Hepatitis B is a public health problem of worldwide importance. Familial clustering of HBV infection has been reported infrequently. Intrafamilial transmission of HBV plays a substantial role in maintaining the endemicity of the virus in the region. We report a family of 8 members, among which 5 members across 3 generations were HBsAg positive.
Keywords: Hepatitis B e antigen (HBeAg), hepatitis B surface antigen (HB s Ag), hepatitis B virus (HBV)
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Pai A, Selvi S, Muthukumaran K, Ramkumar G, Balamurali R, Solomon RT, Ganesh P. Familial clustering of hepatitis B infection in South India: A case report. Ann Trop Med Public Health 2015;8:304-6
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Pai A, Selvi S, Muthukumaran K, Ramkumar G, Balamurali R, Solomon RT, Ganesh P. Familial clustering of hepatitis B infection in South India: A case report. Ann Trop Med Public Health [serial online] 2015 [cited 2020 Aug 6];8:304-6. Available from: https://www.atmph.org/text.asp?2015/8/6/304/162651
Familial clustering of hepatitis B virus (HBV) infection has been reported infrequently. We report a case of a family of eight members among whom five were across three generations; all the members were hepatitis B surface antigen (HB s Ag) positive. Four subjects were found to be hepatitis B e antigen (HBeAg) positive. All the subjects were symptomatic at the time of presentation. The liver function test (LFT) of the four subjects among them revealed that they have elevated liver enzyme levels and higher HBV DNA levels. All the four subjects except one were started on antiviral drugs and the follow-up LFT returned normal results.
A 22/F (index case) was referred after being detected HB s Ag positive incidentally during the master health checkup and was referred for further evaluation. She was asymptomatic at the time of presentation with no history of jaundice or other risk factors. On evaluation, her liver enzyme levels were found to be four times elevated, with the HBV DNA level being 110,000,000 IU/mL and qHB s Ag level 71,116 IU/mL. She was found to be HBeAg positive and immunoglobulin M (IgM) anti-hemoglobin C (HBc) negative. She was started on tenofovir and her follow-up LFT returned normal results.
The mother (aged 38 years) of the index case was found to be HB s Ag positive during the family screening. She was asymptomatic at the time of presentation with a history of jaundice 5 years before and took some native medications. On evaluation, her liver enzyme levels were found to be within normal limits, with the HBV DNA level being 361 IU/mL, qHB s Ag level 6792 IU/mL, and HBeAg being nonreactive.
The brother (aged 18 years) of the index case was found to be HB s Ag positive during family screening. He was asymptomatic at the time of presentation with no history of jaundice or other risk factors. On evaluation, his liver enzymes levels were found to be three times elevated, with the HBV DNA level being 110,000,000 IU/mL and qHB s Ag levels 27,400 IU/mL. He was found to be HBeAg positive and IgM anti HBc negative. Liver biopsy was done that demonstrated chronic active hepatitis. He was started on tenofovir and his LFT normalized during the follow-up.
The younger sister (aged 12 years) of the index case was found to be HB s Ag positive during family screening. She was asymptomatic at the time of presentation with no history of jaundice or other risk factors. On evaluation, her liver enzymes levels were found to be twice elevated, with the HBV DNA level being 42,700 IU/mL, and qHB s Ag level 4,433 IU/mL. She was tested HBeAg positive and IgM anti-HBc negative. She was started on tenofovir and her LFT normalized during the follow-up.
The son (aged 2.5 years) of the index case was found to be HB s Ag positive during family screening. He was asymptomatic at the time of presentation with no history of jaundice or other risk factors. He was born by normal vaginal delivery and was breast-fed till the age of 6 months. He was completely immunized for his age. On evaluation, his liver enzyme levels were found to be twice elevated, with the HBV DNA level being 110,000,000 IU/mL, and qHB s Ag level 1,000,000 IU/mL. He was found to be HBeAg positive and IgM anti-HBc negative. He was started on lamivudine and his LFT normalized during the follow-up.
A younger brother and the husband of the index case were found to be HB s Ag negative. We recommended vaccination for the unaffected family members.
Hepatitis B is a public health problem of worldwide importance. It has been estimated that more than two billion people have serological markers of hepatitis B infection, including 350 million chronic carriers.  However, the prevalence of HBV infection has a wide geographical variation depending on the rate of chronic carrier and the predominant route of transmission.  Multivariate analysis showed that HB s Ag transmission occurred among the family members vertically and horizontally. Vertical transmission occurred if the subject’s parents were HB s Ag positive. Horizontal transmission occurred if the married subjects had unsafe sex with patients with HB s Ag positivity. Pronounced familial clustering of HBV infection have been reported by several studies, suggesting that intrafamilial childhood horizontal transmission is an important means by which HBV endemicity rates are maintained in this region. , It is well-established that the risk of developing chronic HBV infection varies with age. Infants born to HB s Ag and HBeAg-positive mothers are at a high risk of acquiring infection and become chronic carriers. Postnatally, HBV infection at early childhood may account for 30% of chronic infections. Quite often, several members of the same household are infected with HBV infection but while in the studies it was shown that spouses were frequently anti-HBs positive, the siblings or parents were often HB s Ag positive. Therefore, it is suggested that HBV in such cases may be transmitted through intrafamilial contact and the higher rate of carriers among siblings is associated to the early infancy infection. In addition, horizontal transmission through close family contact is also important in early life. It has been suggested that household members can transmit HBV possibly through direct or indirect personal oral, mucosal, or percutaneous contacts. Seroconversion in 1-year-old children strongly suggests the importance of intrafamilial transmission.
In an Indian survey, Chakravarty et al. reported cases of 140 (19.4%) HB s Ag positive individuals from 722 households of HBV-infected patients.  An Iranian study conducted by Alizadeh on intrafamilial prevalence of hepatitis B virologic markers among the members of an HB s Ag-positive family based in Nahavand, 12 (11%) members were found to be HB s Ag-positive.  In the Indian study, the rates of prevalence of HB s Ag were 28.81% among mothers and 8.75% among spouses. In Nahavand, Iran, the highest rates of prevalence of HB s Ag were among the brothers (25%) and fathers (12.5%). In another survey, the prevalence rates of HB s Ag among family members of patients with hepatitis B were 20% among brothers, 18.2% among sisters, and 13.6% among spouses. In other countries, the high prevalence rate of HB s Ag infection among spouses may be due to sexual transmission during menstrual period. The high prevalence rate of HB s Ag among brothers suggests that probably prenatal and household contacts in the earliest years of life increases the risk of acquiring hepatitis B.
The precise mechanism of the intrafamilial spread of HBV infection is not determined. It is transmitted through direct and indirect individual contacts and also some unknown oral, mucosal, and dermal contacts between individuals from different households.  In an investigation in Ghana, the reported rate of prevalence of hepatitis B was 20.9%; common use of towels, chewing gums, and toothpastes and making excoriations on the skin were among the behaviors that were significantly associated with the prevalence of hepatitis B among the family members of the patients.  In a survey in Greece, the risk of acquiring hepatitis B was 15.8% in family members group and 10.85% in the control group and the higher prevalence rate of hepatitis B was reported in rural areas and low-educated groups.  The high rate of risky behaviors as well as higher rate of illiteracy in these families reported by different studies emphasizes on the importance of promoting education and hygienic precautions in the society. The time sequence of transmission among family members in cross-sectional studies is vague and so, there is no warrant that the carrier labeled as the “index case” is actually the first infected member of the family. Therefore, establishment of an effective surveillance system for detection and a proper follow-up of the HBV-positive cases is mandatory. 
Compared to the general population, the substantially large share of the HBV infection rate among family members of virus carriers shows that intrafamilial transmission of HBV infection is a very common spread path for the HBV, which can be simply prevented through education and adherence to hygienic precautions. Undoubtedly, intrafamilial transmission of HBV plays a substantial role in maintaining the endemicity of the virus in the region. So screening all contacts of HB s Ag-positive individuals and administration of active immunization to them are recommended. Establishment of an effective surveillance system for the detection and a proper follow-up the HBV-positive cases are mandatory.  Furthermore, HB s Ag should be introduced as a routine laboratory test for all pregnant women, irrespective of the presence of risk factors.
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