title: Ongoing transmission of hepatitis B virus in rural parts of the Netherlands, 2009-2013.
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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Epidemiology and Surveillance Unit, Centre of Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, The Netherlands.
authors.forename: Loes C
authors.initials: LC
authors.lastname: Soetens
authors.affiliation: Epidemiology and Surveillance Unit, Centre of Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, The Netherlands.
authors.forename: Birgit H B
authors.initials: BH
authors.lastname: van Benthem
authors.affiliation: National Coordination Centre for Communicable Disease Control, Centre of Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, The Netherlands.
authors.forename: Anouk
authors.initials: A
authors.lastname: Urbanus
authors.affiliation: Infectious Diseases Research, Diagnostics and Screening, Centre of Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, The Netherlands.
authors.forename: Jeroen
authors.initials: J
authors.lastname: Cremer
authors.affiliation: Infectious Diseases Research, Diagnostics and Screening, Centre of Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, The Netherlands.
authors.forename: Kimberly S M
authors.initials: KS
authors.lastname: Benschop
authors.affiliation: Department of Infectious Disease Control, Municipal Health Service Hart voor Brabant, 's-Hertogenbosch, The Netherlands.
authors.forename: Ariene
authors.initials: A
authors.lastname: Rietveld
authors.affiliation: Department of Infectious Disease Control, Municipal Health Service Drenthe, Assen, The Netherlands.
authors.forename: Erik I
authors.initials: EI
authors.lastname: van Dijk
authors.affiliation: Epidemiology and Surveillance Unit, Centre of Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, The Netherlands.
authors.forename: Susan J M
authors.initials: SJ
authors.lastname: Hahné
mesh_terms: D000328:Adult; D005260:Female; D006509:Hepatitis B / Q000453:epidemiology* / Q000635:transmission*; D006515:Hepatitis B virus; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D017720:Molecular Epidemiology; D008969:Molecular Sequence Data; D009426:Netherlands / Q000453:epidemiology; D012424:Rural Population