Hepatitis B infection is a major global health problem. Vertical transmission is the commonest route of spreading hepatitis B virus (HBV) in many endemic areas. In order to control such transmission in Hong Kong, neonatal immunization programme was implemented for more than two decades. A declining prevalence of HBV infection was expected. However, the prevalence remained unabated at around 10% in recent studies. We suspect that one of the explanations of this persistent high prevalence is deficient knowledge on infection with the HBV and its prevention. Our paper gives an overview of the knowledge on HBV infection among Chinese population in both high and low endemic areas and discusses the potential factors that influenced the knowledge on as well as the implication of the sources of information for HBV infection, which was not addressed in previous studies.
Hepatitis B infection is a worldwide problem with over 350 million carriers [
There are few reported studies on the knowledge of HBV infection among pregnant women, which can be taken as proxy for the fertile females among the general population. To address this issue, we have conducted a survey to examine the knowledge of HBV infection in a nonselected cohort of Chinese pregnant women attending our antenatal clinic in 2008 [
Summary of hepatitis B knowledge among Chinese population in low and high endemic areas.
First author and year in which study was conducted | Chan et al. [ |
Chung et al. [ |
Leung et al. [ |
Coronado et al. [ |
Cotler et al. [ |
Taylor et al. [ |
Hislop et al. [ |
Thompson et al. [ |
Thompson et al. [ |
Ma et al. [ |
---|---|---|---|---|---|---|---|---|---|---|
Study population ( |
Pregnant women |
General public ( |
General public ( |
General public ( |
Patients attended routine care |
General public ( |
General public |
Women ( |
Women ( |
General public |
Study location | Hong Kong | Hong Kong | Hong Kong | Seattle, USA | Illinois, |
Washington, USA | Vancouver, Canada | Vancouver, |
Washington, USA | New York, USA |
There is a blood screening test for hepatitis B infection (yes) | 93 | 96 | — | — | — | — | — | — | — | 55 |
There is a hepatitis B vaccine available for nonimmune adult (yes) | 75 | 79 | — | — | — | — | — | — | — | 53 |
HBV can be spread by someone who looks health (yes) | — | — | — | 80 | 50 | 79 | 80 | 68 | 48 | — |
| ||||||||||
Mode of transmission | ||||||||||
Through food or drink (no) | 24 | 53 | 27 | — | 31 | — | — | — | — | — |
Through blood or blood products (yes) | 76 | 82 | 65 | — | 90 | — | — | — | — | — |
During sexual intercourse (yes) | 53 | 59 | 44 | 56 | 60 | 54 | 65 | 56 | 48 | 40 |
Sharing use of needles (yes) | 69 | 83 | — | — | — | — | — | — | — | 52 |
During childbirth (yes) | 88 | 58 | 67 | 70 | 91 | 70 | 76 | — | — | 40 |
Shaking hands with infected person (no) | 50 | 92 | — | — | — | — | — | 71 | 58 | 85 |
Sharing razor or toothbrush | — | — | 41 | — | — | 55 | 68 | 86 | 68 | 52 |
Tattooing or body piercing | — | — | 37 | — | — | — | — | — | — | — |
Sharing eating utensils (yes) | — | — | — | — | 57** | 84** | 89** | — | — | 61 |
Eating food prepared by an infected person (no) | — | — | — | — | — | 23 | 24 | 41 | 21 | 67 |
Eating food that has been prechewed by an infected person (yes) | — | — | — | — | — | — | — | 82 | 69 | — |
| ||||||||||
Prevention of transmission | ||||||||||
Hepatitis B screening and vaccination (yes) | 87 | 92 | — | — | 95 | — | — | — | — | 62 |
Regular exercise and get enough rest (no) | 14 | 41 | — | — | — | — | — | — | — | 57/74 |
Balanced diet and vitamin C (no) | 14 | 98 | — | — | — | — | — | — | — | 76 |
| ||||||||||
Sequelae of infection | ||||||||||
Lifelong infection (yes) | — | — | — | 38 | 75 | 37 | 45 | 39 | 27 | — |
Cirrhosis (yes) | 86 | 90 | — | — | 98 | 75 | 83 | — | — | — |
Liver cancer (yes) | 83 | 87 | — | 71 | 92 | 73 | 81 | 61 | 46 | 72 |
* Year of paper was published.
**Original answer by authors was “no”.
Each item listed with the correct answer inside parenthesis. Figures were rounded to whole number. Data were presented as percent of correct answer for each item.
Vertical transmission of HBV from an infected mother to her infant is a major source of infection in many endemic areas [
Nevertheless, despite the fact that the HBV vaccine and the immunization prgramme have been introduced since the 1980s, the knowledge on perinatal transmission of HBV was quite variable among different Chinese populations, ranging from 40% to 91%. Knowledge was most deficient amongst the Chinese immigrants in New York city, where only 40% of the surveyed subjects could give a correct response [
In addition to perinatal transmission, HBV can spread through sexual intercourse and contact with infected blood products through transfusion, sharing of needles and unsafe injecting equipments. Transmission through sexual contact is documented as a major route of spread of HBV in countries with low and intermediate endemicity [
However, another important aspect of deficient knowledge in Asian and Chinese communities worldwide is the risk of horizontal transmission through means others than sexual intercourse, because of the unique culture associated with the Chinese and their family settings, especially the sharing of food and eating utensils. Earlier studies have shown the presence of HBsAg in several body fluids such as saliva, semen, and urine [
On the other hand, in line with other researchers, we have also found erroneous knowledge amongst our subjects. In our study, only 24% of the subjects recognized that HBV is not transmitted by the oral-fecal route, which was consistent with the findings of other studies in the same area [
Only a few studies had examined the knowledge on prevention of HBV transmission, and the majority of the respondents knew that HBV transmission could be prevented by hepatitis B screening and vaccination (62–95%). In Hong Kong, vaccination programmes are provided to all nonimmune adults who requested vaccination by institutions such as universities, and nongovernment organizations such as the Family Planning Association, and by general practitioners [
Among the public, less is known about the risk and importance of horizontal transmission; although health education pamphlets, posters, and television advertisements have explained about the risk of HBV in needle-sharing, acupuncture and tattooing, it is not certain to what extent do the general and obstetric population realizes the importance of such information. In Hong Kong, safe injection practice is performed in the clinical settings without the reuse of syringes and needles in both public and private hospitals, and our pregnant women are at minimal risk of HBV infection via routine antenatal blood taking or drug injection. However, acupuncture and beauty treatments were risk factors in the spread of HBV infection [
At the same time, there remains a substantial portion of our subjects with erroneous knowledge on the prevention of HBV transmission, as only 14% of pregnant respondents knew that neither a balanced diet and vitamin C consumption, nor regular exercise, nor getting enough rest can prevent HBV infection. However, in another recent study amongst the general public, up to 98% of the respondents knew that balanced diet and vitamin C could not prevent HBV infection [
In some low endemicity countries such as the United States and Canada, immigration from highly endemic areas such as Southeast Asia has been the major contributor to the horizontal transmission from the carriers to other susceptible individuals, leading to an increasing prevalence of chronic HBV infection [
In Hong Kong, the Viral Hepatitis Preventive Service has been launched by the Department of Health in Hong Kong in July 1998, conducting epidemiological surveillance and distributing information through various channels to the general public. There are also other local sources or channels available for the dissemination of information regarding HBV infection in Hong Kong, such as healthcare professionals, mass media, the Department of Health website [
We found that mass media is the most important source of hepatitis B knowledge among our pregnant women, with the two leading sources of knowledge being television programmes (63.0%) and newspapers (38.8%) (Figure
The distribution of the source of information on HBV knowledge.
As we have noted that incorrect or misleading messages have been provided to our subjects, the effects of the various channels of dissemination of the information on HBV infection were assessed by multivariate logistic analysis and the adjusted odds ratios of the source of information for incorrect response on individual item were presented in Figure
The adjusted odds ratios and 95% CI of the source of information for incorrect responses to items.
Numerous studies on HBV infection, its sequelae, and the various means of prevention have been published in the past three decades. Yet even the latest studies have found areas of deficient or even erroneous knowledge on HBV infection, and we are especially disappointed to learn from the findings in our pregnant women that there is much room for improvement in the provision of appropriate and correct information on HBV transmission and prevention to the public. We suspect that deficient knowledge and misconceptions, especially regarding the various means of horizontal transmission, have probably contributed to the persistently high prevalence of HBV infection in our obstetric population. Social stigma can result from poor knowledge on HBV infection, as is the case in Mainland China. In China, HBV carriers face social discrimination affecting both their life and work as many employers and universities refuse to accept those who were tested positive from the preemployment and preenrolment medical checkup, although according to Ministry of Health of the People’s Republic of China, the China Government has decided to legislate against the hepatitis B discrimination recently [