Incidence of Acute Hepatitis B --- United States, 1990--2002

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MMWR

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January 2, 2004 / 52(51);1252-1254

Incidence of Acute Hepatitis B --- United States, 1990--2002

Hepatitis B virus (HBV) is a bloodborne and sexually transmitted virus that

is acquired by percutaneous and mucosal exposure to blood or other body

fluids of an infected person. Clinical manifestations of acute hepatitis B

can be severe, and serious complications (i.e., cirrhosis and liver cancer)

are more likely to develop in chronically infected persons. In the United

States, approximately 1.2 million persons have chronic hepatitis B virus

(HBV) infection and are sources for HBV transmission to others. However,

since the late 1980s, the incidence of acute hepatitis B has declined

steadily, especially among vaccinated children. To characterize the

epidemiology of acute hepatitis B in the United States, CDC analyzed

national notifiable disease surveillance data for 1990--2002. This report

summarizes the results of that analysis, which indicated that, during

1990--2002, the incidence of reported acute hepatitis B declined 67%. This

decline was greatest among children and adolescents, indicating the effect

of routine childhood vaccination. The decline was lowest among adults, who

accounted for the majority of cases; incidence increased among adults in

some age groups. To reduce HBV transmission further in the United States,

hepatitis B vaccination programs are needed that target men who have sex

with men (MSM), injection-drug users (IDUs), and other adults at high risk.

CDC analyzed surveillance data for acute hepatitis B cases reported weekly

from state health departments and the District of Columbia during

1990--2002. Data included each patient's county of residence, sex,

race/ethnicity, and age. Clinical and risk factor data were available for

approximately 35% of cases reported since 1990, including death from acute

hepatitis B, reported injection-drug use, sex and number of sex partners,

and exposure to a household or sex contact during incubation period. Acute

hepatitis B incidence was calculated by using population denominators from

the U.S. Census Bureau.

Summary of Incidence

During 1990--2002, the incidence of acute hepatitis B declined 67%, from 8.5

per 100,000 population (21,102 total cases reported) to 2.8 per 100,000

population (8,064 total cases reported) (Figure). By region*, in 2002,

incidence was highest in the South (3.6), followed by the Northeast (3.5),

the West (2.3), and the Midwest (1.6). During 1990--2002, decreases in

incidence were greatest in the West (78%), followed by the Midwest (72%),

the South (59%), and the Northeast (52%); however, incidence in the

Northeast has increased 41% since 1999.

The incidence of acute hepatitis B among men has been consistently higher

than among women. In 1990, the incidence among men and women was 9.8 and

6.3, respectively; in 2002, the incidence was 3.7 and 2.2, respectively.

Overall, incidence among women has declined more than among men; the

male-to-female acute hepatitis B rate ratio was 1.5 in 1990, compared with

1.7 in 2002.

By age, the most significant decline (89%) in acute hepatitis B incidence

during 1990--2002 occurred among persons aged 0--19 years, from 3.0 in 1990

to 0.3 in 2002. Among persons aged 20--39 and >40 years, acute hepatitis B

incidence declined 67% and 39%, respectively; however, the majority of this

decline occurred during 1990--1998. Since 1999, the incidence of acute

hepatitis B has increased 5% among males aged 20--39 years and 20% and 31%,

respectively, among males and females aged >40 years (Figure). Among 6,790

(32%) of the 21,102 cases reported in 1990 and 3,079 (38%) of the 8,064

cases reported in 2002 for which risk factor data were available, the

proportion of persons who reported injection-drug use was similar (17% and

15%). However, the proportion of heterosexuals reporting multiple sex

partners increased from 14% to 29%, as did the proportion of self-identified

MSM, from 7% to 18%. During 1990--2002, the proportion of MSM reporting

multiple sex partners was approximately 50%.

Examples of Local Trends

Data from two counties illustrate the changing epidemiology of acute

hepatitis B in the United States. In both counties, overall incidence and

incidence among children have declined. In Baltimore County (Baltimore,

land), acute hepatitis B incidence has been consistently higher than the

national average. Since 1990, incidence has declined 26% overall; however,

during 2000--2002, incidence increased 15%. In 2002, Baltimore County

reported 50 acute hepatitis B cases (29 among men and 21 among women) for an

overall incidence of 6.6; incidence for men and women was 8.1 and 5.3,

respectively, with a male-to-female rate ratio of 1.5. Of the 38 persons

with available risk factor data, 15 (40%) reported injection-drug use, eight

(21%) reported having multiple heterosexual sex partners, and three (8%)

reported both risk factors; six (16%) persons reported exposure to an

HBV-infected household or sex contact, and three (8%) reported being an MSM.

Since 1990 in Mecklenburg County (Charlotte, North Carolina), reported acute

hepatitis B incidence has been above the national average; however, during

the same period, incidence has declined 82%. In 2002, Mecklenburg County

reported 39 acute hepatitis B cases (28 among men and 11 among women) for an

overall incidence of 5.6; incidence for men and women was 8.2 and 3.1,

respectively, with a male-to-female rate ratio of 2.6. Risk factor data were

available for all 39 cases; eight (21%) persons reported having multiple

heterosexual sex partners, eight (21%) reported being MSM, and three (8%)

reported both risk factors. Five (13%) persons reported exposure to an

HBV-infected household or sex contact; no persons reported injection-drug

use.

Reported by: State and local health depts. land Dept of Health and

Mental Hygiene. North Carolina Dept of Health and Human Svcs. J , MPH,

L Finelli, DrPH, BP Bell, MD, Div of Viral Hepatitis, National Center for

Infectious Diseases, CDC.

Editorial Note:

In 1991, a comprehensive strategy to eliminate HBV transmission was

implemented in the United States and has reduced the incidence of acute

hepatitis B among children. The strategy included universal infant

vaccination, universal screening of pregnant women, and postexposure

prophylaxis of infants born to infected mothers to prevent perinatal HBV

infection; since 1982, adolescents and adults at high risk have been

recommended to receive HBV vaccine (1). In 1995, the strategy was expanded

to include routine vaccination of all adolescents aged 11--12 years and, in

1999, to include all persons aged 0--18 years who had not been vaccinated

previously (2). The incidence of acute hepatitis B has declined steadily

during the preceding decade, in part because of successful vaccination and

other prevention programs. The observed decline in the incidence of acute

hepatitis B among children occurred coincident with an increase in hepatitis

B vaccination coverage among children aged 19--35 months, from 16% in 1992

to 90% in 2000 (3).

Since 1999, after more than a decade of decline, hepatitis B incidence among

men aged >19 years and women aged >40 years has increased. The most common

risk factors reported among adults with acute hepatitis B continue to be

multiple sex partners, MSM, and injection-drug use (4). Different high-risk

behaviors accounted for the majority of transmissions in different locales.

Increases in sexually transmitted diseases (STD), including syphilis and

human immunodeficiency virus (HIV) infection among MSM (5,6) have been

attributed to increases in high-risk sexual behavior (e.g., unprotected anal

intercourse with more than one partner and unsafe sex while under the

influence of alcohol or recreational drugs) (5,6). Changes in patterns of

sexual behavior also could be responsible for the increasing transmission of

HBV among MSM.

In 1982, the Advisory Committee on Immunization Practices recommended

hepatitis B vaccination for sexually active homosexual and bisexual men and

IDUs and, in 1985, for heterosexuals with multiple sex partners or a recent

STD (1). Trends in acute hepatitis B infection also reflect poor vaccination

coverage among persons who engage in these behaviors. Of 3,432 young MSM in

seven U.S. metropolitan areas, only 9% had received HBV vaccine (7). In a

San Diego County, California, survey, only 6% of IDUs had completed the

3-dose HBV vaccine series (8).

Persons at high risk for HBV infection often seek health care in settings in

which vaccination services could be provided. During 1996--1998,

approximately half of persons reported with acute hepatitis B had been

treated for an STD or incarcerated: 89% of IDUs, 35% of MSM, and 70% of

persons with multiple sex partners (4,9). Both STD clinics and correctional

facilities are settings in which hepatitis B vaccination services are

recommended.

The findings in this report are subject to at least two limitations. First,

the quality of surveillance data varies at local and state levels. Second,

national viral hepatitis case-reporting is incomplete; only approximately

35% of all reported cases contain risk factor data.

The decline in acute hepatitis B among children indicates that successful

hepatitis B vaccination programs are possible. These programs must consider

the local epidemiology of hepatitis B and identify ways to reach populations

at high risk. Integration of hepatitis B vaccination into health-care

programs that target persons at high risk is feasible and cost effective

(8,10). Hepatitis B vaccination programs have been implemented in STD

clinics, juvenile and adult detention facilities, HIV-counseling

and -testing centers, and other sites.

No national adult hepatitis B program exists that is similar to those that

have proven successful for children and adolescents. Components of a

national adult vaccination program must include policies for vaccination,

including methods for achieving higher vaccination rates among adults at

greatest risk and appropriate resources to support implementation.

References

CDC. Hepatitis B virus: a comprehensive strategy for eliminating

transmission in the United States through universal childhood vaccination:

recommendations of the Immunization Practices Advisory Committee (ACIP).

MMWR 1991;40(No. RR-13).

CDC. Update: recommendations to prevent hepatitis B virus

transmission---United States. MMWR 1999;48:33--4.

CDC. Hepatitis B vaccination---United States, 1982--2002. MMWR

2002;51:549--52, 563.

Goldstein ST, Alter MJ, IT, et al. Incidence and risk factors for

acute hepatitis B in the United States, 1982--1998: implications for

vaccination programs. J Infect Dis 2002;185:713--9.

Wolitski RJ, Valdiserri RO, Denning PH, Levine WC. Are we headed for a

resurgence of the HIV epidemic among men who have sex with men? Am J Public

Health 2001;91:883--8.

CDC. Primary and secondary syphilis among men who have sex with men---New

York City, 2001. MMWR 2002;51:853--6.

MacKellar DA, Valleroy LA, Secura GM, et al. Two decades after vaccine

license: hepatitis B immunization and infection among young men who have sex

with men. Am J Public Health 2001;91:965--71.

CDC. Hepatitis B vaccination among high-risk adolescents and adults---San

Diego, California, 1998--2001. MMWR 2002;51:618--21.

Khan A, Goldstein S, I, Bell B, Mast E. Opportunities for hepatitis

B prevention in correctional facilities and sexually transmitted disease

treatment settings [Abstract]. Antiviral Therapy 2000;5(suppl 1):21.

Weinstock HS, Bolan G, Moran JS, man TA, Polish L, Reingold AL. Routine

hepatitis B vaccination in a clinic for sexually transmitted diseases. Am J

Public Health 1995;85:846--9.

* Northeast=Connecticut, Maine, Massachusetts, New Hampshire, New Jersey,

New York, Pennsylvania, Rhode Island, and Vermont; Midwest=Illinois,

Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North

Dakota, Ohio, South Dakota, and Wisconsin; South=Alabama, Arkansas,

Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana,

land, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee,

Texas, Virginia, and West Virginia; and West=Alaska, Arizona, California,

Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah,

Washington, and Wyoming.

Figure

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