European Journal of Cardiovascular Medicine

In 1965, while investigating human serum lipoprotein allotypes, Blumberg discovered a new antigen in the serum of an Australian aborigine. This antigen produced a clear, defined line of precipitation when reacted with sera from two haemophiliacs who had undergone multiple blood transfusions. The antigen was initially named the "Australia antigen." By 1968, it was determined that the "Australia antigen" was linked to serum hepatitis. Further research revealed that it was the surface component of the hepatitis B virus (HBV), and the name was subsequently changed to hepatitis B surface antigen (HBsAg).¹

HBV is highly infectious and transmitted mainly through blood, body fluid contact and vertical transmission. It is also known that hepatitis B is 50 to 100 times more infectious than HIV (Human Immunodeficiency Virus).² It is the prototype member of the Hepadnaviridae (hepatotropic DNA virus) family and has a strong predilection for infecting liver cells. HBV virions are double-shelled particles, 40-42 nm in diameter, with an outer lipoprotein envelope that contains envelope glycoproteins (or surface antigens). The most abundant protein on the virion surface is the 24 kDa hepatitis B surface antigen (HBsAg) or S protein. The virus causes 60%-80% of all primary liver cancers, which is one of the top three causes of cancer deaths in the East and Southeast Asia Region, the Pacific Basin and Sub-Saharan Africa.³ Members of this family of viruses have a narrow host range and predominantly infect hepatocytes in their respective hosts. HBV infection can be either acute or chronic and may range from asymptomatic infection or mild disease to severe or rarely fulminant hepatitis.⁴

Acute hepatitis B is marked by acute inflammation and hepatocellular necrosis, with a case fatality rate of 0.5–1%.⁴ Unlike its chronic variant acute hepatitis B is usually a self-limiting disease. Chronic hepatitis B infection is defined as persistent HBV infection with or without associated active viral replication and indication of hepatocellular injury. ⁴ Persistent HBV infection would mean the existence of hepatitis B surface antigen (HbsAg) in the blood or serum for longer than six months. Age plays an important role in chronic infection; risk of chronicity is more in neonates and young children than in infection that is acquired in adulthood. Around the world, majority of people who have chronic hepatitis B acquired the infection at birth or in early childhood. Chronic HBV infection has a myriad presentation and outcome. In some people, it is inactive and does not lead to any significant liver disease (chronic carrier state). In others, it may gradually lead to fibrosis and ultimately end in cirrhosis and end-stage liver disease. In others, it acts as a trigger for hepatocellular carcinoma (HCC).³ 

WHO estimates that 254 million people were living with chronic hepatitis B infection in 2022, with 1.2 million new infections each year. In 2022, hepatitis B resulted in an estimated 1.1 million deaths, mostly from cirrhosis and hepatocellular carcinoma (primary liver cancer).⁵ The prevalence of HBV infection varied from high(≥ 8%) to intermediate(2-7%) and low(<2%).⁶ In India, HBsAg prevalence among the general population ranges from 2 to 8%, which places India in an intermediate HBV endemicity zone, and India with 50 million cases is also the second largest global pool of chronic HBV infections.⁷

A hospital based retrospective cross-sectional study was carried out in a tertiary care hospital in a rural area over a period of 1 year from May 2023 to April 2024. All patients admitted for various elective surgeries across departments of General Surgery, ENT, Ophthalmology, and Orthopaedics were screened for Hepatitis B Surface Antigen (HBsAg). Demographic data including age, gender, marital status, literacy and socioeconomic status were collected. Socioeconomic status was calculated using the modified BG Prasad's Classification for 2024.Any relevant history regarding hepatitis B infection was also noted. 

For the testing procedure, 3 ml of venous blood were collected from each patient under all aseptic precautions and left at room temperature to clot. The serum was then separated using low-speed centrifugation to obtain a clear supernatant. Two drops (70 μL) of serum were tested for the presence of HBsAg using a rapid one-step immunoassay test kit (HEPACARD manufactured by J. Mitra and Company Private Limited., India) which is based on antigen capture (sandwich) principle. Results were read after20 min.

In this test, the patient’s serum flows through the membrane assembly of the device, where a monoclonal anti-HBsAg colloidal gold conjugate forms a complex with any HBsAg present in the sample. As the complex continues to flow through the membrane, it is captured by another monoclonal anti-HBsAg antiserum immobilized in the test region, leading to the formation of a pink-purple coloured band. The appearance of two pink bands, one in the test region and one in the control region, indicates a positive result. A single pink band at the control region alone indicates a negative result as shown in Figure 1

Fig. 1. Immunochromatographic test results for HBsAg detection

The collected data were entered and organized in Microsoft Excel for analysis. The Chi-square test was performed to assess associations between categorical variables, with a P-value of ≤ 0.05 considered statistically significant.

A total of 11,131 pre-surgical patients undergoing elective surgery were screened for HBsAg using the Immunochromatographic Test (ICT) over the one-year study period.

Out of these a total of 231 patients were found to be positive for HBsAg. This constitutes a total seroprevalence of 2.07% among the presurgical patients in the major surgical specialities at a tertiary care centre as shown in Figure 2.

Fig. 2. Distribution of positive cases among the total tested for HbsAg

Out of 231 positive patients, 160 (69.2%) were married and 71 (30.7%) patients were unmarried. Majority of the patients belonged to socioeconomic Class 3 (31.6%), followed by Class 4 (23.4%) and Class 5 (22.1%). The majority of the patients were illiterate (34.6%) followed by education up to primary school (29.4%). Majority (58.2%) of the patients were agricultural workers with 76.9% males and 24% females. The majority (76 %) of female patients were homemaker. No statistical significance was however found in these parameters. None of the patients presented with signs and symptoms of hepatitis. All cases were found on routine screening.

Out of the 231 patients who were seropositive for HbsAg, Of the seropositive cases, 170 (73.6%) were males and 61 (26.4%) females. The seroprevalence among males and females was 2.42% and 1.48%, respectively. This difference was found to be statistically significant (P = 0.0008). Gender distribution among positive cases is illustrated in Figure 3 and Table 1.

Fig. 3. Gender distribution among the positive cases

Table 1. Gender-wise seroprevalence of HBsAg among preoperative patients

The age distribution showed that most seropositivity was found in the age group of 21-40 accounting for 37% of the cases followed by 41-60 years with 33% of cases. The extremes of age showed lower positivity with 24% in the above 60 category and 6% among 0–20-year age group.  This was also found to be statistically significant (p = 0.004) .This is depicted in the Table 2 below.

Table 2. Age distribution among the cases in relation with Hepatitis B

As shown in Figure 4, the majority of positive cases were observed in the 21-40 (85 cases) age group, followed by the 41-60 (77 cases) and >60 (56 cases) age groups. Also, the seropositivity was 2.6% for 0-20 age group, 2.01%,1.6% and 3.5% for the other groups respectively.

Fig. 4. Age range among the positive cases

Among the reactive inpatients, majority were found to be admitted to General surgery (34.2%), followed by Orthopaedics (27.7%) and ENT (24.2%). However, this difference was not found to be statistically significant. This is depicted in the table 3.

Table 3: Distribution of patients admitted in various wards and association with Hepatitis B infection

Of the 231 cases positive for HBsAg, 2 cases (1.29%) were found to be positive for HCV (hepatitis C Virus) also and 1 case (0.4%) had coinfection with HIV (Human Immunodeficiency virus). Both the cases of coinfection with HCV had history of multiple transfusions.

Table 4: Coinfection of Hepatitis B with Hepatitis C and HIV infections

The prevalence of Hepatitis B (HBsAg positivity) in our study was found to be 2.07%, which is consistent with findings from various studies conducted in different regions. For instance, Nahvi N et al.⁸ reported a prevalence of 1.88% in a study from Northern India. Similarly, MK Lohano et al.⁹ found a prevalence of 2.54% in preoperative ophthalmology cases, while Kayalı S et al.¹⁰ observed a prevalence of 2.6% in a large cohort of 25,978 surgical patients. Conversely, a study conducted in Ethiopia by Taye M et al.¹¹ reported a much higher prevalence of 9%, which can be attributed to Ethiopia's status as a high-burden country for Hepatitis B, with a national HBsAg prevalence of 35.8%. In a hospital-based study by Vazhavandan G et al.¹² in South India, 1.61% of the 19,513 sera tested were found to be HBsAg-positive. Similarly, Mohan et al.¹³ reported a prevalence of 2.09% in their study.

The present study also found a higher prevalence of HBsAg positivity in males compared to females. This observation aligns with the findings of Datta et al.¹⁴, who reported a male positivity rate of 35.3% compared to 19.3% in females. P. Jain et al.¹⁵ also noted a higher prevalence in males, with 62.54% of male participants testing positive, compared to 23.22% in females. In the study by Vazhavandan et al.¹², the seroprevalence in males was 73% (230 cases), while only 27% (85 cases) were females. These trends are consistent with our own findings, which demonstrate a higher seroprevalence among men. The possible reason for this higher male preponderance could be from a higher exposure of males to risk factors such as illicit drug use and multiple sexual partners due to their employment away from their homes. It has been reported that females tend to clear HBsAg from their plasma more efficiently as compared to males.¹⁶

In terms of age distribution, this study identified the highest seroprevalence in the age group of 21-40 years. Similar results have been observed in other studies, which report the maximum seropositivity within this age range: 40.39%¹⁷, 53.35%¹⁸, and 45.07%.^{12, 13} This can likely be attributed to the increased exposure to risk factors and inadequate awareness regarding Hepatitis B prevention, particularly in rural areas, where individuals in this age group may be more vulnerable to acquiring the infection. The higher prevalence among 21-40 years age group could be due to higher exposure to occupational risk factors as well as high risky behaviour among young individuals.^{16, 17}

Our study found prevalence of HBsAg was higher among married individuals. This is in accordance with Khatoon et al¹⁶ who found 72.5% 0f their participants to be married. However, there are other studies that show increased prevalence in unmarried attributed to promiscuous behaviour.

The number of illiterate individuals were higher in our study and found to concur with Khatoon et al¹⁶. This may be because of the rural setting of our study. Most of our participants were less educated and engaged in agricultural work. This combination of rural living, illiteracy and agricultural background could lead to increased possibility of medical consults with unskilled medical practitioners, tattooing and other high-risk behaviour.

Most of our patients were from the General surgery department. Khatoon et al had an increased number from the Orthopaedic department. This may be due to the load in the department and does not seem to be significant.

HCV is a single stranded RNA virus belonging to genus Hepacivirus and family Flaviviridae. Most common modes of transmission include exposure to small quantities of blood during injection drug abuse, unsafe injection practices and use of unscreened blood and blood products. Owing to similar modes of transmission HBV and HCV co infection has been reported in high-risk patients screened before surgery with a worldwide prevalence of 1-15%^8,11. Our study found a prevalence of 1.29% while Nahvi et al found 0.3% cases with coinfection of HBV and HCV.

Human Immunodeficiency virus (HIV), the causative agent of acquired immunodeficiency syndrome (AIDS) is an RNA virus belonging to the family retroviridae and genus lentivirus. Again, owing to shared modes of transmission, chronic coinfection with HBV is common among people with HIV. Globally, an estimated 8% to 10% of people with HIV have chronic HBV infection, although the prevalence of coinfection varies significantly by region¹⁹. In our study the prevalence was 0.4 %.

These findings are consistent with those of various authors from different geographical regions, highlighting the importance of preoperative screening for Hepatitis B to identify at-risk individuals and implement appropriate infection control measures and to avoid other infections with similar transmission.

Hepatitis B Virus (HBV) is one of the most prevalent viral infections worldwide, affecting approximately 350-400 million people, with an estimated 1 million deaths annually due to its complications.⁵ The prevalence of HBV varies by country, influenced by a combination of behavioural, environmental, and host factors. Generally, it is lowest in countries with high standards of living, such as Australia, North America, and Northern Europe, and highest in regions with lower socioeconomic levels, including China, Southeast Asia, and South America.⁵ By 2030, it is projected that chronic HBV could result in 17 million deaths globally.²⁰ Vaccinating healthcare workers and the general population with the HBV vaccine is the most effective, cost-efficient, and accessible preventive measure.¹⁰

HBV is often asymptomatic, making it a ‘silent’ disease that can spread through even minute amounts of infected blood, underscoring the need for accurate and rapid diagnosis, particularly in asymptomatic individuals. In resource-limited settings, rapid immunoassay tests may be the only feasible diagnostic option. Healthcare workers, especially surgeons, are at an increased risk of acquiring bloodborne infections due to frequent exposure to blood and percutaneous injuries. In 2000, percutaneous injuries led to 66,000 HBV infections among healthcare workers.²¹ Choosing appropriate screening tests, taking proper precautions, and ensuring the safe disposal of biomedical waste are essential strategies to reduce the transmission of these viral infections.

Preoperative testing for HBsAg is crucial to identify patients who are carriers of the Hepatitis B virus (HBV), even if they are asymptomatic. Detecting HBsAg provides valuable information about the risk of transmission to healthcare workers, other patients, and during surgical procedures. It also informs clinical management decisions, such as the need for antiviral treatment, and ensures appropriate infection control practices.  Routine HBsAg screening in preoperative patients should be considered an essential practice, particularly in intermediate-to-high endemic areas. This approach facilitates early identification, minimizes nosocomial transmission, and helps protect both healthcare workers and patients.

Acknowledgement

The authors would like to express their sincere gratitude to the administration and medical staff of NRI Institute of Medical sciences for their support and cooperation throughout the study.

Conflict of Interest

The authors declare that there is no conflict of interest related to this study. No financial support, grants, or sponsorships were received, and there are no personal or professional relationships that could have influenced the research.

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