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1 March 2011 Annals of Internal Medicine Volume 154 Number 5 319
Original Research
Hepatitis B Virus in the United States: Infection, Exposure and Immunity Rates
NHANES comprised a stratified, multistage probability sample of the civilian, noninstitutionalized U.S. population of all 50 states and the District of Columbia. Extensive efforts were made to ensure participation. All
participants were reimbursed for their time, transportation,
and childcare expenses, if necessary. Participants were initially interviewed in person at home and then invited to
attend a mobile examination center for examinations,
blood tests, and additional interviews.
Participants aged 2 years or older (n 47 484) were
eligible for anti-HBs testing, of whom 39 787 gave a suitable blood sample (final response rate for testing was
83.8%). Only participants aged 6 years or older (n 42
773) were eligible for anti-HBc and HBsAg testing, of
whom 37 259 (87%) were tested. Persons with or without
available HBV serologic testing did not substantially differ
with respect to major risk factors for HBV infection (age,
sex, and race or ethnicity).
Caution
Laboratory Methods
Context
Hepatitis B virus (HBV) infection is an important cause of
morbidity and mortality in the United States. Population
demographic characteristics, the use of HBV vaccine, and
behaviors that lead to exposure to HBV have been changing over the past 2 decades. Current estimates of HBV
infection and immunity are needed to appropriately target
prevention and treatment efforts.
Contribution
Implication
Real progress has been made in protecting children and
adolescents in the United States from HBV infection.
Adults remain an important population for targeted
immunization efforts.
The Editors
METHODS
Study Design
Hepatitis B Virus in the United States: Infection, Exposure and Immunity Rates
and may become negative in a large proportion of previously vaccinated persons (511). However, among children
aged 2 years, the presence of anti-HBs probably reflects
effective infant hepatitis B vaccination with reasonable accuracy: Children aged 2 years should have completed their
recommended hepatitis B vaccination series but should not
have experienced any substantial decline in anti-HBs levels.
Hence, prevalence of anti-HBs is reported separately
among children aged 2, 3, 4, and 5 years.
Absence of vaccination-induced immunity, as defined
herein, does not necessarily indicate absence of protection
against HBV infection because persistence of immunologic
memory can still be detected in vitro in peripheral blood
lymphocytes from persons whose anti-HBs has become undetectable in vivo (14). However, detecting the presence of
anti-HBs is the easiest way to demonstrate existing immune protection in a population, and rates of anti-HBs in
adults may inform future discussions on whether booster
vaccinations are required in adults.
Statistical Analysis
Stata/SE software, version 11 (StataCorp, College Station, Texas) was used for all analyses. NHANES used a
complex, multistage sampling design, including oversampling for certain demographic groups (low-income persons,
adolescents aged 12 to 19 years, persons aged 60 years or
older, and black and Mexican persons). Weights are pro-
Original Research
vided to account for oversampling as well as survey nonresponse and a poststratification adjustment to match the
year 2000 U.S. census. The survey commands of Stata
were used to account for both the sampling and the
weighting processes, such that the results are representative
of the U.S. population. The variables used to denote the
primary sampling units and strata were sdmvpsu and sdmvstra, respectively. Appropriate weights were calculated for
the 10-year period by multiplying 4/10 times the 4-year
weight provided by the NHANES for 1999 to 2002 (4/
10 wtmec4yr) and 2/10 times the 2-year weights provided for each period 2003 to 2004, 2005 to 2006, and
2007 to 2008 (2/10 wtmec2yr) (15).
The prevalence and 95% CIs of serologic markers of
HBV in the United States were calculated for the entire
population and among subgroups defined by selected risk
factors for HBV by using the svy:proportion command in
Stata. Prevalence was multiplied by the total civilian, noninstitutionalized population in the United States averaged
across the NHANES studies from 1999 to 2008 (www.cdc
.gov/nchs/nhanes/response_rates_CPS.htm) for persons
aged 6 years or older (about 262 611 444) to estimate the
number of persons. Univariate and multivariate logistic regression were used to determine the unadjusted and adjusted odds ratios and 95% CIs of selected predictors of
infection, exposure, or immunity, by using the svy:logit
Table 1. Prevalence and Predictors of Chronic Hepatitis B Virus Infection (Positive HBsAg) Among Persons Aged 6 Years or Older
in the United States, 1999 to 2008
Variable
Participants Tested, n
All participants
37 259
0.27 (0.200.34)
NA
Sex
Female
Male
19 033
18 226
0.17 (0.090.24)
0.38 (0.250.50)
1
2.27 (1.313.96)
5833
5931
6508
3956
3900
3148
3583
4400
0.03 (0.000.06)
0.02 (0.000.04)
0.25 (0.090.42)
0.31 (0.150.47)
0.33 (0.160.50)
0.57 (0.330.81)
0.19 (0.030.35)
0.20 (0.050.34)
1
0.63 (0.142.8)
9.6 (2.537)
11.6 (2.947)
12.5 (4.039)
21.5 (6.472)
7.1 (1.241)
7.4 (1.831)
Age
612 y
1317 y
1829 y
3039 y
4049 y
5059 y
6069 y
70 y
Prevalence of HBsAg
(95% CI), %
Unadjusted OR
(95% CI)
Race or ethnicity
Non-Hispanic white
Non-Hispanic black
Hispanic*
Other race
15 259
8850
11 670
1480
0.11 (0.060.15)
0.73 (0.41.0)
0.05 (0.0030.11)
1.97 (1.02.9)
1
6.9 (3.713.1)
0.52 (0.21.5)
19.0 (10.235.5)
Birthplace
United States
Mexico
Elsewhere (white, black, or Hispanic)
Elsewhere and other race
30 181
4056
2419
577
0.17 (0.110.22)
0.026 (0.00.0007)
0.59 (0.270.91)
3.28 (1.415.14)
1
0.16 (0.030.82)
3.6 (1.96.6)
20.4 (10.340.6)
Original Research
Hepatitis B Virus in the United States: Infection, Exposure and Immunity Rates
Table 2. Prevalence and Predictors of Exposure to Hepatitis B Virus (Positive Anti-HBc) Among Persons Aged 6 Years or Older in
the United States, 1999 to 2008
Characteristic
Participants
Tested, n
Aged >6 y*
Aged 2059 y
Aged 2049 y
All participants
37 259
4.6 (4.15.0)
NA
NA
NA
NA
Sex
Female
Male
19 033
18 226
3.9 (3.44.4)
5.3 (4.75.9)
1
1.39 (1.21.6)
1
1.62 (1.41.9)
1
1.36 (1.041.8)
1
1.44 (1.072.0)
0.4 (0.060.8)
0.5 (0.30.7)
2.2 (1.62.8)
4.0 (3.34.7)
6.5 (5.57.5)
7.9 (6.79.1)
6.1 (5.07.3)
7.6 (6.39.0)
1
1.07 (0.42.8)
5.1 (2.112.5)
9.4 (2.823)
15.6 (6.537)
19.4 (7.948)
14.7 (6.036)
18.7 (7.646)
1
1.10 (0.43.1)
4.5 (1.712)
9.2 (3.524)
18.5 (7.248)
24.4 (9.265)
18.9 (7.249)
26.4 (1969)
NA
NA
1
2.3 (1.53.6)
5.0 (3.37.4)
6.4 (4.110.0)
NA
NA
NA
NA
1
1.8 (1.12.9)
3.5 (2.25.5)
NA
NA
NA
Age
612 y
1317 y
1829 y
3039 y
4049 y
5059 y
6069 y
70 y
5833
5931
6508
3956
3900
3148
3583
4400
Prevalence of
Anti-HBc,
(95% CI), %
Unadjusted OR
(95% CI)
Race or ethnicity
Non-Hispanic white
Non-Hispanic black
Hispanic
Other race
15 259
8850
11 670
1480
2.8 (2.53.1)
10.4 (9.411.4)
3.5 (2.74.3)
17.6 (14.820.4)
1
4.02 (3.54.6)
1.24 (0.971.6)
7.37 (69.1)
1
4.48 (3.95.2)
1.04 (0.81.4)
2.89 (1.84.6)
1
4.12 (3.25.3)
1.11 (0.71.7)
2.95 (1.55.7)
1
3.27 (2.44.5)
0.75 (0.41.3)
3.54 (1.58.2)
Birthplace
United States
Mexico
Elsewhere (white, black, or Hispanic)
Elsewhere and other race
30 181
4056
2419
577
3.4 (3.03.7)
2.4 (1.73.1)
11.0 (9.113.0)
31.3 (26.536.1)
1
0.71 (0.530.95)
3.57 (2.94.4)
13.1 (10.316.8)
1
0.86 (0.61.3)
3.30 (2.64.2)
6.72 (3.911.6)
1
0.75 (0.41.3)
3.55 (2.45.2)
8.21 (3.618.6)
1
1.21 (0.62.3)
5.0 (3.27.9)
7.0 (2.618.5)
Family income
2 times poverty threshold
11.9 times poverty threshold
Below poverty threshold
16 993
9197
8328
3.6 (3.24.0)
6.2 (5.47.0)
5.7 (4.76.7)
1
1.79 (1.52.1)
1.63 (1.12.0)
1
1.93 (1.62.3)
1.93 (1.62.4)
1
1.98 (1.52.6)
1.69 (1.32.3)
1
1.91 (1.32.7)
1.39 (0.962.0)
7191
15 950
8.7 (7.69.8)
4.8 (4.35.3)
1
0.53 (0.470.60)
NA
NA
1
0.82 (0.61.1)
1
0.92 (0.71.3)
12 713
2159
2142
747
5412
1588
4.7 (4.05.3)
7.5 (6.18.9)
7.7 (6.29.1)
8.6 (6.410.8)
4.8 (3.95.6)
7.3 (5.68.9)
1
1.65 (1.322.1)
1.70 (1.42.1)
1.91 (1.42.6)
0.80 (0.670.95)
1.60 (1.22.1)
NA
NA
NA
NA
NA
NA
1
0.68 (0.31.8)
1.67 (1.12.5)
1.43 (0.92.2)
2.18 (1.63.0)
2.65 (1.83.8)
1
1.12 (0.43.5)
1.91 (1.32.9)
1.78 (1.12.9)
2.06 (1.43.1)
2.57 (1.64.0)
9710
3205
6.0 (5.26.8)
7.0 (6.17.9)
1
1.18 (0.991.4)
NA
NA
1
1.35 (1.0051.8)
1
1.07 (0.61.8)
Blood transfusion
No
Yes, 1992present
Yes, 19721991
33 623
848
1123
4.3 (3.84.7)
5.8 (3.58.2)
6.3 (4.87.8)
1
1.39 (0.92.1)
1.51 (1.21.9)
NA
NA
NA
1
0.86 (0.32.2)
1.30 (0.72.4)
1
0.49 (0.30.7)
0.99 (0.42.3)
11 000
2485
302
4.0 (3.54.4)
5.1 (4.16.0)
27.3 (20.833.8)
1
1.29 (1.051.6)
9.1 (6.412.9)
NA
NA
NA
1
1.41 (1.071.9)
1.30 (0.72.4)
1
1.18 (0.81.7)
1.86 (0.94.0)
4.3 (3.35.3)
3.5 (3.04.1)
1
0.82 (0.61.1)
NA
NA
1
0.67 (0.50.99)
1
0.49 (0.30.7)
2134
6462
www.annals.org
Hepatitis B Virus in the United States: Infection, Exposure and Immunity Rates
Original Research
Table 2Continued
Characteristic
Prevalence of
Anti-HBc,
(95% CI), %
Unadjusted OR
(95% CI)
Aged >6 y*
Aged 2059 y
Aged 2049 y
2087
1579
601
3.8 (2.94.7)
6.4 (5.07.8)
15.5 (11.919.1)
0.88 (0.61.3)
1.52 (1.12.1)
4.1 (2.85.9)
NA
NA
NA
0.58 (0.40.92)
0.92 (0.61.4)
1.82 (1.0093.3)
0.47 (0.30.8)
0.58 (0.40.9)
1.20 (0.62.5)
36 794
465
4.1 (3.64.5)
38.5 (32.644.4)
1
14.8 (11.219.6)
NA
NA
NA
NA
1
9.3 (4.917.6)
11 841
73
3.9 (3.4-4.4)
50.9 (37.9-64.0)
1
25.5 (14.7-44.1)
NA
NA
NA
NA
1
19.3 (8.1-46.3)
1
3.26 (2.74.0)
NA
NA
NA
NA
1
1.87 (1.32.6)
1019
2049
50
Participants
Tested, n
9105
2709
3.0 (2.53.5)
9.1 (7.810.5)
anti-HBc antibody against hepatitis B core antigen; NA not applicable; OR odds ratio.
* Adjusted for sex, race or ethnicity, age, family income, and birthplace.
Adjusted for sex, race or ethnicity, age, family income, birthplace, educational attainment, marital status, service in the U.S. armed forces, blood transfusion, lifetime street
drug use, and lifetime number of sexual partners.
Adjusted for all characteristics in the previous 2 footnotes in addition to hepatitis C virus, HIV, and herpes simplex virus 2 status.
Category includes ages 20 to 29 y for the adjusted ORs limited to persons aged 20 y.
Includes Mexican Americans and other Hispanic persons.
Only data for men aged 17 y are presented in the univariate analyses.
** Antibody to hepatitis C virus confirmed by recombinant immunoblot assay.
RESULTS
Among persons aged 6 years or older, 0.27% (95% CI,
0.20% to 0.34%) had chronic HBV infection (about
704 000 persons), 4.6% (CI, 4.1% to 5.0%) had been
exposed to HBV (about 11 993 000 persons), and 22.6%
(CI, 21.8% to 23.4%) tested positive for serum anti-HBs
without anti-HBc as a result of previous vaccination
against HBV (about 59 297 000 persons). These estimates
from 1999 to 2008 were significantly lower (P 0.001)
than previous estimates for infection (0.42% [CI, 0.32%
to 0.55%]) and exposure (5.1% [CI, 4.4% to 5.8%]) in
www.annals.org
Original Research
Hepatitis B Virus in the United States: Infection, Exposure and Immunity Rates
Table 3. Prevalence and Predictors of the Presence of Anti-HBs but Not Anti-HBc Among Persons Aged 6 Years or Older in the
United States, 1999 to 2008
Characteristic
Participants
Tested, n
Prevalence of
Positive Anti-HBs
and Negative
Anti-HBc
(95% CI), %
Unadjusted OR
(95% CI)
Aged >6 y*
Aged 2059 y
Aged 2049 y
All participants
37 259
22.6 (21.823.4)
NA
NA
NA
NA
Sex
Female
Male
19 033
18 226
24.1 (23.025.2)
21.0 (20.221.8)
1
0.84 (0.790.89)
1
0.73 (0.70.8)
1
0.61 (0.50.7)
1
0.56 (0.50.7)
5833
5931
6508
3956
3900
3148
3583
4400
52.3 (49.954.7)
62.4 (59.165.6)
32.2 (30.234.1)
15.7 (14.217.2)
12.1 (10.813.5)
11.2 (10.012.5)
7.2 (6.18.3)
3.7 (2.94.5)
1
1.5 (1.31.7)
0.43 (0.40.5)
0.17 (0.10.2)
0.13 (0.110.15)
0.12 (0.100.13)
0.07 (0.060.08)
0.04 (0.030.05)
1
1.5 (1.31.7)
0.43 (0.40.5)
0.17 (0.10.2)
0.12 (0.100.14)
0.11 (0.090.12)
0.07 (0.050.08)
0.03 (0.0250.04)
NA
NA
1
0.53 (0.450.63)
0.38 (0.310.45)
0.33 (0.270.40)
NA
NA
NA
NA
1
0.56 (0.50.7)
0.40 (0.30.5)
NA
NA
NA
Race or ethnicity
Non-Hispanic white
Non-Hispanic black
Hispanic
Other race
15 259
8850
11 670
1480
21.5 (20.522.4)
24.2 (23.025.5)
24.6 (23.126.1)
28.4 (24.831.9)
1
1.17 (1.11.3)
1.20 (1.11.3)
1.45 (1.21.7)
1
0.91 (0.81.0)
1.0 (0.91.1)
1.17 (0.91.5)
1
0.86 (0.71.0)
0.92 (0.71.2)
1.48 (1.02.1)
1
0.89 (0.71.1)
0.90 (0.71.2)
1.53 (1.02.3)
Birthplace
United States
Mexico
Elsewhere (white, black, or Hispanic)
Elsewhere and other race
30 181
4056
2419
577
23.4 (22.524.3)
14.0 (12.115.9)
17.7 (15.519.9)
23.2 (18.727.7)
1
0.53 (0.460.62)
0.70 (0.590.83)
0.99 (0.771.27)
1
0.55 (0.50.7)
0.91 (0.81.1)
1.18 (0.81.6)
1
0.58 (0.40.8)
0.86 (0.61.1)
0.83 (0.51.3)
1
0.53 (0.40.8)
0.80 (0.61.1)
0.78 (0.41.4)
Family income
2 times poverty threshold
11.9 times poverty threshold
Below poverty threshold
16 993
9197
8328
22.6 (21.623.5)
21.7 (20.323.1)
26.1 (24.228.0)
1
0.95 (0.91.05)
1.21 (1.11.3)
1
0.80 (0.70.9)
0.81 (0.70.9)
1
0.81 (0.660.99)
0.78 (0.630.97)
1
0.84 (0.71.05)
0.81 (0.61.03)
7191
15 950
7.7 (6.78.7)
15.6 (14.816.4)
1
2.21 (1.922.55)
NA
NA
1
1.75 (1.42.1)
1
1.58 (1.32.0)
12 713
2159
2142
747
5412
1588
12.6 (11.713.5)
5.6 (3.97.3)
11.5 (9.613.5)
11.9 (8.715.2)
27.3 (25.529.1)
18.4 (15.721.0)
1
0.42 (0.300.57)
0.90 (0.741.10)
0.94 (0.681.29)
3.88 (3.54.3)
1.57 (1.311.89)
NA
NA
NA
NA
NA
NA
1
1.09 (0.62.1)
0.87 (0.71.1)
0.83 (0.51.3)
1.42 (1.21.7)
1.08 (0.91.3)
1
0.75 (0.22.3)
0.71 (0.50.99)
0.83 (0.51.3)
1.45 (1.21.8)
1.11 (0.91.4)
9710
3205
15.6 (14.516.6)
9.2 (7.810.5)
1
0.55 (0.460.66)
NA
NA
1
1.31 (1.001.7)
1
1.60 (1.22.2)
Blood transfusion
No
Yes, 1992present
Yes, 19721991
33 623
848
1123
24.0 (23.124.8)
10.0 (7.512.4)
12.0 (10.114.0)
1
0.35 (0.270.46)
0.43 (0.360.53)
NA
NA
NA
1
0.95 (0.61.5)
1.10 (0.71.6)
1
0.99 (0.61.7)
1.28 (0.82.0)
11 000
2485
302
17.8 (16.8-18.8)
13.7 (11.715.7)
14.7 (9.220.1)
1
0.73 (0.620.87)
0.79 (0.511.23)
NA
NA
NA
1
0.77 (0.60.9)
1.04 (0.61.7)
1
0.76 (0.60.9)
1.14 (0.62.1)
Age
612 y
1317 y
1829 y
3039 y
4049 y
5059 y
6069 y
70 y
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Hepatitis B Virus in the United States: Infection, Exposure and Immunity Rates
Original Research
Table 3Continued
Characteristic
Prevalence of
Positive Anti-HBs
and Negative
Anti-HBc
(95% CI), %
Unadjusted OR
(95% CI)
2134
6462
2087
1579
601
17.9 (15.620.2)
17.9 (16.719.2)
17.8 (15.819.8)
12.7 (10.914.4)
12.7 (9.915.4)
36 794
465
Participants
Tested, n
Aged >6 y*
Aged 2059 y
Aged 2049 y
1
1.0 (0.851.18)
0.99 (0.831.18)
0.66 (0.540.82)
0.67 (0.510.87)
NA
NA
NA
NA
NA
1
0.98 (0.81.2)
1.03 (0.81.3)
0.77 (0.61.0)
0.88 (0.61.2)
1
0.98 (0.81.2)
1.07 (0.81.4)
0.75 (0.51.03)
0.81 (0.61.2)
22.8 (22.023.6)
7.7 (5.210.2)
1
0.28 (0.200.40)
NA
NA
NA
NA
1
0.66 (0.41.3)
11 841
73
20.3 (19.221.3)
11.5 (3.319.6)
1
0.51 (0.221.15)
NA
NA
NA
NA
1
0.63 (0.22.1)
9105
2709
21.7 (20.522.9)
14.3 (12.416.3)
1
0.60 (0.510.71)
NA
NA
NA
NA
1
0.79 (0.60.99)
anti-HBc antibody against hepatitis B core antigen; anti-HBs antibody against hepatitis B surface antigen; NA not applicable; OR odds ratio.
* Adjusted for sex, race or ethnicity, age, family income, and birthplace.
Adjusted for sex, race or ethnicity, age, family income, birthplace, educational attainment, marital status, service in the U.S. armed forces, blood transfusion, lifetime street
drug use, and lifetime number of sexual partners.
Adjusted for all characteristics in the previous 2 footnotes in addition to hepatitis C virus, HIV, and herpes simplex virus 2 status.
Category includes ages 20 to 29 y for the adjusted ORs limited to persons aged 20 y.
Includes Mexican Americans and other Hispanic persons.
Only men aged 17 y are presented in the univariate analyses.
** Antibody to hepatitis C virus confirmed by recombinant immunoblot assay.
United States had a particularly high prevalence of exposure to HBV, especially if they were not white, black, or
Hispanic (31.3%). The prevalence of exposure to HBV
increased dramatically with age and was higher in persons with low family income and low educational attainment. Consistent with known methods of HBV transmission, persons who reported intravenous drug use or
numerous sexual partners had a particularly high prevalence of exposure to HBV. Persons with serologic evidence of exposure to other hematogenous or sexually
transmitted viruses (HIV, hepatitis C virus [HCV], or
herpes simplex virus 2) had a very high prevalence of
exposure to HBV. Blood transfusion, even before 1991,
was associated with only a slightly increased prevalence
of exposure to HBV.
Figures 1 and 2 show that up to a 50-fold change in
the prevalence of exposure to HBV was observed as age,
race, and ethnicity varied or as age and country of birth
varied. Although exposure to HBV is very uncommon
(1%) in persons aged 6 to 19 years, regardless of race or
ethnicity or country of birth, the rate is more than 9%
among black persons aged 50 years or older, more than
30% among persons of other racial or ethnic groups who
are aged 50 years or older, and more than 43% in persons
of other race or ethnicity born outside the United States
who are aged 50 years or older.
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Hepatitis B Virus in the United States: Infection, Exposure and Immunity Rates
Anti-HBcPositive Persons, %
50
40
30
20
10
0
619
2029
3039
4049
5059
6069
70
Age Group, y
Hispanic
Other
Black
White
DISCUSSION
The prevalence of chronic HBV infection in the
United States from 1999 to 2008 was 0.27% (CI, 0.20%
to 0.34%) among persons aged 6 years or older, corresponding to 704 000 persons. This estimate is slightly
lower than previous national estimates from 1976 to 1980
(0.33% [CI, 0.21% to 0.51%]) or 1988 to 1994 (0.42%
[CI, 0.32% to 0.44%]) (1). The prevalence of exposure to
HBV (past or chronic infection) from 1999 to 2008 was
4.6% (CI, 4.1% to 5.0]), corresponding to 11 993 999
persons. This estimate is also lower than previous national
estimates from 1976 to 1980 (5.5% [CI, 4.8 to 6.2]) or
1988 to 1994 (5.1% [CI, 4.4 to 5.8]).
Guidelines for universal childhood vaccination were
published in 1991, federal programs for routine vaccination of infants began in late 1992, and vaccination of adolescents who were not vaccinated as infants was included
326 1 March 2011 Annals of Internal Medicine Volume 154 Number 5
in the Vaccines for Children program in 1995. The Advisory Committee on Immunization Practices additionally
recommends routine screening of all pregnant women,
postexposure immunoprophylaxis of infants born to
HBsAg-positive women, and vaccination of adults at increased risk for infection (2, 18). The modest decline in
HBV infection and exposure that is reported herein may be
related to these immunization efforts. Even if universal
childhood vaccination had been achieved since 1992, more
dramatic reductions in infection and exposure rates would
not have been expected by the study period (1999 to 2008)
because children vaccinated since 1992 have not yet
reached adulthood when most exposure to HBV occurs in
the United States.
Most cases of HBV infection or exposure in the
United States occur among black persons or persons of
other race or ethnicity (primarily Asian) and persons born
outside the United States. Therefore, race, ethnicity, and
country of birth are the most important epidemiologic correlates of HBV infection in the United States.
Exposure to HBV in the United States is very low
among persons aged 18 years or younger (0.5%) and increases with age thereafter. This is true even among persons
of other race or ethnicity (mostly Asian), suggesting that
little exposure to HBV occurred in the United States in the
past 20 years as a result of vertical or perinatal transmission, even among Asian persons. Rather, most exposure to
HBV in the United States occurs in adulthood as a result
of sexual intercourse or intravenous drug use.
Figure 2. Prevalence of anti-HBc, by age and birthplace.
70
60
Anti-HBcPositive Persons, %
Original Research
50
40
30
20
10
0
619
2029
3039
4049
5059
6069
70
Age Group, y
Mexico
Elsewhere
(other)
Elsewhere
(white, black, Hispanic)
United
States
Hepatitis B Virus in the United States: Infection, Exposure and Immunity Rates
Original Research
Program.
Potential Conflicts of Interest: Disclosures can be viewed at www.acponline
.org/authors/icmje/ConflictOfInterestForms.do?msNumM10-1301.
1 March 2011 Annals of Internal Medicine Volume 154 Number 5 327
Original Research
Hepatitis B Virus in the United States: Infection, Exposure and Immunity Rates
Affairs Puget Sound Health Care System, Gastroenterology, S-111Gastro, 1660 South Columbian Way, Seattle, WA 98108; e-mail,
georgei@medicine.washington.edu.
Author contributions are available at www.annals.org.
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TO
Appendix Table. Hepatitis B Virus Infection and Exposure Prevalence From NHANES III (1988 to 1994) and NHANES 1999 to 2008
NHANES Period
19881994
19992008
Participants, n
21 260
37 259
HBsAg
(95% CI), %
Anti-HBc
(95% CI), %
HBsAg
(95% CI), %
Anti-HBc
(95% CI), %
0.38 (0.280.48)
0.27 (0.200.34)
5.3 (4.76.0)
4.6 (4.15.0)
0.38 (0.280.42)
0.26 (0.190.34)
5.5 (4.85.2)
4.4 (4.04.9)
anti-HBc antibody against hepatitis B core antigen; HBsAg hepatitis B surface antigen; NHANES National Health and Nutrition Examination Survey.
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