HEPATITIS B: CANADA'S OVERLOOKED STD

Heterosexual transmission of hepatitis B viru s: A public health perspective

JEAN ROBERT, MD, MSc, CSPQ, FRCPC

J ROBERT. Heterosexual transmission of hepatitis B virus: A public he'J].th perspective. Can J Infect Dis 199 1;2(Suppl A):23A-26A. Given the objectives of the medical aspects of publ.ic health, the 'heterosexual transmission· approach may be restrictive and too conventional as it considers transmission only through two individuals of different sexes and only by peno-vaginal penetration, to the exclusion of all other sexual activities. Bloodborpe disease transmission in intravenous drug users must be considered as well as anal transmission of this disease. Three sine qua non conditions must be met before public health interventions ar e initiated: the disease agent must be known or pres umed; a causal relatiopship must exist between the agent and disease; and the proposed intervention must be both pertinent and effective. The fi rst two conditions have been established in the case of hepatitis B virps infection. The latter condition, however. has proven difficult to fulfill. It must be determinecj whether the approach of immu nizing all infants, drug addicts and prostitutes is cost effective and accepted by a moral society. Consideration must be given to all possible modes of transmission in order to develop an effective public health s trategy lo combat hepatitis B.

Key Words: Hepatitis B: Heterosexual transmission: Public health

La transmission heterosexuelle du virus de l'hepatite B: Une perspective de sante publique RESUME: Compte tenu des objectifs medicaux de sante publique, s'en tenir a la transmission heterosexuelle du virus de I' hepatite B pourrait etre une a pproehe trop restrictive et trop conventionnelle vu qu'elle n'envisage que les rapports genitaux survenant enlre deux per­ sonnes de sexes opposes, a !'exclusion de toutes au tres activites sexuelles. Or il faut tenir compte de la transmbsion de la maladie par voie inlraveineuse chez !es toxicomanes. et de la dissemina tion par voie anale. II faut remplir trois conditions indispensables avant de lancer toute initiative de sante publique: !'agent pathologique doit etre connu ou presume: une relation causale doil exister entre !'agent et Ia m a ladie: !'intervention proposee doit etre a la fois pertinente et efficace. Les deux premieres conditions sont etablies dans le cas de !'infection par le virus de I'hepatite B. La demiere s·est toutefois averee difficile. II faut determinn si une campagne de vaccination visant tous les enfants, Jes toxicomanes et !es prostitue(e)s serait rentable et acceptee pq-r une societe morale. On doit tenir eompte de tous lcs modes possibles de transmission pour pouvoir etablir une strategie de sante pu blique efficace pour combaltre I'hepatite B.

Chief Public H ealth Department, H6pital St-Luc. Clinical /\ssociate Pn1/essur. Faculty ,?{Medicine. Universitt; de Montreal. Montreal. Quebec Correspondence and reprints: Dr J Robert. H6pital St-Luc. I 00 I. rue St DenL'i. Montreal. Quebec E-I2X .3H9

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~ E IMPORTANC~ OF HEPA1:ITIS 8 VI.RU~ INF~Cf!ON. arise in individuals. It must also be borne in mind Tits repercussions and global distribution ac­ that the scope of public health care includes psy­ cording to three endemic levels are universally chosocial reactions. recogniZed. No one questions the merits of vac­ cines or vaccination programs as a primary (ie , A NONSELECTIVE VIRUS before exposu re) or post primary (ie, after expo­ In 'high and average endemic' areas, universal sure) preventive measure (1). And yet. we have vaccination of all children is accepted in principle failed to control and eventually eradicate this in­ as the best primary measure of preventive care (5). fec tion. In children. infection occurs early (vertical and Given the objectives of the medical aspects of horizontal transmission) and morbidity and mor­ public health, the 'heterosexu al transmission' ap­ tality rates are high. Fortunately, children are proach may be restrictive and too conventional. It easier to reach through the expanded program on is restrictive in the sense that it only considers primary immunization. Since the virus in children transmission between two individuals of different is not trans mitted through direct sexual contact. sexes du ring , and conventional children may be viewed as innocent victims. In because it only considers transmission through this context, u niversal vaccination of children is peno-vaginal penetration, to the exclusion of other introduced before or soon after contact with the sexual acts. infective agent, without taking into account the group's ultimate , sexual PRINCIPLES OF PUBLIC HEALTH behaviour or drug use habits . ln matters of public Public health is defined as the art of protecting health, as in other areas, decisions are easier to and promoting health. ie, the physical, mental. make when issues such as sexuality or drug ad­ environmental and social well-being of popula­ diction - referred to euphemistically as behaviour tions without excluding the health of the indivi­ and lifestyle - are not involved. dual (2). This art calls upon several sciences. With respect to hepatitis B virus infection, hep­ notably microbiology, physiology, pharmacology, atitis B virus is the sole biological aggressor im­ psychology, sociology, economics and epidemiol­ plicated in a serious pathological process. ogy. The art of public health is practised by pre­ Fortunately, a vaccine is available which can be venting one or several diseases under the administered at a pertinent time. namely, before fo llowing three sine qua non conditions: the dis­ or shortly after contact with the source of the ease agent must be known or presumed: a causal infection. Hence, the three sine qua non condi­ relationship must exist between the agent and tions are satisfied. disease: and the proposed intervention must be In 'low endemic' areas such as Canada. the both pertinent and effective. If one of these condi­ situation is more complex a nd problematic. Viral tions is not met, intervention is often in vain and transmission is more common among adolescen ts sometimes detrimental and thus would not fall and young adults primarily through sexual and \vithin the realm of public health. blood contacts than among infants or at birth. In A more precise definition of public health re­ this case, a second aggressor exists: the ·curse' or quires an understanding of the notion of comple­ 'punishment' fo r acts deemed reprehensible by a mentarity. which is not always obvious, between society which imposes a certain morality. Thus, curative and preventive medicine. In curative one is confronted with two epidemic situations medicine. the patient. who initiates the proceed­ with two aggressors: the biological infectious virus ings with the physician, is considered ill unW and the circumstantial event of possible transmis­ there is evidence to the contrary. Intervention to sion. Without the virus , there can be no infection. restore health is then undertaken on an individual Circumstan tial even ts alone such as . level. Abdominal pain leading to the diagnosis of drug addiction a nd male or female (hetero-, bi- or appendicitis and subsequent surgical treatment is homo-) sexual practices, cannot cau se hepatitis B. such an example. In preventive medicine, the phy­ sician initiates the proceedings. Patients are con­ TRANSMISSION IN MALE OR FEMALE sidered healthy unless evidence suggests HETEROSEXUALS otherwise and interven tion is undertaken at the There has been a reported decrease in the rela­ group level. One example is routine vaccination tive number of hepatitis B virus infec tions in the against measles at 12 months. In Quebec. articles adult male homosexual population (not deter­ 16.1 to 16. 7 (inclusive) of the Public Health Act mined in female homosexuals) countered by a (3,4) recognize the principle of the common good disturbing relative increase among male and fe­ and agree to provide compensation for the exceed­ male heterosexuals. It must be recogniZed that ingly ra re but serious complications that may this finding is not due to the success of a ny

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routine vaccination policy. Indeed. the male same time: to halt the spread of hepatitis B virus homosexual community has taught an important and to ease the sense of evil and punishment. lesson in public health. It has taken upon itself, Only one must be chosen, however, and the other as in the case of the AJDS epidemic ca used by the taken into consideration. HIV virus, to protect or change certain circum­ is multilingual (7) as indi­ stantial events. This has produced indirectly a cated by the Star of Venus (8) whose Hve points beneficial effect on hepatitis B \.irus. thanks to the intersect and touch autologous and heterologous intervention of persons not accountable to public anatomical sites. No one can say whether coi tus health departments. (9) . sodomy. , cunnilingus, , mas­ In the early 1980s, the committee responsible turbation, tribadism or kissing are of themselves fo r fo rmulating a selective program to provide the homosexual, heterosexual or bisexual modes of hepatitis B virus vaccine free of charge chose the transmission. Sexologists Kinsey (10). Hite (1 1), following four target groups: infants born to in­ (12) and ma ny others. have fected mothers; patients undergoing long term widely demonstrated the multivalent nature or blood treatment (hemophiliacs. thalassemia suf­ human beings and have also shown that our ferers, hemodialysis patients); household or fam­ closed and definitive classifi cation of sexual orien­ ily contacts of carriers; and health care personnel tation is simply theoretical and sometimes not in (6). These were chosen from a list of about 10 keeping with reality. target groups ranging from infants born to in­ More consideration should be given to the many fected mothers to the general population, includ­ female heterosexual prostitutes who live with ing. among others. the incarcerated, drug addicts, women longing to be mothers and to the number male homosexuals, prostitutes and migrants. of their male customers who fa ntasize about anal For newborn babies and patients on blood ther­ penetration and pay double not to use a . apy the reasoning was simple: obvious biological Consideration should also be given to the num ber justification, noble social value. and anticipated of male and female escort agencies and massage low n umber of people affected (and, therefore, parlours that cater to business women. It should relatively low cost). Despite their numbers. health be recognized that 90% of the men who visit male care personnel ranked high in terms of medical­ prostitutes are married and, hence. are living so­ social and professional standing. although from a cially and offic ially as heterosexuals. Further­ biological viewpoint they were at a disadvantage. more, some people find prostitution to be the most Household members (ie, those residing in the profitable way to pay for drugs. which in tum same dwelling) or family contacts of carriers were might be considered necessary for selling one's defined as 'individuals (spouses and children) who body. have intimate contact with a carrier within the Feeling uncomfortable about such fo rceful im­ family'. Such a definition sparked a lively debate ages is indicative of an ignorance and inability to as to what constitutes a family. For example, does come to terms intelligently with human sexuality this include the common-law spouse. the biologi­ within the context of STDs. including hepatitis B. cal children of the husband and wife. more than Over the past decades, control of this disease has two spouses. and spouses of the same sex? This regrettably failed. despite the availability of peni­ matter was left to be resolved by public health cillin and other antibiotics. new microbiological officers who, as heads of public health depart­ screening techniques. a nd antihepatitis B virus ments. would have to use their own discretion and vaccination programs. draw fu nds fro m their own budgets. The health of the budget has sometimes taken THE SOLUTION precedence over that of the target population. The The only solution for the control and eventual other groups were not included in the policy due eradication of hepatitis B. even in 'low endemic' to the view that they are already a financial bur­ areas, is the universal vaccination of children. The den on society and are present in large numbers. adult subpopulations affected by hepatitis B virus Consequently. 80 to 85% of hepatitis B virus and certain vertical and horizontal modes of hep­ vaccine doses have been administered to health atitis B \.in1s transmission are known. The asso­ care workers. despite an infection rate just slightly ciated risks of hepatitis B virus infection can be above that of the general population. assessed to some extent. The potential for trans­ mission through such vehicles as saliva, sperm. THE DILEMMA menstrual and vaginal secretions, urine, fecal For the person in charge of public health. the matter and tears, however. is poorly understood ambiguity is enormous initially and the tempta­ (13). The biological vaccine product offers a solu­ tion overwhelming to pursue two priorities at the tion. without waiting for the advent of adoles-

CAN J INFECT DIS V OL 2 SUPPL A AUGUST 1991 25A ROBERT USE O ~y ·DO NOT con

cence. by ba nking on fu ture contact with the tutes and all sexual beings directly? The inclusion circulating virus to serve as a booster in ·average of the antiwhooping cough component of the diph­ and high endemic' areas or in situations of high theria-whooping cough-tetanus vaccine in 1946 professional exposure (personal communication). was primarily due to its low cost. The same holds Fear of being accused of promoting sexuality or true for the antimumps component in the com­ drug addiction has driven the health care sector bined measles-germa n measles-mumps vaccine to practise 'postvention·. ie. intervening after in­ in 1976. fection. instead of prevention. This attitude only The rule that states that antihepatitis B vi rus serves to ease consciences rather than benefiting vaccination be given within 14 days after sexual the health of patients. Sex and drugs are not contact with an infectiou s source may not be waiting for promotion. Young people are already useful as it was established by simple analogy confronted with them from the mean age of 12 with immu noglobulins against hepatitis A vi ms. years (±4) . Furthermore, this rule would not benefit the pa­ tient who visits the doctor on day 15 or 16. AT WHAT COST? For hvo years now, pharmaceutical manufac­ CONCLUSIONS turers have said that they can produce a pediatric A clearer vision of this health problem on the vaccine for under $1 a dose (14) on the condition , part of p ublic health authorities and society in however, that they receive a firm worldwide order general might have led to the timely im­ of 200 million doses annually. But international plementation of a selective, u nbiased prima ry public health agencies are waiting for a price pre-exposure vaccination program for the youth announcement before they make any firm orders. of tomorrow who would be at risk. By default or Wha t sort of financial compromise is society pre­ elimination, we must now seriously consider a pared to make in order to contribute to the world­ u n iversal vaccination program against hepatitis wide eradication of a virus, without B in all children. The indirect effect of such a procrastinating. to protect travellers and mission­ program will also benefit and protect those who a ries indirectly a nd protect drug addicts, prosti- escape vaccination.

REFERENCES Garanciere. 1984. l. Andre F-E. Prevention of transmission of hepatitis 8. Robert J. Comportements ct gestes {1 risque. In: B infection by sexual route. In: Piot P. Andre F- E. Morisset R. Pechere J -C, ds. Reconn aitre. eds. Hepatitis B: A Sexually Transmitted Disease Comprendre. Traiter les MTS. Montreal et Paris: in Heterosexuals. Amsterdam: Elsevier Science Edisem et Maloine. 1990:467. Publishers , 1990:89. 9. Germain B. Langis P. La sexu alite : Regards 2. Robert J. VIH et sante publique. In: Olivier C. actuels. Montreal: Etudes Vivantes. 1990:33 l. Thomas R. eds . Le SIDA, Un Nouveau Defi Medical. 10. Kinsey AC. et al. Concepts of normality a n d Montreal: L'Association des medecins de langue a bnormality in sexual behavior. In: Hoch PH . fran<;aise du Canada. 1990:321. Zubin J, eds. Psychosexua l Development in 3. Gourvemement du Quebec. Loi sur la protection Health and Disease. New York: Grune and de la sante publique. 1985: LRQ c. P-35. art Stratton, 1949. 16.1-16.7. 11. Hite S. Le Rapport Hite sur !es Hommes. Paris: 4. Gouverncment du Quebec. Reglement Robert Laffont. 1981. d'application de la Loi de la protection de la sante 12. Masters artd Johnson. Les Perspectives Sexuelles. publique. 1987: art 233-58. Paris : Ed Medis. 1980. 5. Kane M-A. Transmission of the hepatitis B virus in 13. Judson F. Control of sexual transmission of areas of low endemicity. In: Piot P. Andre F-E, eds. hepatitis B virus infections. In: Piot P. Andre F-E. Hepatitis B: A Sexually Transmitted Disease in eds . Hepatitis B: A Sexually Transmitted Disease Heterosexuals. Amsterdam: Elsevier Science in Heterosexu als. Amsterdam: Elsevier SciC'ncT Publishers. 1990:9. Publishers. 1990:101. 6. Gouvernement du Quebec. Minist.ere des AITaires 14. Vaccine (1990. 8-S): Proceedings of the sociales. 1983 Directive 1983-06. Vaccination International Conference on Prospects for cont.re l'hepaute B. Eradication of Hepatitis B Virus. Geneve. 1989. 7. Dal1an P. Moloch. Traite de Sexologie. Paris: Guildford: Butterworths. 1989.

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