Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

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Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2021 | Month : July | Volume : 15 | Issue : 7 | Page : DC10 - DC14 Full Version

Seroprevalence of Hepatitis B Virus Infection among the Tribal Population of Attapady, Kerala, India


Published: July 1, 2021 | DOI: https://doi.org/10.7860/JCDR/2021/48444.15079
Irene Jose Manjiyil, Kavitha Paul Konikkara

1. Assistant Professor, Department of Microbiology, Government Medical College, Thrissur, Kerala, India. 2. Associate Professor, Department of Microbiology, Government Medical College, Thrissur, Kerala, India.

Correspondence Address :
Kavitha Paul Konikkara,
Associate Professor, Department of Microbiology, Government Medical College, Thrissur, Kerala, India.
E-mail: kavithageejo@gmail.com

Abstract

Introduction: Hepatitis B Virus (HBV) infection remains a significant global health concern that may cause acute or chronic hepatitis. Chronically infected patients are at risk for cirrhosis and hepatocellular carcinoma. The disease causes a problem in the tribal communities. There are lack of studies on the prevalence of HBV among the tribal population.

Aim: To assess the seroprevalence of HBV infection among the tribal population of Attapady, Kerala.

Materials and Methods: This was a community based cross- sectional study conducted on serum samples collected from 269 subjects among the tribal population of Attapady. Serum samples were tested for quantitative antibody to HBsAg (anti-HBs), Hepatitis B surface antigen (HBsAg) and Hepatitis B envelope antigen (HBeAg) Enzyme Linked Immunosorbent Assay (ELISA). Total hepatitis B core antibody (anti-HBc) and IgM antibody to hepatitis B core antigen (anti HBc IgM), frequencies were obtained using proportion and 95% Confidence Interval (CI).

Results: The seroprevalence of HBsAg was 10.4%. HBeAg was detected in 7.1% of HBsAg positive patients. A 21.2% had protective anti-HBs titre. Anti-HBe was detected in five patients. Anti-HBc total and anti-HBc IgM were positive for 26.7% and 2.6%, respectively. Anti-HBc IgM alone and isolated anti-HBc were detected in 1.5% and 5.9%, respectively. Anti-HBs and anti-HBc total both became positive in 8.6% cases.

Conclusion: The HBV infection poses a huge burden on tribal health. All HBsAg positive patients should be tested further to determine the stage of the disease. There is need to explore high HBV prevalence areas with studies on associated risk factors to bring out the ongoing transmission process and focus on preventive measures. HBV vaccination, antenatal screening, and health awareness should be given priority to tackle the burden.

Keywords

Enzyme linked immunosorbent assay, Hepatitis B surface antigen, Serology

The HBV infection is a significant public health problem (1). HBV, an enveloped DNA virus belongs to the family Hepadnaviridae (2). It causes a spectrum of diseases ranging from self limiting hepatitis to acute fulminant hepatitis and chronic hepatitis that can lead to liver cirrhosis, hepatic failure and hepatocellular carcinoma (3).

The World Health Organistaion (WHO) has divided the world into three areas where the prevalence of chronic HBV infection is high (>8%), intermediate (2-8%), and low (<2%) (4). According to the WHO, the Western Pacific Region and African Region have the highest prevalence of 6.2% and 6.1% of the adult population, respectively, while the American region has the lowest prevalence of 0.7% (5). Nearly, 80-90% of infants were infected with HBV during the first year of life and 30-50% of children were infected with HBV before six years of age who of them developed chronic HBV infection (5). The risk of chronicity in those infected as adults is <5% and 20-30% of them developed cirrhosis and/or liver cancer (5). Although, acute HBV infection can be severe, serious consequences occur more in chronically infected persons. Eventhough, a large number of chronically infected patients remain symptomless, still they can transmit the infection to healthy ones (6).

Infection with HBV is mainly transmitted parenterally through infected blood and blood products (1). Infection is also transmitted by both vertical and horizontal routes. Occupational transmission of HBV from infected patients to healthcare and public safety workers is also important (3),(7).

The HBV infection create a large burden on tribal health. The tribal population of India, as per 2011 census, is 10.43 crores, constituting 8.6% of the total population (8). Kerala is also home to many primitive tribes. As per 2011 census, scheduled tribe population in Kerala is 4.85 lacs, which accounts for 1.45% of the total population of the state (8). The prevalence of HBV infection among the tribal communities is much higher worldwide (10-30%) (9). This has been attributed to inbreeding, unhygienic living conditions, illiteracy, low immunisation rates, long close contact with HBV infected persons and some sociocultural practices like tattooing, ear/nose piercing (10).

The evolution of serological markers following HBV infection is complex and depends largely on host immune response. Serodiagnosis of HBV infection involves testing a panel of HBV specific antigens- Hepatitis B surface antigen (HBsAg) and Hepatitis B envelope antigen (HBeAg) and antibodies- antibody to HBsAg (anti-HBs), antibody to HBeAg (anti-HBe) and antibody to HBcAg (anti-HBc IgM and IgG). At least one serological marker is present in all phases of infection. Only 9% of HBV infected persons have been diagnosed worldwide (11).

The HBsAg is the first serological marker to appear in acute HBV infection (2). Routine screening for HBV infection is primarily based on the detection of serum HBsAg. It is the commonly done test for the diagnosis of acute HBV infection and carrier state (12),(13). Serological assays are commercially available for all HBV markers except for HBcAg. The presence or absence of a combination of these viral markers helps to know whether the patient has acute, resolving, chronic infection or whether the person is immune or susceptible to HBV infection.

To the best of our knowledge, there is no published data on the seroprevalence of HBV infection among the tribal population of Attapady, Palakkad district of Kerala, India. Most of the studies in the literature were focused to detect only the seroprevalence of HBsAg (1),(3). In this study, as an initial effort to know the burden of HBV infection, all the HBV serological markers were evaluated among the accessible tribal population of Attapady, Kerela, India.

Material and Methods

A community based, cross-sectional study was conducted for a period of one year from July 2016 to June 2017 in Government Medical College, Thrissur, Kerala, India, after getting due approval from the Institutional Ethical Committee (IEC).

Sample size calculation: A HBsAg prevalence of 28.8% was reported among the tribal population of Agali and Pudur areas of Attapady following a Hepatitis B outbreak investigation conducted by a medical team from Government Medical College, Thrissur in June 2014. As per the formula, n=4pq/l2, the minimum sample size for the present study was calculated as 228.

For this study, out of the 28 primary health subcentres in Attapady, six subcentres were selected by lottery method. Forty-five participants from each subcentre were selected by simple random sampling method. Medical camps were conducted at these subcentres with the help of the Health Service Department.

Inclusion and Exclusion criteria: All the available members in the household who gave informed consent were included in the study. Informed consent from their parent/guardian was taken in case of a minor subject. And those who cannot attend the medical camp due to physical disability were excluded. Blood samples were collected from 270 study subjects, one blood sample was lysed and so, the study was carried out with 269 participants.

Study Procedure

Approximately, 5 mL of the venous blood sample was collected from each participant under aseptic precautions. The samples were transported in the cold chain to Microbiology Laboratory, GMC Thrissur. Blood samples were centrifuged, sera separated and transferred into sterile vials and stored at -200C till the test was performed. All serum samples were tested for the detection of HBsAg, anti-HBc total and anti-HBc IgM. Quantitative anti-HBs was estimated for HBsAg negative samples. HBsAg positive sera were tested for HBeAg.

All viral markers were tested employing commercially available ELISA kits. HBsAg was detected using Meriscreen ELISA kits. Quantitative anti-HBs, anti-HBc total, anti-HBc IgM, HBeAg and anti-HBe were tested by ELISA kits manufactured by DIA-PRO Diagnostics Bioprobes Srl (Italy). Tests were performed as per the manufacturer’s instructions. Detection of anti-HBs titre of ≥10 mIU/mL is considered a correlate of vaccine induced protection and adequate immunity (14). Based on the presence or absence of the serological markers detected, participants who were susceptible or immune to infection, or in different stages of HBV infection was identified (Table/Fig 1) (4),(15),(16),(17),(18).

Statistical Analysis

The data obtained was entered into Microsoft Excel and analysed using Statistical Package for the Social Sciences (SPSS) statistical software version 16.0. Frequencies were obtained using proportion and 95% Confidence Interval.

Results

In this study, 269 participants between 1 and 75 years of age were included. Majority of them, (40.5%) belonged to the 21-30 years of age group. There were 185 (68.8%) females and 84 (31.2%) males. There were 153 females among the reproductive age group (15-49 years of age) which accounted for 56.9% of the participants. There were 36 antenatal women. (19.5% of women participants). The (Table/Fig 2) shows the age wise distribution of participants.

All the 269 samples were tested for HBsAg. Serum HBsAg was detected in 28 participants. The seroprevalence of HBsAg in this study was found to be 10.4% (95% CI:7.42-13.4). The highest HBsAg seroprevalence was found to be among 21-30 years age group (14.7%), followed by those among 31-40 years of age (11.1%). Among the 185 females tested, HBsAg was positive for 21 females (11.4%). Among 153 females in the reproductive age group, 20 of them were HBsAg positive (13.1%). Only one, among 36 (2.8%) antenatal women was HBsAg positive. Out of 84 males tested, seven were HBsAg positive (8.3%). All HBsAg positive cases in the present study showed positivity to one/other serological markers of HBV.

The HBeAg detection was done for all (28) HBsAg positive patients. HBeAg was detected in two among 28 HBsAg positive patients (7.1%). One antenatal patient and a 10-year-old patient was HBeAg positive (Table/Fig 2).

(Table/Fig 3) shows the age wise prevalence of HBV antibodies- anti-HBs, anti-HBc total, Anti-HBc IgM. Quantitative estimation of anti-HBs was done for all HBsAg negative samples (n=241). Anti-HBs titre above 10 mIU/mL was considered to be protective. Out of the 241 subjects whose serum anti-HBs estimation was performed, 51 (21.2%) had a titre above 10 mIU/mL. Among the participants in the age group of 0-10 years, 56.7% had a protective anti-HBs level. Anti-HBs was the only serological marker detected in 22 subjects (9.1%). Anti-HBs level below 10 mIU/mL was detected in 190 subjects (78.8%). Anti-HBe could be done only for 13 patients who were HBeAg negative but, among them five cases were positive. Anti-HBc total and anti-HBc IgM were tested for all participants. Anti-HBc total was positive for 72 (26.7 %) and anti-HBc IgM was positive for seven cases (2.6%). Anti-HBc IgM alone was positive in four cases (1.5%). Anti-HBc total alone was positive for 16 (5.9%) cases. Anti-HBs and anti-HBc total both were positive in 23 (8.6%) cases while all the other markers tested were negative. In this study, 170 (63.2%) subjects were negative for all the HBV serological markers tested. The (Table/Fig 4) shows the different patterns of serological marker positivity detected in this study participants with possible interpretation.

Discussion

In this study, 269 participants between 1 and 75 years of age were included. There were 185 (68.8%) females and 84 (31.2%) males. This higher female participation in the present study could be explained by the fact that adult males were at their workplace during day time when we collected the blood samples. Similarly, in previous studies conducted tribal population with higher female gender composition has been explained as dual households are common among tribal groups and adult males go out for work during daytime (19),(20),(21).

Seroprevalence of HBsAg in this study was 10.4% (95% C.I: 7.42-13.4). Hence, according to the WHO classification, present study area has a high HBsAg prevalence (4). The majority of HBsAg positive cases were between 21-30 years of age. The higher seropositivity after the second decade of life may be due to their greater exposure and social interactions. Gokale SK et al., and Trupti BN et al., have reported the highest incidence of HBsAg among 21-40 years of age and the lowest among 0-20 years of age (22),(23). In this study, only one HBsAg positive case was detected among 0-10 years of age. The lower prevalence of HBsAg seen in the younger age group in the present study could be due to the effect of Hepatitis B vaccination. The proportion of children under five years age with chronic HBV infection was estimated to be under 1% (5).

Seroprevalence of HBsAg among males and females was 8.3% and 11.4%, respectively. HBsAg was positive in 13.1% of females among the reproductive age group. A higher HBsAg prevalence (22.6%) in females was reported in the hilly tribes of Himachal Pradesh (19). Even though the clearance is better in females, no sex predilection has been attributed to HBV infection (19). Seroprevalence rate was reported higher in males in some studies (3),(24).

Among 36 antenatal women tested in this study, only one was HBsAg positive (2.8%). This higher prevalence rate may be due to the less sample size of antenatal women studied. Data on recent HBsAg seroprevalence among antenatal women of tribal population of south India is restricted in the literature. HBsAg positivity among pregnant women of Nicobarese tribe of Andaman and Nicobar Islands was reported as 20.5% (9). Studies conducted in different states of India among antenatal women of general population during 2011 to 2019 has revealed a decreasing trend in HBsAg seroprevalence rate towards the end of the decade (25),(26),(27).

Though, the HBV prevalence is intermediate in India, it is reported very high among some isolated tribes (Table/Fig 5) (9),(10),(19),(20),(21),(28),(29),(30),(31),(32). In this study, 170 subjects (63.2%) were negative for all the markers tested and might have never infected with HBV and hence, identified as susceptible population.

Quantitative estimation of anti-HBs was done for all HBsAg negative samples. A protective anti-HBs titre above 10 mIU/mL was detected in 51 subjects (21.2%) and 56.7% of them belonged to 0-10 years of age. Anti-HBs is the only serological marker detected in persons who acquire immunity solely due to hepatitis B vaccination (2). Anti-HBs was detected as the only marker in 22 of the participants (9.1%). Anti-HBs titre below 10 mIU/mL was detected in 190 subjects (78.6%) who had no or inadequate immunity. Among the Nicobarese tribe of Andaman and Nicobar Islands, anti-HBs prevalence reported among those in 35-45 years of age and among children below five years of age was 38.1% and 4.3%, respectively (9). Among the Idu Mishmi tribe of northeast India, 57.3% of those in the 6-15 years age group had adequate anti-HBs titre (20).

The HBeAg indicates a high infectivity and its seroconversion to anti-HBe indicates a low risk of disease progression (33). HBeAg and anti-HBe testing should be done only when initial HBV screening turns positive (33). Among the 28 HBsAg positive patients tested for HBeAg, two were HBeAg positive (7.14%). These two patients were positive for HBsAg, HBeAg, and anti-HBc total and considered as HBeAg positive chronic HBV infection. Also, 25 patients (9.3%) were detected to have HBeAg negative chronic HBV infection. Among 13 samples tested, anti-HBe antibodies were detected in five samples.

Though, HBcAg cannot be detected in the serum, anti-HBc is the earliest antibody to develop following acute HBV infection, appearing as anti-HBc IgM. Anti-HBc IgM alone may be detected in early convalescence or window period, when HBsAg has disappeared and anti-HBs not yet appeared (17). IgM anti-HBc usually denotes acute infection (2). However, it may be detected in low levels during reactivation of chronic hepatitis as well (15).

In present study, anti-HBc IgM was positive in seven of the patients (2.6%) and majority of them belonged to 21-30 years of age. We detected four cases (1.5%) positive for anti-HBc IgM alone and not to any other markers tested and might be in early convalescence or window period. Testing for anti-HBc IgM is important in the diagnosis of HBV infection in the window period in places where HBV DNA testing is not feasible (17).

Among 269 subjects, one (0.4%) particular case positive for HBsAg, anti HBcIgM and anti-HBc total antibodies and negative for HBeAg was detected. This patient might be having an acute HBV infection or acute exacerbation of chronic infection (15). Also,one (0.4%) HBsAg negative case with serological evidence of anti-HBc IgM and anti-HBs was detected and was considered as HBsAg negative acute HBV infection. Anti-HBc IgM in patients with HBsAg negative hepatitis with or without anti-HBs indicates acute HBV infection (34).

The serological test of choice for establishing past HBV infection is anti-HBc antibody (18). In this study, 72 cases (26.7%) were positive for anti-HBc total antibodies and majority of them belonged to 21-30 years of age. This anti-HBc prevalence of 26.7% among apparently healthy persons at a community level suggested pockets of high HBV transmission in this study area. The persistence of infection in the older age groups may be due to the fact that they might have acquired infection early in life as they had no access to HBV vaccination at that time. Anti-HBc antibodies were detected in 78% of those among 25-34 years of age in the Nicobarese tribe of Andaman and Nicobar Islands (9). A hyperendemic focus of HBV infection with a high anti-HBc prevalence (95.9%) among 6-15 years of age group was reported from an isolated tribe in northeast India (20). In this study, among the participants, 23 (8.6%) were found to be positive for both anti-HBc total and anti-HBs and were immune due to resolved past HBV infection.

In present study, 16 cases (5.9%) of isolated anti-HBc which were negative for HBsAg and anti-HBs but positive for anti-HBc. Isolated anti- HBc is defined as the presence of IgG anti-HBc in the absence of detectable HBsAg and anti-HBs (18). The quantitative anti-HBs titre of all these patients detected was very low and ranged from 0.0 to 5.4 mIU/mL. We could rule out the possibility of a resolving acute HBV infection as these 16 samples were negative for anti-HBc IgM. Another possibility considered particularly in an HBV endemic population was a distant resolved HBV infection with waning or undetectable anti-HBs titre. Thirdly, some patients with isolated anti-HBc may have Occult HBV Infection (OBI) with undetectable HBsAg levels, but the presence of HBV DNA in the liver and may be at risk of liver cirrhosis or hepatocellular carcinoma (18). Being the strongest predictor of progression to cirrhosis and hepatocellular carcinoma, HBV DNA should be tested to find out OBI (12). Hepatitis B screening without inclusion of anti-HBc antibodies can potentially miss a significant number of OBI cases and/or a history of past infection in the endemic population. Another possibility of a false positive result, especially in people with a low risk of past HBV infection should be kept in mind (15),(35). We also considered the possibility of passive transfer of maternal anti-HBc in children below three years, but none of them were among this age group (35).

In the present study, the seroprevalence of HBsAg was found to be highest among 21-30 years of age. HBeAg was detected in 7.1% of HBsAg positive patients. Protective anti-HBs titre was detected in majority among 0-10 years of age. Anti-HBc total and anti-HBc IgM were positive for 26.7% and 2.6%, respectively. Anti-HBe was detected in five patients. This HBV prevalence suggested pockets of high HBV transmission in this tribal area.

Limitation(s)

Authors could not study the risk factors associated with HBV infection among the study subjects. Also, HBV DNA tests could not perform on the participants or screen for sequelae of HBV infection, primarily hepatocellular carcinoma due to financial limitation.

Conclusion

The findings strengthened the need to explore such areas of high HBV prevalence within Kerela. Unless persons are tested and diagnosed, such unseen pockets of transmission will remain active. Hepatitis B screening programs mainly test for HBsAg only. This study shows the need to include other HBV serological markers especially anti-HBc and anti-HBc IgM. All HBsAg positive patients should be tested further to determine the disease stage and screen for sequelae, primarily hepatocellular carcinoma. The data shows that HBV vaccination reduces the chances of childhood infection and thereby chronic infection.Vaccination may be considered for the susceptible population of this study. Efficient HBV vaccination, antenatal screening and awareness about infection and lifestyle modifications, especially among such high-risk populations should be given prime concern for disease control. Studies with detailed workup on the risk factors associated with HBV infection among high risk communities is essential to bring out the ongoing transmission and focus on preventive measures.

Acknowledgement

Sincere thanks to the people of Attapady who participated in the study and the staff of the Health Service Department, Government of Kerala.

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DOI and Others

10.7860/JCDR/2021/48444.15079

Date of Submission: Jan 08, 2021
Date of Peer Review: Feb 03, 2021
Date of Acceptance: Mar 25, 2021
Date of Publishing: Jul 01, 2021

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

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