Seroprevalence of Hepatitis B, Hepatitis C, Syphilis, Human Immunodeficiency Virus and Co-infections among Antenatal Women in a Tertiary care Hospital, Uttar Pradesh, India

Sexually transmitted infections (STI) associated with pregnancy poses a great threat to fetal well being due to vertical transmission. This study was conducted to determine the seroprevalence of hepatitis C virus, hepatitis B virus, HIV and syphilis infection in pregnant women. This retrospective study was conducted in Microbiology department over a period of one year from December 2018 to December 2019 at a tertiary care teaching hospital, Uttar Pradesh, India. In this study, hepatitis B surface antigen (HBsAg), antibodies against hepatitis C virus, HIV and syphilis infection were detected in antenatal women. Total 4037 pregnant women attending antenatal clinic were enrolled in this study. The seroprevalence of HBV was 1.34% (54/4037), HCV was 0.52% (21/4037), syphilis was 0.07% (3/4037), and HIV was 0.12% (5/4037). Only one patient had coinfection of HBV and HCV. Regular antenatal screening of all pregnant females for various infections should be done for proper and timely intervention.


INTRODUCTION
Sexually transmitted infections (STI) associated with pregnancy such as HIV, HBV, HCV and syphilis poses a great threat to fetal well being due to vertical transmission.
Hepatitis B infection is very common and important throughout the World.There is an estimated prevalence of 387 million of HBV infected people with approximate 10 million persons getting infected each year. 1 There are three major routes for transmission of this virus -vertical, horizontal and sexual. 2 Hepatitis B infection during pregnancy is associated with high rate of vertical transmission which may result in fetal and neonatal hepatitis.The HBV infection acquired in early childhood has high probability to later develop into carrier state and chronic diseases with lethal complications like liver cirrhosis and hepatocellular carcinoma in adults. 3epatitis C virus (HCV) comes under flaviviridae family.It is a single stranded RNA virus and mainly causes liver disease. 4The prevalence of hepatitis C virus infection in the asymptomatic people in India ranges from 1.5-4%.The vertical transmission in pregnant women occurs in 3-10%. 5any more studies on the prevalence of hepatitis C infection in pregnant women in India are yet to be done.
Globally, HIV virus prevalence rate was 35 million in 2013.Around 3.2 million infected children were below 15 years of age. 6HIV transmission from infected mother to child is around 25-48% in developing countries which occurs during pregnancy, delivery and breast feeding.The most significant route of transmission in children below 15 years of age is by perinatal transmission.Data from various studies on pregnant women has been used to monitor HIV infection in general population and young children. 7yphilis caused by Treponema pallidum, which is a systemic disease transmitted by sexual route, transfusion of blood and vertical transmission. 8It may adversely affect the pregnancy and results in premature births, abortions, still births or various syphilitic stigmatas in born children. 9nly a few studies had been done in India to know the seroprevalence of all these infections together in antenatal women.Hence, this study had been done to estimate the prevalence of HIV, hepatitis B, hepatitis C, and syphilis infection among antenatal women attending antenatal clinics at our institute.Thus, this study will be helpful to formulate various policies which will play a major role to reduce the spread of these infections.

MATERIALS AND METHODS
This retrospective hospital record-based study was conducted in Microbiology department at a tertiary care teaching hospital, Uttar Pradesh, India.In this study, hepatitis B surface antigen (HBsAg), antibodies against hepatitis C virus, HIV and syphilis infection were detected in antenatal women.Data was collected over a period of one year from December 2018 to December 2019 after taking informed consent and following proper ethical guidelines.Total 4037 pregnant women attending antenatal clinic were enrolled in this study.

Laboratory test for HBsAg
The collected serum samples were screened for HBsAg using HEPALISA (J.Mitra & Co. Pvt.Ltd., New Delhi, India).It is Enzyme linked immunosorbent assay (ELISA) based on the sandwich principle.

Laboratory test for HCV antibodies
The serum samples were screened for antibodies against hepatitis C virus using HCV Microlisa (J.Mitra & Co. Pvt.Ltd., New Delhi, India).It is a 3 rd generation ELISA utilizing combination of various antigens with the sequence of structural and non structural i.e core, E1, E2, NS3, NS4 & NS5.

Laboratory test for Treponema Pallidum
The samples were also screened for syphilis infection by Rapid Plasma Reagin method (RPR).The RPR test (Tulip Diagnostics Pvt. Ltd., Goa, India) is a slide flocculation test using disposable plastic cards for the detection and quantitation of anti lipoidal antibodies.
Data was collected in Microsoft office excel spreadsheet version 2007 and results were presented in tables and simple percentage and analyzed with chi-square test.P values were calculated and P<0.05 were considered significant.

ResUlts
A total of 4037 samples from pregnant women were tested for HIV, HBV, HCV and syphilis infection.There were 54 out of 4037 cases, positive for HBsAg resulting in seroprevalence of 1.34% (54/4037) (Table 1).Seroprevalence was highest in age group 18-25 years (65%) (Table 1).HBV seroprevalence was 50% in second trimester and 33.3% in third trimester (Table 2).
Three women were positive by RPR with seroprevalence rate of 0.07% (3/4037).Two cases in the second trimester and 1 case in first trimester were seropositive for syphilis infection (Table 2).
A single case of coinfection of HBV and HCV noted with co-prevalence rate of 0.02% (1/4037).There was no HIV and syphilis coinfection in HBsAg positive cases.

DISCUSSION
In the present study, seroprevalence of Hepatitis B infection was 1.34 % among pregnant women, which is similar with the prevalence shown in the study done by Sibia P et al. 10 (1.11%).On the contrary, Mehta KD et al. 11 (2.9%),Sehgal A et al. 12 (2.6 %) and Gupta I et al. 13 (2.5%) reported slightly higher prevalence of HbsAg (Table 3).Regarding prevalence of HBV infection (3-4%), India falls into intermediate zone. 14The HBV infection acquired in early childhood has more chances to develop into carrier state.Babies who are born to HBV infected mother, 90% of them become carrier and may develop chronic liver disease and becomes the important source for transmission in community. 15,16Therefore, mandatory antenatal screening for HBsAg is very important to address this problem.Immunoprophylaxis of the babies at risk shortly after birth would help in preventing perinatal transmission. 17n this study, 21 out of 4037 samples were positive for HCV infection (0.52%), which is almost similar to prevalence shown in the study done by Parthiban R et al. 18 (0.6%).On the other hand, Kumar A et al. 14 reported slightly higher prevalence rate (1.03%) in their study.According to the data given by National centre for disease control (NCDC), the seroprevalence of hepatitis C virus infection in India is 1%.HCV is mainly a blood borne pathogen; and there is very high risk of chronicity in it which can lead to serious complications like liver cirrhosis, liver failure and even the malignancy. 19HCV infection among antenatal women may result in various complications like premature contractions, preterm delivery, Gestational diabetes mellitus, vaginal bleeding and mortality. 20,21These complications can be prevented to a large extent, if early screening of all pregnant women during antenatal checkup and timely management of those cases can be done.The seroprevalence of syphilis infection in this study (0.07%) was less comparable to the prevalence seen in the study by Gupta I et al. 13 (1.47%).In India, the prevalence of syphilis in pregnant women remained around 1.5% between 2003 and 2007. 22 In the present study, seroprevalence of HIV infection came out to be 0.12% which is similar to study done by Jethava SD et al. 23 (0.1%).The prevalence rate in the present study were lower compared to the prevalence rate in the study done by Mathur Met al. 24 (1.86%),Mustafa Met al. 25 (1.1%) and Mehta KD et al. 11 (0.38%) (Table 5).In this study, we noted lower trend of HIV prevalence.Although limited sample size, in a single hospital cannot be the representative of whole country.Still we can reduce the perinatal transmission of HIV infection by early antenatal screening for HIV infection, giving perinatal chemotherapy and elective caesarean section.

CONClUsiON
Infection of HBV, HCV, HIV and syphilis is paramount health problem worldwide, requires urgency to take some measures to prevent and control them.Steps should be taken to create awareness among the public to bring about behavioral change in the society.Regular proper antenatal screening for various infections of all the pregnant women should be done.Along with that there should be HBV vaccination of females of reproductive age group on regular basis so that the perinatal transmission rates of these infections can be minimized.Proper preventive and timely interventional measures targeting all the pregnant women should be taken to avoid vertical transmission of these infections to newborns.

Table 1 .
Prevalence of Hepatitis-B, Hepatitis-C, HIV and Syphilis infections among pregnant women in various age groups

Table 3 .
Comparison of seroprevalence of HBsAg positivity among antenatal cases in different studies

Table 4 .
Comparison of seroprevalence of Anti HBc positivity among antenatal cases in different studies

Table 5 .
Comparison of seroprevalence of HIV antibody positivity among antenatal cases in different studiesYadav et al. | J Pure Appl Microbiol | 16(1):435-440 | March 2022 | https://doi.org/10.22207/JPAM.16.1.40 Perinatal transmission of Treponema pallidum may lead to various complications in outcome of pregnancy like stillbirth, spontaneous abortions, low birth weight babies or congenital syphilis in the baby.The Rapid plasma reagin (RPR), a nontreponemal test has traditionally been used as screening test for syphilis.It is also a quantitative test and antibody titers can be used to monitor treatment response.As RPR is a nontreponemal test, sometimes it can give false positive results which could be confirmed with treponemal specific test such as Fluorescent treponemal antibody absorption test (FTA-ABS) test or Treponema pallidum hemagglutination assay (TPHA).Due to financial constraint this test couldn't be done in this study.