We read with interest the AASLD Practice Guidelines on chronic hepatitis B recently published in HEPATOLOGY.1 Table 2 of the guidelines reports groups at high risk for hepatitis B virus (HBV) infection who should be screened. Individuals born in Italy are included on the assumption that Italy is a country at intermediate prevalence (2%-7%) of hepatitis B surface antigen (HBsAg) carriers in the general population. Moreover, (at page 510) in the section “Natural history of chronic HBV infection” it is stated that in Mediterranean countries (including Italy) “transmission of HBV usually occurs from person to person during childhood”.
We would like to clarify the current status of HBV infection in Italy:
The incidence rate of acute B hepatitis decreased from 12 of 100,000 inhabitants in 1985 to 1.3 of 100,000 inhabitants in 2005 (Fig. 1).
The HBsAg prevalence in the general population is largely below 2%, because the prevalence of HBsAg was 0.6% in 7405 subjects 3-19 years of age during the second half of the 1980s,2 1.6% in a national sample of 4993 recruits aged 18-26 years in 1990,3 1.4 % in 9929 pregnant women from 6 Italian regions in 2001,4 and largely below 1% among all age groups in population-based surveys performed in the second half of the 1990s in different Italian areas.5
At present, acute hepatitis B in Italy is mostly a sexually transmitted disease, as more than half of the cases report 2 or more sexual partners in the period of 6 months before onset of the disease.6 Child-to-child transmission is almost absent, because hepatitis B vaccine is compulsory by law in Italy for 3-month-old infants since 1991, reaching a very high coverage.
As a consequence of the declined trend of HBV endemicity in the last decades, a survey performed in 79 Italian hospitals in 2001 has shown that among 10,000 subjects affected by chronic liver diseases, only 10% tested HBsAg-positive.7
On the basis of the reported findings, Italy is a country with a low endemic level of HBV infection. Accordingly, it does not seem advisable that individuals born in Italy should be screened for HBV infection, unless they belong to specific high-risk groups.