|Year : 2016 | Volume
| Issue : 1 | Page : 20-23
Seroprevalence of hepatitis B and C in patients on hemodialysis and their antibody response to hepatitis B vaccination
Anandh Perumal1, Philip Vivian Joseph Ratnam1, Shashikala Nair1, Patricia Anitha1, Veerappan Illangovan2, Reba Kanungo1
1 Department of Microbiology, Pondicherry Institute of Medical Sciences, Puducherry, India
2 Division of Nephrology, K. G. Hospital, Coimbatore, Tamil Nadu, India
|Date of Submission||16-Mar-2016|
|Date of Acceptance||18-May-2016|
|Date of Web Publication||16-Jun-2016|
Philip Vivian Joseph Ratnam
Department of Microbiology, Pondicherry Institute of Medical Sciences, Kalapet, Puducherry - 605 014
Source of Support: None, Conflict of Interest: None
Introduction: Hepatitis B and C viral (HBV and HCV) infections are the most common infections acquired by hemodialysis (HD) patients. The prevalence of HBV and HCV infections in dialysis patients in India is 3.4-43% and 20-80%, respectively. This study was carried out to find out the current prevalence rate of HBV and HCV infections in HD patients in Puducherry.
Materials and Methods: Serum samples from 65 patients with chronic kidney disease, who were admitted to a tertiary care hospital for HD, were screened for hepatitis B surface antigen (HBsAg) and HCV antibodies. The samples were collected on the first visit to the center before starting the dialysis and thereafter periodically. The serological results were correlated with gender, age, and duration of disease. An attempt was made to correlate the evidence of viral infection with clinical evidence of hepatitis, liver profile, and history of any transfusions in the past 3 years.
Results: Among the 65 patients, 14 individuals were found be infected with hepatitis, HBV (5), and HCV (10) accounting for 22%. A single individual was coinfected with both the virus. There was a male preponderance accounting for 77% of patients on dialysis. Hepatitis B vaccination was given to all HBsAg negative patients (77%). Two of the vaccinated individuals were infected with HCV.
Conclusions: Further studies are required to determine risk factors and factors that determine why some escape infection for prolonged periods. Hepatitis B vaccination should be mandatory for individuals undergoing HD.
Keywords: Hemodialysis, hepatitis B, hepatitis C
|How to cite this article:|
Perumal A, Ratnam PV, Nair S, Anitha P, Illangovan V, Kanungo R. Seroprevalence of hepatitis B and C in patients on hemodialysis and their antibody response to hepatitis B vaccination. J Curr Res Sci Med 2016;2:20-3
|How to cite this URL:|
Perumal A, Ratnam PV, Nair S, Anitha P, Illangovan V, Kanungo R. Seroprevalence of hepatitis B and C in patients on hemodialysis and their antibody response to hepatitis B vaccination. J Curr Res Sci Med [serial online] 2016 [cited 2019 Jan 17];2:20-3. Available from: http://www.jcrsmed.org/text.asp?2016/2/1/20/184119
| Introduction|| |
Chronic hepatitis B virus (HBV) infection is one of the common health problems in developing countries. It is estimated that around 350 million people in the world suffer from chronic HBV infection. It poses a major threat to patients on long-term hemodialysis (HD) due to compromised immune system.  HBV infection is one of the most important causes of liver disease in these patients.  The prevalence of HBV among dialysis patients in India is reported to range between 3.4-43%. ,, The incidence of HBV infection in dialysis population has declined the over recent decades, largely because of improvements in infection control and widespread implementation of HBV vaccination. In spite of these preventive measures, outbreaks of infection continue to occur in dialysis units, and prevalence rates remain unacceptably high. For a variety of reasons, dialysis patients are at high risk to acquire HBV infection. They also demonstrate different disease manifestations compared with healthy individuals and are more likely to progress to chronic carriage. HBV is highly infectious compared with other blood-borne viruses. An untreated percutaneous exposure to an infected source carries a risk of seroconversion of up to 30%. 
Hepatitis C virus (HCV) infection is also highly prevalent among patients on HD. The prevalence of HCV infection in HD patients varies markedly from country to country. The prevalence of HCV among dialysis patients in India is reported to range between 20 and 80%.  However, the prevalence of HCV infection in the western countries ranges between 4 and 23.3%. ,,,
Some factors are especially related to these high prevalence rates of HBV and HCV infections such as blood transfusions and duration of dialysis. Nosocomial routes of transmission including the use of contaminated equipment and patient-to-patient exposure are considered to be the risk factors. Several prophylactic measures have been suggested to avoid infection by HBV and HCV in the HD patient. Strict adherence to universal precautions along with isolation of HBV and HCV infected dialysis patients might help to control disease spread in HD units.
HBV infections can be prevented or controlled by vaccination.  However, in HD patients, the response to HBV vaccine is much lower than in healthy individuals due to their poor immunity. It has been observed that around 30-40% HD patients fail to produce antibodies against HBV vaccination.  The percentage of seroconversion is 90% in healthy individuals, whereas in HD patients, it is only 50-70%. Some studies have also shown that there is a decreased immune response to HBV vaccine in patients with HCV infection. 
This study was conducted to detect hepatitis B surface antigen (HBsAg) and HCV antibody in patients undergoing HD in a tertiary care hospital and to detect the antibody levels among these patients who have been vaccinated against HBV.
| Materials and methods|| |
This cross-sectional study was done between March 2014 and February 2015 in the Department of Microbiology at a Tertiary Care Hospital. The study was approved by the Institute Ethics Committee. All patients undergoing repeated HD, admitted to Nephrology Department were included in the study. Patients positive for HBsAg or HCV antibody before HD and patients undergoing HD for the first time were excluded from this study.
Clinical details including transfusion history, transplantation history, vaccination history, and duration of HD were collected. Laboratory parameters such as alkaline phosphatase, alanine transaminase (ALT), and aspartate transferase (AST) were analyzed.
A volume of 5 ml of blood was collected from these patients after obtaining a written informed consent. Samples were tested for HBsAg and HCV antibodies by enzyme-linked immunosorbent assay (ELISA) according to the standard instructions of the kit (HEPALISA and HCV Microlisa, J. Mitra and Co. Pvt. Ltd, New Delhi, India).
Forty blood samples were tested for anti-HBs by enzyme-linked fluorescent assay using commercially available anti-HBs kit (VIDAS Anti-HBs Total Quick, Belgium), in a mini VIDAS system (bioMιrieux, France). Titers <10 mIU/ml were interpreted as negative, and those between 11 and 100 mIU/ml as poor responders and more than 100 mIU/ml as responders.
| Results|| |
Out of 65 HD patients, HBsAg was detected in 4 patients (6%), HCV was detected in 10 patients (15%), HBV and HCV co-infection was detected in 1 patient (2%), and 50 (77%) patients were uninfected [Figure 1]. Among HBV and or HCV-infected HD patients, 87% were males and 13% were females [Figure 2].
|Figure 1: Hepatitis B viral and/or hepatitis C viral infection among patients on repeated hemodialysis|
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|Figure 2: Sex distribution among patients positive for hepatitis B viral and/or hepatitis C viral patients undergoing repeated hemodialysis|
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Six percent of HBV or HCV infected HD patients were in the age group of 21-30 years, 40% of HBV or HCV infected HD patient were in the age group of 31-40 years, 27% of HBV or HCV infected HD patient in the age group of 41-50 years, and 27% of HBV or HCV infected HD patient were in the age group of more than 50 years [Figure 3]. Three HD patients who had a past history of renal transplantation were not infected with HBV and/or HCV.
|Figure 3: Age distribution among hepatitis B viral and/or hepatitis C viral patients on hemodialysis|
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Among 20 patients who had blood transfusion history, two were infected with HBsAg and one was infected with HCV. However, there was no significant difference found between HBV and HCV infected patients compared to uninfected patients, in relation to blood transfusion.
AST, ALT, and ALP values were within normal limit in both infected and uninfected group. Out of 40 patients who completed Hepatitis B vaccination schedule of three doses, 15 patients (37.5%) were nonresponders, 12 patients (30%) poor responders, and 13 patients (32.5%) were responders [Table 1].
|Table 1: Response to hepatitis B vaccination among hemodialysis patients|
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Out of 13 vaccine responders, 8 (61.5%) were male and 5 (38.5%) were female. There was no significant difference in antibody response by age (P > 0.05). Eight (61.5%) of the vaccine responders were above 50 years of age. There was no significant difference in response by duration of HD (P > 0.05). Twelve (92.3%) of the vaccine responders with <4 years duration of dialysis responded to hepatitis B vaccination [Table 2].
|Table 2: Hepatitis B surface antibody response to vaccination in relation to different variables|
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| Discussion|| |
HBV and HCV infections are the most common infections acquired in HD patients. In the present study, the prevalence of HBV infection in HD patients was 6%. Prevalence rates differ in different geographical areas. A study by Burdick et al. showed an HBV prevalence of 0-6.6% across dialysis facilities in Western Europe, Japan, and the USA.  In contrast, a study done in Asian countries found the prevalence of HBV infection to be between 1.3% and 14.6% which is similar to this study. 
HCV prevalence in HD patients varies geographically both within and between countries. Some studies have suggested a decline in HCV prevalence among HD patients in the recent years, mostly due to universal precautions. The present study showed HCV prevalence of 15% among HD patients. Studies by Reddy et al. and Harmankaya et al. showed the prevalence of 4.7% and 5.9%, respectively. , These variations depend mainly on the strict adherence to universal infection control precautions. Adherence to strict infection control and isolation measures also will decrease the HBV and HCV prevalence rate among these patients.
In the present study, HCV (15%) prevalence was higher than HBV (6%) in HD patients, which correlates with an earlier study which reported the prevalence of HCV and HBV to be 20.2% and 13.3%, respectively, in HD patients.  Most of the HBV/HCV infected patients (67%) were in the age group of 31-50 years, but most of the studies including the present study, have not reported any statistical difference of prevalence in different age groups. Higher prevalence of HBV and HCV infection was found among males (87%) as compared to females (13%). Mean values of AST, ALT, and ALP values were found to be within normal limits in both infected and uninfected group in the present study. AST/ALT levels may often be low in patients with chronic renal failure on HD, a feature that is found in uninfected patients also. Transaminase levels are rarely used for the detection of liver disease in these patients because they are usually low even in patients with normal hepatic function and histology who are on dialysis. Hence, the presence of similar values in positive and negative patients in this study should not be considered as being unusual.
The blood transfusion data of HD patients showed that HBV and HCV infected patients had received significantly low number of blood transfusions compared to the uninfected patients which was contradictory to report of Natov et al., which showed more number of transfusions in HCV-infected patients.  However, another Indian study by Salunkhe et al. had not shown any difference in this context, and hence, it is difficult to establish a correlation between the number of transfusions and the HBV/HCV infections. 
Three types of response patterns against Hepatitis B vaccination were found in the present study. They were nonresponders (37.5%), poor responders (30%), and good responders (32.5%). Although vaccination offers significant protection against HBV infection, vaccine response rates are low and unpredictable in dialysis patients. Because of the impaired immune response, HD patients are given larger doses of the vaccine and sometimes revaccination to produce adequate antibody titer. 
| Conclusions|| |
Chronic renal failure patients who undergo repeated HD are at high risk of developing HBV and HCV. They need to be monitored for the early detection of these infections. To decrease the transmission of infection, the patients need to be segregated from the infected patients in the hospital and separate dialysis units have to be used for these infected patients. Prevention of uninfected patients with Hepatitis B vaccination and treatment for HCV-infected persons will decrease morbidity.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]