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Epidemiology of hepatitis B and Delta virus infection in Albania: An approach to universal vaccination
Res. Virol. 1995, 146, 245248
0 INSTITUT PASTEURELSEVIER
Paris 1995
Epidemiology in Albania:
of hepatitis B and Delta virus infection an approach to universal vaccination
G. Da Villa (l) (*), B. Nuri c2),V. Ghisetti c3),L. Picciotto (4), A. Ponzetto c3),R. Angoni c5)and A. Sallabanda (5) (I) Italian Institute for Prevention of Liver Diseases, “F. de Ritis ” Collaborating via G. Orsini n. 42, 80132 Napoli (Italia), (‘) Ministry of Health, Tirana (3’ Department of Gastroenterology and Microbiology, Molinette Hospital, (4’ Institute of Infectious Diseases, Faculty of Medicine, University “Frederic0 II”, (j’ Hygiene and Epidemiology Institute, Tirana (Albania)
Introduction
Albania is a small mediterranean country inhabited by three and a half million people, 10% of whom are in the age group 0 to 4 years. One half of the population lives in urban areas, while the other half is spread out in agricultural settings and mountain villages. There are 70,000 births a year, and the child mortality rate is about 30/1,000. Viral hepatitis is a cause of high morbidity among the Albanian population. Indeed, the annual average rate of its incidence, as reported in the years 1986-1990, is 360/100,000. The morbidity rate is higher in children and adolescents than in adults: 950/100,000 and 5501 100,000, respectively, in the age groups 1 to 5 and 6 to 15. One half of all reported casesof viral jaundice is caused by hepatitis B virus (HBV) infection. Overall, the annual incidence rate of this infection was reported as 182/100,000 for the years 1986-1990, which is 8 times superior to the European annual mean rate of 22/100,000. Epidemiological data regarding hepatitis C and Delta virus (HDV) infection are scanty. The aim of this study was to establish more precisely Received March 25, 1995. (*) Corresponding author.
Center of W.H.O., (Albania), Turin (Italy), Naples (Italy), and
the prevalence of markers for hepatitis B and Delta virus infection in urban and rural populations in Albania among groups of apparently healthy subjects. Population
and tests
A total of 1,348 individuals were enrolled from January through May 1993. Each subject was bled once, and serum was stored at -20°C until tested. Of these subjects, 46 were up to 5 years old, 133 were from 6 to 15 and 1,169 were older than 15. There were 452 males and 890 females. Each serum sample was tested for the presence of HBsAg (hepatitis B surface antigen), HBeAg (hepatitis B envelope antigen) and anti-HBc by an immunoenzymatic assay from Abbott Laboratories. HBsAg-positive sera samples were also tested for anti-HD by a micro ELISA assay (ETI-AB Deltak: Sorin, Saluggia, Italy). Results In the population sample considered, 11.7% gave HBsAg-positive results and among these,
246
G. DA VILLA ET AL.
Table I. Prevalence of HBsAg,
anti-HBc
and HBeAg
in 1,348
Total 0- 5 years > 6-15 years > 15 years Males Females (*) Calculated
No.
1348 46 133 1169 452 896
1.58 7 27 124 65 93
on HBsAg-positive
@IO) (11.7) (15.2) (20.3) (10.6) (14.4) (10.4)
781 26 91 664 236 545
anti-HBc
and HBeAg
Positivity for anti-HBc No. (%I
Categories
No.
No.
(%I
Polytransfused Pregnant women Health care personnel
301 196 99
33 23 8
(11.0)
= = =
hepatitis hepatitis hepatitis
(15.8) (11.1) (17.7) (10.8) (19.4)
133
(11.7) (8.1)
140 66
(44.2) (71.4) (66.7)
HBeAg(*) No. (%) 1 4 0
(3.0) (17.4) -
subjects.
15.8% were HBeAg-positive; positivity for antiHBc was detected in 57.9% (table I). When the results were stratified by age the highest prevalence of HBsAg was found in the 6-E-year age group (20.3%), followed by the 0-5-year age group (15.2%) and the > 15-year age group (10.6%). Overall HBsAg prevalence was 14.4% iu males and 10.4% in females. Data on HBsAg prevalence in specific population subgroups are reported in table II: 11.7% of pregnant women, 11 .O% of polytransfused patients and 8.1% of medical personnel were HBsAg-positive. Table III reports data for 5 out of 12 regions of Albania, distributed into 5 groups: a general population in urban and rural settings, children up to 15 years of age, polytransfused patients, pregnant women and medical staff. For the general popula-
HBcAg HJ3eAg HBsAg
25 0 3 22 178
in different categories of subjects living in Albania.
HBsAg
on HBsAg-positive
(57.9) (56.5) (68.4) (56.8) (52.2) (60.8)
HBeAg(*) No. (%I
subjects.
Table II. Prevalence of HBsAg,
(*) Calculated
living in Albania.
Positivity for anti-HBc No. (%lo)
HBsAg No.
subjects
B core antigen. B envelope antigen. B surface antigen.
tion as well as for pregnant women, HBsAg prevalence was found to be highest in the Tirana region: 13.6% and 16.4%, respectively. Moreover, in the same region, HBeAg was present in 23.0% of HBsAg-positive subjects. Anti-HDV prevalence in 97 HBsAg-positive subjects is reported in table IV. The prevalence was rather low (6.2%).
Discussion Our results show a very high endemicity of viral hepatitis B in the Albanian population, thus confirming data already published (Santantonio et al., 1993; Pupo et aZ., 1992). In fact, in a group of 1,348 apparently healthy inhabitants the preva-
HBV HDV
= =
hepatitis hepatitis
B virus. Delta virus.
153 19 117 2
59 3 41 0
669 91 338 21
269 29 137 0
Shkodar HBsAg+ anti-HBc+ HBeAg+(*)
Fier HBsAg+ anti-HBc+ HBeAg+(*)
Tirana HBsAg+ anti-HBc+ HBeAg+(*)
Durres HBsAg+ anti-HBc+ HBeAg+(*)
0
50 13 32 0
0
0
0
(26.0) (64.0) -
Subjects up to 15 years No. tested (%)
subjects.
(10.7) (50.9) -
(13.6) (50.5) (23.0)
(5.0) (69.4) -
(12.4) (76.4) (10.5)
(8.8) (75.0) (12.5)
(*) Calculated on HBsAg-positive
181 16 136 2
General population No. tested (%)
Elbasan HBsAg+ anti-HBc+ HBeAg+(*)
Region
35 4 0 0
113 16 14 0
3: 0
44
48 2 39 0
60 8 48 1
(11.4) -
(14.1) (12.3) -
(6.8) (75.0) -
(4.1) (81.2) -
49 4 34 0
67 11 45 2
40 4 33 1
30 4 21 1
(8.1) (69.3) -
(16.4) (67.1) (18.1)
(66.6) -
(10.0) (82.5) (25.0)
(13.3) (70.0) (25.0)
Pregnant women No. tested (%)
10 2 1 0
68 5 51 0
0
0
i!t
10 1
(20.0) (10.0) -
(7.3) (75.0) -
(10.0) (70.0) -
Health care personnel No. tested (%)
in subjects living in Albania.
(13.3) (80.0) (12.5)
Polytransfused No. tested (%)
Table III. Prevalence of HBV markers
175 19 102 0
371 46 196 19
z 3 0
65 13 45 1
81 3 60 0
-
(lo.81 (58.2)
(12.3) (52.8) (41.3)
(50.0) -
(20.0) (69.2) (7.6)
(3.7) (74.0) -
Adults No. tested (%)
8 $ %
%
s
:: 2 $ k
: s
%
Q 5 $ 3 6 2
k g 2 -.2
2
248
G. DA VILLA
Table IV. Prevalence
of anti-HDV in 97 HBsAgpositive subjects living in Albania. No. tested
Total Males Females
97 62 35
Positivity for anti-HDV No. (%b) 6 5
1
(6.2) (8.1) (2.9)
ET AL.
these considerations our Institute proposed to the Albanian government a universal anti-hepatitis B vaccination of newborns according to the following schedule: 1st dose at birth; 2nd dose at the 6th week of life ; 3rd dose at the 10th week; 4th dose at the 9th month. The vaccination program was implemented in May 1994. Key-words: Hepatitis B, Hepatitis demiology, Albania, Vaccinations.
lence of HBsAg was 11.7% and the anti-HBc was 57.9%. According to our results, it is evident that HBV infection prevails in children (HBsAg prevalence = 15.2%) and in adolescents (HBsAg prevalence = 20.3 %). Moreover, our seroepidemiological study shows a very low HD infection in HBsAg carriers in Albania (anti-HD prevalence = 6.2%). The high HBsAg prevalence particularly found in pregnant women (11.7%) and children (15.2 %) suggests that vertical transmission (mother to child) and horizontal transmission (child to child in family) are the main routes of HBV infection in Albania. In accordance with
Delta; Epi-
References Santantonio, T., Locaputo, S., Germinario, C., Squarcione, S., Greco, D., Laddogo, V. & Pastore, G. (1993), Prevalence of hepatitis virus infections in Albanian refugees. Eur. J. Epidemiol., 9, 537-540. Pupo, A., Barberio, G., Basso, M.C., Bedin, L., Bertucci, B., Bettarello, G., Borin, M., Chenet, P., Casagrande, G., Paganelli, M., Filippini, M., Marulli, E., Molinari, M., Piccioni, A., Portello, A., Seratini, P., Stomeo, A., Sturabotti, N. & Forte, M. (1992), Risultati preliminari di indagini sanitarie preventive in un gruppo di immigrati albanesi. Atti 2” Convegno “Aspetti sanitari dell’immigrazione extracomunitaria” U.L.S.S. 10 Regione Veneto - Sociem Italiana di Igiene sez.
0 INSTITUT PASTEURELSEVIER
Paris 1995
Epidemiology in Albania:
of hepatitis B and Delta virus infection an approach to universal vaccination
G. Da Villa (l) (*), B. Nuri c2),V. Ghisetti c3),L. Picciotto (4), A. Ponzetto c3),R. Angoni c5)and A. Sallabanda (5) (I) Italian Institute for Prevention of Liver Diseases, “F. de Ritis ” Collaborating via G. Orsini n. 42, 80132 Napoli (Italia), (‘) Ministry of Health, Tirana (3’ Department of Gastroenterology and Microbiology, Molinette Hospital, (4’ Institute of Infectious Diseases, Faculty of Medicine, University “Frederic0 II”, (j’ Hygiene and Epidemiology Institute, Tirana (Albania)
Introduction
Albania is a small mediterranean country inhabited by three and a half million people, 10% of whom are in the age group 0 to 4 years. One half of the population lives in urban areas, while the other half is spread out in agricultural settings and mountain villages. There are 70,000 births a year, and the child mortality rate is about 30/1,000. Viral hepatitis is a cause of high morbidity among the Albanian population. Indeed, the annual average rate of its incidence, as reported in the years 1986-1990, is 360/100,000. The morbidity rate is higher in children and adolescents than in adults: 950/100,000 and 5501 100,000, respectively, in the age groups 1 to 5 and 6 to 15. One half of all reported casesof viral jaundice is caused by hepatitis B virus (HBV) infection. Overall, the annual incidence rate of this infection was reported as 182/100,000 for the years 1986-1990, which is 8 times superior to the European annual mean rate of 22/100,000. Epidemiological data regarding hepatitis C and Delta virus (HDV) infection are scanty. The aim of this study was to establish more precisely Received March 25, 1995. (*) Corresponding author.
Center of W.H.O., (Albania), Turin (Italy), Naples (Italy), and
the prevalence of markers for hepatitis B and Delta virus infection in urban and rural populations in Albania among groups of apparently healthy subjects. Population
and tests
A total of 1,348 individuals were enrolled from January through May 1993. Each subject was bled once, and serum was stored at -20°C until tested. Of these subjects, 46 were up to 5 years old, 133 were from 6 to 15 and 1,169 were older than 15. There were 452 males and 890 females. Each serum sample was tested for the presence of HBsAg (hepatitis B surface antigen), HBeAg (hepatitis B envelope antigen) and anti-HBc by an immunoenzymatic assay from Abbott Laboratories. HBsAg-positive sera samples were also tested for anti-HD by a micro ELISA assay (ETI-AB Deltak: Sorin, Saluggia, Italy). Results In the population sample considered, 11.7% gave HBsAg-positive results and among these,
246
G. DA VILLA ET AL.
Table I. Prevalence of HBsAg,
anti-HBc
and HBeAg
in 1,348
Total 0- 5 years > 6-15 years > 15 years Males Females (*) Calculated
No.
1348 46 133 1169 452 896
1.58 7 27 124 65 93
on HBsAg-positive
@IO) (11.7) (15.2) (20.3) (10.6) (14.4) (10.4)
781 26 91 664 236 545
anti-HBc
and HBeAg
Positivity for anti-HBc No. (%I
Categories
No.
No.
(%I
Polytransfused Pregnant women Health care personnel
301 196 99
33 23 8
(11.0)
= = =
hepatitis hepatitis hepatitis
(15.8) (11.1) (17.7) (10.8) (19.4)
133
(11.7) (8.1)
140 66
(44.2) (71.4) (66.7)
HBeAg(*) No. (%) 1 4 0
(3.0) (17.4) -
subjects.
15.8% were HBeAg-positive; positivity for antiHBc was detected in 57.9% (table I). When the results were stratified by age the highest prevalence of HBsAg was found in the 6-E-year age group (20.3%), followed by the 0-5-year age group (15.2%) and the > 15-year age group (10.6%). Overall HBsAg prevalence was 14.4% iu males and 10.4% in females. Data on HBsAg prevalence in specific population subgroups are reported in table II: 11.7% of pregnant women, 11 .O% of polytransfused patients and 8.1% of medical personnel were HBsAg-positive. Table III reports data for 5 out of 12 regions of Albania, distributed into 5 groups: a general population in urban and rural settings, children up to 15 years of age, polytransfused patients, pregnant women and medical staff. For the general popula-
HBcAg HJ3eAg HBsAg
25 0 3 22 178
in different categories of subjects living in Albania.
HBsAg
on HBsAg-positive
(57.9) (56.5) (68.4) (56.8) (52.2) (60.8)
HBeAg(*) No. (%I
subjects.
Table II. Prevalence of HBsAg,
(*) Calculated
living in Albania.
Positivity for anti-HBc No. (%lo)
HBsAg No.
subjects
B core antigen. B envelope antigen. B surface antigen.
tion as well as for pregnant women, HBsAg prevalence was found to be highest in the Tirana region: 13.6% and 16.4%, respectively. Moreover, in the same region, HBeAg was present in 23.0% of HBsAg-positive subjects. Anti-HDV prevalence in 97 HBsAg-positive subjects is reported in table IV. The prevalence was rather low (6.2%).
Discussion Our results show a very high endemicity of viral hepatitis B in the Albanian population, thus confirming data already published (Santantonio et al., 1993; Pupo et aZ., 1992). In fact, in a group of 1,348 apparently healthy inhabitants the preva-
HBV HDV
= =
hepatitis hepatitis
B virus. Delta virus.
153 19 117 2
59 3 41 0
669 91 338 21
269 29 137 0
Shkodar HBsAg+ anti-HBc+ HBeAg+(*)
Fier HBsAg+ anti-HBc+ HBeAg+(*)
Tirana HBsAg+ anti-HBc+ HBeAg+(*)
Durres HBsAg+ anti-HBc+ HBeAg+(*)
0
50 13 32 0
0
0
0
(26.0) (64.0) -
Subjects up to 15 years No. tested (%)
subjects.
(10.7) (50.9) -
(13.6) (50.5) (23.0)
(5.0) (69.4) -
(12.4) (76.4) (10.5)
(8.8) (75.0) (12.5)
(*) Calculated on HBsAg-positive
181 16 136 2
General population No. tested (%)
Elbasan HBsAg+ anti-HBc+ HBeAg+(*)
Region
35 4 0 0
113 16 14 0
3: 0
44
48 2 39 0
60 8 48 1
(11.4) -
(14.1) (12.3) -
(6.8) (75.0) -
(4.1) (81.2) -
49 4 34 0
67 11 45 2
40 4 33 1
30 4 21 1
(8.1) (69.3) -
(16.4) (67.1) (18.1)
(66.6) -
(10.0) (82.5) (25.0)
(13.3) (70.0) (25.0)
Pregnant women No. tested (%)
10 2 1 0
68 5 51 0
0
0
i!t
10 1
(20.0) (10.0) -
(7.3) (75.0) -
(10.0) (70.0) -
Health care personnel No. tested (%)
in subjects living in Albania.
(13.3) (80.0) (12.5)
Polytransfused No. tested (%)
Table III. Prevalence of HBV markers
175 19 102 0
371 46 196 19
z 3 0
65 13 45 1
81 3 60 0
-
(lo.81 (58.2)
(12.3) (52.8) (41.3)
(50.0) -
(20.0) (69.2) (7.6)
(3.7) (74.0) -
Adults No. tested (%)
8 $ %
%
s
:: 2 $ k
: s
%
Q 5 $ 3 6 2
k g 2 -.2
2
248
G. DA VILLA
Table IV. Prevalence
of anti-HDV in 97 HBsAgpositive subjects living in Albania. No. tested
Total Males Females
97 62 35
Positivity for anti-HDV No. (%b) 6 5
1
(6.2) (8.1) (2.9)
ET AL.
these considerations our Institute proposed to the Albanian government a universal anti-hepatitis B vaccination of newborns according to the following schedule: 1st dose at birth; 2nd dose at the 6th week of life ; 3rd dose at the 10th week; 4th dose at the 9th month. The vaccination program was implemented in May 1994. Key-words: Hepatitis B, Hepatitis demiology, Albania, Vaccinations.
lence of HBsAg was 11.7% and the anti-HBc was 57.9%. According to our results, it is evident that HBV infection prevails in children (HBsAg prevalence = 15.2%) and in adolescents (HBsAg prevalence = 20.3 %). Moreover, our seroepidemiological study shows a very low HD infection in HBsAg carriers in Albania (anti-HD prevalence = 6.2%). The high HBsAg prevalence particularly found in pregnant women (11.7%) and children (15.2 %) suggests that vertical transmission (mother to child) and horizontal transmission (child to child in family) are the main routes of HBV infection in Albania. In accordance with
Delta; Epi-
References Santantonio, T., Locaputo, S., Germinario, C., Squarcione, S., Greco, D., Laddogo, V. & Pastore, G. (1993), Prevalence of hepatitis virus infections in Albanian refugees. Eur. J. Epidemiol., 9, 537-540. Pupo, A., Barberio, G., Basso, M.C., Bedin, L., Bertucci, B., Bettarello, G., Borin, M., Chenet, P., Casagrande, G., Paganelli, M., Filippini, M., Marulli, E., Molinari, M., Piccioni, A., Portello, A., Seratini, P., Stomeo, A., Sturabotti, N. & Forte, M. (1992), Risultati preliminari di indagini sanitarie preventive in un gruppo di immigrati albanesi. Atti 2” Convegno “Aspetti sanitari dell’immigrazione extracomunitaria” U.L.S.S. 10 Regione Veneto - Sociem Italiana di Igiene sez.