lkccine, Vol. 13, Supplement 1, pp.

S31-S34,1995
Copyright 0 1995 Elsevier Science Ltd
Printed in Great Britain. All rights reserved
0264-410X/95 $10.00 + 0.00

Risk of hepatitis B in adolescence and

young adulthood
Andr6 Meheus*

In countries of low hepatitis B virus (HBV) endemicity, infection occurs mainly in adoles-
cents and young adults (15-34 years old). The most important risk factors for infection are
heterosexual activity, homosexual activity and intravenous drug use. In industrialized coun-
tries, therefore, HBV infection is classified among the major sexually transmitted infections,
as more than 50% of infections are spread in this way. Transmission from mother to new-
born and during infancy is of less importance, except in some countries of southern Europe
and in some southern states of the USA. The highest concentrations of HBV are found in
blood of infected individuals, but HBsAg is also present in semen and vaginal and cervical
secretions, which forms the biological explanation for sexual transmission of the virus. In
epidemiological studies, HBV is, in general, associated with indicators of sexual activity
such as number of lifetime or recent sexual partners, years of sexual activity and a history
or serological marker of other sexually transmitted infections. Providing immunity from
infection before risk-taking behaviour is adopted should be the major control strategy for
HBV infection. Just as for other sexually transmitted infections, this can be best achieved by
universal vaccination of young adolescents or infants, or both groups.

Keywords: Hepatitis B; adolescent

INCIDENCE OF ACUTE INFECTION
Different types of data are available to describe the epi-
demiology of hepatitis B virus (HBV) infection. The inci-
dence of hepatitis B infection provides the best estimate of
risk for this condition. If a reliable figure of hepatitis B
incidence can be obtained, the incidence of acute HBV
infection, and subsequently the incidence of chronic infec-
tion, can be estimated. Public health authorities have set up
reporting systems to obtain incidence data on a number of
infectious diseases, including hepatitis B.
Figures of reported hepatitis B must be corrected for
under-reporting by a factor of 2-10, depending on the
country. Symptomatic cases of hepatitis B comprise only
33-50% of all hepatitis B virus (HBV) infections, which
means that the number of reported cases must be multi-
plied by a factor of 2-3, to obtain an estimate of the inci-
dence of HBV infection. In summary, figures of reported
hepatitis B must be corrected by a factor of between 4 and
30 to estimate the true incidence of HBV infection.
INCIDENCE OF CHRONIC INFECTION
It is estimated that 6-10% of acute HBV infections
become chronic. Risk of chronicity depends on the age at
which acute infection occurs, with the greatest risk occur-
ring in younger age groups. For instance, in the USA, 8%
of acute infections occur in children under 10 years of age,
*Department of Epidemiology and Community Medicine,
University of Antwerp, 2610 Antwerp, Belgium
whereas infection during this age period accounts for
approximately 30% of chronic infections’.
This means that vaccinating 1 1-year-olds in the USA
will prevent 92% of acute infections but only 70% of
chronic infections. This type of data is important when
determining the most appropriate intervention strategy.
EXAMPLE OF INCIDENCE ESTIMATION
In the USA, 25 000 cases of HBV disease are reported
annually (10 cases per 100 000 population)*. If corrected
by a factor of four for under-reporting and a factor of three
for asymptomatic infection, the estimated number of HBV
infections is 300 000 annually (120 infections per 100 000
population).
Chronic HBV infection (6-10% of acute infections) is
therefore estimated at 18 000-30 000 cases every year3.
This type of calculation can be made for any country based
on the number of reported hepatitis B disease cases.
While the USA has 10 reported hepatitis B cases per
100 000 population, the figure is l-2 cases per 100 000 in
the UK, 3 per 100 000 in Sweden and 7 per 100 000 in
(West) Germany. For the WHO European Region, recent
data show a figure of 20 cases per 100 ooo4.
PREVALENCE OF HBV MARKERS
Much data are available on the prevalence of HBV mark-
ers in the general population or in selected subgroups,
which are at normal or high risk for infection. Because
serological markers for HBV remain positive for many

Vaccine 1995 Volume 13 Supplement 1 s31

 B in adolescence: A. Meheus
Risk of hepatitis

Table 1 Risk categories in percentage of reported cases of hepati-

tis B, USA, 1991

Risk category %

Heterosexual 41
Homosexual 14
Intravenous drug user 12
Household contact 4
Healthcare workers 2
Other 1
Unknown 26

Source: CDC, unpublished data

hepatitis B cases are sexually transmitted. For this reason,

0”““““““““““’
69 71 73 75 77 79 81 83 85 87 89
70 72 74 76 78Y;;r82 84 86 88 90
Figure 1 Clinical hepatitis B in Sweden, 19691990Reproduced
from Ref. 5 with permission of Mosby-Wolfe
years after infection, prevalence of such markers can pro-
vide an estimate of cumulative incidence. This approach is
particularly useful in estimating the importance of HBV as
a sexually transmitted infection. Comparing prevalence of
HBV markers in young adolescents (age 10-14 years) with
prevalence in adults (age 354l years) can yield an esti-
mate of HBV incidence in late adolescence/young adult-
hood.
RISK FACTORS
In the USA the different risk categories and their relative
importance in HBV disease have been documented, based
on reported cases. As shown in Table I, in 1991,41% of
total reported cases indicate heterosexual activity and 14%
homosexual activity as risk factor for hepatitis B (CDC,
unpublished data). It can be assumed that a large fraction
of the category ‘unknown’ is also related to sexual risk.
This means that, overall, the largest proportion of reported
in industrialized countries, HBV is classed among the four
major sexually transmitted viral infections, together with
human papillomavirus, herpes simplex and human
immunodeficiency virus (HIV).
Reported cases of clinical hepatitis B in Sweden are
now 3 per 100 000 population and the incidence has
steadily decreased in the last 20 years (Figure 1). The two
peaks in incidence in the early and late 1970s were due to
outbreaks related to intravenous drug use. In Sweden, 43%
of reported hepatitis B cases indicate sexual activity as risk
factor and 43% indicate intravenous drug uses.
Although reported cases of hepatitis B have now stabil-
ized in Sweden, the surveillance system of hepatitis B sur-
face antigen (HBsAg) seems to indicate a considerable
increase in chronic carriers (Figure 2). Clearly there is a
potential for an increase in the numbers of reported hepat-
itis B cases in the near future.
AGE GROUPS
The incidence of reported hepatitis B in different age
groups in the USA is given in Figure 3 6. The age distribu-
tion is indicative of a lifestyle disease linked with at-risk
behaviour in late adolescence (age 15-19 years) and young
adulthood (age 20-29 years). The incriminated risk factors
are principally sexual behaviour and injecting drug use.
Other countries have documented a similar age pattern. In
Germany, the age groups most affected are 15-45 years
(Figure 4)‘. Swedish data also show a peak incidence in

2000

1750

1250
8
~1000
.-
:
- 750

500

250

0
1969197019711972197319741975197619771978197919801981198219831984198519861987198819891990
Year
Figure 2 Repotted cases of hepatitis B in Sweden, 1969-l 990.0, Hepatitis B surface antigen; n, acute hepatitis 8. Reproduced from Ref. 6
with permission of Mosby-Wolfe

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 Risk of hepatitis 6 in adolescence: A. Meheus

25

I I I I
o-14 15-19 20-29 30-39 40+
Age group (Years)
Figure 3 Reported hepatitis B by age, USA 1990. Reproduced
from Ref. 6 wfth permission of Mosby-Wolfe
young adults (age 20-24 years), with hepatitis B being rare
before age 15 years and after age 35 years (Figure 5)5.
Prevalence of serological HBV markers according to
age, sex and race in the USA is given in Figure 6. In both
White and Black populations, markers of HBV infection
increase markedly from age groups 18-24 years onwards,
to reach a plateau in late adulthood of approximately 7-8%
for Whites and 30-40% for Blacks. Black males aged
25-34 years show a very high prevalence of HBV serolog-
ical markers, which could indicate a cohort effect of inject-
ing drug uses.
A seroepidemiological survey on HBV infection in a
representative sample of the total population was recently
performed in Flanders, Belgium. The data show a 1.3%
prevalence in those aged O-14 years, 0.9% prevalence in
those aged 15-24 years and 6.8% prevalence in those aged
25-34 years; this shows an approximately sevenfold
increase in HBV infection markers once lifestyles con-
I
0
<I l-5 5-15 15-25 25-45 45-65 >65
Age (years)
Flgure 4 Casesof hepatitis B, distribution by age. Total number
of cases, 3607 (Germany, 1966). Reproduced from Ref. 7 with
permission of Mosby-Wolfe
ducive to HBV transmission have been adopted (M.
Beutels, P. Van Damme and R. Vranckx, unpublished
report). In other countries the jump in ‘cumulative inci-
dence’ in HBV markers occurs somewhat earlier in life.
ROUTES OF TRANSMISSION OF HBV IN
YOUNG ADULTS
Thereare two main routes of transmission of HBV in ado-
lescents and adults: exposure to semen, vaginal secretions
(and menstrual blood); and exposure to blood. Exposure to
blood is by means of needle sharing in injecting drug
users, needle sticks in healthcare workers, open wounds in
household and other close contacts (horizontal transmis-
sion) and multiple transfusions in haemophiliacs. HBV is
predominantly a sexually transmitted infection through
sexual contact, both homosexual and heterosexual.

100

80 I

<9 IO-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-59 >60
Age (years)
Figure 5 Incidence, by age, of clinical hepatitis B cases in Sweden, 1976, 1960, 1985 and 1990. Reproduced from Ref. 5 with permission of
Mosby-Wolfe. l ,1976; n, 1960; 0,1965; A, 1990

Vaccine 1995 Volume 13 Supplement 1 s33

Risk of hepatitis B in adolescence: A. Meheus

z 25
b
$J 20
.-
.2
2 15

10

0
0.5-2 3-5 6-8 9-11 12-14 15-17 18-24 25-34 35-44 45-54 55-64 65-74
Age (years)
Figure 6 Age-specific prevalence of hepatitis B virus markers, by race, sex and age in the USA, 1976-l 980. Reproduced from Ref. 8 with per-
mission of Mosby-Wolfe. n, Black males; 0, Black females; +, White males; A, White females.

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S34 Vaccine 1995 Volume 13 Supplement 1