AN OVERVIEW OF THE PREVALENCE OF HEPATITIS B INFECTION

AMONG MALE AND FEMALE BLOOD DONORS IN DEVELOPING

COUNTRIES

Submitted by:Bisma Nasir

Registration #2016-GCUF-066470

Discipline: BS (Hons) Medical Laboratory Technology (MLT)

AFRO-ASIAN INSTITUTE, LAHORE.

A RESEARCH REPORT IS SUBMITTED TO THE AFRO-ASIAN INSTITUTE, LAHORE IN PARTIAL
FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF BS(Hons)MEDICAL LABORATORY
TECHNOLOGY (MLT)

BY

BISMA NASIR

Supervisor

MS. AQSA IQBAL

Principal

Dr. MUHAMMAD FAROOQ TARIQ BUTT

 DEDICATION

I would like to dedicate my research to my beloved PARENTS who spent their whole life, worn
out their energies on grooming me.

i
 DECLARATION

I hereby declare that the contents of the thesis “An Overview of the Prevalence of Hepatitis B
Infection among Male and Female Blood Donors in Developing Countries” are the creation
of my own research. I further declare that this work has not been submitted for the award of any
other degree/diploma yet. The university may take action if the information provided is found
inaccurate at any stage (In case of default, the scholar will be proceeded against as per HEC
plagiarism policy).

BISMA NASIR

MLT

ii
 CERTIFICATE OF APPROVAL

We, the supervisory committee, certify that the contents and forms of a thesis submitted by
Bisma Nasir, Roll no. 33005 have been found satisfactory and recommend it to be processed for
evaluation by the External/Internal Examiners for the award of degree.

RESEARCH SUPERVISOR

__________________________________

Ms. AQSA IQBAL

Lecturer of MLT Department

_____________________ ______________________

INTERNAL EXAMINER EXTERNAL EXAMINER

iii
 ACKNOWLEDGMENT

All praises to Almighty Allah the one Who has given us the wisdom and knowledge to
identify the right path and reach the truth. All respects for his Holy Prophet (PBUH) who is
forever beacon of light for all of us.

I would like to express my sincere gratitude to Dr. Muhammad Farooq Tariq Butt,
Principal and Sir Abid Ali, Director of Academics, Afro-Asian Institute for their strong support
and encouragement during this whole course.

I feel immense pleasure in expressing my gratitude to my research supervisor, Ms Aqsa

Iqbal, Lecturer of MLT Department, Muhammad Naveed, Head of department of MLT, Afro-
Asian Institute for sharing their vast knowledge, extending prudent advice, sympathetic attitude
and strong motivation to address the problems encountered during research.

I would like to articulate my thanks to my parents and my siblings for their kind
cooperation and prayers.

Bisma Nasir

iv
 ABBREVIATIONS

Short Form Full Form

HBV Hepatitis B Virus

HCV Hepatitis C Virus

HIV Human Immunodeficiency Virus

HBsAg Hepatitis B Surface Antigen

Anti-HBc Antibody Against Hepatitis B Core Antigen

ELISA Enzyme Linked Immunosorbent Assay

PCR Polymerase Chain Reaction

ICT Immuno Chromatography Technique

TTIs Transfusion Transmitted Infections

CDC Center of Disease Control

Rh Rhesus

v
 CONTENTS

DEDICATION……………………………………………………………………..i

DECLARATION...…………………………………………………………………ii

CERTIFICATE OF APPROVAL…………………………………………………..iii

ACKNOWLEDGEMENT....……………………………………………….……….iv

ABBREVIATIONS…………………………………………………………….……v

CHAPTERS……………………..……………………………………………….…..vii

LIST OF FIGURES…………………………………………………………………viii

vi
SR. NO. CHAPTERS PAGE NO.

1. INTRODUCTION 1

2. REVIEW OF LITERATURE 3

3. MATERIALS AND METHODS 6

4. RESULTS 7

5. DISCUSSION 12

6. CONCLUSION 13

7. REFERENCES 14

vii
Figure
List of Figures Page #
#

Prevalance of hepatitis B infection among male and female blood

8
4.1 donors.

Frequency of hepatitis B among different age groups of blood

4.2 9
donors

4.3 Different ways of transmission of hepatitis B among blood donors 10

4.4 Prevalence of HBV among blood donors in different regions of India 11

viii
 ABSTRACT
Hepatitis B is an inflammatory liver disease caused by hepatitis B virus (HBV). Hepatitis
B infection poses a major health issue as it causes serious liver infections including acute
hepatitis, chronic hepatitis, cirrhosis and carcinoma of liver. Hepatitis B has become a leading
cause of mortality and morbidity around the globe. Hepatitis B causes infection of 2 billion
peoples of world's population and 350 million people suffer from chronic hepatitis B and
approximately 0.6 million people die every year due to hepatitis B. Among transfusion
transmitted infections, viruses were considered as prominent pathogens transmitted through
blood transfusion. The risk of transmission of HBV through blood transfusion was found to be
200 per million donations. The purpose of this review is to study the prevalence of hepatitis B
infection among male and female blood donors in developing countries. A comprehensive and
systemic literature search strategies were used to find relevant literature. In a systematic two-step
method, related papers were selected. First, there was a screening of abstracts and titles of all
recognized situations, excluding the articles that did not obviously address the subject of
concern. Secondly, chosen papers were completely evaluated. Among blood donors, males have
prominently high prevalence of hepatitis B as compared to females. This high prevalence in
males was due to large population of males as blood donors as compared to population of female
donors. Hepatitis B was mainly prevalent in blood donors having age ranges from 18- 30 years.
According to blood groups, hepatitis B was prevalent in Rh positive blood groups as compared to
Rh negative blood group.

Keywords: Prevalence, Hepatitis B, Blood donors, Age group.

Chapter 1
INTRODUCTION

[1]
Hepatitis B is an inflammatory liver disease caused by hepatitis B virus (HBV) .
Hepatitis B infection poses a major health issue as it causes serious liver infections including
[2]
acute hepatitis, chronic hepatitis, cirrhosis and carcinoma of liver .Hepatitis B has become a
leading cause of mortality and morbidity around the globe. Hepatitis B causes infection of 2
billion peoples of world's population and 350 million people suffer from chronic hepatitis B and
approximately 0.6 million people die every year due to hepatitis B [1].
HBV, the causative agent of hepatitis B infection belongs to family Hepadnaviridae. HBV
is 42 nm in size and contain incomplete double stranded DNA as a genetic material. HBV is
considered as silent killer as most of the carriers not realized its presence in body unless it cause
massive deterioration. HBV is considered 10 times more infectious as compared to Hepatitis C
virus and 50 times from human immunodeficiency virus [3].
HBV uses different transmission routes in order to cause hepatitis B among individuals.
Transmission of HBV can occur through blood, body fluids, perinatal and blood contaminated
[4]
material including syringes, blades and razors . Other methods by which HBV can be
transmitted were transfusion of unscreened blood, ear piercing and dental extraction [5].
Host response in case of pathogenesis and recovery of HBV infection mainly depend upon
adaptive immune response of the body. In adaptive immune response, both humoral and cellular
parts play their respective roles. Cellular immune plays the major role in removing of virus
infected cells while humoral immune response contributes in clearing of circulating virus
particles and their spreading within the host [6].
HBV does not causes pathological effects in infected hepatocytes as it is not a cytopathic
virus. Hepatocytes damage in HBV infections were caused by hepatitis B specific Cytotoxic T
cells. In order to remove viral infection, Cytotoxic T cells not only killed of infected hepatocytes
but also produce large amount of various cytokines in order to remove viral infection [7].
Clinical symptoms related to HBV include acute and chronic hepatitis depending upon the
duration of infection. Fever, nausea, vomiting, jaundice and abdominal pain were the general
symptoms seen during hepatitis infection. In acute infection, body immune system showed
vigorous response and remove infection from body while in case of chronic infection, persistent

1
presence of virus causes severe complications including carcinoma of liver and end stage liver
disease [8].
Among transfusion transmitted infections, viruses were considered as prominent pathogens
transmitted through blood transfusion. Hepatitis B, hepatitis C, Human immunodeficiency virus
and West Nile viruses were included in transfusion transmitted virus infections. Among all, the
risk of transmission of HBV through blood transfusion was found to be 200 per million
donations [9] and the prevalence of HBV among blood donors was found to be highest followed
by HIV and HCV [10].
The prevalence of HBV infection was found to be increasing in developing countries like
Cameroon. The prevalence of HBV among blood donors was increasing with time with 10.7% in
2001 and 11.2% in 2014. In 2014, positive cases of HBV among male and female blood donors
were 10.5 % and 1% respectively showing high prevalence in males as compared to female
donors [11].
Diagnosis of HBV can be done by using different methods. Enzyme linked immunosorbent
assay (ELISA), chromatography devices and polymerase chain reaction (PCR). In order to make
rapid diagnosis, immuno chromatography (ICT) devices were frequently used as these devices
were economically be used. For accurate and error less diagnosis, ELISA and PCR was
preferable as compared to these ICT devices [12].
Among blood donors, before transfusion a donor's blood is screened for HIV, hepatitis B,
hepatitis C, syphilis and malaria. For HBV screening, ELISA method is used for detection of
HBsAg and anti- HBc. Antibody against hepatitis b core antigen can detect the infection present
in window period. Other methods can be used for the confirmation of HBV by checking the
presence of HBV DNA by performing PCR [13].
In this background this study was planned to find the prevalence of hepatitis B infection
among blood donors in developing countries.

2
Chapter 2
REVIEW OF LITERATURE

A study was conducted in Nigeria in order to find prevalence of hepatitis B virus

infection among blood donors. 14.3 % of blood donors were positive for HBV infection. The
prevalence of HBV infection was higher in males as compared to females. Blood donors having
20-30 years of age were show higher prevalence as compared to other age groups [14].
In Ghana, a country in West Africa the prevalence of HBV infection was 7.5 % among
blood donors. Among these blood donors, the prevalence of HBV infection in females was
higher as compared to males. No specific reasons were mentioned for this higher prevalence of
HBV infection in females' blood donors [15].
In 2016, the prevalence of 4 blood borne pathogens including hepatitis b virus among
blood donors was evaluated in Sierra Leone. Among these pathogens, the prevalence of HBV
infection was 9.7%. This prevalence was found to be high in males (10%) as compare to females
(8%). The highest cases of these blood borne pathogens were found among blood donors with 18
to 27 years of age [16].
The prevalence of HBV infection was found to be increasing in developing countries like
Cameroon. The prevalence of HBV among blood donors in Cameroon was increasing with time
with 10.7% in 2001 and 11.2% in 2014. In 2014, positive cases of HBV among male and female
blood donors were 10.5 % and 1% respectively. This high prevalence in males showed that the
main transmission of HBV may be due to use of contaminated shaving blades by barbers. Age
group of 21 to 30 years was prominently affected with HBV infection as this age group may be
involved in unprotected sexual activities [11].
In Ethiopia, the prevalence of common blood borne pathogen was noted in a period of four
years from 2010 to 2014. During this period, the prevalence of HBsAg among blood donors was
9.48 % with 9.35 % among males and 0.13 % in females blood donors. Among different blood
groups, HBV infection was highly prevalent in A negative and B negative blood groups followed
by O positive blood group and least prevalent in AB negative blood group [17].
In Tehran, prevalence of hepatitis B among blood donors in association with different
blood groups was 0.39 % during a period of 6 years. Among all blood groups, hepatitis B was
found to be high among Rh positive donors as compared to Rh negative donors. Among Rh

3
positive, hepatitis B were more frequent among AB positive followed by B positive, A positive
and O positive blood donors. Among Rh negative donors, O negative were mostly affected by
HBV infection followed by B negative, A negative and AB negative [18].
The prevalence of HBV infection in Duhok city of Iraq was found to be 0.78 %. In this
study, all HBsAg positive blood donors were males with average age of 30 years. The HBsAg
positive donors were show the history of dental extraction, surgical procedure, blood transfusion
and tattooing [19].
Association of blood groups with different infections including HBV and HCV were
noted in Baghdad, a capital city of Iraq, among blood group donors. Rh positive blood group
showed high prevalence of HBV as compared to Rh negative blood group. Blood group O
showed high prevalence followed by B blood group, A blood group and AB blood group. Age
group 26-45 years age group showed high frequency of HBsAg among blood donors [20].
In Kashmir, the prevalence of HBV and HCV was noted during a period of 10 year. The
overall prevalence of HBV was 0.48 % during period of 10 years. Seroprevalence of HBsAg was
high among males as compared to females. During this period, a decreasing trend was found
because of implementation of awareness and immunization programmes [21].
In Pakistan, prevalence of transfusion transmitted pathogens including HBV, HCV,
syphilis and HIV among blood donors showed that HBV infection were highly prevalent in O
negative blood group followed by B negative blood group. Other blood groups showed high
prevalence was AB positive followed by A positive and B positive [22].
According to WHO guidelines, countries are categorized on the basis of hepatitis B
prevalence as high, intermediate and low endemic countries with 8%, 7-2% and less than 2%
respectively. A study on blood donors in Karnataka region of India showed that male donors
were frequently give positive as compared to females having prevalence of 0.65% and 0.25%
respectively. Most of the HBV positive donors were belong to age less than 35 years [23].
In Tamil Nadu, HBV among blood donors have prevalence of 3.5% with males as a
prominent gender having positive screening test. Among these, routes of transmission and blood
group were also analyzed. O blood group was prominently noted along with B blood group.
Highest rate of transmission were noted for blood donors used contaminated blades by barbers,
history of surgery, tattooing and ear piercing [24].

4
 In one of the study to compare prevalence of different blood transmitted pathogens among
blood donors was conducted. The findings showed the comparison of HBV, HCV and HIV.
Among these pathogens, HBV was frequently present as compared to other two pathogens.
Gender wise distribution was high for males with prominent age group of 17 – 40 years [25].
In China, most effected population of blood donors having positive test for HBV was 18-
25 years and on second number age group of 26-35 years with male gender having high
prevalence as compared to females. Over all prevalence was noted about 2.3% [26].
In Bangladesh, occurrence of HBV among blood donors was 1.5 % with all positive cases
in males. According to blood groups, Rh positive were mostly affected as compared to Rh
negative group with O positive blood group as a prominent group followed by A positive and B
positive [27].
In Congo, rate of occurrence of HBV in blood donors was 3.9 % with male as a
prominent gender showing positive reaction for hepatitis B screening. The majority of blood
donors having positive serology report were belongs to 18-38 years [28].

5
Chapter 3
MATERIALS AND METHODS

Systematic literature search:

A systematic search of the literature was performed in abstracts meetings of PubMed,
MEDLINE and Google Scholar. Papers mentioned in this review have been recognized from the
authors, databases and complemented by 1997–2018 searches on PubMed, Google scholar and
internet publications. It included only peer-reviewed, English-language publications. The
keywords Hepatitis B, transfusion transmitted infections, prevalence and blood donors were used
in different combinations.

Selection of articles:
In a systematic two-step method, relevant papers were chosen. First, there was a
screening of abstracts and titles of all identified references, excluding the articles that did not
obviously address the subject of concern. Secondly, chosen papers were completely. The
systematic review did not include articles that did not meet our area of interest nor had
inadequate information for assessment. Articles that met predefined requirements for
incorporation have been systematically evaluated and quality assessed.

Sample Processing:

Among selected articles, processing of sample for performing screening of hepatitis B

among blood donors were performed including serological investigation with HBsAg, anti-HBc
Ag detection and Polymerase chain reaction for presence of HBV DNA.

6
Chapter 4
RESULTS

Hepatitis B has become a common liver infection around the globe. Hepatitis B virus, a
causative agent of hepatitis B is a prominent blood borne viral pathogen other than HCV and
HIV. As a blood borne pathogen, HBV can transmit through blood transfusion. This transmission
can make it compulsory for the screening of HBV in all blood donors.
In our study, we have reviewed the articles related to prevalence of hepatitis B among
males and females blood donors in developing countries. Hepatitis B has become a prevalent
disease among blood donors of developing countries. In this gender wise and age wise
prevalence of hepatitis B among blood donors was noted
Among blood donors, males have prominently high prevalence of hepatitis B as
compared to females [Figure 4.1].This high prevalence in males was due to large population of
males as blood donors as compared to population of female donors. Hepatitis B was mainly
prevalent in blood donors having age ranges from 18- 30 years [Figure 4.2]. Majority of
population of blood donors were belong to this age group showing high prevalence of hepatitis
B.
According to blood groups, hepatitis B was prevalent in Rh positive blood groups as
compared to Rh negative blood group. No specific reasons were found for this prevalence in Rh
positive blood groups. In blood donors, transmission of HBV was due to having history of
barbers visit, dental extraction, surgery, tattooing and ear piercing [Figure 4.3].

7
 12.00%

10.50%
10.00% 10.00%
9.35%

8.00% 8%

6.00% males
females

4.00%

2.00%
1%
0%
0.00%
Ethiopia Cameroon Sierra leone

Figure 4.1:Prevalance of hepatitis B infection among male and female blood

donors.

Prevalance of hepatitis B is found to be high in male gender as compared to

female gender of blood donors.

8
 5.30%

19.20%
38.10%
25-19
35-26
45-36
45<

37.40%

Figure 4.2: Frequency of hepatitis B among different age groups of blood donors

Frequency of hepatitis B among different age groups has been showed. Among these
age groups, age group (19-25) has high frequency followed by (26-35) age group of blood
donors.

9
 Ear piercing, (2%)

Surgery, Barbers
(5%) visit, (10%) Barbers visit
Tattooing
Surgery
Ear piercing
Tattooing, (7%)

Figure4.3: Different ways of transmission of hepatitis B among blood donors

Among blood donors, history of different transmission routes was found

including barbers visit, surgery, tattooing and ear piercing. Prominent transmission route was
barbers visit as they used contaminated blades as a source of transmission.

10
 New
Kanpur Delhi
14% 17%
Kolkatta New Delhi
10% Kerala
Madurai
Kerala Maharashtra
Maha-
19% Kolkatta
rashtra
14% Kanpur

Madurai
25%

Figure4.4: Prevalence of HBV among blood donors in different regions of India

India is one of the most populated developing country and having high prevalence of
HBV among blood donors present in different cities. Madurai showed the prominent prevalence
for HBV.

11
Chapter 5
DISCUSSION

The prevalence of hepatitis B varies from nation to nation and region to region. Hepatitis B
is the most common viral disease encountered in health care sector. Hepatitis B accounts for
prominent cause of illness around the globe. Each year approximately 0.6 million people die
every year due to hepatitis B [1].
Transfusion of blood in a health care sector is an important procedure which requires
proper measures for the safe transfer of blood from a donor to recipient. Screening of blood was
done in order to check the presence of pathogens including HBV, HCV and HIV in a blood
donor. For the screening, most commonly ICT and ELISA methods were used for the detection
of HBV presence in blood donor [12].
The prevalence of hepatitis B in males and females showed that the hepatitis B was
highly prevalent in males' donor population as compared to female donor population. The ratio
may vary but it has a constant trend. The reason for high prevalence in males was due to the fact
that majority of donors were males and very low number of females were selected for blood
donation because of various physiological factors. Physiological factors which limit the females
to donate blood were pregnancy, breast feeding and common anemic condition in females due to
menstrual blood loss.
Among all reviewed articles, prevalent age group of blood donors showing positive
results were belong to range of 18 to 35 years. As a blood donor must feel strong during donation
so majority of blood donors were young and this high population belongs to above mentioned
age group. Other parameter including blood group variation showed that Rh positive blood
donors have high prevalence as compared to Rh negative. For this, no specific reasons were
found in blood donors.
In this background, efforts must be produced to monitor secular patterns of prevalence
of hepatitis B infection among male and female blood donors in developing countries.

12
Chapter 6
CONCLUSION
Among blood donors, males have prominently high prevalence of hepatitis B as
compared to females. This high prevalence in males was due to large population of males as
blood donors as compared to population of female donors. Hepatitis B was mainly prevalent in
blood donors having age ranges from 18- 30 years. According to blood groups, hepatitis B was
prevalent in Rh positive blood groups as compared to Rh negative blood group. No specific
reasons were found for this prevalence in Rh positive blood groups. In blood donors,
transmission of HBV was due to having history of barbers visit, dental extraction, surgery,
tattooing and ear piercing.

Future recommendations:

For safe transfusion and donation of blood, appropriate policies, preventive measures and
care improvement should be implemented. For evaluation of trends of this disease, nationally
representative surveys must be ordered for improving public awareness. Additionally, significant
trend, epidemiology and transmission of disease among male and female blood donors are
needed to be studied.

13
Chapter 7
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16