|Year : 2017 | Volume
| Issue : 2 | Page : 113-118
Antenatal screening for hepatitis B virus infection
Magdy A Gad1, Mohamed A Metwally1, Hesham A Eissa2, Mahmoud A Gehad3, Moataz M Rayan4
1 Department of Hepatology, Gastroenterology and Infectious Diseases, Faculty of Medicine, Benha University, Benha, Egypt
2 Department of Clinical and Chemical Pathology, Faculty of Medicine, Benha University, Benha, Egypt
3 Department of Gynecology and Obstetrics, Faculty of Medicine, Benha University, Benha, Egypt
4 Hepatology, Gastroenterology and Infectious Diseases, Faculty of Medicine, Cairo University, Shibin Al. Quanater City, Egypt
|Date of Submission||29-Mar-2016|
|Date of Acceptance||02-Aug-2016|
|Date of Web Publication||20-Nov-2017|
Moataz M Rayan
Kafr Al-Shoubak Village, Al-Qalubia, Shibin Al-Qanater, 13711
Source of Support: None, Conflict of Interest: None
Background Hepatitis B virus (HBV) infection continues to have a relatively high incidence and prevalence worldwide. In the postvaccination era in developing countries, perinatal vertical transmission remains the most common mode of transmission. Prevention of mother-to-child transmission requires screening of pregnant women for hepatitis B surface antigen (HBsAg) to identify which newborns must be immunized.
Aim This study aimed to evaluate the prevalence of HBV infection among pregnant mothers who were attending the outpatient clinic of the Department of Obstetric at Benha University Hospital for routine antenatal care.
Patients and methods A cross-sectional study included 448 pregnant women. Enzyme-linked immunosorbent assay technique for HBV was performed for all women and all patients positive for HBsAg were subjected to alanine transaminase, aspartate transaminase, bilirubin (total and direct) evaluation, hepatitis B envelope antigen test, and abdominal ultrasonography.
Results Out of 448 pregnant women, seven (1.56%) were positive for HBsAg by enzyme-linked immunosorbent assay test, where alanine transaminase, aspartate transaminase, and bilirubin were normal in six positive cases but high in the seventh positive case, hepatitis B envelope antigen was negative in all seven positive cases, and abdominal ultrasound was normal in six positive cases and showed hepatosplenomegaly in the seventh positive case. There was no significant association between the seroprevalence of HBV infection (HBsAg) in the studied women and their sociodemographic data. No statistically significant difference was seen between HBsAg-positive patients and HBsAg-negative patients in terms of age and duration of marriage, history of blood transfusions, history of hospitalization, history of major operations, history of diabetes mellitus, having a husband who is HBsAg positive, and history of addiction.
Conclusion HBV infection is prevalent among pregnant mothers attending our outpatient services. Therefore we recommend screening of all Egyptian pregnant mothers for HBV to prevent neonatal infection by immunoprophylaxis.
Keywords: chronic liver disease, hepatitis B, perinatal transmission, pregnancy, viral hepatitis
|How to cite this article:|
Gad MA, Metwally MA, Eissa HA, Gehad MA, Rayan MM. Antenatal screening for hepatitis B virus infection. Benha Med J 2017;34:113-8
| Introduction|| |
Of the estimated 350 million individuals chronically infected with hepatitis B virus (HBV) worldwide, it is generally accepted that at least 50% acquired their infections either perinatally or during early childhood, especially in countries where HBV is endemic  . Perinatal vertical transmission is the most common mode of transmission worldwide . Vertically transmitted HBV infection is becoming an important risk factor for acquisition of HBV among children born after the era of mass vaccination in Egypt . High maternal viral load and maternal serum hepatitis B envelope antigen (HBeAg) positivity increase the risk for perinatal transmission . Infants born to mothers known to carry HBV can be treated with hepatitis B immunoglobulin. When the vaccine is given within 12–24 h of birth, the risk of acquiring HBV is reduced by 90% .
Prevention of mother-to-child transmission requires screening for hepatitis B surface antigen (HBsAg) in pregnant women to identify which newborn should be immunized . This study aimed to evaluate the prevalence of HBV infection among pregnant mothers and to identify risk factors that may lead to HBV acquisition among these women.
| Patients and methods|| |
This study was designed as a cross-sectional investigation to estimate the prevalence of HBsAg among pregnant women. The study was conducted on 450 women who were visiting the Antenatal Care Clinic in the Gynecology and Obstetrics Outpatient Clinic in Benha University Hospital between January 2013 and January 2014.
The study protocol was approved by the Ethical Committee of Benha Faculty of Medicine.
Patients who signed an informed consent form were included in the study and were subjected to the following:
- History taking, which included the following:
- Personal history
- Phone number.
- Name of the contact during an emergency.
- Address of the contact during an emergency.
- Phone number of the contact during an emergency.
- General medical history
- Date of birth.
- Expected date of delivery.
- Place of previous delivery.
- History of blood transfusion.
- History of major operation.
- History of major accidents.
- History of tattooing.
- History of intravenous drug addiction.
- Renal dialysis.
- History of schistosomiasis.
- History of antischistosoma therapy.
- History of sexually transmitted diseases.
- History of diabetes mellitus.
- Number of marriages.
- Duration of marriage.
- Family history of hepatitis B.
- History of husband with hepatitis B.
- History of addiction in the husband.
- Number of deliveries.
- Obstetric history
- Number of pregnancies.
- History of jaundice that needed treatment in previous infants.
- Place of previous deliveries.
- Duration of previous delivery.
- Method of previous delivery (episiotomy, using suction, cesarean section, spontaneous vaginal delivery).
- Clinical examination.
- Laboratory investigation, which included the following:
- Serum HBsAg: A solid-phase enzyme-linked immunosorbent assay (ELISA) technique, based on the sandwich principle with use of microliter plates, was developed for the detection of HBsAg. Results could be read within 1 day by the naked eye or by using a colorimeter. The detection level was less than or equal to 5–10 ng of HBsAg/ml.
- Patients with HBsAg positive were subjected to the following:
- Evaluation of alanine transaminase (ALT), aspartate transaminase (AST), and bilirubin levels (total and direct).
- HBeAg test.
Sample size was calculated on the basis of an estimated prevalence of 4%. A sample size of 450 patients gives 95% confidence interval (CI) with a width of 4%.
Prevalence was calculated as percentage and 95% CI.
Nonparametric tests were used for comparison of parameters between positive and negative HBsAg women because of the small size of the HBsAg-positive group.
| Results|| |
The study was conducted on 448 women who were visiting the Antenatal Care Clinic in the Gynecology and Obstetrics Outpatients Clinic of Benha University Hospital from January 2013 to January 2014.
The studied women were screened for HBsAg using the enzyme-linked immunosorbent assay technique. Positive cases were only seven and they were subjected to the following tests:
- Evaluation of ALT, AST, and bilirubin (total and direct) levels.
- HBeAg test.
- Abdominal ultrasound.
In the present study the prevalence of HBsAg was around 1.56%. The sample size was calculated on the basis of an estimated prevalence of 4%. A sample size of 448 patients gave 95% CI with a width of 4%. Prevalence was calculated as percentage and 95% CI.
ALT, AST, and bilirubin concentrations were normal in six positive cases but high in the seventh positive case, HBeAg was negative in all seven positive cases, and abdominal ultrasound was normal in six positive cases and showed hepatosplenomegaly in the seventh positive case.
There was no significant association between the seroprevalence of HBV infection (HBsAg) in the studied women and their sociodemographic data.
There was no statistically significant difference between HBsAg-positive patients and HBsAg-negative patients regarding the following:
- Age and duration of marriage.
- History of blood transfusions.
- History of hospitalization.
- History of major operations.
- History of diabetes mellitus.
- History of HBsAg positivity in the husband.
- History of addiction ([Table 1] and [Table 2] and [Figure 1]).
|Figure 1 Prevalence of hepatitis B surface antigen (HBsAg) positivity in the studied population (prevalence of HBsAg, 1.6%; 95% CI, 0.44–2.76%).|
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The number of patients with HBsAg positivity was only seven, making statistical analysis for categorical or dichotomous variables difficult because of the small number per cell.
- All patients who were HBsAg positive were HBeAg negative (7/7; 100%).
- Out of seven patients who were HBsAg positive, six (85.71%) patients had normal ALT and AST levels.
| Discussion|| |
The prevalence of HBV varies between 2% in developed countries, where the prevalence is low, to about 8% in developing countries, where infection is endemic, with sex, age, and socioeconomic status being important risk factors for infection ,. Countries are classified as having low endemic rates (<2%), intermediate endemic rates (2–8%), or high endemic rates (>8%) positive for HBsAg . The prevalence of HBV in Egypt is of intermediate endemicity (2–8%) ,. A rate of maternofetal transmission of 51.8% was reported among HBsAg-positive women in Egypt .
Our study showed that out of 448 pregnant women, seven (1.56%) were positive for HBsAg with 95% CI. This result is in agreement with a study from Egypt, Saudi Arabia, and Libya, where 1.75, 2.4, and 1.5% of the studied women were positive for HBsAg ,,.
A study from Nigeria and Iran reported higher prevalence rates of HBV of 8.3 and 6.5%, respectively ,.
Studies from Tunisia, Jordan and Pakistan also reported prevalence of seropositive HBsAg among pregnant women of 4.3%, 4.6% and 5.7% respectively ,,,.
High prevalence rates of HBsAg were also reported from Ghana (10.5%) and Yemen (13.2%) ,.
Prevalence of HBV infection varies in different parts of the world. In addition, this prevalence varies from country to country, from one region to another region, and from one group to another group in a country .
Factors influencing the incidence and prevalence of HBV infection in a particular community in addition to ethnicity and immigration patterns include intravenous drug use and high-risk sexual activity .
Pregnant women are considered to be at higher risk because of increased exposure to risk factors (such as blood transfusion, intravenous drugs, or surgical procedures) . However, our results showed that 50.7% of cases were multigravidae with no significant difference between multigravidae and primigravidae. This is in agreement with the results of some studies from different regions ,,.
However, a study from Pakistan reported a higher frequency of HBV infection among multigravidae women .
There might be increased risk for HBV infection among multigravidae women because of their past pregnancies, and history of hospital admission, blood transfusion and/or any surgical procedure in the past. Therefore, with each pregnancy and childbirth, chances of exposure to HBV become greater .
Blood transfusion continues to cause hepatitis B infection in countries where blood donors are not screened. Transmission of HBV from transfusion of unscreened blood continues to be a problem and may account for a majority of infections among children and adults . In our study, a history of previous blood transfusion was not observed in a significant number of cases. Our study results are in agreement with those of some studies from Egypt, Saudi Arabia, and Mexico ,,.
However, other studies have reported that blood transfusion is an important risk factor for acquiring HBV infection ,.
In our study, previous hospital admission was reported in 0.2% of cases, which was not significant. In contrast to our results, other studies reported that previous surgery and hospitalization were observed in a higher percent of HBsAg-positive cases than in HBsAg-negative controls but the difference between the two groups was not statistically significant ,.
History of previous surgeries was reported in 0.2% of our cases, which was not significant either. History of previous surgeries is a major risk factor for transmission of HBV . Our study comes in agreement with another two studies that reported a nonsignificant distribution of previous surgeries among their studied women for the transmission of HBV infection ,.
However, one study from Egypt reported a history of previous surgeries in 80% of their cases, which was also significant .
In our study, most of the HBsAg-positive women belonged to rural areas with poor socioeconomic and low educational status. Socioeconomic conditions among the poor and less educated, and crowded living conditions especially in rural areas, may contribute to HBV exposure .
In our study, husband being infected with hepatitis B was reported in 28.57% of cases. However, although statistical analysis was difficult, it appears that pregnant women with HBsAg positivity had a higher rate (28.57%; 95% CI, 0–62.04%) of husbands with HBsAg positivity compared with patients with HBsAg negativity (0%). Our study comes in agreement with that of El-Shabrawi et al. , who reported that husbands with HBsAg positivity were observed in a higher percentage of HBsAg-positive cases than among HBsAg-negative controls.
History of addition in the husband was reported in 42.85% of our cases. However, although statistical analysis was difficult, it appears that pregnant women with HBsAg positivity had a higher rate (42.85%; 95% CI, 6.19–79.51%) of addiction in the husband than did patients with HBsAg negativity (4.31%; 95% CI, 2.41–6.21%). Our study comes in agreement with some that reported a significant distribution of addiction among husbands when studying the transmission of HBV infection among their studied women ,.
Our study showed that out of 448 pregnant women, seven were positive and all of the positive cases were HBeAg negative. This comes in agreement with a study from Iran that reported HBeAg negativity in a high percentage of their HBsAg-positive cases .
The HBeAg-negative variant accounts for more than 80% of chronic hepatitis B in Egypt , and represents a late phase of HBV infection characterized by persistent viral replication, progression of liver disease, and early development of cirrhosis .
Reductions in HBeAg prevalence among HBsAg-positive women between 1990 and 2005 could be related to improved hepatitis B vaccination coverage. This may explain decreases particularly observed in Egyptian women (reduction up to 14%) .
One of the most common mutations in HBV occurs in the precore or core promoter regions. This precore mutation stops the virus from producing or secreting the envelope antigen. Despite its inability to secrete this protein, these mutated viruses are able to live and replicate without it .
Patients with the precore mutation are positive for HBsAg and negative for HBeAg and they often have normal liver enzyme levels. Unfortunately, patients negative for this e antigen often have active liver disease .
The prevalence of these mutations ranges from 20 to 90% among patients from Europe and the Middle East, including Egypt, Libya, Tunisia, Algeria, and Morocco .
In our study, normal ALT level was reported in six of the seven (85.71%) positive cases, which was highly significant. Our study comes in agreement with a study from Iran that reported normal ALT levels in a high percentage of their HBsAg-positive cases .
Recent preliminary reports showed that 12–43% of Egyptian patients with chronic HBV infection and HBsAg positivity had persistently normal ALT levels .
| Conclusion|| |
In the postvaccination era in Egypt, HBV infection prevalence among pregnant women is low.
Most HBV-infected pregnant women are asymptomatic and unaware of their infection until screened; therefore, antenatal screening of pregnant women for HBsAg is important to identify which newborns should be immunized.
The study is considered a pilot study to help implement a national program for the prevention of vertical transmission of HBV as the schedule for HBV vaccination in our country is at the age of 2, 4, and 6 months.
- Screening of pregnant women for HBsAg and evaluation of women for treatment and neonatal immunoprophylaxis.
- Screening of contacts with high risk for partners with addiction.
- Screening and vaccination of contacts with hepatitis B-infected partners.
- Study for long follow-up of infected pregnant women and their children.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]