D Hussein Azzam Al-Bataineh,
Department of Paediatrics
Prince Hashem Ben Alhussin Hospital
PO BOX 260
Aim: To measure the prevalence
of hepatitis B carrier status in the pediatric
population before and after the era of hepatitis
Method: A prospective study
done in two cities of Jordan Tafeleh and Zarqa,
a random screening for HBs Ag by ELISA method
for 247 children who were not vaccinated during
the year of 1997, and also done for the same number
of children who were vaccinated for the same age
group during the year of 2004.
Results: 8 (3.3) persons
are HBs-Ag positive and only one child (0.4)is
positive from the vaccinated group .
Conclusion: Hepatitis B is
a common disease, and vaccination is effective
in reducing the carrier status, and we concentrated
on routine screening for all pregnant mothers
as a part of prenatal care.
It is evident that
HBV infection is a serious public health problem in
the middle east area. The majority of countries in the
region have an intermediate or high indemicity of HBV
The chronic carrier of hepatitis B is
an important risk factor in the development of serious
diseases, such as chronic persistent hepatitis , chronic
active hepatitis, and liver cirrhosis and hepatocelluler
The World Health Organization (WHO) has
considered it a disease of public health importance.
So it has recommended universal immunization against
it by including a vaccine into Expanded Program for
Immunization (EPI) schedule for children.(3)
The first Middle East countries
to introduce hepatitis B vaccination into their EPI,
were Saudi Arabia and Qatar in 1989. These were followed
by Oman in 1990, Bahrain, Iraq, Syrian Arabic Republic,
UAE in 1991, Egypt in 1992, Palestine in 1993, Jordan
and Tunisia in 1995, and the Republic of Yemen in 1998.(4)
Our aim is to measure the prevalence
of HB carrier status in children before and after the
period of hepatitis vaccine, and to find the most effective
way of protection .
A random selection of children who are
below the age of 10 years was done after taking the
consent of the parents. Blood samples were taken and
tested for HBs Ag using the ELISA method , 247 children
were included in the study during the year of 1997 .
The same numbers of children were screened during the
year of 2004 for the same age group who received the
three doses of vaccine via the national vaccination
program during the first year of their life.
A complete evaluation for the patients
who were found to be HBs-positive , included liver function
test , prothrombin time, partial thromboplastin time,
HBs-Ab ,HBe-Ag and Ab, HBc-Ab, HAV-Ab , HCV-Ab. Family
screening was done for all the family members.
During the year of 1997 a total number
of 247 children were screened; 106 (43%) were females
and 141 (57%) were males; a total of 8 patients were
found to be HBs Ag-positive.
The same number of patients was screened
for HBs Ag, for the group of children who received INGERIX
vaccine via the national vaccination program. It consisted
of three doses. The first dose is given at the age of
two months, and the second dose is given at three months
and the third dose at the fifth or the six month. The
age group ranged from the first year of life to ten
years of age.
Only one child was found to be HBs -Ag positive. This
child is an eight month old and he was admitted with fever
and was found to have acute viral meningitis. Liver function
tests showed mild elevated liver enzymes, hepatitis screen
showed HBs Ag positive, HBs Ab was negative, Anticore
Ab was positive for IgG. The family screening showed a
HBs positive mother, and she was not aware of her status.
According to the percentage of
HBV chronic carriers among the adults in the general
population , the countries were classified into three
categories as low endemicity (<2%) , intermediate
endemicity (2%-5%), and high endemicity (>5%).(5)
Here in Jordan the prevalence of HBS Ag
positive ranges from 2.6-10%.(6)
Hepatitis B virus is one of the world's
most important causes of disease and death. More than
one third of the world population have serologic evidence
of past or present infection, with over ????
being chronic carriers of the virus. (7,8)
There are many modes of transmission,
including vertical transmission and horizontal transmission.
Vertical transmission: the virus does
not cross the placenta but is transmitted from the pregnant
carrier through invasive procedures such as amniocenteses,
and when the newborn comes into contact with the mothers
infected blood, during delivery. The infant can be protected
The proportion of infected newborns depend
on levels of infectivity; if the mother is HBS Ag positive
and HBe Ag positive, 90% of infants will become infected
without appropriate prophylaxis, but if the mother is
only HBs positive the risk of transmission is about
90% of infected infants will become HBV
carriers and 25% will ultimately develop a good morbidity
rate from hepatitis B related disease.(9)
Horizontal transmission occurs to the
family, friends and close contacts. The mechanism is
not fully understood, but the vehicle is a small amount
of infected saliva or blood contacting an open wound
which may be a small abrasion.(10)
Also hepatitis B is considered to be a
sexually transmitted disease (STD). Blood from minor
lesions, semen and vaginal secretions are considered
to likely be positive. The number of sexual partners,
the number of years of sexual activity and a history
of other sexual transmitted diseases have an increased
risk of HBV infection.(11)
Another way of horizontal transmission
is via HBV-contaminated blood and blood products, contaminated
surgical instruments and other hazards.
The large majority of HBs-Ag carriers
have normal function tests (75-90%), 1-5% develop chronic
active hepatitis and the remaining had chronic persistent
About 20% of individuals with chronic
active hepatitis B progress to cirrhosis. (14)
In patients with cirrhosis, the annual
incidence of hepatocelluler carcinoma ranges from 2%
So as we can see from our study before
the era of vaccination Jordan (Tafelah and Zarqa) have
an intermediate endemicity rate of chronic hepatitis
B carrier status. This chronic asymptomatic carriage
can be prevented or decreased by vaccination. The vaccine
is highly immunogenic, the sero-protection rates are
greater than 95% after a 3-dose vaccine course, and
the protection lasts for at least 8-10 years, even though
the presence of antibodies would continue to provide
protection against HBV infection.(15)
The most important aspect is the protection
of newborn babies by giving the vaccine and the immunoglobulin
as soon as possible after birth, and this can be achieved
only by detecting the carrier mother before delivery
as our patient's mother was neither screened nor vaccinated
for hepatitis B.
It is apparent that
vaccination of children under one year of age would
be the most effective way of decreasing the prevalence
of Hepatitis in accordance with the Expanded Program
on Immunization (EPI).
Also we recommend a routine screening
for the pregnant women as a part of antenatal care,
and vaccination for HBs-Ag negative mothers ,and immediate
vaccination for newborns of carrier mothers as soon
as possible after birth. (12)
||N.Qirbi and A.J.Hall, Epidemiology
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||Dragosics B ,Ferenci
P , Hitchman E , Denk H , Long term follow up study
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||Center for Disease
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||Davis LG , et al
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||Dragosics B, Ferenci
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donors in Austria :a clinical and histologic evaluation
of 242 cases hepatology 1987;7:302-306.
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