Hepatitis B infection more than doubled in three Appalachian states from 2006-2013, with significant increases among those aged 30-39, injection drug users, and non-Hispanic whites, according to a study published Jan. 28 in MMWR.

“A hepatitis B epidemic is emerging in Kentucky, Tennessee, and West Virginia,” according to Dr. Aaron Harris of the division of viral hepatitis at the Centers for Disease Control and Prevention and his coauthors.

A total of 3,305 cases of acute HBV infection in the three states were reported to the National Notifiable Diseases Surveillance System (NNDSS) between 2009 and 2013. The proportion of those with HBV who reported injection drug use was significantly higher during the period from 2010-2013 than during the 2005-2009 time frame (75% vs. 53%, P less than .001).

Characteristics that significantly increased the likelihood of an individual having HBV infection included being 30-39 years, being non-Hispanic white, and being an injection drug user (all P less than .001). Sex was not a significant differentiator, and full demographic and drug use data were not available for all reported cases (MMWR Morb Mortal Wkly Rep. 2016:65;47-50).

The rise in HBV infections was statistically significant in non-urban counties, but not in urban counties (P less than .001 for trend).

This large regional increase in acute HBV infection is in contrast to stable HBV infection rates in the U.S., with an overall rate of 1 case in 100,000 in 2013. Though the vaccination is effective at preventing HBV infection, two-thirds of Americans aged 19-49 years are not fully vaccinated.

Hepatitis B vaccination has been part of the childhood immunization series since 1991, and has been recommended for children aged 18 and younger since 1999, so adults aged 33 years and older at the end of the study period would not have received HBV immunization routinely.

“The concurrent increase in reports of acute HBV and HCV infections, as well as an increase in injection drug use reported among this population is concerning,” wrote Dr. Harris and his coauthors, who added that hospital admissions for prescription opioid abuse increased by 17.1% and for heroin use by 7.4% in the three states during the study period.

The authors noted several study limitations, many of which may have resulted in under-reporting of the true incidence of HBV. The study data come from a passive surveillance system, and the case definition only includes those whose disease is symptomatic. Additionally, individuals who are high risk and underserved by the health care system may be missed.

Kentucky, West Virginia, and Tennessee are using a variety of strategies to target at-risk populations, according to the report, including partnering with jails and prisons to increase vaccination rates among incarcerated individuals, reaching out to those who run rehabilitation and harm reduction services, and mandating reporting of HBV infection in pregnant women and young children.

“Evidence-based prevention strategies, including increasing hepatitis B vaccination coverage, testing and linkage to care, and implementing education campaigns that target persons who inject drugs are urgently needed,” Dr. Harris and his coauthors wrote.

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