11

Title

Serum HBsAg and anti-HBs in Brazilian families of index cases with Hepatitis

B Virus Chronic Liver Disease: Comparison of Oriental and Occidental origin.

Flair J Carrilho*1, Suzane K Ono-Nita1, Rita A Cardoso1, Luís EP Fonseca1, José

EM Medeiros-Filho1, Eduardo LR Cancado1, João RR Pinho1, Venâncio AF Alves2,

Luiz CC Gayotto2, Luiz C Da Silva1

Address: 1Hepatology Branch, Department of Gastroenterology and 2Department

of Pathology, University of São Paulo School of Medicine, São Paulo, Brazil

E-mail:

Flair J Carrilho* - fjcarril@netpoint.com.br;

Suzane K Ono-Nita - sk_ono_nita@ig.com.br;

Rita A Cardoso - rita@statistika.com.br;

Luís EP Fonseca - edmundofonseca@uol.com.br;

José EM Medeiros-Filho – eymard1@uol.com.br;

Eduardo LR Cancado – edulrc@uol.com.br;

João RR Pinho – jrrpinho@usp.br;

Venâncio AF Alves - venancio@uol.com.br;

Luiz CC Gayotto - gayotto.lcl@uol.com.br;

Luiz C Da Silva - cepahe@globo.com

* Corresponding author

22

Background

Several sero-epidemiological studies in the general and blood-donor populations

have identified asymptomatic carriers of the viral surface antigen of hepatitis B

(HBsAg). Upon investigation, a significant proportion of those individuals turned out

to have some liver injury, from minor alterations to chronic active hepatitis, liver

cirrhosis and hepatocellular carcinoma [1].

Hepatitis B Virus (HBV) chronic infection in humans is frequent in certain

regions of the world, where the prevalence of HBV carriers in the general

population is high [2 - 5].

In Brazil, studies on the HBsAg prevalence were carried out in the general

population, but mainly in volunteer candidates for blood donation [1]. The observed

prevalence was 0.3% in the South of the country [6] and 11.3% in the Amazon

region [7]. For the state of São Paulo, about 1.0 % was found in the capital and

from 0.3 to 1.3% in the interior [1, 8].

The prevalence of asymptomatic carriers varies among countries, being

considered as low- (0.2- 0.5%), median- (2.0 – 7.0%) and high-prevalent (8.0 –

20.0%) areas [9, 10]. As discussed below, this prevalence also varies within

countries, from region to region, depending on different factors, such as

socioeconomic conditions, drug addiction, alcoholism, professional blood donation,

homosexualism and high familial incidence [1, 2, 11 - 20].

The familial occurrence of the HBV infection is well established for some ethnic

groups. Initially, OHBAYASHI et al. reported three Japanese families, in which 36

of the 54 members were HBsAg positive. Among these, there were healthy carriers

as well as individuals with liver cirrhosis and hepatocellular carcinoma [21].

Similar observations were reported for the American [2, 22 - 27], European [28 -

32] and Asian continents [21, 26, 33 - 36].

However, there are only few comparisons among populations of different ethnic

backgrounds living in the same country [26, 37, 38].

Among us, research on familial HBV carriers began in 1971 at the “Hospital das

Clínicas” (Discipline of Clinical Gastroenterology, University of São Paulo – School

of Medicine). Even so the preliminary data have not been published and until 1984,

33

when our group started this work, there was not a publication on this issue from

Brazil.

In view of the need of knowing the familial HBV occurrence in our environment

and comparing it among different ethnic groups, the aim of this study was to

prospectively determine the presence of HBV markers in the relatives of patients

with chronic liver disorders related to HBV of Japanese and occidental ethnicity.

Material and Methods

Patients

Nineteen patients of Japanese background and 26 of occidental origin were

attended at the Hepatology Branch, Discipline of Clinical Gastroenterology,

University of São Paulo School of Medicine. These patients were considered the

index cases and their relatives were prospectively studied as two groups regarding

their familial relation: (i) genetic-related group – consanguineous (parents,

brothers, sisters, sons, daughters, grandparents, aunts, uncles, cousins, nieces

and nephews) and (ii) non-genetic-related group - non-consanguineous (husband,

wife, brothers-in-law, sisters-in-law, and others that could directly or indirectly be in

contact with the family). Altogether, 165 relatives from Japanese background and

186 from occidental origin were enrolled.

Inclusion criteria

Index cases were HBsAg seropositive with a chronic liver disease, including

chronic hepatitis, liver cirrhosis and hepatocellular carcinoma, diagnosed by liver

biopsy. Parents of the index cases belonged to the same ethnicity.

Methods

Seroimmunologic markers for present (HBsAg) and past (anti-HBs) HBV

infection were searched for in the relatives of the index cases.

Identification

For each index case and respective relatives, the parameters age, sex,

ethnic origin and degree of familial relation were evaluated.

HBsAg and anti-HBs determination

44

The presence of the antigen HBsAg and the antibody anti-HBs in serum was

determined by the enzyme-immunoassays AUSZYME II and AUSAB EIA,

respectively, provided by ABBOTT LABORATORIES (U.S.A).

Statistical analysis

The mean age of index cases in both ethnic groups (Japanese and

Occidental) were compared using t-test [39]. Categorical variables were compared

by chi-square or Fisher’s exact test.

The influence of the ethnic origin (Japanese and Occidental) and degree of

familial relation (genetic- and non-genetic-related) on the serum immunologic

markers were evaluated by linear model methods as typified by the Grizzle,

Starmer, Koch [40, 41] approach.

Four sub-populations determined by the variables ethnic group and familial

degree were considered (Japanese genetic-related, Japanese non-genetic-related,

Occidental genetic-related and Occidental non-genetic-related). The results of the

HBV serum markers were considered the response variable (HBsAg, anti-HBs and

negative).

The calculations were made using the SAS System, following the CATMOD

procedure [42].

Results

Index cases

Nineteen patients from oriental (Japanese) and 26 from occidental origin

were the index cases, for whom the gender (11 males / 8 females and 21 males / 5

females, respectively; p = 0.0945) and the mean age did not differ significantly

[39.8 + 11.3 (19 – 63) and 34.5 + 17.3 (7 – 61) years old, respectively (p > 0.05)].

Familial HBV Markers

HBsAg and anti-HBs

Altogether the frequency of both HBsAg and anti-HBs was 135/165 (81.8%)

for the Japanese relatives and 68/186 (36.5%) for those of occidental origin (p <

0.0001). Significant differences were also observed between the brothers and

55

sisters (p <0.0001), sons and daughters (p < 0.0001) and other relatives (p <

0.0007) of both groups (oriental and occidental) as shown in Table 1. Among the

parents of the index cases, in turn, there was just a trend to a significant difference

(p = 0.0578). Such a small number of cases was further compensated with the

inclusion of other parents belonging to the same familial hub.

HBsAg

A significant difference (p = 0.0001) was found between the frequency of the

HBsAg obtained for the Japanese relatives, 79/165 (47.9%), and for the occidental

ones, 10/186 (10.7%). Concerning the degree of familial relation, there was a

significant difference for the mothers (p = 0.0045), brothers and sisters (p <

0.0001) and sons and daughters (p < 0.0001) between the two groups.

Anti-HBs

The anti-HBs frequency found for the oriental relatives was 56/165 (33.9%),

which was not significantly different (p = 0.1209) from that of the occidental group,

48/186 (25.8%). Regarding the degree of familial relation, a significant difference

was observed only for the parents (0.0170) and other familial relatives (p =

0.0388).

Frequency of Familial Aggregation Rate per Ethnic Group

The familial aggregation frequency, given by the number of families having

at least one HBsAg or anti-HBs positive member (except the index case) per total

of studied families, was 94.7% and 88.5% for the Japanese and occidental groups,

respectively (p = 0.4319; Table 2).

HBV Markers in Progeny to HBsAg Positive Mothers

The progeny to 16 mothers of Japanese- and seven of occidental-

background was studied (Table 3); of the 67 from the former group, 56 (83.6%)

presented HBsAg and five (7.5%) anti-HBs, whereas of the 20 members from the

latter group, eight (40%) were HBsAg and four (20.8%) anti-HBs positive (p =

0.0004).

HBV Markers in Progeny to HBsAg Positive Fathers

Ten fathers of Japanese and 20 of occidental origin were enrolled in the

study (Table 4). Of the 30 members of the Japanese progeny, seven (23.3%) were

66

HBsAg and seven (23.3%) anti-HBs positive. For the 69 occidental descendents,

the markers were found in eight (11.6%) and six (8.7%) members, respectively (p =

0.0255).

HBV Markers in Progeny to Fathers or Mothers (HBsAg) of Japanese

origin

Nine HBsAg-positive fathers and 15 HBsAg-positive mothers having a 26-

and 63-member progeny, respectively, were enrolled in this investigation. HBsAg

was detected in three (11.6%) and anti-HBs in seven (26.9%) members of the first

group. While for the second group, 52 (82.6%) were found to be HBsAg and five

(7.9%) anti-HBs positive (difference significance: p < 0.0001). One family was

excluded from the results presented, for both father and mother were HBsAg

positive.

HBV Markers in Progeny to Fathers or Mothers (HBsAg) of Occidental

origin

Eighteen HBsAg-positive fathers gathering a progeny of 64 members and

five mothers having 15 children were studied. HBsAg was detected in seven

(10.9%) and anti-HBs in six (9.4%) of the 64 descendents of the first group; while

for the 15 of the second group, HBsAg was found in seven (46.6%) and anti-HBs in

four (26.7%) individuals (p = 0.0002). Two families were excluded from the results

presented, for both father and mother were HBsAg positive.

Frequency of HBV Markers in Progeny to Fathers or Mothers (HBsAg)

from Japanese and Occidental origins

The progenies enclosing 90 and 78 individuals from 27 fathers and 20

mothers (HBsAg-positives), respectively, were investigated. Among the first group,

HBsAg was detected in 10 (11.1%) and anti-HBs in 13 (14.4%) members; whereas

out of the second group, the frequency found for these markers was 75.7% (59/78)

and 11.5% (9/78), respectively (p = 0.0001).

Frequency of HBV Markers per Ethnic Group and Degree of Familial

Relation

The frequency of the HBV markers according to the ethnic origin (Japanese

and occidental) and the degree of familial relation (genetic- and non-genetic

77

related) were compared and presented in Table 5; the variance analysis has

shown significant difference (p = 0.0001) in both comparisons.

Since the interaction between ethnic group and familial relation was not

significant, the model was adjusted taking into consideration only the main effects.

Finally, the analysis for categorical data has shown that the observed and

expected probabilities were perfectly concordant (Table 6).

Discussion

Families make up an excellent model to look for qualitative and quantitative

features concerning host response to certain etiologic agents and transmission

mechanisms through people exposed to a variety of environmental characteristics

[43]. Familial studies have been proven important to the knowledge of viral

hepatitis B that shows little clinical symptoms but a clear trend to chronicity [25, 44,

45].

The mechanisms of hepatitis B transmission are not fully understood, but

they seem to have various aspects [22, 25, 26, 28, 46, 47]; the genetic component,

in particular, is still debated [48 - 50].

Despite all those unclear features, there are few studies worldwide in large

scale, including geographic areas of low- and high- incidence of HBV infection.

Numerous reports of families with multiple cases of acute and chronic hepatitis B

[25, 27, 51 - 56] have confirmed the possibility of familial aggregation. However,

they are of little value for estimating the frequency of these events in the population

and for the understanding of certain aspects of HBV familial aggregation [29, 57].

Taking into consideration some informations from outside Brazil [2, 11, 28,

37, 51, 58] and preliminary data [1] from our environment about relatives of HBV-

positive patients with liver disease, two populations of distinct ethnic origins were

studied — the relatives of index cases from Japanese and Occidental origins. The

choice was based on the fact that the immigrants of these two ethnic groups

comprise a great proportion of the population of the State of São Paulo. In fact,

São Paulo accounts for the largest Japanese-descendent population after Japan.

88

One of the main objectives of the present work was to investigate whether

our data are similar to the reported in the literature.

Concerning the inclusion criteria, it is worth mentioning the work from other

authors. BRUGUERA et al. [59] have studied 100 relatives of 29 patients with

HBV-related liver disease admitted at the Hospital of the University of Barcelona.

HBsAg was detected in 12 members of the families and, of these, eight were

asymptomatic HBV carriers, one had cirrhosis and three progressed to acute

hepatitis. There was no report of parenteral exposure within the familial contacts.

The HBsAg frequency (12.0%) in the families was considerably higher than the

prevalence of the antigen in patients (0.3%) without liver disease and in volunteer

blood donors (0.4%).

The same group from Barcelona [57] has published a study about familial

contacts to index cases with acute hepatitis, chronic hepatitis and healthy HBV

carriers, establishing the occurrence of HBsAg and anti-HBs in comparison to

volunteer blood donors. The prevalence of these markers was significantly higher

among the 178 relatives (39.2%) with domestic contact to the 54 HBsAg carriers

than in the control group of 834 blood donors (12.1%; p < 0,001). They came to the

conclusion that the risk of acquiring HBV infection for the relatives of patients with

some HBV-related liver disease (acute = 33.0%; chronic = 46.3%) was higher than

for those individuals with no familial case of liver disorders (13.4%; p < 0.01).

Similar data were reported by others [2, 23, 25, 29, 30, 32, 35, 38].

Due to the relevance of those results and the ease to study patients with

chronic liver diseases as compared to the acute forms, the families of the chronic

cases were given priority in this study. Unpublished data have shown us that the

existence of a member with a chronic form of liver disease greatly motivates the

family to join up the study.

Searching for HBsAg and anti-HBs has been generally adopted to detect

present or past HBV infection [62]. The anti-HBc is also another marker for HBV

infection that is largely used [26, 60].

In relation to age and gender, the index cases of Japanese and occidental

origin were not significantly different.

99

This work has shown that the general occurrence of the HBsAg and anti-

HBs markers, that expresses HBV contact, was 81.8% for the Japanese and

36.5% for the occidental families (Table 1). This difference is significant and our

data are comparable to those of OHBAYASHI et al. [21] in Japan (79.9%) and of

TONG et al. [26] in members of families of Chinese people living in the United

States in comparison to members living in the Orient. Our findings are also similar

to reports from various European (26.0% - 71.1%) [29, 57, 61] and American

authors (32.0% - 46.0%) [23, 26] in relation to the occidental people.

Concerning the degree of familial relation, the HBsAg has been found in

90.0% of the mothers, 79.6% of the brothers and sisters and 37.9% of the

progenies of oriental origin and, for the occidental equivalents, in 30.7%, 8.5% and

3.3%, respectively. These differences are significant and suggest, specially for the

Japanese subjects, that vertical or peri-natal transmission from mothers are the

most important way of acquiring HBV infection, as it will be seen later. These

results also corroborate with the literature [23, 25, 33, 35, 37, 46, 57].

The presence of anti-HBs, that indicates in the majority of the cases a host

immune response to the HBV and past infection [62], occurred in 33.9% of the

members of the Japanese families and in 25.8% of those of occidental origin. This

difference was not significant, and the literature reported occurrence for this

antibody in 2.2% to 50.0% of the oriental [21, 25, 26, 37, 46] and in 16.0% to

57.4% of the occidental subjects [22, 26, 37, 57].

Regarding the degree of familial relation, the anti-HBs occurred in 100% of

the fathers and in 78.6% of the partners of oriental origin. For those of occidental

origin, the occurrence was 40.0% and 70.0%, respectively; the difference was

significant between the groups of oriental and occidental fathers.

It is worth emphasizing that there is no similar concomitant study with these

two ethnic groups in the literature.

In general, 41 (91.1%) of the 45 families presented familial aggregation,

characterized by the existence of members (except the index case) with signs of

present (HBsAg positive) or past (anti-HBs positive) infection. Such aggregation

occurred in 94.7% and 88.5% of the Japanese and occidental families, respectively

1010

(p = 0.4319; Table 2). These values are higher than those observed by

BRUGUERA et al. (68.5%) in Spain [57], by COLTORTI et al. (77.7%) in Italy [29]

and by SZMUNESS et al. (8.4% - 21.0%) in the United States [38]. This

discrepancy may be viewed, at least in part, as a consequence of the various

behaviors of the families in different situations: chronic or acute liver disorders or

HBsAg healthy carriers [2, 38, 57, 63].

The analysis of the HBsAg and anti-HBs markers in progenies to mothers or

fathers positive for the antigen was carried out taking into consideration all the

familial possibilities; for instance, children from a genetic-related relative of the

index case were also included to increase the sampling for the statistical analysis.

The analysis of the HBV markers and degree of familial relation revealed

that the HBsAg was more frequent within those genetic-related individuals,

whereas among the non-genetic related ones, the anti-HBs was more prevalent

(Table 5).

The Japanese subjects showed an alarming high frequency of HBsAg

among the genetic-related relatives, being the parents, brothers, sisters, children

(47.9%, Table 1), or also other genetic-related members of the family (60.3%,

Table 1). These frequencies are higher than the ones found for any other risk

group ever investigated [64].

Altogether, the results presented here show that: 1. There is a high

frequency of intra-familial HBV spreading, especially in those of Japanese origin; 2.

Applying certain statistical methodology [40 - 42] allows the prediction of the

frequency of the HBV markers per ethnic group and per degree of familial relation;

in fact, the observed values are in agreement with the expected ones (Table 6).

This is a valuable contribution of practical use and, as far as we know, there is no

similar report in the literature; 3. Among the families from both ethnic groups, the

infected mothers are the most likely to spread the HBV. This fact strongly suggests

that vertical transmission is an important way of getting the infection. On the other

hand, the non-genetic related relatives presented a higher trend for developing

anti-HBs upon contact with HBsAg-positive carriers. The reason for such

1111

phenomenon is because the contact with HBV is in the adult phase, when the

possibility to eliminate the virus is more frequent.

The present results have shown fundamental differences in the HBsAg

occurrence between families of Japanese and occidental origin, and similar facts

were observed by others [26, 37, 46, 68]. It is worth noting, however, the lack of

publications on related studies, including different ethnic groups from a single

country. Altogether, these studies have shown that the spreading and persistence

of the HBV are more efficient within the Asian people than other ethnic groups [4,

26, 66 - 69]. To explain such phenomenon, hypotheses have been raised

concerning environmental, nutritional and genetic factors, yet they remain

unproved [29, 51, 70 - 78].

The HBsAg carriers should be clinically investigated, monitored by

laboratorial tests and, if appropriate, to undergo biopsy [6].

The practice of these prophylactic measures including active immunization

has significantly decreased the incidence of HBV infection in both occidental and

oriental countries [79 - 81].

The search for other HBV markers (anti-HBc, HBeAg, anti-HBe, HBsAg

subtypes and HBV genotyping) in the relatives of patients are under investigation

in our group [82].

Conclusions

(i) The frequency of familial aggregation – given by the presence of one of the HBV

markers (HBsAg or anti-HBs) in serum in one or more relatives of patients with a

HBV-related liver disease – was equally elevated in groups from oriental and

occidental origin; (ii) The general occurrence of the HBsAg and anti-HBs was

significantly higher in families of Japanese origin; (iii) The HBsAg occurrence was

significantly higher in relatives of patients from Japanese background with close

genetic relation (mothers, daughters, sons, brothers and sisters); (iv) Concerning

the anti-HBs, there was no significant difference between relatives of oriental and

occidental origin. This marker was more frequently found in the fathers, sexual

partners and in the group of other relatives; (v) The children to HBsAg-positive

1212

mothers from Japanese origin presented higher frequency of HBV infection than

those from occidental mothers; the same fact was observed for the children to

Japanese fathers; (vi) Comparing mothers and fathers from Japanese origin,

transmission from the former group to their children was significantly higher; (vii)

Among the closely related individuals, the HBsAg was the more frequent marker,

whereas within the more distantly related subjects, the anti-HBs was the

predominant one; (viii) These facts strongly suggest the occurrence of vertical

transmission among the closely genetic related relatives; and, (ix) The high intra-

familial dissemination of the HBV calls for prophylatic measures. (x) Some

statistical methods allow the prediction of the frequency of the HBV markers per

ethnic group and per familial degree relation, with a close agreement with the

observed values. This is a valuable contribution of practical use and, as far as we

know, there is no similar report in the literature.

List of abbreviations

HBV, Hepatitis B Virus

HBsAg, Hepatitis B surface antigen

Anti-HBs, Hepatitis B surface antibody

Anti-HBc, Hepatitis B core antibody

HBeAg, Hepatitis B e antigen

Anti-HBe, Hepatitis B e antibody

HBV DNA, Hepatitis B Virus deoxyribonucleic acid

Competing interests

None declared.

Authors’ contributions

FJC conceived, designed, carried out the entire study in addition to the

standardization of the protocol and preparation of the manuscript. SKON, LEPF,

JEMMF and ELRC assisted in data collection. JRRP participated of the

1313

determination of HBV markers. RAC participated ofthe design of the study and

performed the statistical analysis. VAFA, LCCG and LCDS all participated of the

design and preparation of the manuscript. All authors read and approved the final

manuscript.

Acknowledgments

This study was in part supported by research grants from the FINEP –

Financiadora de Estudos e Projetos and Alves de Queiróz Family Fund for

Research. Authors thank Dr. Gabriela Ribeiro-dos-Santos for critically reviewing

the manuscript.

References

1. Carrilho FJ, Corrêa MCJM: Magnitude of hepatitis B and C in Latin

America. In Therapies for Viral Hepatitis. Edited by Schinazi RF,

Sommadossi JP, Thomas HC. London: International Medical Press;

1998:25-34.

2. Barrett DH, Burks JM, McMahon B, Elliott S, Berquist KR, Bender TR,

Maynard JE: Epidemiology of hepatitis B in two Alaskan

communities. Amer J Epidem 1977, 105:118-22.

3. Beasley RP, Hwang LY, Lin CC, Leu ML, Stevens CE, Szmuness W,

Chen KP: Incidence of hepatitis B virus infections in pre-school

children in Taiwan. J infect Dis 1982, 146:198-204.

4. Hann HW, Kim CY, London WT, Whiteford P, Blumberg BS: Hepatitis B

virus and primary hepatocellular carcinoma: family studies in Korea.

Int J Cancer 1982, 30:47- 51.

1414

5. Kashiwagi S, Hayashi J, Ikematsu H, Nomura H, Kusaba T, Shingu T,

Hayashida K, Kaji M: An epidemiologic study of hepatitis B virus in

Okinawa and Kyushu, Japan. Amer J Epidem 1983, 118:787-94.

6. Carrilho FJ, Baldy JLS, Takata PK, Adum S, Zeitune JMR: Prevalence

and study of asymptomatic carriers of hepatitis B surface antigen

(HBsAg, in blood donors in Londrina, South of Brazil. Gastroent

Endosc Digest, S. Paulo 1984, 3:13- 20.

7. Gayotto LCC, Quarentei AA, Cabral GL: Soro epidemiologia das

hepatites A e B nas regiões dos rios Biá e Alto Juruá, Amazônia

Ocidental. Gastroent Endosc Digest, S Paulo 1984, 3:106-12.

8. Foccacia R, Conceição OJG, Sette Jr H et al: Estimated prevalence of

viral hepatitis on the general population of the municipality of São

Paulo, measured by serological markers through samples collected

from a stratified, randomized and residence-based population

survey. Braz J Infect Dis 1998, 2:268-83.

9. Zuckerman AJ: Controversies in immunization against hepatitis B.

Hepatology 1985, 5:1227-30.

10.The EASL Jury: EASL International Consensus Conference on

Hepatitis B. J Hepatol 2003, 38:533-40.

11.Berris, B, Wrobel DM, Sinclair JC, Feinman SV: Hepatitis B antigen in

families of blood donors. Ann Intern Med 1973, 79:690-93.

12.Coleman JC, Waugh M, Dayton R: Hepatitis B antigen and antibody in

a male homosexual population. Brit J vener Dis 1977, 53:132-34.

13.Drachler DH: Hashish and the transmission of hepatitis. N Engl J Med

1975, 293:667.

1515

14.Ellis WR, Coleman JC, Fluker JL, Keeling PWN, Banatvala JE, Murray-

Lyon IM, Evans BA, Bull J, Simmons PD, Willcox JR, Thompson RPH:

Liver disease among homosexual males. Lancet 1979, 1:903-5.

15.Hadziyannis SJ, Merikas GE: Australia antigen in a family. Lancet

1970, 1:1057-8.

16.Lim KS, Wong VT, Fulford KWM, Catterall RD, Briggs M, Dane DS: Role

of sexual and non-sexual practices in the Transmission of hepatitis

B. Brit. J vener Dis 1977, 53:190-2.

17.Mazzur S, Blumberg BS, Friedlaender JS: Silent maternal transmission

of Australia Antigen. Nature, London 1974, 247:41- 3.

18.Steinberg SC, Alter HJ, Leventhal BG: The risk of hepatitis

transmission to family contacts of leukemia patients. J Pediat 1975,

87:753-6.

19.Szmuness W, Much MI, Prince AM, Hoofnagle JH, Cherubin CE, Harley

EJ, Blockj GH: On the role of sexual behavior in the spread of

hepatitis B infection. Ann intern Med 1975, 289:489-95.

20.Van Etta LL, Peterson LR, Gerding DN: Asymptomatic hepatitis B

carriers in a family. N Engl J Med 1981, 305:1093-4.

21.Ohbayashi A, Okochi K, Mayumi M: Familial clustering of

asymptomatic carriers of Australia antigen and patients with chronic

liver disease or primary liver cancer. Gastroenterology 1972, 62:618-

625.

22.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. Amer J Epidem 1982, 116:199-211.

1616

23.Sampliner RE, Loevinger BL, Tabor E, Gerety RJ: Intrafamilial cluster of

hepatitis B virus infection: study of a large family in the United

States. Amer J Epidem 1981, 113:50- 4.

24.Szmuness W, Prince AM, Hirsch RL, Brotman B: Familial clustering of

hepatitis B infection. N Engl J Med 1973, 289:1162-6.

25.Tong MJ, Thursby MW, Lin JH, Welssman JY, McPeakj CM: Studies on

the maternal-infant transmission of the hepatitis B virus and HBV

infection within families. Prog med Virol 1981, 27:137-47.

26.Tong MJ, Weiner JM, Ashcavai MW, Redeker AG, Comparini S, Vyas

GN: A comparative study of hepatitis B viral markers in the family

member of Asian and Non-Asian patients with hepatitis B surface

antigen-positive hepatocellular carcinoma and with chronic hepatitis

B infection. J infect Dis 1979, 140:506-12.

27.Velasco M, Giaconi J, Cruz-Coke R, Fuente C, Ruiz A: Distribuición

familiar del antígeno Australiano en poblacion chilena. Rev méd

Chile 1973, 101:758-62.

28.Bosch J, Bruguera M, Rodés J: Familial spread of type-B hepatitis.

Lancet 1973, 2 :457.

29.Coltorti M, Del Vecchio-Blanco C, Caporaso N, SuozzoR, Servillo F:

Familial clustering of HBV infection and chronic liver disease. Front

gastroint Res 1984, 8:169-79.

30.Eliakin M, Ligumski M, Sandler Sg, Zlotnick A: Familal clustering and

immune response in family contacts of patients with HBsAg-positive

liver cirrhosis. Dig Dis Sci 1978, 23:407-12.

1717

31.Hellawell JM, Woolf IL, Jones DM, Dymock IW: Epidemiological

observations on the families of hepatitis B antigen carriers and

hepatitis B antibody-positive individuals. Gut 1975, 16: 402.

32.Hess G, Born M, Dormeyer H, Zoller B, Arnold W, Knolle J: Hepatitis B

virus markers among family contacts of asymptomatic HBsAg

carriers. Scand J Gastroent 1979, 14:373-8.

33.Anderson KE, Stevens CE, Tsuci JJ, Lee WC, Sun SC, Beasley RP:

Hepatitis B antigen in infants born to mothers with chronic hepatitis

antigenemia in Taiwan. Amer J Dis Child 1975, 129:1389-92.

34.Beasley RP, Hwang LY, Stevens CE, Lin CC, Hsieh FJ, Wang KY, Sunj

TS, Szmuness W: Efficacy of hepatitis B immune globulin for

prevention of perinatal transmission of the hepatitis B virus carrier

state: Final report of a randomized double-blind placebo-controlled

trial. Hepatology 1983, 3:135-41.

35.Grossman RA, Benenson MW, Scott RM, Snitbhan R, Top Jr FH,

Pantuwatana S: An epidemiologic study of hepatitis B Virus in

Bangkok, Thailand. Amer J Epidem 1975, 101:144-59.

36.Scobie B, Woodfield DG, Fong R: Familial hepatocellular carcinoma

and hepatitis B antigenemia in a New Zealand chinese family. Aust N

Z J Med 1983, 13:236-9.

37.Asami K, Tsuchiya M: Comparative study of incidence of HBV

infection in Japanese descendents and native bolivians in Santa

Cruz, Bolivia. Acta gastroent Bolivia 1983, 3 :5-8.

38.Szmuness W, Harley EJ, Prince AM: Intrafamilial spread of

asymptomatic hepatitis B. Amer J med Sci 1975, 270:293-304.

1818

39.Snedecor GW, Cochran WG: The comparison of two samples. In

Statistical methods. 7th edition. Edited by Snedecor GW, Cochran WG.

Ames: The Iowa State University Press; 1980:83-102.

40.Grizzle JE, Starmer CF, Koch GG: Analysis of categorical data by

linear models. Biometrics 1969, 25:489-504.

41.Koch GG, Imrey PB, Singer JM, Atkinson SS, Stokes JME: Lecture notes

for analyses of categorical data Post graduate Course in the Department

of Biostatistics. Chapel Hill: University of North Carolina Press; 1984.

42.SAS Institute Inc: SAS User´s Guide: Statistics. 5nd edition. Cary: SAS

Institute; 1985.

43.Frost WH: The familial aggregation of infectious disease. In Papers of

Wade Hampton Frost, MD: a contribution to epidemiological method.

Edited by Maxcy KF. New York: Commonwealth Fund; 1993:120-269.

44.Lo KJ, Tong MJ, Chien MC, Tsai YT, Liaw YF, Yang KC, Chian H, Liu

HC, Lee SD: The natural course of hepatitis B surface antigen-

positive chronic active hepatitis in Taiwan. J infect Dis 1982, 146:205-

10.

45.Sung J.L, Chen DS: Maternal transmission of hepatitis B surface

antigen in patients with hepatocellular carcinoma in Taiwan. Scand J

Gastroenterol 1980, 15:321-4.

46. Kashiwagi S, Hayashi J, Ikematsu H, Nomura H, Kajiyama W, Shingu T,

Hayashida K, Kaji M: Transmission of hepatitis B virus among

siblings. Amer J Epidem 1984, 120:617-25.

47. Marinier E, Barroi V, Larouze B, London WT, Cofer A, Diakhate L,

Blumberg BS: Lack of perinatal transmission of hepatitis B virus

infection in Senegal, West. Africa. J Pediat 1985, 106:843-9.

1919

48. Lok AS, Heathcote EJ, Hoofnagle JH: Management of Hepatitis B:

2000 – Summary of a Workshop. Gastroenterology 2001, 120:1828-53.

49. Conjeevaram HS, Lok AS. Management of chronic hepatitis B. J

Hepatol 2003, 38:S90-S103.

50. Liaw YF, Leung N, Guan R, Lau GKK, Merican I: Asian-Pacific

consensus statement on the management of chronic hepatitis B: An

update. J Gastroenterol Hepatol 2003, 18:239-45.

51. Boss LP, Bender TR, Schreeder MT, Lanier AP, Hardison HH, Maynard

JE: Hepatitis B testing in the families and villages of five young

Eskimos with primary hepatocellular carcinoma. Amer J Epidem

1981, 114:95- 101.

52. Bruguera M, Bosch J, Rodés J: Family outbreak of hepatitis B. N Engl

J Med 1973, 289:1144.

53. Koff RS, Slavin MM, Connelly LJD, Rosen DR: Contagiousness of

acute hepatitis B. Secondary attack rates in household contacts.

Gastroenterology 1977, 72:297-300.

54. Mitch WE, Wands JR, Maddrey WC: Hepatitis B transmission in a

family. J Amer med Assoc 1974, 227:1043-4.

55. Reeves WC, Peters CJ, Moon TE, Purcell RH: Familial clustering of

hepatitis B surface antigen among Panamanian indians. J infect Dis

1975, 131:61- 70.

56. Tong MJ, Coj RL: Hepatitis B virus markers in Asian families. Ann

intern Med 1985, 103:307-8.

2020

57. Bruguera M, Caballeria J, Acero D, Bosch J, Rodés J: Transmission

intrafamiliar del virus de la hepatitis B. Gastroent Hepatol 1980, 3:13-

8.

58. Beasley RP, Trepo C, Stevens CE, Szmuness W: The e antigen and

vertical transmission of hepatitis B surface antigen. Amer J Epidem

1977, 105:94- 8.

59. Bruguera M, Bosch J, Rodés J, Pedreira J: Familial clustering of

hepatitis B antigen: A study in relatives of patients with liver

diseases and hepatitis B antigenaemia. Brit Med J 1974, 3:495-97.

60. Papaevangelou G, Karaboyia-Karafyllidis P, Kyriakidou A: Prevalence

and epidemiologic significance of to hepatitis B core antigen in

Greece. Amer J Epidem , 1977, 106: 502-6.

61. Hadziyannis SJ: Nonparenteral transmission of viral hepatitis in

Greece. Amer J med Sci 1975, 270:313-8.

62. Holland PV: Hepatitis B surface antigen and antibody. In Hepatitis B.

Edited by Gerety RJ. Orlando: Academic Press; 1985:5-25.

63. Pastore G, Dentico P, Angarano G, Lapedota E, Schiraldi O: Infectivity

markers in HBsAg chronic carriers and intrafamilial spread of

hepatitis B virus infection. Hepato-Gastroenterol 1981, 28:20- 2.

64. Carrilho FJ, Nita SKO, Da Silva LC, Cardoso RA, Fonseca LEP, Alves

VAF, Gayotto LCC: Behavior of HBV markers in Brazilian families of

occidental and oriental origin of patients with chronic HBV infection

[abstract]. Hepatology 1996, 24(4, Pt 2):493A.

65. Arakawa, K, Tsuda F, Takahashi K, Ise I, Naito S, Kosugi E, Miyakawa

Y, Mayumi M: Maternofetal Transmission of IgG-bound hepatitis B e

antigen. Pediat Res 1982, 16:247-50.

2121

66. Stevens CE, Beasley RP, Tsui J, Lee WC: Vertical transmission of

hepatitis B antigen in Taiwan. N Engl J Med 1975, 292:771-4.

67. Pongpipat D, Suvatte V, Assateerawatts A: Vertical transmission of the

hepatitis B surface antigen in Thailand. Southeast Asian J trop Med

publ Hlth 1980, 11:582-7.

68. Derso A, Boxall EH, Tarlow M J, Flewett TH: Transmission of HBsAg

from mother to infant in four ethnic groups. Brit med J 1978, 1:949-52.

69. Skinhoj P, Aldershvile J, Kjersem M, Black F: Hepatitis B infection in

Vietnamese families. J med Vir 1983, 11:125-9.

70. Chang MH, Hsu HJC, Lee CY, Chen DS, Lee CH, Lin KS: Fraternal

hepatocellular carcinoma in young children in two families. Cancer

1984, 53:1807-10.

71. Follett EAC, McMichael S, Goel KM, Thomson R: Hepatitis B in the

school environment. Brit med J 1978, 1:1279-80.

72. Helske, T, Nevanlinna HR: Familial accumulation of carriers of Au

antigen. J med Genet, 1973, 10:270-2.

73. Jeannet M, Farquet JJ: HLA antigens in asymptomatic chronic HBAg

carriers. Lancet 1974, 2:1383-4.

74. Kashiwagi S, Naito S, Kaneoka H, Miyanaga O, Jimi S, Yamaguchi M,

Kaji M: A family study of HBsAg carrier and major histocompatibility

antigens. Fukuoka Acta med 1978, 69:156-61.

75. Nasrallah SM, Nassar VH, Shammaa MH: Genetic and immunological

aspects of familial chronic active hepatitis (type B). Gastroenterology

1978, 69: 302-306.

2222

76. Sampliner RE, Bias WB, Carney E, Hillis A, Hillis WD: HLA antigens

and HBV infection: evaluation in the chronic carrier state and in a

large family. Tissue Antigens 1981, 18: 247-51.

77. Tong MJ, Weiner JM: Lack of supportive evidence for an autosomal

recessive inheritance in chronic hepatitis B infections. Dig Dis Sci

1979, 24:286-8.

78. Vyas GN: Evidence against recessive inheritance of susceptibility to

the chronic carrier state for hepatitis B antigen. Nature, London 1974,

248:159-60.

79. Lee CF, KO YC. Hepatitis B Vaccination and Hepatocellular

Carcinoma in Taiwan. Pediatrics 1997, 99:351-3.

80. Beutels P, Edmunds WJ, Antonanzas F, De Wit GA, Evans D, Feilden R,

Fendrick AM, Ginsberg GM, Glick HA, Mast E, Pechevis M, Van

Doorslaer EK, Van Hout BA: Viral Hepatitis Prevention Board.

Economic evaluation of vaccination programmes: a consensus

statement focusing on viral hepatitis. Pharmacoeconomics 2002,

20:1-7.

81. Ni YH, Chang MH, Huang LM, Chen Hl, Hsu HY, Chiu TY, Tsai KS, Chen

DS: Hepatitis B virus infection in children and adolescents in a

hyperendemic area: 15 years after mass hepatitis B vaccination. Ann

intern Med 2001, 135:796-800.

82. Clemente CM: Sequencing, genotyping and philogenetic analysis of

hepatitis B virus in oriental and occidental background families of

patients with chronic infection. PhD thesis. University of São Paulo

School of Medicine, Department of Gastroenterology, Brazil; 2003.

Table 1. Frequency of HBsAg and anti-HBs in familial members of index cases with HBsAg seropositive chronic liver disease

Ethnic GroupsJapanese Origin Occidental Origin

HBsAg Anti-HBs Negative HBsAg Anti-HBs Negative χ2 pn (%) n (%) n (%) n (%) n (%) n (%)

MembersRelatives 9 (52.9) 8 (47.1) 0 7 (30.4) 10 (43.5) 6 (26.1) 5.70 0.0578

Mothers 9 (90.0) 1 (10,0) 0 4 (30.7) 6 (46.2) 3 (23.1) - -Fathers 0 7 (100.0) 0 3 (30.0) 4 (40.0) 3 (30.0) - -

Brothers and Sisters 39 (79.6) 10 (20.4) 0 4 (8.5) 10 (21.3) 33 (70.2) 61.47 <0.0001Sons and Daughters 11 (37.9) 1 (3.5) 17 (58.6) 2(3.3) 7 (11.7) 51 (85.0) 19.27 <0.0001Spouses 1 (7.1) 11 (78.6) 2 (14.3) 1 (5.0) 14 (70.0) 5 (25.0) 0.61 0.7387Other relatives 19 (33.9) 26 (46.4) 11 (19.7) 6 (16.7) 9 (25.0) 21 (58.3) 14.48 <0.0007Total 79 (47.9) 56 (33.9) 30 (18.2) 20 (10.7) 48 (25.8) 118 (63.5) 87.16 <0.0001

Figure 1

Table 2. Frequency of familial aggregation rate with HBV past or present infection per ethnic group

Ethnic Group Familial Aggregation RateNo. of studied families n (%) Exact Fisher Test (p)

Japanese origin 19 18 (94.7) 0.4319Occidental origin 26 23 (88.5)

Figure 2

Table 3. Frequency of HBV markers in progeny to HBsAg positive mothers

Ethnic Group HBsAg (+) Mothers Total Children HBsAg Anti-HBs HBV negative markers

n n n (%) n (%) n (%)Japanese origin 16 67 56 (83.6) 5 (7.5) 6 (9.5)Occidental origin 7 20 8 (40.0) 4 (20.0) 8 (40.0)χ2 = 15.54 p = 0.0004

Figure 3

Table 4. Frequency of HBV markers in progeny to HBsAg positive fathers

Ethnic Group HBsAg (+) Fathers Total Children HBsAg Anti-HBs HBV negative markers

n n n (%) n (%) n (%)Japanese origin 10 30 7 (23.3) 7 (23.3) 16 (53.4)Occidental origin 20 69 8 (11.6) 6 (8.7) 55 (79.7)χ2 = 7.34 p = 0.0255

Figure 4

Table 5. Frequency and variance analysis of HBV markers per Ethnic Group and Degree of Familial Relation

HBsAg Anti-HBs HBV negative markers

Total

Ethnic Group Degree of familial relation

n n n n

Genetic related (consanguineous)

76 28 22 126Japanese origin

Non-genetic related (non-consanguineous)

3 28 8 39

Genetic related (consanguineous)

19 30 105 154Occidental origin

Non-genetic related (non-consanguineous)

1 20 10 31

Intercept: 2 Freedom grades; χ2 = 20.39 p = 0.0001Ethnic Group: 2 Freedom grades; χ2 = 71.15 p = 0.0001Degree of familial relation: 2 Freedom grades; χ2 = 45.46 p = 0.0001Residual: 2 Freedom grades; χ2 = 2.71 p = 0.2580

Figure 5

Table 6. Frequency of HBV markers per Ethnic Group and Degree of Familial Relation; Observed and predicted probabilities

Observed results Predicted resultsEthnic Group Degree of familial

relationHBV markers Probability Standard error Probability Standard error

HBsAg 0.60 0.04 0.60 0.04Anti-HBs 0.22 0.04 0.21 0.03

Genetic related (consanguineous)

Negative 0.17 0.03 0.19 0.03HBsAg 0.08 0.04 0.10 0.04

Anti-HBs 0.72 0.07 0.75 0.06

Japanese origin

Non-genetic related (non-consanguineous)

Negative 0.20 0.06 0.15 0.04HBsAg 0.12 0.03 0.13 0.03

Anti-HBs 0.19 0.03 0.21 0.03Genetic related (consanguineous)

Negative 0.68 0.04 0.67 0.04HBsAg 0.03 0.03 0.02 0.01

Anti-HBs 0.64 0.09 0.58 0.07

Occidental origin

Non-genetic related (non-consanguineous)

Negative 0.32 0.08 0.40 0.07

Figure 6

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