SEROPREVALENCE OF HEPATITIS B VIRUS INFECTION AMONG PATIENTS ATTENDING A TERTIARY CARE CENTRE IN NORTH-EAST INDIA.
Hepatitis B virus infection (HBV) is a common public health problem. About 2 billion people (or 30% of the world population) have serological evidence of current or past infection with hepatitis B virus. It is known to be the 10th leading cause of death and HBV related hepatocellular carcinoma is the 5th most frequent cancer worldwide.  An estimated 350 million people harbour chronic infection. The number of HBsAg carriers in India have been estimated to be over 40 million.  Major complications of chronic HBV infection are liver cirrhosis and primary cell carcinoma.
According to WHO and NCDC countries are classified as having high (8% or more), intermediate (2-7%), or low (less than 2%) HBV endemicity based on the prevalence of hepatitis B carrier state in the general population.
India is at the intermediate endemic level of hepatitis B, with hepatitis B surface antigen prevalence between 2% and 7% among the populations studied.
The primary routes of transmission are perinatal, early childhood exposure, sexual contact, and per cutaneous exposure to blood or body fluids (i.e. injections, needle stick, blood transfusion). The hepatitis B surface antigen (HBsAg) in serum is the first sero-marker to indicate active HBV infection, either acute or chronic. 
The important source of infection is blood of a carrier. It is a heat stable and can survive outside the body for at least 7 days, as little as 0.00001ml of infected blood or infected material by Hepatitis B virus can be an infectious. The incubation period is 30 to 180 days. The virus may be detected within 30 to 60 days after infection and can persist and develop into chronic hepatitis B.  Virus may also be present in body fluids and excretions (Saliva, breast milk, semen, vaginal secretion, urine & bile) and faces. A large population of patients suffering from hepatitis B may be asymptomatic and can transmit the disease to healthy population.
Human immunodeficiency virus (HIV), hepatitis B virus (HBV) and hepatitis C virus (HCV) have similar routes of transmission, namely through blood and blood products, sharing of needles to inject drugs and sexual activity. [4,5] Co-infection of HBV and HCV in HIV positive patients is associated with reduced survival and an increased risk of progression to severe liver diseases with higher susceptibility towards hepato-toxicity due to antiretroviral therapy.
The present study was undertaken to determine the seroprevalence of HBV infection among patients attending a tertiary care centre in North-East India and to assess the demographic profiles of seropositive patients/individuals. This study also aimed to highlight the presence of co-infection of HCV & HIV, if any, among HBV infected patients.
MATERIALS & METHODS
This is a hospital-based, retrospective descriptive study conducted in the department of Microbiology from July 2017 to June 2018. The study includes patients of all age groups & both sexes attending various outpatient departments or admitted in the wards of medicine, surgery, orthopedics, obstetrics and gynaecology or pediatrics, who were undergoing HBsAg test as part of routine preoperative screening or for diagnostic purposes. HIV positive clients referred from ART centre for HBV and HCV screening were also included.
At least 5 ml of blood was collected aseptically by venepuncture into sterile, disposable vials without anticoagulants and labelled with patient identification details. Serum was separated by centrifugation at a speed of 3000 rpm for 10 minutes and placed in sterile serum storage vials. All the serum samples were tested for HBsAg using 3rdgeneration ELISA (Qualisa HBsAg, Qualpro Diagnostics, Goa, India) following standard protocol and manufacturer's instructions with adequate quality control. Samples were considered reactive according to the manufacturer's specifications. However, any doubtful or indeterminate results were excluded from analysis. HBsAg positive samples were further subjected to qualitative detection of anti-HCV antibody using 3rd generation ELISA (Qualisa HCV, Qualpro Diagnostics, Goa, India)
Analysis of data was done using descriptive statistics using such as percentage.
A total of 11399 serum samples were collected and processed for HBsAg during the study period of 12 months. Among these, 2901 (25.44%) and 8498(74.55%) were from male and female patients respectively (Table 1). The prevalence rate of HBV infection was found to be 1.23%. The prevalence of hepatitis B virus infection was found to be higher amongst males (2.2%) as compared to the female (0.89%).
In this hospital-based study, highest occurrence of HBV infection among males was observed in age group of 21-30 (3.29%) years followed by 31-40 (2.94%) years and 41-50 (2.37%) years (Table 2). Among females, highest prevalence was found in age group of 51-60 (1.39%) years followed by 61-70 (1.15%) years and 41-50 (1.13%) years (Table 2).
In this study, co-infection of HBsAg and HCV was observed in 0.096% (11/11399). HIV co-infection with HBsAg and HCV was seen in 1.6% and 19.1% respectively. The distribution of HBV and HCV co-infection in patients infected with HIV is shown in Table 3.
A total of 11399 serum samples tested for detection of HBsAg. Sero-prevalence of HBsAg in our center is 1.23% which is lower than most of the Indian studies (2-8%). Sharma et al. have reported the prevalence of 2.31% among general population attending OPD at a tertiary care hospital. 
In this present study, higher HBV prevalence was observed among in males (2.2%) as compared to the females (0.89%) in females. Findings were in concordance with other earlier studies. [7-11] Patel et al. showed the intermediate level of prevalence of 2.67%, in younger age group affecting more males.  Male predominance of HBsAg virus infection as compared with the female might be probably due to the higher exposure of male to occupational HBV indicating horizontal transmission, which may be due to unsafe injection practices, intravenous drug abuse, unsafe sexual practices and also probably because females clear the HBV more efficiently as compared to males. [2, 12]
Among males, highest occurrence was found in age group of 21-30 (3.29%) yrs. followed by 31-40 (2.94%) yrs and 4150 (2.37%) yrs. Similar results were noted by Sood et al and Patel et al. [8, 11] However, Tripathi et al observed highest prevalence in 31-40 years followed by 21-30 years, so it can be concluded that highest prevalence in 21-40 years indicating horizontal transmission. 
Among females, highest prevalence was found in age group of 51-60 (1.39%) years followed by 61-70 (1.15%) years and 41-50 (1.13%) years Similar results were noted by Patil et al and Quadri et al. [13,14]
In our study, co-infection of HBV and HCV was observed in 0.096% which was lower than that of Desikan et al (1.89%).  Of the total 214 HIV infected individuals included in our study, co-infection with HBV and HCV was found in 1.6% and 19.1% respectively. The higher prevalence rate of HCV in HIV positive patients in comparison to the rate for HBV positivity in HIV infected patients in our centre could be attributed to diverse factors such as increase in the rate of drug addiction, lack of vaccine for HCV. However, co-infection of HIV was noticed more in HBV rather than HCV in most of the Indian studies. [16,17]
Seroprevalence of Hepatitis B infection (1.23%) was found to be slightly lower when compared to other parts of the country. Males especially in younger age group were found to be more affected. Our study re-emphasizes need for adequate public awareness to tackle this silent epidemic by improving prevailing health care practices and proper counselling.
 Prevention of Hepatitis B in India--an overview. World Health Organization South-East Asia Regional Office, New Delhi, 2002.
 World Health Organization. Hepatitis B. World Health Organization Fact Sheet No. 204 (Updated July 2015). http://www.who.int/mediacentre/factsheets/fs204/en/ (Last accessed on July 2017)
 Cariappa MP, Jayaram J, Bhalwar R, et al. Epidemiological differentials of Hepatitis B carrier state in the army: a community based seroepidemiological study. Med J Armed Forces India 2004;60(3):251-4.
 Saravanan S, Velu V, Kumarasamy N, et al. Co-infection of hepatitis B and hepatitis C virus in HIV-infected patients in South India. World J Gastroenterol 2007;13(37):5015-20.
 Mohammad M, Talel G, Sheikhian A, et al. Survey of both hepatitis B virus (HBsAg) and hepatitis C virus (HCV-Ab) co-infection among HIV positive patients. Virol J 2009;6:202.
 Sharma M, Bohra S, Mehra SK, et al. Seroprevalence of Hepatitis B virus infection among OPD patients attending tertiary care hospital. Int Arch BioMed Clin Res 2017;3(2):51-3.
 Karki S, Ghimire P, Tiwari BR, et al. Trends in hepatitis B and hepatitis C seroprevalence among Nepalese blood donors. Jpn J Infect Dis 2008;61(4):324-6.
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 Sood S, Malvankar S. Seroprevalence of Hepatitis B surface antigen, antibodies to the Hepatitis C virus, and Human Immunodeficiency Virus in a hospital-based population in Jaipur, Rajasthan. Indian J Community Med 2010;35(1):165-9.
 Tripathi PC, Chakraverti TK, Khant NR. Seroprevalence of hepatitis B surface antigen and antibody to hepatitis C virus at a tertiary care centre in Telangana. Int J Res Med Sci 2015;3(1):297-300.
 Patel PH, Nerurkar AB, Patel MR. Seroprevalence of Hepatitis B surface antigen in patients attending a tertiary care hospital Valsad, South Gujarat, India. Int J Med Microbiol Trop Dis 2016;2(3):103-6.
 London WT, Drew JS. Sex differences in response to hepatitis B infection among patients receiving chronic dialysis treatment. Proc Natl Acad Sci USA 1977;74(6):2561-3.
 Patil SR, Ghorpade MV, Patil SS, et al. Seroprevalence of Hepatitis--B surface antigen among the patients reporting at tertiary care hospital from India. Bangladesh J Med Sci 2016;15(3):455-9.
 Quadri SA, Dadapeer HJ, Arifulla MK, et al. Prevalence of Hepatitis B surface antigen in hospital based population in Bijapur, Karnataka. Al Ameen J Med Sci 2013;6(2):180-2.
 Desikan P, Khan Z. Prevalence of hepatitis B and hepatitis C virus co-infection in India: a systematic review and meta-analysis. Indian J Med Microbiol 2017:35(3)332-9.
 Ahuja S, Malhotra S, Chauhan A, et al. Sero-prevalence of Hepatitis B and C co-infection in HIV positive patients from a tertiary care hospital. J Int Med Sci Acad 2013;26(2):91-2.
 Tripathi AK, Khanna M, Gupta N, et al. Low prevalence of Hepatitis B virus and Hepatitis C virus co-infection in patients with human immunodeficiency virus in Northern India. J Assoc Physicians India 2007;55:42931.
Ningombam Homendro Singh (1), Rajkumar Manojkumar Singh (2), Huidrom Lokhendro Singh (3), Yumlembam BishwabatiDevi (4)
(1) Postgraduate Student, Department of Microbiology, Jawaharlal Nehru Institute of Medical Sciences, Imphal, Manipur, India.
(2) Associate Professor, Department of Microbiology, Jawaharlal Nehru Institute of Medical Sciences, Imphal, Manipur, India.
(3) Professor and HOD, Department of Microbiology, Jawaharlal Nehru Institute of Medical Sciences, Imphal, Manipur, India.
(4) Microbiologist, Department of Microbiology, Jawaharlal Nehru Institute of Medical Sciences, Imphal, Manipur, India.
'Financial or Other Competing Interest': None.
Submission 14-11-2018, Peer Review 06-12-2018, Acceptance 13-12-2018, Published 24-12-2018.
Corresponding Author: Rajkumar Manojkumar Singh, Associate Professor, Department of Microbiology, Jawaharlal Nehru Institute of Medical Sciences, Imphal-795005, Manipur, India.
Table 1. Gender Seroprevalence of HBsAg Gender Total No. of HBsAg Sera Tested Positive (%) Male 2901 64 (2.2) Female 8498 76 (0.89) Total 11399 140 (1.23) Table 2. Age & Gender Distribution of Screened Samples Gender Age Group Total Samples Male Female (Years) Tested 0-10 284 178 106 11-20 1322 211 1111 21-30 3814 364 3450 31-40 2349 510 1839 41-50 1474 590 884 51-60 1025 451 574 61-70 708 361 347 > 70 423 236 187 Total 11399 2901 8498 HBsAg +ve Age Group Male (%) Female (%) Total HBsAg (Years) +ve (%) 0-10 0 0 0 11-20 4 (1.89) 5 (0.45) 9 (0.68) 21-30 12 (3.29) 29 (0.84) 41 (1.0) 31-40 15 (2.94) 18 (0.97) 33 (1.4) 41-50 14 (2.37) 10 (1.13) 24 (1.62) 51-60 9 (1.99) 8 (1.39) 17 (1.65) 61-70 7 (1.93) 4 (1.15) 11 (1.55) > 70 3 (1.27) 2 (1.06) 5 (1.18) Total 64 (2.2) 76 (0.89) 140 (1.23) Table 3. Co-Infection of HIV with HBV & HCV Gender HIV +ve HBsAg +ve Anti HCV Ab +ve Male 99 1 (1.2%) 29 (29.29%) Female 115 2 (1.9%) 12 (10.4%) Total 214 3 (1.6%) 41 (19.1%)
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|Title Annotation:||Original Research Article|
|Author:||Singh, Ningombam Homendro; Singh, Rajkumar Manojkumar; Singh, Huidrom Lokhendro; Devi, Yumlembam Bis|
|Publication:||Journal of Evolution of Medical and Dental Sciences|
|Date:||Dec 24, 2018|
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