A Cross-Sectional Study of Anti-Hepatitis B Antibody Status in STD Patients: Need for Improved Immunization.

Sir,

Hepatitis B virus (HBV) infection has been a vaccine-preventable disease since the early 1980s. In India, HBV carriage is a major health problem with a 2-8% prevalence of Hepatitis B surface antigen (HBs Ag) in general population[1] and 3.7% among antenatal mothers.[2] Joyee et al. reported 25.9% HBsAg positivity in STD clinic patients from Chennai.[3] Risbud et al. reported 3.6% and 26.5% positivity for HBsAg and anti-HBsAntibody (Anti HBsAb) respectively, in STD patients.[4] The National Guidelines on Prevention, Management and Control of Sexually Transmitted Infections envisage that the partner of a STI patient should be referred for voluntary counseling and testing for HIV, syphilis, and Hepatitis B.[5] However, the vaccination is not routinely recommended or offered.

Although a high HBV infection rate in STD clinic patients has been documented;[35] meager data are available from Delhi. The present study was initiated with an aim of determining the awareness about HBV infection or its vaccination; and its sero-prevalence among STD clinic attendees of a tertiary care hospital In East Delhi, India. It was a cross-sectional, analytical study carried out in the Departments of Dermatology and Microbiology, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, on symptomatic STD clinic attendees between January and August 2012. All patients clinically diagnosed to have an STD were recruited in the study after obtaining informed consent. Their details based on socio-demographic characteristics, health care awareness and use, risk behavior, immunization coverage, and sexual practices were recorded.

Semiquantitative analysis of anti-HBs antibodies for hepatitis B was done by a commercially available ELISA kit following manufacturers’ instructions [ANTISURASE B-96 (TMB) General Biologicals Corp., Taiwan]. HBs antigen and HIV antibody detection was done in all the study participants as per the standard protocol followed in the STD clinic. Any patient with HBsAb positivity was considered immune to HBV (which can be because of a resolved infection or previous vaccination).[6] Any patient with HBsAg was considered HBV infected. A total of 60 patients diagnosed with STD were included in the study. The study group comprised 31 females (51.67% cases), 25 males (41.67% cases), and 4 transgenders (6.66% cases). The demographic profile of the cohort is depicted in Figure 1. The profile of STDs seen in the group is depicted in [Figure 2]. A total of four patients tested positive for HBs Ag (6.66%) and 13 patients tested positive for anti-HBs Ab (21.66%). Both these groups were mutually exclusive. None of the anti-HBsAb-positive patients had received immunization in the past. Seven of our patients tested positive for HIV (11.06%). None of the patients were aware of the risk of transmission of hepatitis B through sexual route. Also, none of these 60 patients were vaccinated against hepatitis B. Thus, a total of 28.2% were either infected with or exposed to HBV. This signifies a high risk of HBV acquisition; and coupled with a history of no vaccination, this indicates an alarming situation. The prevalence of HBs Ag positivity in our study group was similar to the report by Sarkar et al.;[7] however, the additional data about Hbs antibody positivity suggest a much higher prevalence than previously assumed.

Figure 1

Demographic profile of STD clinic attendees (n = 60)

Figure 2

Profile of STD patients included in the study (n = 60). GMC = Genital molluscum contagiosum, CA = Condyloma acuminata, NGU = Non-gonococcal urethritis, RHPG = Recurrent herpes progenitalis, BV = Bacterial vaginosis, NGC = Non-gonococcal cervicitis, VVC = Vulvo-vaginal candidiasis, PID = Pelvic inflammatory disease, HPG = Herpes progenitalis

Although, a lot of IEC (Information, Education and Communication) activities for STI patients focus on HIV; HBV remains relatively ignored. Our study shows that much work needs to be done in this regard, to raise the level of awareness of health care workers and STI clinic attendees regarding the availability and need of HBV vaccine in previously unvaccinated individuals.

This study suffers from the limitation of sample size. A lack of controls, as well as data from a restricted geographical area are other potential confounders. Only patients diagnosed with an STI were included. However, it goes to show that the risk of HBV transmission is high in this subgroup and HBV vaccination in this cohort may be a much needed intervention to strengthen STD control programs in India.

The high rate of HBV infection in adults attending STI clinics strongly emphasizes the need for routine HBV vaccination for high-risk groups. Future research could address ways of providing better education and counseling to STD clinic attendees; ensuring availability of routine vaccination facilities at the centre itself; investigating compliance with a shortened vaccination schedules; and investigating the need for boosting these short schedule vaccines to ensure better coverage of the target population.