ArticlesEstimations of worldwide prevalence of chronic hepatitis B virus infection: a systematic review of data published between 1965 and 2013
Introduction
Chronic hepatitis B virus (HBV) infection continues to be a major public health issue worldwide1, 2, 3, 4 despite the availability of an effective vaccine and potent antiviral treatments. The risk of developing chronic HBV infection decreases with age at infection, from about 90% when infected perinatally up to 6 months of age to 20–60% between the ages of 6 months and 5 years.1, 5 25% of people who acquire HBV as children will develop primary liver cancer or cirrhosis as adults.6 Recent Global Burden of Disease estimates indicate a high morbidity and mortality attributable to chronic HBV, despite decreases over the past decades.7, 8
In sub-Saharan Africa and east Asia, transmission predominantly occurs in infants and children by perinatal and horizontal routes (ie, resulting from close contact which is not parenteral, perinatal, or sexual in nature) whereas in more industrialised countries, rates of new infection and acute disease are highest among young adults and transmission predominantly occurs via injection drug use and high-risk sexual behaviours.9, 10, 11, 12, 13
In 2014, the 67th World Health Assembly of the WHO reaffirmed the resolution on viral hepatitis prevention and control highlighting the need to monitor viral hepatitis prevention, diagnosis and treatment progress.14 Accurate, national-level epidemiological information is imperative to inform prevention and control priorities, to assess the impact of implemented strategies and for updating burden of disease estimates. However, there are no up-to-date global systematic reviews reporting country-level chronic HBV prevalence. Previous systematic reviews on HBV prevalence were limited in scope (eg, they focused on specific regions or populations).15, 16, 17, 18, 19, 20
We report national-level prevalence estimates of chronic HBV derived by a systematic review of peer-reviewed literature reporting HBV prevalence (hepatitis B surface antigen [HBsAg]) in the general population for all countries for which sero-epidemiologic data were available. We also estimate the number of people living with chronic HBV infection on a national, regional, and global level and address changes over time.
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Search strategy and study selection
We undertook and report our systematic review in line with the criteria outlined in the PRISMA guidelines.21 We did a systematic search on articles published between Jan 1, 1965, and Oct 23, 2013, in the databases Medline, Embase, CAB Abstracts (Global health), Popline, and Web of Science. We developed a search strategy and adapted it for each database using a combination of Medical Subject Headings (MeSH) and free text including terms related to HBV and to prevalence (appendix). We
Results
After removal of duplicates and initial screening, we reviewed 4310 papers in full, of which 1800 eligible reports on the prevalence of HBsAg covering 161 countries were included in the systematic review (figure 1). Included studies on HBsAg entailed 109 415 627 individuals. The highest numbers of reports were available for China (n=167), India (n=129), Brazil (n=108), and Nigeria (n=85).
On a global level, HBsAg prevalence was 3·61% (95% CI 3·61–3·61). HBsAg seroprevalence and the number of
Discussion
This global systematic review showed that in 2010, about 248 million individuals in the general population, worldwide were chronically infected with HBV. We noted a wide variation in the estimates of HBsAg prevalence between countries, which might be partly explained by varying risk factors and transmission routes across countries. Prevalence estimates at the country level indicate a high burden of infection in sub-Saharan Africa and some countries in the Western Pacific region in particular.
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