Multilevel analysis of hepatitis A infection in children and adolescents: a household survey in the Northeast and Central-west regions of Brazil
1 State University of Pernambuco, School of Medical Sciences, Oswaldo Cruz University Hospital, Rua Arnobio Marques, 310, Santo Amaro, CEP: 50100-130 Recife, PE, Brazil.
2 Federal University of Pernambuco, Department of Tropical Medicine, University Hospital – Bloco A, Av. Prof. Moraes Rego s/n – Cidade Universitaria, CEP: 50670-420 Recife, PE, Brazil.
3 Federal University of Goiás, Institute of Tropical Pathology and Public Health, Department of Community Health, Rua Delenda Rezende de Mello. s/n – Sala 405, Setor Universitario, CEP: 74605-050 Goiania, GO, Brazil.
4 University of Brasília, Health Sciences School, Department of Collective Health, Darcy Ribeiro University Campus – Asa Norte, CEP: 70910-900 Brasília, DF, Brazil.
5 Oswaldo Cruz Foundation, Aggeu Magalhães Research Center, Department of Parasitology, Av. Prof. Moraes Rego s/n – Cidade Universitaria, CEP: 50000-230 Recife, PE, Brazil.
6 Federal University of Pernambuco, Department of Social Medicine, University Hospital – 40 Andar, Bloco E. Av. Prof. Moraes Rego s/n – Cidade Universitaria, CEP: 50670-420 Recife, PE, Brazil.
7 University of São Paulo, School of Public Health, Department of Epidemiology. Av. Dr. Arnaldo, 715, Cerqueira Cesar, CEP: 01246-904 São Paulo, SP, Brazil.
8 Base Hospital of the Federal District, Area Especial, Asa Sul, CEP: 70335-900 Brasilia/DF, Brazil.
9 Adolfo Lutz Institute. Av. Dr. Arnaldo 355, Cerqueira Cesar, CEP: 01246-904 São Paulo, SP, Brazil.
10 National Program of Prevention and Control of Viral Hepatitis – Ministry of Health, Setor Comercial Sul, Quadra 4, Bl. A, Edf. Principal, 40 andar, CEP: 70304-000 Brasilia, DF, Brazil.
* Corresponding author. State University of Pernambuco, School of Medical Sciences, Recife, PE, Brazil. E-mail: Ricardo.ximenes{at}pq.cnpq.br
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Abstract |
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Background The objectives were to estimate the prevalence of hepatitis A among children and adolescents from the Northeast and Midwest regions and the Federal District of Brazil and to identify individual-, household- and area-levels factors associated with hepatitis A infection.
Methods This population-based survey was conducted in 2004–2005 and covered individuals aged between 5 and 19 years. A stratified multistage cluster sampling technique with probability proportional to size was used to select 1937 individuals aged between 5 and 19 years living in the Federal capital and in the State capitals of 12 states in the study regions. The sample was stratified according to age (5–9 and 10- to 19-years-old) and capital within each region. Individual- and household-level data were collected by interview at the home of the individual. Variables related to the area were retrieved from census tract data. The outcome was total antibodies to hepatitis A virus detected using commercial EIA. The age distribution of the susceptible population was estimated using a simple catalytic model. The associations between HAV infection and independent variables were assessed using the odds ratio and corrected for the random design effect and sampling weight. Multilevel analysis was performed by GLLAMM using Stata 9.2.
Results The prevalence of hepatitis A infection in the 5–9 and 10–19 age-group was 41.5 and 57.4%, respectively for the Northeast, 32.3 and 56.0%, respectively for the Midwest and 33.8 and 65.1% for the Federal District. A trend for the prevalence of HAV infection to increase according to age was detected in all sites. By the age of 5, 31.5% of the children had already been infected with HAV in the Northeast region compared with 20.0% in the other sites. By the age of 19 years, seropositivity was 
70% in all areas. The curves of susceptible populations differed from one area to another. Multilevel modeling showed that variables relating to different levels of education were associated with HAV infection in all sites.
Conclusion The study sites were classified as areas with intermediate endemicity area for hepatitis A infection. Differences in age trends of infection were detected among settings. This multilevel model allowed for quantification of contextual predictors of hepatitis A infection in urban areas.
Keywords Hepatitis A infection, multilevel analysis, Brazil, risk factors, contextual effects
Accepted 13 May 2008
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