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Original article

Vol. 147 No. 0708 (2017)

Reduction of acute hepatitis B through vaccination of adolescents with no decrease in chronic hepatitis B due to immigration in a low endemicity country

  • Jean-Luc Richard
  • Christian Schaetti
  • Sabine Basler
  • Virginie Masserey Spicher
Cite this as:
Swiss Med Wkly. 2017;147:w14409


With a hepatitis B prevalence of 0.3%, Switzerland is a country with low endemicity. Unlike most other countries, Switzerland’s recommendation for vaccination against hepatitis B has since 1998 focused on adolescents aged 11 to 15 years rather than on infants, in addition to risk groups since 1982. This paper describes the evolution of the incidence of acute hepatitis B virus (HBV) infection and newly reported chronic cases in Switzerland, as well as their epidemiological features, in order to discuss the implications for the control of hepatitis B through vaccination. Data from mandatory notifications by physicians and laboratories between 1988 and 2015 were analysed for acute and chronic HBV infection. Crude and stratified incidence and notification rates (IR, NR), and incidence and notification rate ratios (NRR, IRR) by year were calculated by means of a Poisson regression. Acute HBV incidence peaked in 1992 at 7.5 cases per 100 000 population and subsequently declined by 11% annually (IRR 0.89, p <0.001) to the lowest rate of 0.4/100 000 in 2015. The decrease in incidence accelerated after the introduction of vaccination for adolescents (IRR 0.93, p <0.001 vs 0.91, p <0.001), and was more pronounced in the targeted age groups (IRR 0.90, p <0.001 vs 0.84, p <0.001 for age 15–19 years and IRR 0.92, p <0.001 vs 0.83, p <0.001 for age 20–24). The use of injectable drugs as an assumed source of exposure decreased from 58.1% to 1.9% of all exposures between 1988–1991 and 2012–2015, while sexual contact with an infected person increased from 10.3% to 67.9%. The NR of chronic cases increased until 1995, then stabilised at around 15/100 000. A growing majority of the chronic cases originated abroad (58.4% in 1988–1991 and 82.2% in 2012–2015), and the NR was significantly higher for foreigners than for Swiss nationals (NRR 7.92, p <0.001), especially when compared with the IRR of 1.55 (p <0.001) for acute cases. The introduction of universal vaccination of adolescents combined with vaccination of risk groups and other nonvaccine-related measures has brought acute HBV infection under control in Switzerland. However, the rate of new notifications of chronic HBV infection has remained stable, largely as a result of the immigration of people chronically infected prior to arrival. The burden of disease is thus likely to increase, requiring the strengthening of secondary prevention of chronic HBV infection, in addition to renewed efforts to vaccinate people and their families originating from countries with high endemicity, and persons who frequently change sexual partners.


  1. World Health Organization. Hepatitis B. Fact Sheet N°204 (updated July 2015); 2015 [accessed 2015 Jun 7]. Available from:
  2. World Health Organization Regional office for Europe. Hepatitis: Data and statistics [accessed 2016 Dec 1]. Available from:
  3. Fretz R, Negro F, Bruggmann P, Lavanchy D, De Gottardi A, Pache I, et al. Hepatitis B and C in Switzerland - healthcare provider initiated testing for chronic hepatitis B and C infection. Swiss Med Wkly. 2013;143:w13793. doi:.
  4. Office fédéral de la statistique. Migration et intégration. Neuchâtel; 2016 [accessed 2016 May 23]. Available from:
  5. Morlok M, Oswald A, Meier H, Efionayi-Mäder D, Ruedin D, Bader D et al. Les sans-papiers en Suisse en 2015: Rapport final à l'attention du Secrétariat d'Etat aux migrations. Bâle: HB,S,S. Vokswirtschaftliche Beratung AG; 2015.
  6. World Health Organization. Expanded programme on immunization. Global Advisory Group--Part I. Wkly Epidemiol Rec. 1992;67(3):11–5.
  7. Beckers K, Schaad UB, Heininger U. Compliance with antenatal screening for hepatitis B surface antigen carrier status in pregnant women and consecutive procedures in exposed newborns. Eur J Pediatr. 2004;163(11):654–7. doi:.
  8. Frischknecht F, Sell W, Trummer I, Brühwiler H. Serological testing for infectious diseases in pregnant women: are the guidelines followed? Swiss Med Wkly. 2011;140:w13138. doi:.
  9. Aebi-Popp K, Kahlert C, Rauch A, Mosimann B, Baud D, Low N, et al. Heterogeneity in testing practices for infections during pregnancy: national survey across Switzerland. Swiss Med Wkly. 2016;146:w14325. doi:.
  10. Kammerlander R, Zimmermann H, Vaudaux B. Stratégies de vaccination contre l’hépatite B. Soz Präventivmed. 1998;43(Suppl. 1):S115–7. doi:.
  11. Office fédéral de la santé publique, Commission suisse pour les vaccinations, Groupe suisse d'experts pour l'hépatite virale. Recommandations pour la prévention contre l'hépatite B. Directives et recommandations. Berne; 1997. [accessed 2017 Jan 15] Available from:
  12. European Centre for Disease Prevention and Control. Vaccine Schedule. Recommended immunisation for hepatitis B; 2015 [accessed 2015 Jan 21]. Available from:
  13. Office fédéral de la santé publique. Tableau présentant les résultats complets de la couverture vaccinale 1999-2015. 2016 (updated 2016 Mar 3) [accessed 2017 Jan 15]. Available from:
  14. Mahoney FJ, Lawrence M, Scott C, Le Q, Lambert S, Farley TA. Continuing risk for hepatitis B virus transmission among Southeast Asian infants in Louisiana. Pediatrics. 1995;96(6):1113–6.
  15. European Centre for Disease Prevention and Control. Hepatitis B and C surveillance in Europe 2012. Stockholm; 2014.
  16. Zanetti AR, Van Damme P, Shouval D. The global impact of vaccination against hepatitis B: a historical overview. Vaccine. 2008;26(49):6266–73. doi:.
  17. Romano’ L, Paladini S, Van Damme P, Zanetti AR. The worldwide impact of vaccination on the control and protection of viral hepatitis B. Dig Liver Dis. 2011;43(Suppl 1):S2–7. doi:.
  18. Office fédéral de la santé publique. Vaccination des adolescents contre l'hépatite B en Suisse: impact important sur l'incidence de la maladie dans le groupe d'âge concerné. Bulletin BAG/OFSP. 2004:49:923–31.
  19. Stroffolini T, Mele A, Tosti ME, Gallo G, Balocchini E, Ragni P, et al. The impact of the hepatitis B mass immunisation campaign on the incidence and risk factors of acute hepatitis B in Italy. J Hepatol. 2000;33(6):980–5. doi:.
  20. Iwarson S, Jilg W, Stroffolini T. Substantial decline of notified hepatitis B in major parts of Europe after 1985. Scand J Infect Dis. 1994;26(1):19–22. doi:.
  21. Scheitlin T, Joller-Jemelka HI, Grob PJ. [Hepatitis and HIV infection in users of illegal drugs]. Schweiz Med Wochenschr. 1992;122(39):1432–45. Article in German.
  22. Steffen T, Blättler R, Gutzwiller F, Zwahlen M. HIV and hepatitis virus infections among injecting drug users in a medically controlled heroin prescription programme. Eur J Public Health. 2001;11(4):425–30. doi:.
  23. Veldhuijzen IK, Smits LJ, van de Laar MJ. The importance of imported infections in maintaining hepatitis B in The Netherlands. Epidemiol Infect. 2005;133(1):113–9. doi:.
  24. Hahné S, van Houdt R, Koedijk F, van Ballegooijen M, Cremer J, Bruisten S, et al. Selective hepatitis B virus vaccination has reduced hepatitis B virus transmission in the Netherlands. PLoS One. 2013;8(7):e67866. doi:.
  25. Salleras L, Dominguez A, Bruguera M, Cardeñosa N, Batalla J, Carmona G, et al. Dramatic decline in acute hepatitis B infection and disease incidence rates among adolescents and young people after 12 years of a mass hepatitis B vaccination programme of pre-adolescents in the schools of Catalonia (Spain). Vaccine. 2005;23(17-18):2181–4. doi:.
  26. Patrick DM, Bigham M, Ng H, White R, Tweed A, Skowronski DM. Elimination of acute hepatitis B among adolescents after one decade of an immunization program targeting Grade 6 students. Pediatr Infect Dis J. 2003;22(10):874–7. doi:.
  27. Porgo TV, Gilca V, De Serres G, Tremblay M, Skowronski D. Dramatic reduction in hepatitis B through school-based immunization without a routine infant program in a low endemicity region. BMC Infect Dis. 2015;15(1):227. doi:.
  28. Erol S, Ozkurt Z, Ertek M, Tasyaran MA. Intrafamilial transmission of hepatitis B virus in the eastern Anatolian region of Turkey. Eur J Gastroenterol Hepatol. 2003;15(4):345–9. doi:.
  29. Yao GB. Importance of perinatal versus horizontal transmission of hepatitis B virus infection in China. Gut. 1996;38(Suppl 2):S39–42. doi:.
  30. Toukan AU, Sharaiha ZK, Abu-el-Rub OA, Hmoud MK, Dahbour SS, Abu-Hassan H, et al. The epidemiology of hepatitis B virus among family members in the Middle East. Am J Epidemiol. 1990;132(2):220–32.
  31. Salkic NN, Zildzic M, Muminhodzic K, Pavlovic-Calic N, Zerem E, Ahmetagic S, et al. Intrafamilial transmission of hepatitis B in Tuzla region of Bosnia and Herzegovina. Eur J Gastroenterol Hepatol. 2007;19(2):113–8. doi:.
  32. Chakravarty R, Chowdhury A, Chaudhuri S, Santra A, Neogi M, Rajendran K, et al. Hepatitis B infection in Eastern Indian families: need for screening of adult siblings and mothers of adult index cases. Public Health. 2005;119(7):647–54. doi:.
  33. Beasley RP, Hwang LY. Postnatal infectivity of hepatitis B surface antigen-carrier mothers. J Infect Dis. 1983;147(2):185–90. doi:.
  34. Craxì A, Tinè F, Vinci M, Almasio P, Cammà C, Garofalo G, et al. Transmission of hepatitis B and hepatitis delta viruses in the households of chronic hepatitis B surface antigen carriers: a regression analysis of indicators of risk. Am J Epidemiol. 1991;134(6):641–50.
  35. Whelan J, Sonder G, Heuker J, van den Hoek A. Incidence of acute hepatitis B in different ethnic groups in a low-endemic country, 1992-2009: increased risk in second generation migrants. Vaccine. 2012;30(38):5651–5. doi:.
  36. Cai W, Poethko-Müller C, Hamouda O, Radun D. Hepatitis B virus infections among children and adolescents in Germany: migration background as a risk factor in a low seroprevalence population. Pediatr Infect Dis J. 2011;30(1):19–24. doi:.
  37. Hahné S, Ramsay M, Balogun K, Edmunds WJ, Mortimer P. Incidence and routes of transmission of hepatitis B virus in England and Wales, 1995-2000: implications for immunisation policy. J Clin Virol. 2004;29(4):211–20. doi:.
  38. Rimšelienė G, Nilsen Ø, Kløvstad H, Blystad H, Aavitsland P. Epidemiology of acute and chronic hepatitis B virus infection in Norway, 1992-2009. BMC Infect Dis. 2011;11(1):153. doi:.
  39. Chu JJ, Wörmann T, Popp J, Pätzelt G, Akmatov MK, Krämer A, et al. Changing epidemiology of hepatitis B and migration – a comparison of six Northern and North-Western European countries. Eur J Public Health. 2013;23(4):642–7. doi:.
  40. Hahné SJ, Veldhuijzen IK, Wiessing L, Lim TA, Salminen M, Laar Mv. Infection with hepatitis B and C virus in Europe: a systematic review of prevalence and cost-effectiveness of screening. BMC Infect Dis. 2013;13:181. doi:.
  41. Zuckerman J, van Hattum J, Cafferkey M, Gjørup I, Hoel T, Rummukainen ML, et al. Should hepatitis B vaccination be introduced into childhood immunisation programmes in northern Europe? Lancet Infect Dis. 2007;7(6):410–9. doi:.
  42. MacLachlan JH, Allard N, Towell V, Cowie BC. The burden of chronic hepatitis B virus infection in Australia, 2011. Aust N Z J Public Health. 2013;37(5):416–22. doi:.
  43. Meffre C, Le Strat Y, Delarocque-Astagneau E, Dubois F, Antona D, Lemasson JM, et al. Prevalence of hepatitis B and hepatitis C virus infections in France in 2004: social factors are important predictors after adjusting for known risk factors. J Med Virol. 2010;82(4):546–55. doi:.
  44. Nguyen VT, Razali K, Amin J, Law MG, Dore GJ. Estimates and projections of hepatitis B-related hepatocellular carcinoma in Australia among people born in Asia-Pacific countries. J Gastroenterol Hepatol. 2008;23(6):922–9. doi:.
  45. Idris BI, Brosa M, Richardus JH, Esteban R, Schalm SW, Buti M. Estimating the future health burden of chronic hepatitis B and the impact of therapy in Spain. Eur J Gastroenterol Hepatol. 2008;20(4):320–6. doi:.
  46. Ott JJ, Stevens GA, Groeger J, Wiersma ST. Global epidemiology of hepatitis B virus infection: new estimates of age-specific HBsAg seroprevalence and endemicity. Vaccine. 2012;30(12):2212–9. doi:.
  47. Office fédéral de la santé publique, Commission fédérale pour les vaccinations. Plan de vaccination suisse 2016. Directives et recommandations. Berne; 2016 [accessed 2017 Jan 15]. Available from:
  48. Bart PA, Jacquier P, Zuber PL, Lavanchy D, Frei PC. Seroprevalence of HBV (anti-HBc, HBsAg and anti-HBs) and HDV infections among 9006 women at delivery. Liver. 1996;16(2):110–6. doi:.
  49. Russmann S, Dowlatshahi EA, Printzen G, Habicht S, Reichen J, Zimmermann H. Prevalence and associated factors of viral hepatitis and transferrin elevations in 5036 patients admitted to the emergency room of a Swiss university hospital: cross-sectional study. BMC Gastroenterol. 2007;7(1):5. doi:.
  50. Heininger U, Vaudaux B, Nidecker M, Pfister RE, Posfay-Barbe KM, Bachofner M, et al. Evaluation of the compliance with recommended procedures in newborns exposed to HBsAg-positive mothers: a multicenter collaborative study. Pediatr Infect Dis J. 2010;29(3):248–50. doi:.