Hepatitis B virus (HBV) and hepatitis C virus (HCV) are among the principal causes of severe liver disease, including hepatocellular carcinoma (HCC) and cirrhosis-related end-stage liver disease(3). Hepatitis B virus (HBV) infection is leading health problem globally. There are approximately 2 billion people infected by HBV and about 400 million carriers worldwide(14, 15). Majority of these reside in Asia and West Pacific(14). Although HBV is present all over the world, its prevalence is significantly different across different countries(5). An estimated 57% of cases of liver cirrhosis and 78% of cases of primary liver cancer result from HBV or HCV infection(9, 17). In terms of endemicity, India comes in Intermediate zone(15). According to WHO, the prevalence of Hepatitis B in general population in India ranges from 0.1% to 11 %(11), whereas various studies about epidemiology of hepatitis B in India report HBsAg seropsitivity range from 2%-4.7%(1). The reason for this heterogeneity is variation in social, economic and health factors in different regions of India(10). Most of these studies are carried in blood donors or antenatal mothers, but there is limited data of epidemiology of hepatitis B in community(15) more so in rural population(10). WHO report of hepatitis C suggests its prevalence 3% in the world which is a significant burden on public health(18). hepatitis C is responsible of about one third of hepatocellular carcinoma(8).
Hepatitis B and hepatitis C share a common risk factors and common mode of transmission, so it is rationale to study prevalence of these two together. In present study, 1833 randomly selected subjects were interviewed for risk factors for transmission and tested for markers of hepatitis B and hepatitis C infection. Study population was from a village in a rural area of Western Maharashtra, India.
This was a community based cross sectional study. The study protocol was approved by institutional ethics committee. The study was undertaken in general population of a village situated in rural area in Maharashtra state. Sample size calculation: it was calculated as 2015 on the basis of prevalence of HbSAg reported as 4.47%. Study population was determined by electoral roll and admission register of the only school in the village. Both lists were merged together. Each person in the list was given an unique serial number. Two thousand and five hundred subjects were contacted taking into consideration the expected attrition. Two thousand and five hundred random numbers were generated by computer.
All the subjects in the sample population were approached by B.A.M.S. interns who were trained to fill the case response proforma. Written valid informed consent was taken from all the subjects (or their guardians if subject is minor). Blood sample, from the subjects who gave consent was obtained using universal sterile precautions. The samples were subjected to card test (J Mitra) for HBsAg and anti HCV antibodies. All the positive card tests were confirmed by ELISA. Considering technical difficulties in blood collection, children below 5 years of age were excluded from study. All the generated biological waste was disposed off in accordance with standard guidelines. The data was collected and compiled in excel sheet. Appropriate statistical tests (Chi square test for qualitative analysis) were used for analysis of data.
Out of 2400 subjects approached, 1833 agreed to participate. Response rate for participation was 76.38%. 47.41% of study population was male .Total 17 (8 male and 9 female) subjects were positive for HBsAg (Table 1). None of the subjects was positive for anti HCV antibody. Point prevalence for HBsAg positivity was 0.92%. None of the subject's age less than 10 year (number 287) and more than 51 year was positive for HBsAg (Table 2). Being healthcare worker and having tattoo were significantly associated with HBsAg positive results. Nose and ear piercing was reported by almost everybody and was not significantly associated with HBsAg positivity. History of blood or blood product transfusion, I/V drug abuse, multiple sexual partners, unsafe Injections, hemodialysis and any h/o surgery was not associated with HBsAg positivity. History of male to male sex, acupuncture, organ transplant was not given by any of the participants (Table 3).
|Age group||Total N||Male||Female||Positive||% Positive|
|Present in HBsAg positive||Present in HBsAg negative||P value|
|Health care workers||3||5||0.001|
|Nose or ear piercing||16||1794||0.1150|
|Any H/O surgery||3||90||0.208|
|Blood or blood product transfusion||1||15||0.139|
|I/V drug use||0||4||1|
|Multiple sexual partners||0||10||1|
|Male to male sex||0||0||1|
This study presents population based observations regarding prevalence and risk factors for transmission of hepatitis B in randomly selected rural population of Western India. Detection of HBsAg in the serum of an individual indicates that the person is currently infected with the virus. According to a metaanalysis prevalence in Indian population is not uniform. They concluded the point prevalence of hepatitis B infection in non-tribal populations is 2.4% and among tribal populations is 15.9%(4). Our study shows much less prevalence than this finding. This indicates a decreasing trend of hepatitis B which may be because of adoption of universal immunization against hepatitis in newborns and improved living standards. HBsAg positivity was not significantly associated with any age group in our study.
Population prevalence of HCV infection is 1% and major route of transmission is through blood transfusion and unsterile glass syringes(2). We did not found any subject with HVC infection in our study.
Healthcare workers are at increased risk of exposure to hepatitis B and C. Immunization against hepatitis B is recommended in healthcare workers but there is ignorance and lack of awareness regarding this(13).
There is no vaccine available at present against hepatitis C infection, observance of universal precautions may protect healthcare workers. A recent study from south India concluded that the knowledge and practice of universal precaution among paramedics was unsatisfactory(16). The risk of infection after needle-stick injury is 23%-62% for HBV and 0%-7% for HCV among susceptible HCW(12).
Another study from Delhi showed that 29 of 72 (40.28%) microbiology lab workers were susceptible to HBV infection(7). Although guidelines are available for prevention of hepatitis B and C infection in HCWs, there is urgent need to form policies and strategies to implement these.
We found that having a tattoo was significantly associated with HBSAg seropositivity. A study of STD (sexually transmitted diseases) clinic patients in Pune mentions similar observation(6). Reuse of the needle without proper sterilisation may be responsible for transmission of hepatitis B. This finding emphasises need of education of masses regarding modes of transmission hepatitis B virus and its prevention. Use of disposable needles and proper sterilisation of paraphernalia may reduce transmission.
Male to male sex was not reported by any of the subjects. This may be because of the social stigma or actual low existence of such practice. Accupuncture is not common in this part of the world and was not reported by any subjects. Hemodialysis is a risk factor for both hepatitis B and C transmission. We did not found any association between lifetime history of hemodialysis and HBSAg positivity. This may be because of small number of subjects having history of hemodialysis.
None of the subjects reported history of organ transplant or institutionalisation.
There are many potential limitations to our study. First is the low participation rate of 76.36% in the study. Lack of awareness regarding the disease in general population and population based nature of the study may be the factors affecting participation. Second there is potential recall bias regarding the risk factors such as unsafe injections. Third we exclauded children less than 5 years of age because of technical difficulties expected in blood collection. This is a small portion of population and universal immunisation against hepatitis B in newborns in India may have an impact on prevalence of hepatitis B in this group. Fourth occult and cured infections could not diagnosed because other serological markers like anti hepatitis B core antibody were not tested.
Seroprevalence of HBsAg in rural population of Maharashtra was 0.92% and none of the 1833 subjects was positive for anti HCV antibody. Healthcare workers and having tattoo was significantly associated with HBsAg positivity. Educating common people regarding mode of transmission of Hepatitis B and C will help to reduce their transmission.