Kentucky, Tennessee and West Virginia have seen a large increase in hepatitis B that is related to injection drug use in the region, according to the Centers for Disease Control and Prevention (CDC).

Acute hepatitis B increased 114 percent in those states from 2009 to 2013. Nationally, the incidence of hepatitis B remained stable during those years, USA Today reports. Injection drug use was a factor in three-quarters of cases starting in 2010.

“I wish I could say this is a surprise, but it’s not,” Van Ingram, Executive Director of the Kentucky Office of Drug Control Policy told the newspaper. “All of the blood-borne pathogens are a concern because of how they spread…Nine in 10 people who abuse prescription pills or heroin are injecting them intravenously, and many are using dirty needles.”

The disease is spread when a person comes into contact with bodily fluids, such as blood or semen, from an infected person. Some people who get hepatitis B are sick only for a short time, but others have long-term infections. About 2.2 million Americans have chronic hepatitis B, which can lead to liver cancer or cirrhosis.

Hepatitis B can be prevented with a vaccine. Hepatitis C, which is spread in smiliar ways, cannot be prevented with a vaccine. Hepatitis C can lead to liver failure, cancer and sometimes death.

In July 2015, the CDC announced hepatitis C is spreading quickly among people injecting drugs in Appalachia. Injection drug use can also spread HIV through shared needles.

Acute hepatitis C infections more than tripled from 2007 to 2012 among young people in rural areas in Kentucky, Tennessee, Virginia and West Virginia. About 73 percent of those hepatitis C patients said they injected drugs.