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Hepatitis B in an Extended Family -- Alabama

In July 1986, a case of clinical hepatitis B in a 3-year-old boy was reported to the health department in Houston County, Alabama. During the subsequent investigation, the public health nurse found no obvious risk factors for the child's illness and decided to screen other family members for hepatitis B surface antigen (HBsAg), hepatitis B core antibody (anti-HBc), and hepatitis B surface antibody (anti-HBs) in an attempt to determine whether any other household members were infected.

Thirty-two family members or sexual partners of family members were identified; approximately half of these persons lived in or frequently visited the same dwelling. Three were not available for testing. Ten (34%) of the 29 persons tested (including the index patient) showed evidence of hepatitis B virus (HBV) infection, and seven were positive for HBsAg. Nine of the 16 persons who lived in or frequently visited the dwelling were seropositive; one of the 13 who infrequently visited was seropositive (pless than 0.01).

Only the index patient had a history of illness consistent with hepatitis, and none of the persons with HBV infection knew of previous exposure to persons known to have hepatitis. None worked in a medical or dental field or had previously injected illegal drugs. One seropositive 21-year-old female had had a blood transfusion in June 1986. She had lived in the same dwelling as the index patient for the 6 months prior to diagnosis of his illness. Three persons with HBV infection had self- administered tattoos that had been applied 3 years earlier. However, two of the nonfamily members who were tattooed during the same session with the same applicator were seronegative. Four toothbrushes were shared by nine immediate family members; one toothbrush was used by the index patient and two of his HBsAg-positive uncles. One 16-year-old male HBsAg carrier has muscular dystrophy and requires assistance in motor activities, although he has never been institutionalized. The younger children reportedly have frequent contact with him.

All HBsAg-positive persons, except the index patient and his half-sister, have been retested and confirmed as chronic HBV carriers because they were anti-HBc-IgM negative on initial testing and have remained HBsAg positive for more than 6 months. All HBsAg-positive carriers who were tested were also HBeAg positive. The index patient was positive for anti-HBe when his illness was diagnosed. HB vaccine was given to susceptible family members who continued to reside in the household, and persons found to be seropositive received follow-up care. In addition, health officials counseled the persons involved on the risk factors for HBV infection. Reported by: MA Price, RN, ME Crumpton, MD, Houston County Health Dept; WE Birch, DVM, CH Woernle, MD, State Epidemiologist, Alabama Dept of Public Health. Hepatitis Br, Div of Viral Diseases, Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note:

In the United States, acute hepatitis B is primarily a disease of adults and often occurs among members of high-risk groups. Less than 3% of acute hepatitis B cases occur among persons under 14 years of age. Fewer than 10% of children infected with HBV have well-described risk factors such as prior blood transfusion, hemophilia, hemodialysis, drug abuse, and institutionalization in facilities for the retarded. In contrast, 28% of these children have had contact with a person with hepatitis B, and 63% indicate no apparent source of infection when interviewed (1). In the latter instance, the most likely source of infection is a household member who is an HBV carrier or has an acute case of hepatitis B.

When a child is found to have acute or chronic hepatitis B infection, an investigation of the circumstances surrounding transmission is warranted. In some instances, as in this family, the child may signal a more extensive pattern of HBV transmission. Previous studies have shown that persons living in the same household as an HBV carrier have a 40% or higher likelihood of current or prior HBV infection (2,3). Serologic testing of household members may detect other infected persons who require medical evaluation and counseling and will identify susceptible persons who may require prophylaxis.

This investigation illustrates a number of possible modes of HBV transmission that contribute to the intrafamilial spread of this virus. The 21-year-old woman who was a carrier probably transmitted the virus perinatally to her three children. Other potential modes of transmission among the infected persons may include intimate contact in overcrowded settings, sharing of toothbrushes and other toiletry items, sexual contacts, self-administered tattoos, and the presence of a severely handicapped child who was an HBV carrier and who frequently played with the other children.

Since 1982, the Immunization Practices Advisory Committee has recommended that all household contacts of HBV carriers be screened for susceptibility to HBV and that susceptible contacts receive hepatitis B vaccine (4). Regular sexual contacts of adults with acute HBV infection are at high risk of infection (approximately 30%) (5) and should receive hepatitis B immune globulin (HBIG). Physicians may also choose to add hepatitis B vaccine to this regimen (4 ). Other household contacts usually need not be treated since the infectious period is limited and the attack rate is low among such household members unless they have been exposed to blood from the index patient (4,6,7). Finally, since perinatal transmission of HBV is highly efficient and leads to death from primary liver cancer or cirrhosis in a high proportion of cases, it is imperative that women at high risk for HBV infection be screened for HBsAg and that infants of infected mothers be treated at birth with HBIG and HB vaccine (4).


  1. Centers for Disease Control. Hepatitis surveillance report no. 50. Atlanta: US Department of Health and Human Services, Public Health Service, 1986:16-25.

  2. Szmuness W, Harley EJ, Prince AM. Intrafamilial spread of asymptomatic hepatitis B. Am J Med Sci 1975;270:293-304.

  3. Bernier RH, Sampliner R, Gerety R, Tabor E, Hamilton F, Nathanson N. Hepatitis B infection in households of chronic carriers of hepatitis B surface antigen: factors associated with prevalence of infection. Am J Epidemiol 1982;116:199-211.

  4. Immunization Practices Advisory Committee. Recommendations for protection against viral hepatitis. MMWR 1985;34:313-24,329-35.

  5. Redeker AG, Mosley JW, Gocke DJ, McKee AP, Pollack W. Hepatitis B immune globulin as a prophylactic measure for spouses exposed to acute type B hepatitis. N Engl J Med 1975;293:1055-9.

  6. Koff RS, Slavin MM, Connelly LJD, Rosen DR. Contagiousness of acute hepatitis B: secondary attack rates in household contacts. Gastroenterology 1977;72:297-300.

  7. Aldershvile J, Orholm M, Tage-Jensen U, Hardt F, Nielson O, Copenhagen Hepatitis Acuta Programme. Hepatitis B virus infection among household contacts of patients with acute HBsAg positive hepatitis. Infection 1981;9:164-6.

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