Prevalence of Serological Markers of Hepatitis B Virus and Hepatitis C Virus among Thalassemia Patients in Diyala Province/Iraq
AnsamDawod salman1, Abdulrazak SH. Hasan2, Ammar Ahmed Sultan3
1College of Sciences-University of Diyala
2College of Medicine-University of Diyala
3College of Education for Pure Sciences-University of Diyala Abstract
Background
:
Hepatitis B virus (HBV) and Hepatitis C virus (HCV) infection are a global public health problem and blood borne virus (BBV) infection. HBV and HCVwere recognized as an important hazard for patients and staff in blood center unit, this due to frequent blood transfusion and nosocomial transmission.Objectives
:
The present study aimed to explore the prevalence of serological markers (HBVsAg, HBV c IgG, HBV c IgM, HBVeAb and anti-HCV Ab) amongthalassemia patients in Diyala, Iraq.Methods
:
This study was carried out on 90 patients with thalassemia from 1/ 12 / 2019 to 30 / 5 / 2021.The patients were attended Blood Specialist Center-Diyala Directorate of Health.Fifty one of patients were females and 39 were males. The age range was <10 years to ≥60 years. Patients were screened for HBVsAg, HBV c IgG, HBV c IgM, HBVeAb and anti- HCV Abusing an ELISA test.Demographic data of study group were recorded. Simple statistical analysis was done using SPSS Version 25 and P value was considered significant wherever it is below 0.05.
Results
:
The results indicated that the number of serum patients infected with HBV and HCV were(6.7%, 7.8%)respectively using ELISA technique. These patients had many markers named HBsAg, HBcIgG, HBcIgM, HBeAb and anti-HCV Ab with percentages 6.7%, 6.7%, 1.1%, 4.4% and 7.8% respectively.Conclusion
:
HBV and HCV seropositivity in current study were relatively high among multitransfused patients with thalassemia in Diyala, Iraq.Keywords
:
HBVsAg, HBV c IgG, HBV c IgM, HBVeAb, anti-HCV Ab and thalassemia.Introduction
Annually, million units of blood are collected from the donors worldwide as the blood transfusion is integral to management of patients suffering from diverse diseases, particularly hematological disorders (thalassemia patients) (Golam et al.,2021). Accordingly, transfusion transmitted infections (TTIs) (especially hepatitis B and hepatitis C infection) continue to be a major public health issue in many parts of the world and multi-transfused patients of
Thalassemia (a group of inherited hemoglobinopathies caused by mutations in the beta globin chain of hemoglobin) are at a particularly increased risk of TTIs (Islam et al.,2018).
Hepatitis B virus (HBV) and Hepatitis C virus (HCV) infection are a global public health problem (Oula and Meaad,2018). HBV is endemic throughout the world and shed in blood and all body fluids by individuals with acute or chronic infections.It has been estimated that more than one third of the World’s population was infected with HBV leading to the deaths of 1 - 2 million people annually, and there are nearly more than 350 million chronic carriers of hepatitis B virus (Chen and Tian, 2019; Zhang et al., 2019).The HCV causes both acute and chronic hepatitis, globally, an estimated 71 million people have chronic hepatitis C virus infection. A significant number of those who are chronically infected will develop cirrhosis or liver cancer. WHO estimated that in 2016, approximately 399 000 people died from hepatitis C, mostly from cirrhosis and HCC (Mehmet et al., 2018).
The HBV is transmitted by three main routes: Firstly, blood and blood products,transmission by this route occurs through blood transfusion, plasma transfusion, blood cell transfusion, platelets transfusion, sharing of needles, or razors, lancets, skin piercing instruments, surgical instruments, tooth brushes, bath brushes (Lewis et al., 2015). The second route for transmission of HBV is sexual intercourse. Third main route of transmitted is vertical transmission (from infected mother to the baby) (Lvet al., 2014; Bineetaet al., 2018).Transmission of HCV involves direct exposure to contaminated blood and is associated with intravenous drug use, iatrogenic exposures, tattooing, body piercing, and less frequently through vertical transmission and high‑risk sexual behavior (Dunfordet al.,2012).
There are serological markers Hepatitis B surfaces antigen (HBsAg), Hepatitis B e antigen (HBeAg), Hepatitis B patients also contain circulating antibodies against Hepatitis B core antigen, Hepatitis B e antigenand Hepatitis B surfaces antigen called Hepatitis B core antibody (HBcAb), Hepatitis B e antibody (HBeAb) and Hepatitis B surfaces antibody (HBsAb). Hepatitis B core antigen (HBcAg) was found only in hepatocytes and not found in blood stream. There are sequential appearance and disappearance of these five serological markers during atypical course of infection (Bartlett and Stirling,2003; Rasha and Basima,2014). The most useful detection methods are ELISAs for HBV antigens and antibodies and PCR for viral DNA (Ameret al., 2018).
The diagnosis of chronic hepatitis C infection is basedon the presence of both anti‑HCV antibodies (Ab),detected by enzyme immunoassays, and HCVRNA, detected by molecular assays and is essentialfor the management of HCV (Oula and Meaad,2018).
Materials and Methods:
Study group:
The present study was conducted in Diyala province for the period from 1/ 12 / 2019 to 30 / 4 / 2021.Ninety patients with thalassemia were enrolled in current study. The patients were attended Blood Specialist Center-Diyala Directorate of Health. Fifty one of patients were
children and young adults (89.9%). Special questionnaire was pre-constructed to collect information regarding age, sex, residence, education level and vaccinated with HBV vaccine.
The information was collected through short personal interview with patient's parents.
Blood samples collection:
Five milliliters of venous blood was collected from each participant using 5 milliliters sterile disposable plastic syringes after cleaning the area of aspiration by 70 % ethyl alcohol. The blood samples were poured in 10 milliliters disposable plastic tubes soon after aspiration. The tubes were left in a rack in upright position for 30 minutes at room temperature for clotting.
Thereafter, the tubes were transferred to the laboratory by cool box. At the laboratory, the tubes containing blood samples were centrifuged at 3000-4000 rotation/minute (RPM) for 5 minutes using bench centrifuge for separation of sera. Serum samples were aspirated and poured in new plastic disposable tubes using 250 microliters automatic pipette and disposable tips. Serum samples were divided into aliquots 250 microliter each in Eepindorff plastic tubes. These tubes were arranged in a rack in upright position and kept at -20 C till use.
Detection of serological markerHBsAg (serum):
This test was performed using commercially available kit (Dia.PRO, Italy HBs Ag ELISA).
Reactive results were indicated by the absorbance reading of 1.1 and above, while the non- reactive results were indicated by the absorbance reading less than 0.9.
Detection of serological marker Anti-HBcAb:
This test was performed using commercially available kit (Dia.PRO, Italy HBcAb ELISA). Reactive results were indicated by the absorbance reading of 1.1 and above, while the non-reactive results were indicated by the absorbance reading less than 0.9.
Detection of serological marker Anti-HBcIgM:
This test was performed using commercially available kit (Dia.PRO, Italy HBcIgM ELISA). Reactive results were indicated by the absorbance reading of 1.1 and above, while the non-reactive results were indicated by the absorbance reading less than 0.9.
Detection of serological marker Anti-HBeAb:
This test was performed using commercially available kit (Dia.PRO, Italy HBeAb ELISA).
Reactive results were indicated by the absorbance reading of 1.1 and above, while the non- reactive results were indicated by the absorbance reading less than 0.9.
Detection of serological marker Anti-HCV Ab:
This test was performed using commercially available kit (Dia.PRO, Italy Anti-HCV Ab ELISA). Reactive results were indicated by the absorbance reading of 1.1 and above, while the non-reactive results were indicated by the absorbance reading less than 0.9.
Statistical analysis:
Analysis of data was carried out using the available statistical package of SPSS-25 (Statistical Packages for Social Sciences- version 25).
Results:
Study population:
Ninety patients with thalassemia were included in this study. Mostly are children and young adults (89.9%). Mostly were females (56.7%) and all (100%) of them were vaccinated, table (4.3).
Table (1): Variables of the thalassemia group.
Variables No. %
Age (Ys)
<10 years 65 72.2
10---19 15 16.7
20---29 9 10.0
30---39 - -
40---49 - -
50---59 - -
=>60 years 1 1.1
Gender
Male 39 43.3
Female 51 56.7
Residence
Urban 37 41.1
Rural 53 58.9
Level of education
Illiterate 46 51.1
Primary 34 37.8
Intermediate 9 10.0
Secondary and above 1 1.1
Vaccination with HBV
Yes 90 100
No - -
Distribution of serological markers according to study group:
Table (2) revealed that the HBsAg positivity rate among thalassemia patients were 6.7%.
Therefore the difference among the study groups was statistically insignificant (P= 0.748).
Regarding the anti-HBcIgG antibody, the results showed that the anti-HBcIgGAb among the thalassemia patients (6.7%).
The results of the anti-HBcIgMAb revealed that the positivity rate among thalassemia group was 1.1% with statistically insignificant difference (P= 0.296). The HBeIgGAb positivity rate among thalassemia patients were 4.4%. The difference was statistically different (P= 0.024).
Lastly, The anti-HCV Ab positivity rate among thalassemia group were 7.8% with a statistically high difference (P= 0.0001).
Table (2): Distribution of study groups according to serological markers.
Education
Thalassemia P
value
No. %
HBsAg
Positive 6 6.7
0.784
Negative 84 93.3
Anti-HBV core IgG
Positive 6 6.7
0.0001*
Negative 84 93.3
Anti-HBV core IgM
Positive 1 1.1 0.296
Negative 89 98.9 Anti-HBVeIgG
Positive 4 4.4
0.024*
Negative 86 95.6
Anti-HCV Ab
Positive 7 7.8
0.0001*
Negative 83 92.2
*Significant difference between proportions using Pearson Chi-square test at 0.05 level.
Discussion:
Blood borne virus (BBV) infection (HBV and HCV) was recognized as an important hazard for patients and staff in blood center unit, this due to frequent blood transfusion and nosocomial transmission (Elizabeth et al.,2019).
In the present study, HBs Ag was detected in 6.7% of thalassemia patients. Since, Iraqi studies had reported variable results, so the present results were disagree with some of these studies, like that conducted in NinevehGovernorate / Iraq which reported an infection rate 0.55% among thalassemia patients with HBsAg positive (Rasha and Basima,2014). However, it was higher than that reported by other study, in Babylon/Iraq, HBsAg was detected in 3%
of thalassemia patients (Al-Sharifiet al.,2019). Nevertheless, worldwide studies have yielded variable HBs Ag rate among thalassemia patients; for instance, in Iran (Hosnie, 2019) reported aHBsAg rate of 3.8%, and in Palestine, the HbsAg rate was 0.7% (Kamal et al.,2018).
The current study found that there is HBcIgM and HBcIgG positivity rate in of thalassemia patients were 1.1% and 6.7% respectively. Other Iraqi researchers reported uneven results among thalassemia patients for HBcAb, (Rasha and Basima,2014) 1.1% positivity rate of HbcAb resulted among thalassemia patients. Additionally, (Al-Sharifiet al., 2019) reported 12% of thalassemia patients had a positive HBcAb. Also the present results were uneven with results of other worldwide researchers were reported HBcAb rate 19%, 2.49% and 4.33%
(Kamal et al.,2018; Mohammad et al.,2020; Ahmad et al.,2021).
Regarding the prevalence of HBeAb, the present study was 4.4% among thalassemia individuals, these results which are consistent to Iraqi study was conducted in Nineveh Governorate / Iraq by (Rasha and Basima,2014) reported 1.8% among renal thalassemia patients.
In the current study, the overall prevalence of HCV Ab in thalassemia patients was 7.8%, and this rate was in agreement with other rate was (7.5%) reported by Adnan and Widad, (2014)
Thalassemia major in Babylon Center of Hereditary blood disorders. Nevertheless, this rate in present study was lower than what is reported in different parts of our country. Anti-HCV antibodies were detected in 67.3% among thalassemic children in Baqhadad (Al-Kubaisyet al., 2006), and 26%in other study was done in B thalassemia patients attending Ibn-AL- Baladi center of blood diseases in AL-Sader city, in AL-Resafa Quarter of Baghdad(Zena and Isam, 2018). The present result was uneven with other worldwide studies, like that conducted in Iran which reported 17% positive rate of anti-HCV Ab among Iranian patients with thalassemia(Amir et al.,2019). However, in Egypt, anti-HCV Ab detection rate was 25% in thalassemia patients (Zeze and Wafaa, 2017). Whereas, in Saudi Arabia, the rate of anti-HCV was 13.2% (Golamet al.,2021).
This variation in the results in present study with different serological markers and other results perhaps due to other study were done on different age groupadult and children) and variation of the sensitivity of kits (ELISA). Additionally, this difference between results may be attributed to contaminated equipment, surfaces, and (HBV and HCV) infected among the most common modes of transmission of nosocomial infections. This difference may also be attributed to inadequate hematological investigations such as PCR for HBV and HCV mainly on blood and blood products as the mean number of blood transfusions in HBV and HCV infected group is significantly higher than the non-HBV and HCV group (Telakuet al., 2009).
Thalassemic patients have required long‑term and multiple blood transfusions to decrease the complications of severe anemia and prolong their survival rate. However, this recurrent blood transfusion increases the risk of transmission of transfusion‑related viruses – hepatitisB and C viruses (Al-Sharifiet al.,2019). The low rate of different serological markers of HBV in thalassemia patients can be due to the improvement of knowledge about HBV transmission routes, HBV vaccination among thalassemia patients.
Conclusion:
HBV and HCV seropositivity in current study were relatively high among multitransfused patients with thalassemia in Diyala, Iraq.
Thus, we recommend continuing surveillance of thalassemia patients in addition to hepatitis markers screening by special type of PCR technique for the diagnosis of HBV and HCV during the window period.
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