Hepatitis B in Pregnant Females. A Cross Sectional Study in Nile Delta, Egypt

Background Hepatitis B is a classied as of intermediate endemicity. has high materno-fetal transmission. The aim of this study was to assess hepatitis B virus infection in Egyptian pregnant females in Nile Delta as regards risk factors and magnitude of the Methods: This cross sectional study was performed on 1948 pregnant females. Historical and sociodemographic data were collected through short simple questionnaire. They were screened for hepatitis B surface antigens. Positive ones were subjected to test hepatitis B e antigen and viral load by real time polymerase chain reaction. Results: Thirty patients (1.54%) were hepatitis B surface antigen positive. Only two of them (6.67%) were hepatitis B e antigen positive with high viral load. Others were hepatitis B e antigen negative and low viral load. Family history of hepatitis B, occupation, age more than 27 years, and history of surgical or dental procedures were signicant risk factors associated with hepatitis B acquisition.


Background
Hepatitis B virus infection (HBV) is a serious infection, and is considered within the most fatal ten health problems [1,2]. It is one of the silent killers because many people are not aware that they have HBV infection [3]. About Two billion people have history of HBV infection whatever chronic carriers, or previous infection. Acute hepatitis B can lead to fulminating hepatitis. Chronic HBV causes 700000 deaths yearly because it can be complicated with hepatocellular carcinoma even without cirrhosis, liver cirrhosis, and liver failure [4].Hepatitis B surface antigen (HBsAg) is the main marker to detect the presence of infection; also, it helps in screening and studying the prevalence of the virus in speci c area or speci c group of people [5]. In Egypt, HBV is considered intermediately endemic in 2010, with prevalence between 3 to 11% mainly in males [6].
Hepatitis B virus can be transmitted perinatally. Pregnant women infected with hepatitis B can transmit the infection to their new born during pregnancy or delivery [7]. This is associated with little knowledge about hepatitis B and absence of HBV screening in antenatal care units [8]. The risk of mother to infant transmission can reach up to 51% in Egypt [9]. The presence of active hepatitis, positive HBeAg, or high viral replication increases the risk of materno-fetal transmission [10]. However, giving the newborn a dose of hepatitis B immunoglobulin (HBVIG) and the rst dose of vaccine on the rst day of birth will decrease the risk that infant will have HBV infection to 10% [11]. In addition, HBV can cause maternal mortality mainly in developing countries [12]. In Egypt, routine HBV vaccination was started in 1992 on 2, 4, and 6 months of age. However, routine HBV screening in pregnant women did not take place [13]. These factors encourage the importance of addition of HBV screening using HBsAg to antenatal care program [14]. This study aimed to assess hepatitis B virus infection in Egyptian pregnant females in Nile Delta as regards risk factors and magnitude of the problem.

Methods
This was a cross sectional study performed between September 2019 to September2020.Pregnant females came asking for antenatal follow up in Tanta University Hospital within this period were included in the study. This study was performed in accordance with the Declaration of Helsinki. Approved of Ethical Committee, Faculty of Medicine, Tanta University was obtained before the study.

Data collection and processing
Participants were asked to answer short questionnaire (as shown in Table 1) consisted of historical data, sociodemographic data, history of HBV vaccination, and history of exposure to one or more risk factor for HBV acquisition. Screening for HBV infection was done for all participants by HBsAg using ELISA (Murex HBsAg Version 3, Diasorin, Italy). Females who were HBsAg positive were subjected to other investigations including HBeAg and HBV DNA viral load. HBeAg was detected using (ETI-EBK PLUS, Diasorin, Italy). HBVDNA viral load was detected by real-time polymerase chain reaction (PCR). HBV-DNA was quanti ed by real-time detection polymerase chain reaction primers. The detection limit was 20 IU/ml.

Statistical analysis
Statistical analysis was done using SPSS (version 22.0, IBM, New York, USA). Descriptive analysis of data was expressed in the form of number and percentage. Categorical data were analyzed using Chisquare test with Yate's (continuity). Fisher , s Exact test was used if one or more expected value <5. The set point of alpha level was 5% with signi cance level 95%, and a beta error accepted up to 20% with a 80% power of study [15].Univariate and multivariate analysis using binary logistic regression were done to evaluate the signi cance of risk factors for HBV infection.

Results
This study was performed on 1948 pregnant females. Their age ranged between 18-46 years, with mean age (27.93+5.75). There were 1519 (78%) from rural areas, and 429 (22%) from urban areas. Primigravida cases were 455 (29%), and multi gravid cases were 1463 (71%). HBsAg positivity was detected in 30 (1.54%) of them. There were directed to follow up in units of viral hepatitis and to perform full investigations. On performing of HBeAg and HBVDNA, only two cases were HBeAg positive with high HBVDNA>200000 IU/ml (Immunotolerant phase), and they were advised to come to take treatment in rst trimester to prevent fetal transmission. Other cases were HBV carriers with HBeAg negative and were advised to make follow up every six months. Table 2, comparison of questionnaire elements between HBV cases and others showed a signi cant difference in age, family history of HBV, history of HBV vaccination, working in health care elds, and history of dental procedures. Logistic regression analysis (univariate and multivariate analysis) showed that the most signi cant risk factors associated with HBsAg positivity were health care eld occupation, family history, and history of dental procedures (Table 3).

Discussion
Egypt is considered by WHO as intermediate area as regards epidemiology of HBV [16]. Between 1980 and 2007, studies detected that HBV prevalence in Egypt was 6.7% generally, 11.7% in Upper Egypt, 4.6 in Lower Egypt, and 4% in pregnant women [17]. In a cross sectional study performed in 2015, 1.4% of general Egyptian populations were positive for HBV with 1.9% prevalence in males, and 1.1% prevalence in females [18].
Our study showed that HBsAg prevalence was 1.54% in pregnant women. In Egypt, many studies were made to identify prevalence of hepatitis B in different states. Similar study in 2016-2017 in Alexandria showed that HBsAg prevalence in pregnant females was 3.39% [19]. However, sample size in each study and different socioeconomic status could result in some variability in results of studies in different Egyptian states and differences throughout the countries. In Ismailia, 18.3% of women were HBcAb positive, and 5% were HBsAg positive [20]. HBsAg seropositivity was found to be 1.56% in Benha in agreement with our study [21]. In Upper Egypt, sero-prevalence of HBsAg was 4.8% in Assiut [22].Findings of the present study were similar to ndings in Libya and Algeria. Both had low prevalence rates (1.5% and 1.6%) respectively [23]. However, Differences were detected in Saudi Arabia (4.1%) [24], Pakistan (4.6%) [25], Sudanese antenatal clinics (10.2%) [26], and Nepal (17%) [27].This study showed that rural areas had HBV cases more than urban areas but the difference was not statistically signi cant. However; in another study in Minia, rural areas were signi cantly higher in prevalence than urban areas, which could be explained by different educational level, and presence of home delivery in rural areas [28]. As regards age, HBV was more prevalent in those ≥ 27 years with signi cant statistical difference. However, no signi cant difference detected as regards gestational age in the present study. Similar ndings were reported in Ethiopia, Saudi Arabia [29,30]. Yohanes et al; agreed with our study that gestational age was not signi cantly related to hepatitis B infection [31]. However; in Alexandria, no signi cant association was detected between age or gestational age and HBV [19].
In our study, multigravidae and primigravidae did not differ signi cantly. This was in agreement with previous study made in Benha [21], and in Nigeria [32]. However, Azhar et al; stated that multigravidae had higher percentage of infection because of multigravidae exposure to many risk factors as multiple pregnancies, blood transfusion, and hospital admission [33].Occupation is a risk factor for HBV infection. People who work as physician or medical staff have chance to catch the infection many times than general population [34]. Our study showed that working in health care elds was a signi cant risk factor for HBV acquisition. This was in agreement with Eke et al; who reported that about 25% of health care workers were HBsAg positive [35]. However, results of studies made by Taseer et al; and Shari -Mood et al; were not signi cant as regards the occupation [25,36]. Our study also detected signi cant prevalence of HBsAg positivity in those with family history of HBV. This might be due to presence of contaminated infected surfaces with HBV in living areas of chronic infected ones. This was in agreement with other studies also [11].
Although blood transfusion is a risk factor for hepatitis B transmission, it was not that in this study and other studies in Egypt, Mexico, and Saudi Arabia [11, 37, and 38]. This could be due to application of screening of blood donors. However; in other countries, blood transfusion was an important risk factor [25].In our study many cases of HBV did not take vaccine before (p = 0.045). Many Egyptian studies had similar ndings because many pregnant women were born before of the introduction of vaccine [33,35]. There were some risk factors which were not signi cantly associated with HBV prevalence in this study (IV drug or syringe use, hospital admission, history of endoscopic procedures, history of Shistosomiasis, and tattooing), and these ndings were in agreement of some studies and in disagreement with others.
Taseer et al; reported the association between hepatitis B infection and multiple injection therapy [25]; also, addiction of patient's husband was found to be a signi cant risk factor in another study [21]. Previous studies reported non signi cant difference between HBsAg positive and negative ones as regards history of hospital admission [11,39]. However, many other studies found the signi cant role of hospitalization in presence of HBV infection [40].
Our study detected a signi cant association between HBsAg positivity and history of surgery and as well as history of dental procedures. Another study was similar to our study in which 80% of HBsAg positive cases were set for surgeries [11]. However, previous surgery was not signi cant risk factor in some other studies [19,21]. Also, other studies detected that dental procedures were no longer signi cant risk factor for HBV. This might be attributed that large number of patients in our sample underwent dental procedures [11,24].Our study detected that 2 (6.67%) of 30 cases were immunotolerant with HBeAg positive and high viral load. They needed follow up and introduction of therapy in the last trimester to prevent fetal acquisition. The remaining 28 cases were carriers with HBeAg negative and low viral load.
This percentage was similar to an Egyptian study made by Elsabaawy et al; in 2020. This study detected (82.4%) HBeAg negative and 33(17.6%) HBeAg positive [41]. However; in studies in Ismailia and Benha, all cases were HBeAg negative and HBeAb positive [20,21]. Reduction of HBeAg positivity in HBV infected ones in Egypt might be attributed to improve vaccination coverage [42].

Conclusion
Hepatitis B virus is still present in Egypt. Screening for hepatitis B in antenatal care unit is important mainly in presence of risk factors (occupation, family history, surgical, or dental procedures) for follow up and treatment of pregnant mother when treatment indicated and for protection of the fetus to prevent widespread of hepatitis B.

Declarations
Ethics approval and consent to participate The study was approved by Ethical Committee in Faculty of Medicine, Tanta University. All participants accepted to be enrolled in the research after full explanation. They signed on informed consent the participants. They were provided with information about the purpose, bene ts of research. The participants were told that their participation was voluntary and they had the right to withdraw from the study at any time without consequences.

Consent for publication
Not applicable

Availability of data and materials
The dataset analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests
The authors declare that there are no con icts of interest.

Not applicable
Author contributions Rami Elnaggar contributed in study design, data acquisition, data analysis, and interpretation. Mahmoud Elkadeem performed the data analysis and interpretation; Mahmoud Elkadeem wrote and revised the manuscript; two authors read and approved the nal manuscript. Authors contributed to making critical revisions related to important intellectual content of the manuscript; Authors contributed to nal approval of the version of the article to be published.