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. 2015 Feb 23;10(2):e0117703.
doi: 10.1371/journal.pone.0117703. eCollection 2015.

Ongoing transmission of hepatitis B virus in rural parts of the Netherlands, 2009-2013

Loes C Soetens  1 , Birgit H B van Benthem  1 , Anouk Urbanus  2 , Jeroen Cremer  3 , Kimberly S M Benschop  3 , Ariene Rietveld  4 , Erik I van Dijk  5 , Susan J M Hahné  1
Affiliations

Ongoing transmission of hepatitis B virus in rural parts of the Netherlands, 2009-2013

Loes C Soetens et al. PLoS One. .

Abstract

Background: Reported acute hepatitis B incidence in the Netherlands reached its nadir in 2013. However, regional signals about increased number of hepatitis B cases raised the question how hepatitis B incidence was distributed over the country. In this study, regional differences in hepatitis B epidemiology were investigated using epidemiological and molecular data.

Methods: Acute hepatitis B virus (HBV) infections, reported between 2009-2013, were included. If serum was available, a fragment of S and C gene of the HBV was amplified and sequenced. Regional differences in incidence were studied by geographical mapping of cases and cluster analysis. Regional differences in transmission were studied by constructing regional maximum parsimony trees based on the C gene to assess genetic clustering of cases.

Results: Between 2009 and 2013, 881 cases were notified, of which respectively 431 and 400 cases had serum available for S and C gene sequencing. Geographical mapping of notified cases revealed that incidences in rural border areas of the Netherlands were highest. Cluster analysis identified two significant clusters (p<0.000) in the South-western and North-eastern regions. Genetic cluster analysis showed that rural border areas had relatively large clusters of cases with indistinguishable sequences, while other regions showed more single introductions.

Conclusion: This study showed that regional differences in HBV epidemiology were present in the Netherlands. Rural border regions showed higher incidences and more ongoing transmission, mainly among MSM, than the more urban inland areas. Therefore, preventive measures should be enhanced in these regions.

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Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

Figures

Fig 1
Fig 1. Regions for sexual health care in the Netherlands.
Purple areas indicate the more rural regions, green areas indicate the more urban regions.
Fig 2
Fig 2. Incidence of acute HBV in the Netherlands, by year and overall incidence 2009–2013.
The dark grey circles indicate regions with significant geographic clusters.
Fig 3
Fig 3. Maximum parsimony trees of HBV cases (2009–2013) in the Netherlands based on C-gene sequences (N = 400), by region (Fig. 3A) and most probable mode of transmission (Fig. 3B).
(3A: purple = rural areas, green = urban areas; Genotypes: gA = genotype A, gB = genotype B, gC = genotype C, gD = genotype D, gE = genotype E, gF = genotype F, gG = genotype G; patients with indistinguishable sequences are displayed together in one node and the size of the node is relative to the number of indistinguishable sequences)
See this image and copyright information in PMC

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