Assessment of the seroprevalence of viral hepatitis B,viral hepatitis C and HIV in multitransfused thalassaemia major patients in Karachi,Pakistan

Abstract

This cross-sectional study reveals the seroprevalence of hepatitis B, hepatitis C and HIV in multi-transfused thalassemia major patients. Thirty-four out of 79 (43.0%) patients enrolled in the study serologically tested positive for hepatitis C (mean ± standard deviation age = 12 ± 4.1 years), four (5.1%) for hepatitis B and none for HIV. Some of the measures that should be adapted are: safe blood transfusions; awareness programmes through print and electronic media; and the early screening of such hazardous infections.

Introduction

Beta thalassaemia is the most prevalent genetic disorder of haemoglobin synthesis. It has 5% to 7% carrier rate in Pakistan.¹ Different studies estimate that the number of thalassaemia major patients born each year is of the order of 4000–9000.² Lifelong blood transfusions predispose the patient to complications of iron overload and transfusion transmitted infections such as HIV, hepatitis B and hepatitis C, of which hepatitis C poses a major problem. A community-based survey showed 14.63% seropositivity for anti-hepatitis C virus (HCV) antibodies.³ There is a lack of precise data pertaining to seroprevalence of transfusion transmitted infections in thalassaemia major patients in Pakistan and we believe this is the first study about this subject.

Methodology

This cross-sectional study was conducted over a three-month period from July to September 2009, at the Paediatric Emergency Unit (PEU), Civil Hospital, Karachi, Pakistan. The setup of the hospital requires that the thalassaemia major patients visit the PEU for their routine follow-ups and transfusions. The ethical approval was given by the ethical review board of the Dow University of Health Sciences. The sampling technique was non-probability purposive sampling. All thalassaemia major patients who presented during July to September 2009, who had undergone more than 10 transfusions without a screening during the previous 12 months, were included in the study after giving informed written consent. Those who did not fulfill the criteria were excluded from the study.

The parents of the patients were interviewed using a well-structured questionnaire. The first section comprised the demographic variables and the second part included the history of vaccination and the patient's blood group. After the interview a blood sample was obtained and sent for serological analysis of hepatitis B, hepatitis C and HIV. The hepatitis C was tested using Murex anti-HCV fourth generation ELISA method, hepatitis B surface antigen (HbsAg) through Murex third generation ELISA and HIV through p24 antigen and antibodies against HIV1 and HIV2. The tests were repeated for patients whose results were either positive or borderline for hepatitis B and C.

SPSS version 15 was used for data feeding and analysis. The results are given in the text as number and percentages for qualitative data and mean and standard deviation for quantitative data. A chi-square test was used for comparison of qualitative data (gender, education of parents, etc.) and a student t-test for comparison of quantitative data (i.e. age). In all statistical tests, a P value <0.05 was considered as significant.

Results

Of 79 enrolled patients, 46 (58.2%) were males and 33 (41.8%) were females (Table 1). The mean age was 10.8 ± 4.4 years (range 2 to 18 years). The results highlight the educational status of the parents: 78.8% had education less than the Matric and a monthly income below 10,000 Pakistani Rupees (PKR) (Approximately US$123). The vaccination history is reflective of the prevailing situation in the country, with less than half (45.5%) stating that they had had their children vaccinated for hepatitis B.

Table 1

Characteristics of patients who tested positive for hepatitis C

Variables	No. of patients	Hepatitis C +ve
Variables	No. of patients	No.	(%)
Gender
Male	46	19	(41.3)
Female	33	15	(45.4)
Age (years)
Under 5	13	2	(15.4)
5 to 9	18	2	(11.1)
10–14	37	27	(72.9)
15-above	11	3	(27.3)
Blood groups
A	17	5	(29.4)
B	21	8	(38.1)
AB	2	1	(50.0)
O	39	20	(51.3)
Education of the carer
Illiterate	31	14	(45.2)
Primary	31	13	(41.9)
Matric	12	5	(41.7)
Graduate	5	2	(40.0)
Socioeconomics (monthly household income – Pakistani Rupees)
Less than 3000	26	7	(26.9)
3000–5000	19	13	(68.4)
5000–10,000	29	10	(34.5)
10,000–20,000	5	4	(80.0)
Status of house
Own	60	29	(48.3)
Rented	19	5	(26.3)
Vaccination for hepatitis B
Done	36	18	(50.0)
Not done	43	16	(37.2)

Out of 79 patients, 34 (43.0%) tested positive for hepatitis C, four (5.1%) were hepatitis B-positive, two (2.53%) showed a co-existent hepatitis B and hepatitis C infection and none were HIV-positive.

The frequency of hepatitis C was 19 (41.3%) out of 46 for the males and 15 (45.4%) out of 33 for the females (P > 0.05). The seroprevalence of hepatitis C increased with age (and the corresponding increased number of transfusions)–62.5% of those with hepatitis C were aged 10 years and above. The mean ± standard deviation age of the hepatitis C-negative patients was 9.0 ± 4.5 years compared to 12.0 ± 4.1 years for hepatitis C-positive patients. Interestingly, the vaccination for hepatitis B was slightly higher (50%) in the hepatitis C-positive patients. The education and monthly household income were found to be similar to the results mentioned above.

Discussion

The study population represents multitransfused thalassaemia major patients of the PEU, Civil Hospital, Karachi, Pakistan, where local inhabitants and patients from far flung areas come for transfusions.

Our results showed an astonishing 43.03% seroprevalence of antibodies against HCV. These results are in striking contrast to comparable studies done in the recent past. Ocak et al. (Turkey) reported a 4.5% prevalence of antibodies against hepatitis C in a study conducted on multitransfused thalassaemia major and sickle cell anemia patients.⁴ A report by De Paula et al. showed similar results – 16.7% seroprevalence of hepatitis C infection in a Brazilian population.⁵ Hepatitis C is widespread in Pakistan. The seroprevalence of hepatitis C in previous studies of specific areas of Pakistan was in the order of 14.63%.³

Another significant finding was that the preponderance of the patients with hepatitis C positive were aged 10 years or older (80%). More than 60% of the patients who tested negative were under 10 years of age. This shows that the probability of transmission increases with age and number of transfusions undergone.

In our study 5.1% patients tested positive for hepatitis B surface antigen with a mean age of 8.7 years. The improved results compared to hepatitis C can be attributed to vaccination. Jamal noted a 2.4% prevalence of hepatitis B in multitransfused thalassaemia patients in Malaysia.⁶ In our study only 44.8% of the patients had been vaccinated. This is in disparity to not only international standards but also some of the earlier studies from Pakistan. Jafri et al. reported a greater than four-fifths vaccination rate in a study of Karachi children.⁷ This dismal result may be due to the low education level of the patients.

Despite the unsatisfactorily high seroprevalence for HCV and the values of HbsAg being below par with comparable studies, none of the patients tested positive for HIV. This could be because Pakistan, like other Islamic countries such as Malaysia⁶ and Saudi Arabia,⁸ comes within the zone of low prevalence of HIV. The study in India⁹ among thalassaemics receiving numerous transfusions reported an HIV antibody prevalence of 2.5%.

Conclusion

Thalassaemia lays a huge burden on not only the patients but also the whole family. The presence of a co-morbidity such as viral hepatitis exacerbates their suffering. Improved screening techniques, superior surveillance methods, and the availability of print and electronic media have greatly lessened transfusion transmitted infections in the industrial countries and most of the developing countries. It is imperative that we address the above mentioned shortcomings in order to protect future generations from this suffering.

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