RISK FACTORS INTRAFAMILIAL TRANSMISSION OF PATIENTS

WITH HBsAg POSITIVE IN THE MATARAM CITY SOUTH EAST

OF WEST NUSA TENGGARA

THESIS SUMMARY

Main Interest in Field Epidemiology Training Program

Public Health Departement
Faculty of Medicine

Proposed by:
BAI KUSNADI
NIM : 09/293244/PKU/10777

To
Gadjah Mada University
Yogyakarta
2011

ii

ABSTRACT

Background: Hepatitis B is a disease with high prevalence, it may cause

problems in post-acute, chronic, cyrrhosis , primary hepatocellular
carcinoma, morbidity, and mortality. World Health Organization estimates
more than 2 billion people are infected by HBV. About 400 million people
worldwide suffer from chronic HBV infection, with 500,000 of them dying.
Prevalence among countries vary between 0.1% -20%. In Indonesia, the
prevalence of HBsAg ranged from 3-17%. In West Nusa Tenggara (NTB),
hepatitis B carrier rate ranged between 3.9%-20.3% (1982-1990) and
1.4% -12.5% (2002-2007). In the city of Mataram the prevalence of
HBsAg is around 10%. Transmission of hepatitis B occur contact family
(intrafamilial transmission), then conducted research to knowing the risk
factors intrafamilial transmission of patients with HBsAg (+). So it can be
done prevention HBsAg (+) in the family.
Methods: A case-control study of the risk factor of family members of
patiensts HBsAg (+). Risk factor are a history of unsafe intercourse sex
research with people with HBsAg (+), a history of sharing personal
equipment (cutlery/drink, razors, toothbrushes, towels) a history of
parents with HBsAg (+). Interviewed 124 people of cases and controls
(ratio 1:1).Analysid with Chi-square (X2), Odds Ratio, and multiple logistic
regression.
Results: Bivariate analysis showed a history of unsafe sex (OR=2.000,
95%CI= 0.641-6.651), use of utensils/drinking (OR=1.069, 95CI%=0.4892.340), razors (OR=2.230, 95%CI=0.516-11.215), towels (OR = 1.455,
95CI% = 0.486-4.519) the sharing and a history pf parents with HBsAg
(+)(OR=2.703, 95%CI=1.227-5.987) was rather a risk factor, and both
parents (father and mother) HBsAg(+) (OR=0.254, 95%CI=0.064-0.969)
are protective. Multivariate analysis showed unsafe sex (aOR=4.274,
95%CI=1.294-14.117) and a history of parents with mother suffering from
HBsAg (+) (OR = 7.743, 95% CI = 2.566-23.363) is a risk factor for
patients suffering from HBsAg (+) in the family and both parents (father
and mother) HBsAg (+)(OR=0.254, 95%CI=0.064-0.969) are protective.
Conclusion: Unsafe sex with HBsAg (+)(aOR=4.274, 95%CI=1.29414.117), history of parents with mother suffering from HBsAg (+) (OR =
7.743, 95% CI = 2.566-23.363) was a risk to suffer from HBsAg positive in
the family and both parents (father and mother) HBsAg(+) are protective.
While the contact use utensils /drinking, sharing the shaver, tools,
toothbrushes, towels was not a risk factor for suffering from HBsAg
positive in the family.
Keywords: Risk factors, Intrafamilial Transmission, Hepatitis B, HBsAg

iii

BACKGROUND
Hepatitis B is a disease with high prevalence, it may cause problems
in post-acute, chronic, cyrrhosis, primary hepatocellular carcinoma,1
morbidity, and mortality in the world.2 WHO estimates more than 2 billion
people are infected by HBV.3 About 400 million people worldwide suffer
from chronic HBV infection, with 500,000 of them dying. Prevalence
among countries vary between 0.1% -20%. In Indonesia, the prevalence of
HBsAg ranged from 3-17%.2 In West Nusa Tenggara (NTB), hepatitis B
carrier rate ranged between 3.9%-20.3% (1982-1990) and 1.4% -12.5%
(2002-2007).4 In the Mataram City the prevalence of HBsAg is around
10% (high endemic). 2
Based on report of patients visit at Polyclinic Hepatika West Nusa
Tenggara from 2004-2010, the amount patients of HBsAg (+) in 2004
were 719 persons, in 2005 were 1,264 persons, and in 2010 were 295
persons. One of the causes of decreasing cases was availability of
Hepatitis B in other health care facilities. Of the 295 persons. as many as
95 patients came from Mataram city. This number was greater than other
districts or cities in Lombok.5
Transmission of HBV are vertically and horizontally.4 Occurs
vertically at delivery of mother to infants. Horizontally, one of them occured
by intrafamilial transmission.6 About 30% family were positive of HBV,
more than a half because of family contact such as father, mother and
children.7 Couple with positive HBV, mother with infection of HBV, other
family member with infection of HBV, sharing of personal equipments
such as razorblade,

tooth brush, nail clippers, comb, shavers.

10

using of towels, living a few days with HVB carrier,

unsafe sex .

Sharing

11

Intrafamilial transmission with the patients of HBsAg (+) were

contribruted in transmission of Hepatitis B so this researchs goals was to
determine the risk factor of intrafamilial transmission with HBSAg (+) in
Mataram City, West Nusa Tenggara.

RESEARCH METHOD
This was an observational research with case control design, held in
Mataram City, West Nusa Tenggara, in March to May, 2011. The
population was family member of patients with HBsAg (+) which recorded
in Polyclinic of Laboratory Hepatika in 2009 and comes from Mataram city.
Cases and controls were selected by screening of HBsAg to all of
family member of patients with HBsAg (+) who met the inclusion criteria
(domiciled in Mataram, age 5-65 years, live with the patients minimum for
60 days, and ready to be the subjects of this study) and exclusion criteria
(drugs user, patients of HIV/AIDS, ever blood trasfussion 60 days before
screening so tattoo, acupuncture, piercing, Hepatitis B immunization,
infusion therapy, and hemodialysis).
Cases sampling technique was restricted sample.12

controls

sampling was simple random sampling.13 The total number of sample was
124 persons (cases were 62 persons and controls were 62 persons).
Tools of this study were structured quistionnaires which has already been
tried ) and tested the validity and reliabiltas and blood strip test of HBsAg
with immunochromatography (IC) method. Independent variables were
unsafe sex history with patients with HBsAg (+), personal equipments
contact (cutlery, drinking tools, shavers, tooth brush, towel), and history of
parents with HBsAg (+). Dependent variable was patients of HBsAg (+).
Data analysis using chi square, odds ratio, and multiple logistic regression.

RESULTS AND DISCUSSION

Results
1. Screening of HBsAg
The total number of patients of HBSAg (+) was 89 persons consisted
of 45 males and 44 females, and the number of family members were
screened was 370 persons (170 persons were male, 200 persons were
femaile). Screening results can be seen in Table 1.

Table 1. Number of patients HBsAg (+) and family member

who were screened in Mataram City
Number
of
patients
HBsAg(+)

Index case

Number of
family
member
were
screened

Number
of family
member

Number of
family
member
with
HBsAg(+)

Male

45

176

170

38

22.35

Female

44

207

200

37

18.50

Total

89

383

370

75

20.27

Based

on

Table 1

can

persons examined HBsAg,

75

be known
persons

that

from

the 370

(20.27%) were

HBsAg

(+), consisted of 38 persons (22.35%) were males and 37 persons

(18.50%) were females. Family members with HBsAg (+) can be seen
in Table 2.
Tabel 2. Screening result of family member with HBsAg (+)
in Mataram City

Sex

Number
of family
member
with
HBsAg(+)

HBsAg(+)
Fahter/
Mother

Husband/
Wife

Children

Brother/
Sister

Other
family
member

Male

38

5.26

15.79

20

52.63

21.05

5.26

Female

37

8.11

13.51

19

51.35

13.51

13.51

Total

75

6.67

11

14.67

39

52.00

13

17.33

9.33

Based on Table 2 can be known that children was the most patients
with HBsAg (+) (52.0%), brother/sister were 13 persons (17.33%),
husband/wife were 11 persons (14.67%), other family member were 7
persons (9.33%), and father/mother were 5 persons (6.67%).

2. Characteristic of Research Subjects

Results of characteristics of research subjects can be seen in Table 3
Table 3. Results of Characteristics of Research Subjects

Characteristics

Cases
n=62

Age
<16 year
>16 year
Sex
Male
Female
Education
Primary
Secondary and
Higher
Occupation
Employee
Unemployee
Marital status
Married
Unmarried

(%)

Controls
n=62

OR

95%CI

(%)

2
3.23
60 96.77

8
54

12.90
87.10

0.225 0.022-1.208

0.047*

34 48.39
28 51.61

33
29

53.23
46.77

1.067 0.495-2.296

0.857

9 14.52
53 85.48

9
53

14.52
85.48

1.000 0.323-3.092

1.000

6
9.68
56 90.32

13
49

20.97
79.03

0.403 0.117-1.254

0.081

45 72.58
17 27.42

38
24

61.29
38.71

1.671

0.181

0.734-3.833

p value< 0.05

Based on Table 3 can be seen that age was not a risk factor of
HBsAg (+) but statistically was significant. sex and marital status were risk
factors but statistically were not significant. Most of subjects aged > 16
years were 60 persons (96.77%), in cases group were 60 persons
(96.77%) and in control group were 54 persons (87.10%). Most of subjects
were females, in cases group were 33 persons (53.23%) and in control
group 34 persons (54.84%). Most of subjects were married, in cases group
were 45 persons (72.58%) and in control group were 38 persons
(61.29%).

3. Bivariat Analysis
Result of bivariat analysis can be seen in Table 4.
Table 4. Result of analysis risk factors of intrafamilial transmission
with HBsAg (+)
Cases
Variable
Unsafe sex history
(Married respondents,n=83)
Ever

n=62

Controls
n=62

14

31.11

18.42

31

68.89

31

81.58

Cutlery
Ever

24

38.71

25

40.32

Never

38

61.29

37

59.68

Shavers (male respondents,n=67)

Ever
8

23.53

12.12

76.47

29

87.88

Never

OR
95%CI

2.000
(0.641-6.651)

0.187

1.069
(0.489-2.340)

0.854

2.230
(0.516-11.215)

0.223

1.000
(0.012-79.764)

1.000

1.455
(0.486-4.519)

0.454

2.703
(1.227-5.987)

0.006*

Personal equipment contact

Never

26

Tooth brush
Ever

1.61

1.61

61

98.39

61

98.39

11

17.74

12.90

51

82.26

54

87.10

Yes

41

66.13

26

41.94

No

21

33.87

36

58.06

Father and mother

14.63

10

38.46

0.254
(0.064-0.969)

0.019*

Father

4.88

7.69

0.402

Mother

33

80.49

14

53.85

0.424
(0.028- 6.513)
Referent

Never
Towel
Ever
Never
Parents history with
HBsAg (+)
Parents

p value < 0.05, n=sample

Based on Table 4 can be seen that usafe sex history (married

respondents) OR=2.000. 95%CI=0.641-6.651. p=0.185. Cutlery OR=1.069
.95CI%=0.489-2.340. p=0.854. shavers (male respondents) OR=2.230.

95%CI=0.516-11.215. p=0.223.

towel OR=1.455. 95CI%=0.486-4.519.

p=0.454. Parents history with HBsAg (+) OR=2.703. 95%CI=1.227-5.98.

p=0.006 were risk factors of HBsAg transmission in family member. In this
study variable of father and mother was protective factor (OR=0.254.
95%=0.064-0.969.p=0.019) for HBsAg (+).

4. Stratification Analysis
In this study it was estimated that parents with HBsAg (+) was
confounding variable for unsafe sex variable and shavers. Result of
stratification analysis can be seen in Table 5.
Table 5. Result of stratification analysis for unsafe sex variable and shavers with
variable of parents with HBsAg (+)
Parents with HBsAg (+)

Yes

No

Yes

No

Unsafe sex
Ever
Never
Unsafe sex
Ever
Never
Shavers using contact
Ever
Never
Shavers using contact
Ever
Necer

Cases

Controls

aOR

21

11
10

7
24

3.771

2
18

1
13

1.444

6
8

3
16

4.000

cOR

OR
MH

2.000

4.274

95%CI

0.016
0.975-14.934

0.067-91.673
2.230

2.923

0.013
0.619-30.105

aOR= adjusted OR. cOR= Crude OR. OR MH=Mantel Haenszel

Based on Table 5 can be known that unsafe sex variable was a

confounding variable. According this. unsafe sex must be adjusted by
parents with HBsAg (+). This result also showed that there was an
interaction between shavers using and HBsAg (+). Subjects who did not
have parents history with HBsAg (+) have more risk suffer HBsAg (+) if
using shavers. Multiple logistic regression was used to determine the most
related risk factors.

5. Multivariat Analysis
After controlling the confounding variable and interaction testing
showed that Model 2 was the best fit model to determine risk factor of
HBsAg (+) transmission in family member and statistically significant. It
meant that HBsAg(+) transmission in family member occurred when a
married subject having unsafe sex with patients with HBsAg (+). the risk
was 4.274 times (aOR=4.274. 95%CI=1.294-14.117) and subjects who
had parents which mother with HBsAg(+) had risk 7.743 times (OR=7.743,
95%CI=1.294-14.117). Variable subjects who had parents with HBsAg(+)
was a protective variable (OR=0.254, 95%=0.064-0.969, p=0.019).
Model 2 can be used to predict the incidence of HBsAg (+) in family
member as much as 15.07% and the rest were other factors which not
determine in this study. Result of multivariat analysis can be seen in Table
6.
Table 6. Modelling of multivariate analysis risk factors of intrafamilial transmission
with HBsAg (+) in Mataram City
Variable

Model 1
OR
(CI 95%)

Model 2
OR
(CI 95%)

2.000
(0.641-6.651)

4.274
(1.294-14.117)

Model 3
OR
(CI 95%)

Model 4
OR
(CI 95%)

Model 5
OR
(CI 95%)

2.230
(0.51610.257)

2.923
(0.747-11.428)

4.000
(0.787-20.316)

1.938
(0.734-5.602)

3.055
(0.757-12.322)

2.769
(0.918-8.319)

Unsafe sex
Ever
Never
Shavers using contact
Ever
Never
Parents with HBsAg (+)
5.061
(1.84713.865)

Yes
No

7.743
(2.566-23.363)

Shavers using contact*Parents

history with HBsAg (+)
Deviance

0.361
(0.018-7.147)

103.26

97.22

91.04

88.4

87.98

9.79

15.07

1.95

4.79

5.52

83

67

67

83
2

OR= Odds Ratio. CI=Confident Interval. R =Koefisien determinasi. n=jumlah sampel

67

DISCUSSION
This study began by screening all family members of HBsAg (+)
patients which were recorded in Laboratorium Hepatika Mataram in 2009.
This was held to determine whether the subjects were as cases (HBsAg
(+)) or control (HBsAg (-)).
In this study can be known that 20.27% family members were HBsAg
(+).This result was in carrier rate of Hepatitis B in Lombok Island from
1982-1990 (3.9%-20.3%). It was higher than carrier rate in 2002-2007
(1.4%-12.5%)4 This result showed that Mataram City is a high endemic
area. The cases of HBsAg (+) were father. mother. husband. wife.
children.

brother/sister

and

other

family

transmission of HBsAg (+) in family member.

1.3

personal equiepments contact and unsafe sex.

members

showed

that

it was occurred because

14.15.16

this can concluded

that the transmission were horizontally and vertically.

Result of characteristic of subject analysis showed that sex variable

and marital status were the risk factors of HBsAg (+) transmission in family
member. Most of subjects were Dalam > 16 years or adult. Other research
stated that the highest prevalence of HBsAg (+) were > 31 years
especially age group 41-50 years. 16-49 years. 50-60% were adult. umur
21-30 years.17.18.19.20 Cases of HBsAg most in teenager and adult. it was
assumed because of parental exposure. sexual activity. increasing in
occupational showed that transmission was horizontally.16.20.21
This result showed that male was more at risk than female. It is
assumed that male was more active outside than female. Female had
more contact with other family member who had HBV.15.17
Most of subjects were married and having risk of HBsAg (+)
transmission in family member. Previous study stated that married
subjects had risk to transmitted HBsAg (+) in family member.22 such as
sexual activity. having sex without using condom.
11.12.15.16.21.24.25

married couples.

11.23

especially for

This study showed that subjects who having unsafe sex or not using
condom had risk HBsAg (+). Having sex without using condom was more
risk than using condom.16 Especially having sex with infected person.3.27
married.11 especially female.27 Previous study stated that relationship
between having sex and the risk of HBV transmission.24.28
Based on bivariat analysis showed that unsafe sex (not using
condom) was risk factor of HBsAg (+) even statistically not significant.
HBV transmission by unsafe sex or not using condom because contact
with mucous membrane genital tract as a result of sexual contact
containing

infectious

nature

(Redeker

et

al..1975).

It

was

also

possible because the liquid vaginal secretions contain HBsAg (+) (Scott.
1980).3.29 Prevention for this by doing safe sex or using condom.30
Result showed that personal equipment contact such as cutlery.
shavers. and towels was the transmission of HBsAg (+). Previous
research showed that horizontal transmission can be occurred by using
razorblade and towel with HBV patients6 Using of toothbrush together with
friends related to prevalence of HBV.10 Razorblade was related to HBV
transmission.15 Other personal equipment such as glass/cup which
sharing using as risk factor of HBV transmission in family member.14
Heyman stated that using of shavers together in household especially
children related to HBV transmission in family member.3 Widjaya stated
that using of personal equipment together in orphanage such as
razorblade. scutlery and others was one of the important thing of
horizontal transmission.9
Horizontal transmission in one area is different with other areas and
was influenced by some factors such as hygiene and sanitation and other
habits that can transmitted HBV infection.21
It is showed that personal equipment contact was related to age of
subjects. Most of subjects were > 16 years or adult. At this age. behavior
of sharing personal equipments was less because good personal hygiene
in rural community in Mataram City. Poor personal hygiene can be a risk of

10

HBV transmission.14 Health education especially personal hygiene need to

be done to prevent horizontal transmission.14
Transmission of HBV via personal equipments can be occurred
because contaminated with blood. saliva or other liquids by HBV virus.31.32
Transmission via mouth because infectious agent in wounded mouth.33
Lesmana stated that most of Hepatitis B patients (85.7%) had infectious
saliva that can be transmission source.20 Transmission of infection via
mucous membrane occurred when there were lesions at the mucous
membrane of mouth.21
HBV transmission through towel was a horizontal transmission. It
was occurred because contamination of Hepatitis B virus on abnormality
dermatologic. exposure in blood and other body liquids. Transmission
trhough shavers occurred because lesions. scratch or skin inflammation.21
Most of subjects were having parents with HBsAg (+) than other
family members. Mother had risk 7.48 times in HBV transmission.16 Mother
and father and children related to HBsAg (+) transmission.
role in HBsAg (+) transmission.

22

Father had

34

Result of bivariat analysis showed that parents with HBsAg (+) was a
dominan risk factor for transmission in family member than husband/wife.
children. brother/sister and other family member. It is understandable
because parents were naturally closer to other family member so contact
each other can be happened.
Previous study stated that father and mother with HBsAg (+) related
to HBsAg (+) transmission.22 Father had role in HBsAg (+) transmission.34
Mother had risk 7.48 times in HBV transmission.16
Patients who had fathers with HBsAg (+) showed that there was no
risk to suffer HBsAg (+). After comparing fathers group with mothers group
showed that no relationship in HBV transmission.15 However Vahid et al.30.
stated that father with HBsAg (+) related to HBsAg (+) transmission.

11

Multivariat analysis showed that HBsAg transmission in family member

was vertically and horizontally. Vertically transmission occurred if subject
had parents with HBsAg (+).Horizontally transmission occurred when
married subject had unsafe sex with patients with HBsAg (+) after adjusted
by parents with HBsAg (+) history. It is understandable that parents were
married person who in their sexual intercourse activity resulting contact
with their spouses.
Salkic et al.22. stated that family who had parents with HBsAg (+)
may increase risk of HBsAg (+) transmission. Ahn et al.24 stated that
having sex with couple who had HBV was a risk factor of HBV
transmission. Vahid et al.

30

. stated that horizontal transmission in family

member because contact with infected family member through sexual

activity. In some countries such as Brazil. Bangladesh and Thailand
showed the same thing.
Result showed that transmission of HBsAg was vertically and
horizontally.

This

was

stated that in Lombok vertical

confirmed by previous
transmission occurred

research which
about

25.4%

people with HBV. while the rest was horizontal transmission.

transmission.21

CONCLUSSION AND SUGGESTION

Conclussion
Based on the result of this study can be concluded that subject who
did unsafe sex with HBsAg had risk 4.094 times to get HBsAg (+) than
safe sex. Subjects who had parents with HBsAg (+) had protective risk
0.254 times to get HBsAg (+) than HBsAg (+) subjects who had other
family member with HBsAg (+). Subjects who had mother with HBsAg (+)
had risk 7.743 times to get HBsAg (+) than subjects who had other family
member with HBsAg (+).
Sharing using of cutlery, shavers, toothbrush, and towel were not
risk factors of HBsAg (+).

12

Suggestions
Hepatitis B is local specific disease in West Nusa Tenggara.
Prevention program by health office need to be done by coordinating to
private sectors if there are employees with HBsAg positive patients so
family members do vaccinations, provide or make hepatitis B vaccinations
for infants, children and vulnerable family members for free, and
collaboration/coordination with the clinician in private hospitals and
polyclinics to provide health services (vaccinations, treatment and
counseling) hepatitis B for infants, children and vulnerable family
members.
Risk factor of intrafamilial transmission such as unsafe sex (not using
condom) and history of parents with HBsAg (+) can be information and
input of Hepatitis B prevention program to protect transmission in family
members. Counseling about Hepatitis B. intrafamilial transmission. not
sharing personal equipments. vaccination and treatment to the family
members. community. schools/college and private sector need to be done
Family member
doctor to get

health

with

HBsAg

care of

(+)

are

Hepatitis B.

expected to consult

also

need

to

to conduct anti

HBs vaccination to health facilities (hospitals. polyclinics) for prevention of

transmission of hepatitis B as well as safe sex (using condoms) with their
partners. using

disposible shavers.

using

cutlery/drinking

tools

and

personal towels
Further research needs to determine risk factors for intrafamilial
transmission by using a more sensitive tool (ELISA) and the cohort study
to determine

the causal

relationship

of HBsAg (+)to other members.

and

effect of family members

13

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