Journal of Viral Hepatitis, 2015, 22, 1061–1067
doi:10.1111/jvh.12420
Changing 14-year trends in the epidemiology of hepatitis B virus infection in rural and urban Central–Eastern European areas A. Genowska,1 J. Jamiołkowski,1 E. Rodakowska,2 J. Fryc,2 M. Kozela3 and A. Pajaz k3 2
1
Faculty of
Health Sciences, Medical University of Bialystok, Poland; Faculty of Medicine with Division of Dentistry and Division of Medical Education in English, Medical University of Bialystok, Poland; and 3Faculty of Health Sciences, Jagiellonian University Medical College, Krakow, Poland Received February 2015; accepted for publication March 2015
SUMMARY. In Poland, the prevalence of HBV infection con-
stitutes an emerging public health concern. The aim of the study was to analyse changes in hepatitis B incidence rate by age, gender and place of residence in Poland between 1999 and 2012. The data were obtained from Polish state statistics institutions such as the National Institute of Public Health and State Sanitary Inspection. Relationships of hepatitis B incidence with age, gender and rural/urban areas were investigated using v2 and tests for two proportions with Bonferroni adjustment. The incidence of hepatitis B in rural and urban populations was compared using Wilcoxon’s signed-rank tests. Joinpoint regression was used to analyse trends in hepatitis B incidence rate. In Poland, a total of 26 660 cases of hepatitis B were reported in the studied period and 31.6% of
INTRODUCTION Poland is classified as a country of low-level intermediate prevalence of hepatitis B. The estimated prevalence level is between 2 and 4%, but still, it is substantially higher than in Western Europe and Scandinavian countries [1,2]. In Central and Eastern Europe (CEE), nosocomial infections account for the majority of hepatitis B virus (HBV) infections [2,3]. It has been confirmed that vaccination is the most effective way to prevent HBV infections and its complications [4,5]. In Poland, vaccination against hepatitis B is mandatory [6]. According to the National Vaccination Schedule, the first dose of the vaccine is administrated
Abbreviations: AAPC, average annual percentage change; EMCDDA, European Monitoring Centre for Drugs and Drug Addiction; IR, incidence rate; NIPH-NIH, National Institute of Public Health – National Institute of Hygiene; SSI, State Sanitary Inspection. Correspondence: Agnieszka Genowska, PhD, Faculty of Health Sciences, Medical University of Bialystok, Szpitalna 37, 15-295 Bialystok, Poland. E-mail: [email protected]
© 2015 John Wiley & Sons Ltd
these cases occurred in rural areas. There was significantly declining tendency in the hepatitis B incidence rate in the initial period of the study. However, there were periods of significant increase of HBV incidence rate in women from rural areas aged 15–24 years (9.4%/year) and in women from urban areas aged 15–24 years (10.9%/year) and 25–64 years (3.8%/year) in the final years of the observation. Despite the success in controlling this infection, a significant increase in the incidence of hepatitis B among young women living in rural and urban areas, as well as in adult women in urban areas, has been noted. Keywords: HBV infection, health inequalities, incidence, rural/urban areas, trends.
within the first 24 h of life, and then in the 2nd and 7th month of life. However, according to the Global Policy Report on the prevention and Control of Viral Hepatitis in Poland, there is no written national strategy or plan that focuses exclusively or primarily on the prevention and control of viral hepatitis. There has not been an established goal of eliminating hepatitis B at the national level [7]. There is routine national surveillance for viral hepatitis. In Poland, hepatitis B infection has been reportable since 1979 [3,8]. Then the incidence of HBV was close to 45 cases per 100 000 population and decreased slightly to 35 per 100 000 in 1989. In 1993, the intensive vaccination programme was implemented for all newborns and children which caused dynamic decrease in the incidence to 15 per 100 000 in 1997. Since 1996, the incidence of hepatitis B in Poland has been considered as intermediate level (23/100 000) with low prevalence of HBsAg positivity according to WHO [8,9]. Despite these favourable changes and downward incidence trends observed in recent years, it cannot be said that control of this infection is fully satisfying in our country [8]. In the last 10 years, still about 1500 new cases of HBV have been reported
1062
A. Genowska et al.
annually. HBV as a lifelong infection is associated with increased risk of liver cirrhosis and hepatocellular carcinoma and death in those who are chronically infected [5]. Also, asymptomatic carriers are a threat of primary infection for nonimmunized persons. While HBV incidence rate is relatively low, general information on incidence trend in Poland does not give sufficient information for prevention purposes [10–12]. Detailed analyses of incidence by socio-economic position are necessary to determine which part of the population is at the highest risk of HBV infection. According to the Central Statistical Office of Poland, approximately 40% of the Polish population lives in rural areas [13]. They are characterized by lower population density, more difficulties in access to health and social services, higher level of unemployment and poverty and lower level of education [13– 15]. However, the lifestyle of the rural inhabitants is less hazardous compared with the urban population. Some hepatitis B risk factors, such as drug use or risky sexual behaviours, are less common in the rural areas [16,17]. Due to the lower population density, a lower hepatitis B incidence rate in the interpersonal relations should be expected. It is pointed out that people from rural and urban areas may have different health outcomes [14]. The aim of the study was to analyse changes in hepatitis B incidence rate by age, gender and place of residence in Poland between 1999 and 2012.
MATERIALS AND METHODS Surveillance data on hepatitis B incidence in Poland between 1999 and 2012 were obtained from the annually published report ‘Infectious diseases and poisonings in Poland’ by the National Institute of Public Health – National Institute of Hygiene (NIPH-NIH) and The State Sanitary Inspection (SSI) [18]. The study included new cases of hepatitis B as well as mixed cases of hepatitis B and hepatitis C virus infections (B16.0-B16.9 and B18.0B18.1 according to ICD-10) [19]. Incidence rates of hepatitis B per 100 000 population were analysed by age group (
doi:10.1111/jvh.12420
Changing 14-year trends in the epidemiology of hepatitis B virus infection in rural and urban Central–Eastern European areas A. Genowska,1 J. Jamiołkowski,1 E. Rodakowska,2 J. Fryc,2 M. Kozela3 and A. Pajaz k3 2
1
Faculty of
Health Sciences, Medical University of Bialystok, Poland; Faculty of Medicine with Division of Dentistry and Division of Medical Education in English, Medical University of Bialystok, Poland; and 3Faculty of Health Sciences, Jagiellonian University Medical College, Krakow, Poland Received February 2015; accepted for publication March 2015
SUMMARY. In Poland, the prevalence of HBV infection con-
stitutes an emerging public health concern. The aim of the study was to analyse changes in hepatitis B incidence rate by age, gender and place of residence in Poland between 1999 and 2012. The data were obtained from Polish state statistics institutions such as the National Institute of Public Health and State Sanitary Inspection. Relationships of hepatitis B incidence with age, gender and rural/urban areas were investigated using v2 and tests for two proportions with Bonferroni adjustment. The incidence of hepatitis B in rural and urban populations was compared using Wilcoxon’s signed-rank tests. Joinpoint regression was used to analyse trends in hepatitis B incidence rate. In Poland, a total of 26 660 cases of hepatitis B were reported in the studied period and 31.6% of
INTRODUCTION Poland is classified as a country of low-level intermediate prevalence of hepatitis B. The estimated prevalence level is between 2 and 4%, but still, it is substantially higher than in Western Europe and Scandinavian countries [1,2]. In Central and Eastern Europe (CEE), nosocomial infections account for the majority of hepatitis B virus (HBV) infections [2,3]. It has been confirmed that vaccination is the most effective way to prevent HBV infections and its complications [4,5]. In Poland, vaccination against hepatitis B is mandatory [6]. According to the National Vaccination Schedule, the first dose of the vaccine is administrated
Abbreviations: AAPC, average annual percentage change; EMCDDA, European Monitoring Centre for Drugs and Drug Addiction; IR, incidence rate; NIPH-NIH, National Institute of Public Health – National Institute of Hygiene; SSI, State Sanitary Inspection. Correspondence: Agnieszka Genowska, PhD, Faculty of Health Sciences, Medical University of Bialystok, Szpitalna 37, 15-295 Bialystok, Poland. E-mail: [email protected]
© 2015 John Wiley & Sons Ltd
these cases occurred in rural areas. There was significantly declining tendency in the hepatitis B incidence rate in the initial period of the study. However, there were periods of significant increase of HBV incidence rate in women from rural areas aged 15–24 years (9.4%/year) and in women from urban areas aged 15–24 years (10.9%/year) and 25–64 years (3.8%/year) in the final years of the observation. Despite the success in controlling this infection, a significant increase in the incidence of hepatitis B among young women living in rural and urban areas, as well as in adult women in urban areas, has been noted. Keywords: HBV infection, health inequalities, incidence, rural/urban areas, trends.
within the first 24 h of life, and then in the 2nd and 7th month of life. However, according to the Global Policy Report on the prevention and Control of Viral Hepatitis in Poland, there is no written national strategy or plan that focuses exclusively or primarily on the prevention and control of viral hepatitis. There has not been an established goal of eliminating hepatitis B at the national level [7]. There is routine national surveillance for viral hepatitis. In Poland, hepatitis B infection has been reportable since 1979 [3,8]. Then the incidence of HBV was close to 45 cases per 100 000 population and decreased slightly to 35 per 100 000 in 1989. In 1993, the intensive vaccination programme was implemented for all newborns and children which caused dynamic decrease in the incidence to 15 per 100 000 in 1997. Since 1996, the incidence of hepatitis B in Poland has been considered as intermediate level (23/100 000) with low prevalence of HBsAg positivity according to WHO [8,9]. Despite these favourable changes and downward incidence trends observed in recent years, it cannot be said that control of this infection is fully satisfying in our country [8]. In the last 10 years, still about 1500 new cases of HBV have been reported
1062
A. Genowska et al.
annually. HBV as a lifelong infection is associated with increased risk of liver cirrhosis and hepatocellular carcinoma and death in those who are chronically infected [5]. Also, asymptomatic carriers are a threat of primary infection for nonimmunized persons. While HBV incidence rate is relatively low, general information on incidence trend in Poland does not give sufficient information for prevention purposes [10–12]. Detailed analyses of incidence by socio-economic position are necessary to determine which part of the population is at the highest risk of HBV infection. According to the Central Statistical Office of Poland, approximately 40% of the Polish population lives in rural areas [13]. They are characterized by lower population density, more difficulties in access to health and social services, higher level of unemployment and poverty and lower level of education [13– 15]. However, the lifestyle of the rural inhabitants is less hazardous compared with the urban population. Some hepatitis B risk factors, such as drug use or risky sexual behaviours, are less common in the rural areas [16,17]. Due to the lower population density, a lower hepatitis B incidence rate in the interpersonal relations should be expected. It is pointed out that people from rural and urban areas may have different health outcomes [14]. The aim of the study was to analyse changes in hepatitis B incidence rate by age, gender and place of residence in Poland between 1999 and 2012.
MATERIALS AND METHODS Surveillance data on hepatitis B incidence in Poland between 1999 and 2012 were obtained from the annually published report ‘Infectious diseases and poisonings in Poland’ by the National Institute of Public Health – National Institute of Hygiene (NIPH-NIH) and The State Sanitary Inspection (SSI) [18]. The study included new cases of hepatitis B as well as mixed cases of hepatitis B and hepatitis C virus infections (B16.0-B16.9 and B18.0B18.1 according to ICD-10) [19]. Incidence rates of hepatitis B per 100 000 population were analysed by age group (
