CHAPTER donor in Hospital Queen Elizabeth II

CHAPTER 1: ITRODUCTIONThe selection ofhealthy and safe donors has always been a serious concern for blood transfusioncenters worldwide to reduce transfusion-transmitted infections (TTI) for moresafety blood supply. Hepatitis B virus is the most frequenttransfusion-transmitted viral infection (Candotti & Allian, 2009). In Malaysia 2.4million people are carriers of hepatitis B (Malaysian Liver Foundation, 2005).Hepatitis B vaccination has been implemented in Malaysia since 1989 (Raihan etal, 2017).

  According to a study thatanalysed the trend and estimation of Hepatitis B infection cases in Malaysia(2003-2012), the highest number of Hepatitis B infection cases was reported inSabah (Rajamoorthy et al, 2016).Hepatitis Bremains a major risk of transfusion transmitted viral infection. Hepatitis Bvirus (HBV) infection is a major cause of liver disease such as cirrhosis andhepatocellular carcinoma (Ng et al, 2013). To minimize the risk of thetransmission of hepatitis infection through route of transfusion, all donatedblood should screened for evidence of presence of infection prior to therelease of blood and blood components for clinical use.The serology ofhepatitis B virus is complex. Different serological marker will develop duringthe course of infection, including hepatitis B surface antigen (HBsAg) andhepatitis B core antibody (anti-HBc). Other than that, HBV DNA can be detectedin the majority of hepatitis B infection cases.

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Hepatitis B surface antigen(HBsAg) test are recommended by world health organization (WHO) for all donatedblood.   1.1  Objective of the studyThis studypresents data on the prevalence rate of Hepatitis B infection among blood donorin Hospital Queen Elizabeth II from September 2017 to December 2017. The aim ofstudy is determine the prevalence of Hepatitis B virus infection among blooddonors and their demography in department of transfusion medicine, HospitalQueen Elizabeth II.

·        Determine the infected donor background i.e. gender,age, donor status, birth year- born before mass hepatitis B vaccination (before1989) or bon in the year of 1989 and after, occupation, distribution ofpopulation from different ethnicity – improving donor selection. ·        Determine the number of confirmed Hepatitis B casesamong blood donor – Monitoring safety blood supply and donor screeningeffectiveness.            CHAPTER2: LITERATURE REVIEW2.1       HepatitisB virus (HBV)            2.1.

1    Agent HepatitisB remains a major chronic viral illness worldwide. The causative agent ofhepatitis is Hepatitis B virus (HBV) which is an enveloped DNA virus. HepatitisB virus (HBV) is a member in the virus family Hepadnaviridae (Shepard et al,2006). Hepatitis B virus is transmissible by the parenteral route and throughtransfusion of blood or blood product. (Ocama et al, 2005).

The infectiousvirus is 42-47 nm in diameter and the concentrations of HBV circulate in bloodas high as 108 virions per ml of blood. (Shepared et al, 2006).Hepatitis B virus is double –stranded DNA virus with the inner core of thevirus contained Hepatitis core antigen HBcAg, Hepatitis B envelope antigenHBeAg and DNA polymerase with reverse-transcriptase.

Hepatitis B surfaceantigen HBsAg is found on the surface of hepatitis B virus. (Shepard et al,2005). Hepatitis B virus travels to the liver via the bloodstream andreplicates in hepatocytes. In hepatocytes, the virus uncoated and enter thenucleus as covalently closed circular DNA. A template of RNA was produce. RNAare subsequently encapsulated and transcribed in the cytoplasm of cell.

Positive DNA strands that acquire the hepatitis B envelope antigen HBsAg andleave the cell. HbsAg in form of spheres and rods are secreted.Figure 1: Structure of Hepatitis B virus            2.

1.2    Disease and transmission”Hepatitis”is inflammation of the liver, when inflame or damage occur in the liver, thefunction of liver can be affected. Hepatitis is most caused by a viralinfection. Most common types of viral hepatitis are Hepatitis A, Hepatitis Band Hepatitis C (Centers for Disease Control and Prevention, CDC, 2016). Infectionwith Hepatitis B virus can be a serious liver disease. Person infected with HBVmay also develop chronic infection and has a higher probability of progressingto liver cirrhosis and hepatocellular carcinoma. (Shepard et al, 2006). Accordingto World Health Organization (WHO), transmission of HBV can through childbirthand from family member to a child in the early childhood, this route isvertical transmission.

Another route is horizontal transmission, such asthrough occupation exposure, sexual contact, transfusion and the use ofinfected needles. (WHO, 2009)    2.2       Hepatitisin Malaysia2.2.1    CurrentsituationMalaysiawas an intermediate endemicity country, the Hepatitis surface antigen (HBsAg)prevalence is 5% – 7% (Raihan et al, 2017). According to Malaysian LiverFoundation, 2.4 million people are carriers of hepatitis B in Malaysia. Anestimated 1 million people are chronically infected with HBV in Malaysia(Raihan et al, 2017).

Sabah was the highest number of hepatitis B infectioncases reported, followed by Pahang and Wilayah Persekututan, perlis was thelowest cases reported (Rajamoorthy et al, 2016). According to the study ofRajamoorthy et al 2016, the estimated Hepatitis B infection cases indicate thenumber of case and incidence rates will increase in future. Public awarenessprogram are needed to lower the incidence of hepatitis B infection in thegeneral population. 2.

2.2    ExpandedProgram on Immunization (EPI) HepatitisB vaccine was available in 1982. Hepatitis B vaccine are manufactured usingrecombinant DNA technology. Malaysia National EPI was implement in 1989 (Ng etal, 2012). In Malaysia, Hepatitis B vaccination of all newborn infants has beenstarted since 1989 (Raihan et al, 2017).

Through the vaccination program in1989, the rate of infection has been successfully reduced (Rajamoothy et al,2016). Malaysia started routine hepatitis B immunization using three-doseregime. The first dose given shortly after birth, second dose at 1 month, and thethird dose at 5 months old (Malaysia Paediatric Association MPA, 2005).Hepatitis B vaccination to prevent newborn infants from infected of HBV (Ministryof Health Malaysia, 2004).             2.2.

2   Previous study            Anearlier study in 1997, the prevalence of hepatitis B among the healthyvolunteers in Malaysia was 5.2% (Malaysian Liver Foundation, 2005). A study byYousuf et al 2007, investigated the prevalence and trends in hepatitis Binfection among blood donors in Transfusion Medical Unit at Hospital UniversitiSains Malaysia, Kelantan (Yousuf et al, 2007). The study shows that theprevalence of hepatitis B infection in regular and first time donors was 1.1%. Accordingto another study in the Faculties of Medicine and Dentistry, University ofMalaya, the HBsAg prevalence among the 2923 students was 0.

62%. The prevalencerate for those born before 1989 was 1.08% and 0.2% among those born after 1989(Ng et al, 2013). 2.3       ScreeningAssay            2.3.1   Types of assayVarioustypes of assay have been developed for use in blood screening.

The main typesof assay used for blood screening are: Enzyme Immunoassays EIA,Chemiluminescent Immunoassays CLIA / CMIA and Nucleic Acid Amplification TechnologyNAT assays.              2.3.2    Enzyme Immunoassays and Chemiluminescent ImmunoassaysEnzymeand chemiluminescent immunoassays are currently most commonly used assays forblood screening (Candotti et al, 2017). Enzyme and chemiluminescentimmunoassays are suitable for the screening of large number of samples andrequire a range of specific equipment such as the ARCHITECT i200SR immunoassayanalyzer.            Figure2: ARCHITECT i2000SR immunoassay analyzer            Blood samples were taken forserological testing. HBsAg was tested using the ARCHITECTi2000SR immunoassay analyzer. The ARCHITECT HBsAg assay is a two-stepimmunoassay, using chemiluminescent microparticle immunoassay (CMIA)technology, with flexible assay protocols referred to as Chemiflex, for thequantitative determination of HBsAg in human serum and plasma.

In the firststep, sample and anti-HBs coated paramagnetic microparticles are combined.HBsAg present in the sample binds to the anti-HBs coated microparticles. Afterwashing, acridinium-labeled anti-HBs conjugate is added in the second step.Following another wash cycle, Pre-Trigger and Trigger Solutions are added tothe reaction mixture.

The resulting chemiluminescent reaction is measured asrelative light units (RLUs). A direct relationship exists between the amount ofHBsAg in the sample and the RLUs detected by the ARCHITECT i* System optics.The concentration of hepatitis B surface antigen in the specimen is determinedusing a previously generated ARCHITECT HBsAg calibration curve. If theconcentration of the specimen is greater than or equal to 0.05 IU/mL, thespecimen is considered reactive for HBsAg.             2.

3.3    Nucleic Acid Amplification Aechnology AssaysNucleicacid amplification technology assays detects the presence of viral nucleicacid, DNA and RNA (Candotti et al, 2017). A specific DNA or RNA segment of thevirus is amplified. Through the amplification step, amount of the specificsegment of the viral will increase to an easily detectable level.

The presenceof viral nucleic acid indicates the presence of the viral itself. Detection ofHBV DNA reduce the risk of HBV transmission through transfusion of infectedblood donated during the acute window period: HBsAg Test are negative, but HBVDNA is positive (Biswas et al). 2.3.4    ScreeningSerologymarker – Hepatitis B surface antigenViralnucleic acid – HBV DNASeveralserological markers develop during the course of Hepatitis B infection. HBsAgtest is the first-line of blood screening for HBV (Candotti & Allain,2009). HBsAg is the first serological maker of HBV infection.

HBV produces anexcess of hepatitis B surface antigen (HBsAg) (Ocama et al, 2005), also knownas Australia antigen, which can be detected in the blood of infectedindividuals. The level of the virus itself are variable, a study indicate thatsome individuals that have low levels of detectable Hepatitis B surface antigenmay cause the HBsAg test negative (Gerlich et al, 2007). HBsAg test arerecommended as minimum standard for blood screening (WHO).

HBsAg persistsduring this acute phase and clears late in the convalescence period. Failure toclear HBsAg within six months indicates a chronic HBsAg carrier state. HBsAgassays are used to identify persons infected with HBV and to preventtransmission of the virus by blood and blood products as well as to monitor thestatus of infected individuals in combination with other hepatitis Bserological markersIn an infected individual, HBV DNA normally present. HBV DNAcan be detected in most of the cases, although in HBsAg negative phases ofinfection the HBV DNA are generally low “window period”.

Detection of HBV DNA(NAT) reduces the risk of HBV transmission through the transfusion of infectedblood during the window period (Condotti et al, 2017).             CHAPTER 3: MATERIALS AND METHODS3.1       STUDYDESIGNThis was aretrospective cross-sectional study on blood donors to examine the incidence ofhepatitis B infection in the blood donors at the Transfusion transmittableinfection (TTD) screening center for west coast Sabah, namely Queen ElizabethHospital II (QEH II).  3.2       LOCATIONAND PERIOD OF STUDYThis studywas conducted at Transfusion Medicine Department, QEH II, Kota Kinabalu Sabah..The study started from September 2017 to December 2017 3.

3       STUDYVARIABLES3.3.1    Independent Variables?       Sociodemographic factors of age,sex, race, occupation and age?       Birth year, born before masshepatitis B vaccination (before 1989) or born in the year of 1989 and after.  3.3.2    Dependent Variables?       Hepatitis B serology screeningresult?       Hepatitis B serology confirmation result   3.

4       STUDYPOPULATIONA Total of2400 blood donors who donated in the west coast of Sabah were included in thisstudy. 3.5       INCLUSIONAND EXCLUSION CRITERIA            3.5.1    Inclusion Criteria                               i.           Eligibleblood donor based on National Blood Center Guideline                             ii.           Agefrom 17 to 65 years old                           iii.           Hemoglobinmore than 12.

5 g/dl                           iv.           Normalblood pressure                             v.           Bodyweight more than 45 kg                           vi.

           Wholeblood and apheresis blood donation 3.5.2 Exclusion Criteria                               i.           Donornot eligible for donation                             ii.

           Weakpositive screening result                           iii.           Incompletedemographic data in the blood donation form                           iv.           Incompletehepatitis B serology result in the laboratory information system     3.6       SAMPLESIZE CALCULATIONSample sizecalculated based on sample size calculation formula (Pourhoeinholie et al.

, 2013) as following:            n= Z2 P (1-P)                        d2 n= sample sizeZ = confidence intervalP = proportion of prevalence/incidenced = precisionTheproportion was set based on the incidence of hepatitis B infection of 0.62% inthe previous study by Ng et al.(2013), confidence interval was set at 95%, and precision was set at 0.05. Thecalculated sample size was 2400.3.7       SAMPLINGMETHODConveniencesampling method was used to collect data from blood donation record andlaboratory information system in the Transfusion Medicine Department, QEH II,Sabah.3.

8       DATACOLLECTIONBlooddonors’ demographic data and hepatitis B serology result were retrospectivelycollected based on blood donation form and QEH II lab information system namelyDarah Link.  3.9       HEPATITSB SEROLOGY TESTING FOR BLOOD DONORS ·        Blood samples are collected fromdonor.

·        blood samples are sent to transfusionmicrobiology laboratory.·        Perform screening test (HBsAg), usingthe ARCHITECT ABBOTT i2000SR immunoassay analyser.·        blood samples that tested HBsAgpositive(reactive) will then proceed with confirmatory test (neutralizationtest), using the ARCHITECT ABBOTT i2000SR immunoassay analyser.·        Information of donor and the outcomeare recorded.

 3.10     STATISTICALANALYSISAll statistical data were analyzed by SPSS (StatisticalPackage for the Social Sciences) Version 24.0 software (IBM, New York, UnitedStates).

The numerical descriptive results were presented as mean ± standarddeviation for normally distributed data, median for non normally distributeddata and percentage (%) for prevalence results. Multiple linear regression wasused to analyze relationship between demographic factors and hepatitis Binfection among blood donors. Meanwhile chi square test was used to analyze birthyear in relation to hepatitis B infection.  3.

11     ETHICALISSUESEthicalapproval was granted by CRC QEH II, Kota Kinabalu Sabah and department approvalfrom JPT head of department 3.12     STUDYFLOW CHARTStudy population Exclusion                                                                                            Inclusion Sample size Demographic Datacollection from donation form Data collection from Laboratory information system(Hepatitis B screening(HbSAg) result) NonReactive                                                                                      Reactive HepatitisB confirmation (Neutralization test) Datacollection from Laboratory Information system StatisticalAnalysis ResultReporting  References 1.      CandottiD, Allain JP. Transfusion-transmitted hepatitis B virus infection. Journal ofhepatology 51(2009) 798-809.2.      MalaysianLiver Foundation. Hepatitis B: fact sheet for doctors.

(2005)3.      RaihanR, Mohamed R, Hassan M, Said R, Chronic Viral Hepatitis in Malaysia: “where arewe now?”. Euroasian Journal of Hepato-Gastroenterology, January –June2017;7(1): 65-67.4.      RajamoothyY, Taib NM, Rahim KA, Munusamy S.

Trends and estimation of hepatitis cases inMalaysia, Malaysian Journal of Public Health Medicine 2016, 16 (1): 113-120.5.      NGK P, Ngeow Y F, Rozainah K, Rosmawati M. Hepatitis B seroprevalence amongUniversity of Malaya students in the post-universal infant vaccination era, MedJ Malaysia vol 68 NO  2 april 2013,144-147.6.      WorldHealth Organization. Weekly Epidemiological Record 2009;84, 405-420.

7.      ShepardC W, Simard E P, Finelli L, Fiore A E, Bell B P. Hepatitis B Virus infection :Epidemiology and vaccination. Johns Hopkins Bloomberg School of Public Health,Epidermiology reviews 2006; 28: 112-125.8.      OcamaP, Opio C K, Lee W M.

Hepatitis B virus infection: current status. The AmericaJournal of Medicine (2005) 118, 1414.e15-1413.e22.9.      Centersfor Disease Control and Prevention. Hepatitis B.

June 2016. Available from: http://www.cdc.gov/hepatitis.10.  MinistryOf Health Malaysia.

Clinical Practice Guidelines (childhood immunization),MOH/P/PAK/81/04(Gu). December 2004. Available from http://medicaldev.moh.gov.my/casemix/files/Handbook%20For%20Recording%20Diagnosis%20and%20Procedure%20-%20Sep%202010.pdf.11.

  MalaysianPaediatric Association (MPA). Hepatitis B immunization in current practice. 24may 2005.

Available from: http://mpaweb.org.my/article.php?aid=2312.

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6 november 2007, 1070-1074.13.   Candotti D, Boizeau L, Laperche S.

occulthepatitis B infection and transfusion-transmission risk. Transfusion Clinique et Biologique 24 (2017) 189-195.14.  BiswasR et al. comparative sensitivity of HBV NAT and HBsAg assays for detection ofacute HBV infection.

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