HBsAg AND HCV: INCREASING TEST REQUESTS AND DECREASING FREQUENCY OF POSITIVE TESTS AT CLINICAL LABORATORY OF AYUB TEACHING HOSPITAL, ABBOTTABAD

Sirajuddin Hassan Ally, Ruhila Hanif*, Ayesha Ahmed

Department of Pathology and *Biochemistry, Ayub Medical College, Abbottabad

Background: This audit was carried out to assess the frequency of positive results out of the total test requests made for HBsAg and HCV at our laboratory. The frequencies for three years were compared for significance. We have reported monthly total test requests and frequency of positive tests for each of these years in this article. Methods: This study is an audit of all HBsAg and HCV test requests received at clinical laboratory of Ayub Teaching Hospital, Abbottabad during a three year period from 2002-2004. Both the tests were made using Rapid device (immunochromatographic kits) method. Frequencies of positive results were calculated from the total test requests for each month of these three years. Cumulative frequencies were compared for statistical significance of difference. Results: Total HBsAg tests requested for years 2002, 2003 and 2004 were 2058, 2563 and 5207 respectively. The frequencies of HBsAg positive cases out of these were 5.53%, 4.36% and 2.68% respectively. The number of test requests for HBsAg increased significantly from 2002 to 2003 and 2004, while the frequency of positive tests decreased significantly (p<.001) during this period. Total HCV requests for years 2002, 2003 and 2004 were 1261, 1671 and 4638 respectively. The frequencies of HCV positive cases out of these were 14.19%, 8.79% and 5.84% respectively. Just like HBsAg, number of test requests for HCV increased significantly from 2002 to 2003 and 2004, while the frequency of positive tests decreased significantly (p<.001) during this period. Conclusions: The test requests have considerably increased in the last few years, probably as a result of increasing awareness of clinicians and public. However most of these tests are negative. In view of high prevalence of both HBsAg and HCV in Pakistan, this overcautious attitude of clinicians is understandable although this is a burden on the pocket of patients and hospital resources.

Keywords: HBsAg, HCV, Microbiology, Audit, Clinical laboratory


INTRODUCTION

Hepatitis B (HBV) and C (HCV) are rapidly emerging as major health problems in developing countries including Pakistan. Chronic liver disease (CLD) is a major cause of mortality in Northern Pakistan where HCV infection is the main cause of chronic liver disease followed by either HBV or a combination of these viruses.1 HBV and HCV are prevalent in Hazara2,3 and other parts of NWFP,4 like the rest of Pakistan. HCV is a leading cause of chronic liver disease in some parts of the country where still the leading risk factor identified is the use of contaminated syringes by quacks.5 The overall seroprevalence of HCV in male volunteer blood donors has been reported from Karachi to be 1.8%.6 The awareness campaigns have gained momentum in the last few years but still level of awareness is very low. Knowledge of “high risk” professionals like barbers about hepatitis and risks of transmission is very low and their practices like reuse of razor that may spread hepatitis are very common.7 The objective of this study was to determine the frequency of HBsAg and HCV positive tests from the total requests received at our laboratory and to compare the yearly trends for significance of difference.

MATERIAL AND METHODS

This audit was carried out at Microbiology section of Clinical Laboratory of Ayub Teaching Hospital, Abbottabad. This 1000 bed tertiary care hospital is the main teaching hospital of Ayub Medical College. All the laboratory investigations from wards (in-patients) and OPD (outdoor) are referred to clinical laboratory. In addition other primary and secondary care hospitals of the area refer to this laboratory for many investigations. We calculated frequency of HBsAg and HCV positive tests out of the total test requests for each month of the years 2002, 2003 and 2004. The total test requests and frequencies of positive cases were then compared for significance at a confidence level of 95% using chi square test. Both HBsAg and HCV were detected using immunochromato-graphic assay (one step rapid assay kit/rapid Device method).


Table-1: Frequency of HBsAg positive cases out of the total tests requested in the years 2002, 2003 and 2004

 

 

Month

2002

2003

2004

Total Tests Done

Total No. of Positive (%)

Total Tests Done

Total No. of Positive (%)

Total Tests Done

Total No. of Positive (%)

January

151

7 (4.6%)

177

5 (2.8%)

244

5 (3.2%)

February

113

6 (5.3%)

98

8 (8.1%)

229

8 (3.5%)

March

164

11 (6.7%)

194

6 (3.0%)

415

7 (1.6%)

April

155

12 (7.7%)

188

6 (3.1%)

468

13 (2.7%)

May

177

12 (6.7%)

204

10 (4.9%)

477

21 (4.4%)

June

215

17 (7.9%)

186

7 (3.7%)

584

12 (2.0%)

July

211

12 (5.6%)

217

16 (7.3%)

515

12 (2.3%)

August

218

11 (5.0%)

303

13 (4.2%)

525

10 (1.9%)

September

134

4 (2.9%)

317

14 (4.4%)

513

16 (3.1%)

October

225

11 (4.9%)

285

13 (4.6%)

419

8 (1.9%)

November

151

5 (3.3%)

141

8 (5.7%)

325

15 (4.6%)

December

144

6 (4.1%)

253

6 (2.4%)

493

13 (2.6%)

Total

2058

114 (5.53%)

2563

112 (4.36%)

5207

140 (2.68%)

Analysis for table-1

Total HBsAg tests requested:

Total tests received in year 2003 were significantly more than the total tests received in 2002 (p<0.001)

Total tests received in year 2004 were significantly more than the total tests received in 2002 (p<0.001) and 2003 (p<0.001)

Frequency of positive cases calculated out of total tests:

Frequency of positive cases out of total tests in year 2003 was significantly less than the total tests received in 2002 (p<0.001)

Frequency of positive cases out of total tests in year 2004 was significantly less than the total tests received in 2002 (p<0.001) and in 2003 (p<0.001)

 

Table-2: Frequency of HCV positive cases out of the total tests requested in the years 2002,2003 and 2004

 

 

Month

2002

2003

2004

Total Tests Done

Total No. of Positive (%)

Total Tests Done

Total No. of Positive (%)

Total Tests Done

Total No. of Positive (%)

January

80

13 (16.2%)

94

9 (9.5%)

189

17 (8.9%)

February

68

11 (16.1%)

121

8 (6.6%)

191

20 (10.4%)

March

112

20 (17.8%)

124

6 (4.8%)

384

21 (5.5%)

April

111

29 (26.0%)

118

10 (8.4%)

392

30 (7.7%)

May

123

11 (8.9%)

137

13 (9.4%)

392

23 (5.9%)

June

133

22 (16.5%)

119

14 (11.7%)

307

25 (8.1%)

July

119

12 (10.0%)

147

15 (10.2%)

455

33 (7.3%)

August

87

08 (9.1%)

186

22 (11.8%)

451

26 (5.8%)

September

92

16 (17.3%)

212

21 (9.9%)

455

26 (5.7%)

October

142

12 (8.4%)

229

13 (5.6%)

391

13 (3.3%)

November

103

16 (15.5%)

107

9 (8.4%)

301

18 (6.0%)

December

91

9 (9.8%)

77

7 (9.0%)

460

19 (4.1%)

Total

1261

179(14.19%)

1671

147 (8.79%)

4638

271 (5.84%)

Analysis for table-2

Total HCV tests requested:

Total tests received in year 2003 were significantly more than the total tests received in 2002 (p<0.001)

Total tests received in year 2004 were significantly more than the total tests received in 2002 (p<0.001) and 2003 (p<0.001)

Frequency of positive cases calculated out of total tests:

Frequency of positive HCV cases out of total tests in year 2003 was significantly less than the total tests received in 2002 (p<0.001)

Frequency of positive cases out of total tests in year 2004 was significantly less than the total tests received in 2002 (p<0.001) and in 2003 (p<0.001)

RESULTS AND DISCUSSION

The results of this audit are summarized in tables 1 and 2. In case of both HBsAg and HCV the test requests showed a highly significant (p<.001) increase while frequency of positive tests showed a significant (p<0.001) decline from 2002-2004.

The major limitation of our study is that we did not report the history or presenting complaints of our subjects (reason for test request) as in our hospital the trend is to not to send patient history with the test requests. We have tried at different levels to introduce forms for test requests but they are generally filled by not the requesting clinician but by the nurses. However patients of CLD form the largest group of test requests. In addition voluntary blood donors being tested for suitability also form a major group. Similarly people who have any HBsAg or HCV positive close relative want themselves to be tested. Therefore we have restricted our objectives and results to test requests and positive results only.

Our study shows a clear trend of increasing test requests from 2002 to 2004. It reflects increasing will of the clinicians to diagnose presence of HBV and HCV in all relevant scenarios. This over cautiousness is result of government and WHO sponsored campaigns directed at creating awareness in public and in the medial professionals. Surprisingly despite of all the awareness campaigns used syringes, unsafe blood transfusion and barbers still remain most important risk factors for spread of the disease in Pakistan.7 Unsafe blood transfusion in obstetrics cases has been reported from Karachi as a major cause of transmitting HCV.8 Transmission rates of hepatitis C virus (HCV) infection through non-sexual household contacts have been considered to be very low. However a local study has reported that non-sexual household exposure may play a role in efficient HCV spread to household contacts of HCV-infected persons and needs further evaluation.9

No local studies on trend analysis of general population are available however trend analysis of male volunteer blood donors has revealed a significant (P < 0.001) linear increase in proportions of HCV-seropositive donors from 1998 to 2002.6 Another study on blood donated by healthy donors from both Armed Forces and civilian population over a five years period at an Army transfusion facility, reported that 3.3% out of 103858 blood donors were HBsAg while 4.0% were anti HCV.10 It has been reported that seroprevalence of antibodies to HCV in health workers are 20 folds higher than health workers in the developed countries. Similarly, the prevalence of HBV although not as high as HCV has been reported as “significant”.11

We have found a trend of increasing test requests at our hospital. Although our sample is not true representative of our country or even for our region, but we feel this trend will go a long way in controlling this “hidden epidemic” of two deadliest causes of CLD in our country. We are reporting this study with a recommendation to carry out proper statistical trend analysis in all major clinical laboratories. This will have a confidence building booster effect on the organizations trying to control these menaces through extensive campaigns. 

CONCLUSIONS

The test requests have considerably increased in the last few years, probably as a result of increasing awareness of clinicians and public. However most of these tests are negative. In view of high prevalence of both HBsAg and HCV in Pakistan, this overcautious attitude of clinicians is understandable although this is a burden on the pocket of patients and hospital resources.

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10.     Khattak MF, Salamat N, Bhatti FA, Qureshi TZ. Seroprevalence of hepatitis B, C and HIV in blood donors in northern Pakistan. J Pak Med Assoc 2002;52(9):398-402.

11.     Aziz S, Memon A, Tily HI, Rasheed K, Jehangir K, Quraishy MS. Prevalence of HIV, hepatitis B and C amongst health workers of Civil Hospital Karachi. J Pak Med Assoc 2002;52(3):92-4.

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Address For Correspondence:

Dr. Sirajuddin Hassan Ally, Department of Pathology, Ayub Medical College, Abbottabad. Pakistan

Email: ayesha@ayubmed.edu.pk