based upon the NHANES
survey, which does not address the population groups in which HBV is prevalent. Data from
other ad-hoc screening surveys are limited, because they were derived from individuals who
participated in the surveys voluntarily and it is difficult to gauge whether the data are
generalizable. NHANES-type surveys that employ probabilistic sampling of the target
population (e.g., Asian immigrants) that will generate data that are generalizable to the
population will be very helpful not only to assess the current burden of HBV infection in the
population but also to monitor the impact of public health interventions. (CDC, 2014)
The data that are obtained from the death registries and hospital discharge summaries,
lack the clinical details that are necessary for complete understanding of what is going on with
HBV infection in the population, such as impact of wide-spread application of antiviral therapy.
Large cohort studies should be done that include representative samples of the population and
incorporate detailed clinical information may complement the information from public health
sources.
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