Hepatitis B Surface Antigen and DNA Quantification among e Negative Chronic HBV Infected Patients in Two Nigerian Hospitals
Kolawole O. Akande* and Adegboyega Akere
Department of Medicine, University of Ibadan, Nigeria
Kolawole O. Akande, Department of Medicine,
University of Ibadan, Oyo State, Nigeria, Tel: 2348033771279; Email: email@example.com
Submitted: 01 February 2019; Accepted: 17 April 2019; Published: 19 April 2019
Cite this article:
Akande KO, Akere A (2019) Hepatitis B Surface Antigen and DNA
Quantification among e Negative Chronic HBV Infected Patients in Two Nigerian Hospitals. JSM Hepat 3: 5.
Introduction & aim: Hepatitis B is a public health problem, responsible for about 6000 deaths annually. HBV DNA and HBsAg
quantification have implication for chronicity, response to treatment, frequency of long-term complications and chances of cure. This study
aimed to describe the pattern of quantitative hepatitis B surface antigen and DNA quantification among patients with e negative chronic
Materials & method: One Hundred and Twenty-One asymptomatic, treatment naïve, e negative chronic hepatitis B patients were
recruited. HBsAg and HBV DNA quantification and anti HBe were done on their sera.
Results: Of the 121 Subjects recruited, 75 (62%) were males while 46 (38%) were females with ages ranging from 18 to 68years.
Twelve (10%) patients were negative for anti HBe while 109 (90%) were positive for it. The HBsAg quantification ranged from 0.25 to 52,000
IU/ml with a median of 5289and mean 3.33 ± 1.32 log10 UI/ml. Ninety-Three (77%) patients had their HBsAg quantification ≥ 1000 IU/ml.
HBV DNA quantification ranged from 15 to 26,000 UI/ml with a median of 560IU/ml and mean 2.67± 1.24 log10 UI/ml. Ninety-Two (76%)
patients had HBV DNA < 2000 UI/ml. The was no correlation between HBsAg and HBVDNA quantification (rho= 0.13, p=0.13).
Conclusion: Quantitative HBsAg level are high among Nigerian patients with e negative chronic HBV infection despite low HBV DNA
count. There was no correlation between HBsAg and HBV DNA quantification.
Keywords: Chronic Hepatitis B; Hepatitis B surface antigen quantification; HBV DNA quantification; Correlation; Nigeria
Chronic hepatitis B infection is a public health problem with
about 240 million people affected worldwide . The infection is
most common in Africa with a prevalence of 8.83% . The pool
prevalence of HBV infection in Nigeria is 13.6% , and is the
most common cause of chronic liver disease in the country [3,4].
Chronic Hepatitis B infection is responsible for about 600,000
deaths annually . Majority of this mortality is attributable to
liver cirrhosis and or hepatocellular carcinoma, which are the
most important long-term complications of HBV infection .
However, not all patients with chronic hepatitis B will develop
these complications. The main challenge for Clinicians is to
identify those patients that are likely to develop these longterm
complications and recommend the appropriate treatment.
Major international and local guidelines suggested the use of
serum HBV DNA quantification and serum alanine transferase (ALT) as markers to select patients with active chronic hepatitis
B infection [7-10]. European Association for the Study of the
Liver (EASL) and Asian Pacific Association for the study of the
liver (APASL) guidelines recommended HBVDNA quantification
greater than or equal to 2000IU/ml and raised serum alanine
transaminase as criteria for active chronic hepatitis B infection
which should be treated. However, serum level of both HBVDNA
and alanine transaminase fluctuate . Apart from this, long
term complications have been observed even in patients with
either HBV DNA level less than 2000 UI/ml and or normal serum
alanine transaminase . Therefore, HBsAg quantification
(qHBsAg), HB corerelated antigen (HBcrAg) and HBV RNA among
others, have been suggested as additional markers that could
predict more precisely, patients with active infection who are
likely to have long term complications .
There is a renewed interest in the quantitative HBsAg
(qHBsAg) assay as a marker of hepatitis B viral activities in the
last ten years . It is said to corelate well with covalently closed
circular (ccc) DNA and intra hepatic DNA which are responsible
for the perpetuation of the virus in the body [14,15]. In addition,
it is said to separate inactive carriers from active disease, predicts
the possibility of spontaneous sero conversion and response of
patients to Pegylated interferon . The three commercially
available automated assays for quantification of HBsAg level
detect all forms of HBsAg and are comparable [16,17].
There is however paucity of data on the pattern of quantitative
hepatitis B surface antigenaemia and its correlation with the viral
loadin sub-Sahara Africa.
The aim of this study was to describe the pattern of Hepatitis B surface antigen and DNA quantification among patients with
e negative chronic hepatitis B virus infection attending two
hospitals in south west Nigeria and determine if any, correlation
between the two.
This was a cross sectional study done among patients attending
Sacred Heart Hospital Abeokuta, Ogun State and University
College Hospital, Ibadan, Oyo state. Sacred Heart Hospital is a
300-beded mission owned hospital that has been in existence for
more than 120 years. It provides primary and secondary levels of
care to people of Ogun state and its neigbouring states of Lagos,
Oyo and Ondo. The University College Hospital is a 900-beded
premier teaching hospital in Nigeria founded about 60 years
ago. It provides specialist care in various medical fields to the
western region and the whole country in general. The study was
carried out between January 2016 and August, 2017. Chronic
hepatitis B was defined as being hepatitis B positive for at least
six months and/ or Positive HBsAg with negative IgM antibody
to the core antigen (anti HBc). Only patients who were at least
18 years old, treatment naïve and asymptomatic as evidenced
from history, examination and abdominal ultrasound were
recruited for the study. All the patients that met the inclusion
criteria and consented to the study during the study period
were recruited. Ethical approvals were obtained from the ethics
committees of both hospitals. Informed consent was taking from
all the patients and the study was done according to Helsinki
declaration amended by the 64th World Medical Association
general assembly, Fortalena, Brazil, 2013 . Five milliliters of
blood were taken from each patient and the serum were stored in
-800C until analysis. HBsAg quantification was done using COBAS
E 411 from Roche diagnostics and uses chemiluminescence
method with lowest detectable level of 0.25 UI/ml and maximum
of 13,000IU/ml. Serial dilutions were done on the samples of
patients with values greater than 13,000IU/ml until the final
value was arrived at. HBV DNA quantification was done with
using CAPCTM ETAQMAN 48 from Roche diagnostics that uses
real time PCR method with lowest detectable limit of 15IU/ml.
Anti HBe was done using LumiQuick® Diagnostics (California,
USA) immunochromatography test kits with accuracy of 99.6%.
The analysis was done using Statistical Package for Social
Sciences version 20. HBsAg quantification and HBV DNA
quantification were divided in to two categories with cut offs of
999 IU/ml and 1999 IU respectively . Chi square, students’ T
test and spearman’s correlation were used to test for associations
as appropriate. P value less than 0.05 was considered significant.
One hundred and twenty-one patients were recruited for this
study which comprised of 75 (62%) males and 46 (38%) females.
Their ages ranged from 18 to 68 with a mean of 36.6 ± 9.7 years.
Twelve (10%) patients were negative for antibodies to hepatitis
e antigen while 109 (90%) were positive. HBsAg quantification
ranged from 0.25 to 52,000 UI/ml with a median of 5289 IU/
ml. The log 10 of the HBsAg quantification ranged from -0.60 to
4.72 UI/ml mean 3.33 ± 1.32 IU/ml, median3.72 log 10 IU/ml. The HBsAg quantification was more than or equal to 1000 IU/ml
(high) in 93 (77%) while it was less than 1000 UI/ml (low) in 28
(23%) patients. There was no significant relationship between sex
(p=0.46), anti HB e (0.11) and the value of quantitative hepatitis
B surface antigen. There was a negative correlation between the
age of the patients and the value of HBsAg quantification and this
was significant (rho= -0.2, p=0.01).
HBV DNA quantification ranged from 15 to 26,000000 with
a median of 560 UI/ml. The log 10 of the HBV DNA ranged from
1.18 to 7.41 with a mean of 2.67 ± 1.24, median 2.74 log 10 UI/ml)
Ninety-Two (76%) of the patients had HBV DNA quantification
that were less than 2000 IU/ml (low) while 29 (24%) had HBV
DNA quantification levels that were equal or more than 2000 IU/
There was no significant relationship between sex and the
value of the HBV DNA quantification (p= 0.512). However, there
was a significant inverse relationship between anti HBe and the
HBV DNA level (rho= - .14, p= 0.02). There was also a significant
inverse correlation between the age of the patients and the HBV
DNA quantification (rho=-0.223 p=0.014).
Only 20 (16%) patients had HbsAg quantification that was
less than 1000IU/ml and HBVDNA quantification that was less
than 2000 IU/ml. Seventy-Two patients (60%) patients had
HbsAg quantification that was equal to or more than 1000 UI/
ml though their HBV DNA quantification were more less 2000UI/
ml (Table 1). There was no statistically significant correlation
between HbsAg quantification and HBV DNA quantification
among the patients) (rho=0.136, P= 0.136).
Hepatitis B surface antigen is a vital viral protein that is
secreted into the patient blood and its quantification is an
important marker both for the evaluation for possible treatment
and prediction of response to treatment . The median of
5,289 IU/ml of the surface antigen quantification in this study is
slightly higher than 4,672 IU/ml reported among the Senegalese
with chronic hepatitis B . The difference may be because the
Senegalese study included only patients with normal ALT while
our subjects were recruited irrespective of their serum ALT. The
mean of 3.33 log 10 IU/ml for surface antigen quantification
in this study was lower than 3.82 log 10 IU/ml among Ivorian
patients with chronic hepatitis B and HIV infections . The HIV
infection in that cohort could explain the difference. Hepatitis B tends to be more severe in HIV co- infected patients compare to
HBV mono infected cohort . Twenty two percent (28 patients)
had HBsAg quantification that was less than 1000 IU/ml, which
is lower than 14.9% reported in a study among the Chinese .
However, in another study among asymptomatic, treatment naïve
Chinese patients with chronic hepatitis B, only 12.7 % of their
patients had quantitative surface antigeneamia that was more
than or equal to 1000IU IU/ml . These variations in the levels
of the surface antigens may be due to the different phases of the
chronic hepatitis B in the patients, the genotypes of the virus and
the presence of amino acids substitution in the hepatitis B viral
proteins, promoter basal core or pre-core mutations [20,26,27].
Hepatitis B surface antigen quantification of less than 1000 IU/
ml is used to identify inactive patients especially when the HBV
DNA is less than 2000 IU/ml . Titer of HBsAg quantification
less than 100 UI/ml among those with HBV DNA less than 2000
UI/ml was found to accurately identify inactive carriers better
and predict subsequent loss of HBsAg . The suggestion of 100
IU/ml may be more reliable because the study involved repeated
measurement of the surface antigen quantification rather than a
single measurement as it was the case of the study that suggested
1000 IU/ ml. Ninety four percent of our patients with HBV DNA
quantification less than 2000 UI/ml had HBsAg quantification
that was more than 100 IU/ml. This may mean that majority
of our patients with chronic hepatitis B in Nigerian have active
diseases and that functional cure may not be achievable. A study
however suggested that different sub- proteins of the hepatitis B
surface antigen rather than the total q HBsAg is more important
in this prediction .
The negative correlation between age and the level of the
HBsAg is similar to the findings by Kim et al. , and Jang
et., among the Koreans . This is not surprising as HBsAg
quantification tends to be higher in immune tolerance phase
which is typically found among relatively younger people than
immune reactive and reactivation phases whose subjects tend to
be older .
HBV DNA quantification has been designated the most
important marker that determines the risk of a patient having
chronic complications of hepatitis B later in life (32). The range of
the log DNA value from 1.18 to 7.41 in this study is similar to 2.5 to
5.4 among the Senegalese patients . That same study reported
high prevalence of pre-core mutation among their Senegalese
patients and this might be the reason for the low vireamia in
them. No study to the best of our knowledge, has investigated the
presence and prevalence of pre-core mutations in our population
of patients. The mean of 2.7 log 10 UI/ml in this study is similar
to the mean of 2.7 log 10 UI/ml and 2.6 log 10 UI/ml found among
the Senegalese patients with chronic hepatitis B . It is also
similar to that reported by a French study with multi-national
patients with chronic hepatitis B . Ninety-Two (76%) of the
patients in this study had HBV DNA less than 2000 UI/ml and this
is similar to 74% reported among patients in Burundi . Akere
et al, in a study in Ibadan reported 46% of their patients having
HBV DNA quantification that was less than 2000 IU/ml .
About 18% of the patients studied by Akere et al., were HBeAg
positive while this present study was among HBeAg negative patients only. HBV DNA quantification tend to be higher among
patients who are HBeAg positive than those who are HBeAg
negative . A Taiwanese study reported that 50.5% of their
patients had HBV DNA quantification that was more than 2000
IU/ml . Apart from the likely different genotypes of the HBV
in the two populations studied, the Taiwanese study comprised
of relatively older people with non-hepatic malignancies which
are known cause of immunosuppression. The predominate
genotype of hepatitis B in Nigeria and indeed west Africa is E
[37,39] .The fact that the hepatitis B viral load is low does not
necessarily means that the infection is inactive. In an Egyptian
study, 26% of the patients with HBV DNA quantification level
less than 2000 IU/ml were found to have significant fibrosis on
liver biopsy . Interestingly, 78% of the patients in our study
with hepatitis B viral load less than 2000 IU/ml had quantitative
surface antigen quantification that was more than 1000 IU/ml.
Jen chenet al., in a review of the REAVEL-HBV study submitted
that long term maximal and consistent suppression of the HBV
DNA level is desirable rather than an arbitrary level of HBV DNA
level . One cannot agree with him less knowing fully well that
serum HBV DNA levels fluctuate .
This study found no correlation between HBV DNA level
and HBsAg quantification among the patients. This shows that
transcriptional activity might be different from viral replication
in patients with HbeAg negative chronic hepatitis B. A UK study
done among patients of West African extraction did not find any
correlation between HBV DNA and HBsAg quantification among
HbeAg negative patients . There was however a correlation
between HBV DNA quantification and HBsAg quantification
reported in Taiwanese [15,43], and French studies , although
their subjects were mixture of both HBeAg positive and HBeAg
negative patients. Some studies have found a good correlation
between HBsAg quantification and HBV DNA viral quantification
among HBeAg positive patients .
This study showed a weak negative correlation between HBV
DNA quantification and age though it didn’t attain statistical
significance. This is reasonable as the viral load tend to decrease
from the immunetolerance to immune reactive to reactivation
phase. Alams et al., reported less HBV DNA levels among patients
that were older than 40 years compared to those that were less
than 40 years.
Although hepatitis B is said to be commoner and run a more
aggressive course in males, there was no relationship between
sex and HBV level in this study. Perhaps other factors other than
HBV DNA levels are responsible for the more aggressive course
of HBV infection in males.
A larger percentage of patients with chronic hepatic B
infection and e negative antigeamia in south west Nigeria
have low viremia and high qHBsAg quantification. There is no
correlation between HBV DNA quantification and quantitative
surface antigeneamia. This might mean higher tendency to having long term complications despite relatively low vireamia.
It may be beneficial to reduce the threshold of treatment in e
negative HBV patients when the surface antigen quantification is
high despite low vireamia.