The gender difference might reflect the increased frequency of high-risk behaviour, among men

compared to women [14], [15] and [16]. In the present study, risk factors of HBV infection and chronic carriage were gender, scarification practices, and needles in the Primary Care Center. Intramuscular (IM) injections [17] seem C646 to play an important role in horizontal transmission of HBV via inadequately sterilized syringes used for iatrogenic IM injections in a community in which HBV was prevalent and IM injections were common [17] and [18]. Possible routes include intrafamilial or school close contacts, or parenteral transmission via practices like scarification, tattooing, and traditional circumcision was previously reported. These latter practices, although decreasing throughout the country, still exist in regions of lower socio-economic level, particularly in the south of the country, which could explain the higher prevalence of HBsAg positivity found in these regions. However, it is worth noting that the rate of HBsAg positivity may vary within a wide range in the same region. This prevalence variability may reflect more intense viral transmission due either to some particular characteristics of the HBV strains or to the genetic background of the local population [4]. Environmental factors, like the existence of sanitation in the house, seem to be protective against anti-HBc

and HBsAg positivity and reflect a higher socio-economic standard. Some studies have reported Resminostat that HBV infection is more prevalent in find more rural areas and the increasing risk is related to environmental factors [11], [12], [13] and [19]. Intrafamilial horizontal transmission of HBV by coexistence of chronic HBV carriers with

respect to the mother, father, brother or sister seems to be the most important route of transmission of HBV in Tunisia and explains hyperendemic microfoci of HBV transmission where a high clustering of infected cases and carriers is found in the same families. Child-to-child transmission was found to be more important than mother-to-child and father-to-child transmission. Many factors were reported to be associated with intrafamilial transmission of HBV infection [20], [21], [22], [23], [24] and [25]: sharing of various personnel and household articles such as a toothbrush, towel, handkerchief, clothing, razor, comb, or clothing [26]; ear-piercing and scarification [27]. Other studies have demonstrated that premastication of food to the children, a traditional habit frequent in rural Tunisia, is possibly an important factor in the family transmission of HBV [28]. Some other findings show that the risk of horizontal child-to-child HBV transmission is especially important during elementary school years [13], [24] and [29]. The investigation of the mechanism leading to intrafamilial transmission is beyond the scope of our study.