Screening of adult dental patients visiting Khyber College of Dentistry, Peshawar for HBV and HCV infections and identifying the associated risk factors

Objective: To screen out adult patients for HBV and HCV infections visiting Khyber College of Dentistry Peshawar (KCD) for different dental treatments and to identify the associated risk factors. Method: This cross-sectional study was conducted at Khyber College of Dentistry, Peshawar in the year 2013. A total of 1540 patients >15 years, visiting KCD for seeking different dental treatments were screened for hepatitis B & C. Informed consent was taken before blood collection and filling of a structured questionnaire. Blood samples were tested against HBsAg and anti HCV by using ICT that were further confirmed by ELISA. The data was analyzed using Epi info version 6. Results: A total of 1540 patients were screened during the study. Among these 36.4%(561) were males and 63.6%(979) were females. Overall prevalence of HBV and HCV was 5.12%(79). On screening, 2.14%(33) were found to be HBs Ag positive of which 2.5%(14) were males and 1.9%(19) were females. HCV was found positive in 2.98%(46) individuals having male to female ratio of 1.6% and 3.8%. Frequency of HBsAg was high in age group 56-65 year and HCV in 36-45 year group. Previous history of IV/IM injections, spouse patient of hepatitis, blood transfusion, surgical operation were found significant risk factors in the transmission of both hepatitis B and C, while previous history of dental treatment and sharing of clippers were significant risk factor in spreading hepatitis C infection only. Conclusions: Overall prevalence of HCV was higher than HBV. Previous history of injections, spouse patient of hepatitis, blood transfusion, surgical operation were found significant risk factors in the transmission of both hepatitis B and C.


INTRODUCTION
Hepatitis is an inflammatory condition of the liver, most commonly caused by a viral infection. Of these viruses, hepatitis B virus (HBV) and hepatitis C virus (HCV) infections account for a substantial proportion of liver diseases worldwide. 1 They are the major causes of severe liver disease, including hepatocellular carcinoma and cirrhosis-related endstage liver disease.
Both HBV and HCV are blood-borne 2 viruses with distinct routes of transmission. Modes of infection 3 are more or less similar. HBV can be prevented with vaccine which is not possible in case of HCV.
Globally, Hepatitis B has been found to infect about 350 million people 4 and result in 563 000 deaths annually. Most commonly, HBV infection is

Original Article
Screening of adult dental patients visiting Khyber College of Dentistry, Peshawar for HBV and HCV infections and identifying the associated risk factors acquired by vertical transmission from an HBsAg positive mother or via horizontal transmission in childhood 5 through blood and blood products and unsafe sexual contacts, intrafamilial transmission is also reported. 6 Globally, hepatitis C virus (HCV) has infected an estimated 130 million people, most are chronically infected. HCV-infected people act as a reservoir for transmission to others and are at risk for developing chronic liver disease, cirrhosis, and primary hepatocellular carcinoma (HCC). Worldwide, HCV accounts for 27% of cirrhosis and 25% of HCC worldwide. 7 The major modes 8,9 of HCV transmission are use of contaminated needles and instruments in medical practice, unsafe blood and blood product transfusion, intravenous drug use, face and armpit shaving with unsterilized instruments by barbers, ear and nose piercing, poor personal hygiene habits and treatment (practice by non-qualified people). In Pakistan, 10 the single most important cause of HCV transmission is lack of proper screening of the transfusion blood.
Pakistan 11,12 is among the worst afflicted nations due its large population (165 million) and intermediate to high rates of infection. Estimated prevalence of chronic carrier state of Hepatitis B amongst high-risk groups in Pakistan 13 ranges from 6-12% whereas prevalence of Hepatitis C in the high-risk population is much higher -ranging from 15-25%. More ever, it has also been estimated that in general population chronic carriers of Hepatitis C and Hepatitis B is 5% and 3% respectively.
These viruses are present in the saliva 14 or blood of an infected patient therefore dentists and dental health care workers are at a high risk of acquiring infection. In Pakistan, 15-18 several previously conducted studies have shown different prevalence rates of HBV and HCV infection in general population. Many studies are also conducted on prevalence of HBV and HCV in dental patients, but no data is available on finding the risk factors for HBV and HCV in dental patient. Therefore the present study was designed to screen out adult patients for HBV and HCV infections, visiting KCD for different dental treatments and to identify the associated risk factors.

METHODS
The present study was conducted at Khyber College of Dentistry Peshawar during the year 2013. Outdoor patients, referred from different sections of KCD, aged > 15 years and of both sexes were included in the study. The patients had different dental problems and visited for the treatments like scaling, dental extraction, dental filling, root canal treatment, minor oral/maxillofacial surgery. A total of 1540 participants were included in the study. Institutional ethical approval was taken and informed consent was taken from every patient. In patients age 16-17 years consent was taken from the parents/guardians. Brief personal, family and medical history was taken on a structured performa and data was analyzed using Epi info version 6.
The blood samples of all these patients were taken in the KCD lab under strict aseptic conditions by a qualified technician. Gel tubes were used for collection of blood samples (5ml). Sera were collected from these samples and were screened for HBsAg and Anti HCV using immunochromatography technique (ICT) in the PMRC (Pakistan Medical Research Council) labs of Khyber Medical College Peshawar. Positive tests were confirmed by ELISA method.
Test results were kept strictly confidential and were only conveyed to the participants. Those with a positive test result were given advice for further testing and treatment, and were referred to the nearest government health facility.

RESULTS
A total of 1540 patients were screened during the study. Among these 561(36.4%) were males and 979(63.6%) females. The percentage of married and educated participants was 1265(82.1%) and 361(23.4%) respectively. On screening, 33(2.14%) were found to be HBs Ag positive of which 14(2.5%) were males and 19(1.9%) were females. HCV was found positive in 46(2.98%) individuals. Male and female distribution was 1.6% and 3.8% respectively. Overall percentage of HBV and HCV was 79(5.12%) as shown in Table-I.

History of blood transfusion and surgical operation:
HBsAg was reported as positive in 4(11.5%) patients having a history of blood transfusion with statically significant value p< 0.001. On other hand 5(14.3%) cases were positive for anti-HCV antibody in previously blood transfused patients with a significant value of p<0.0007.9(5.4%) cases were positive for HBsAg having a history of surgical operation. Anti-HCV antibody was positive in 11(6.5%) cases with a history of surgical operation having a significant value p<0.002 and p<0.003 respectively. Dental treatment: Among 274 (17.8%) patients with a previous history of dental treatment like extraction, scaling and filling, 14(5.4%) were HBsAg positive having a statistically significant value p<0.02, while it was not a significant risk factor in case of HCV. Haemodialysis: There was only one case reported as HBsAg positive in dental patients with a previous history of haemodialysis.

DISCUSSION
The overall prevalence of of HBV and HCV in this study was 79(5.12%). On screening, 33(2.14%) were found to be HBs Ag positive while HCV positive accounted for 46(2.98%).Viral Hepatitis is a major problem throughout the world. There have been studies regarding the prevalence of hepatitis B surface antigen (HBsAg) and anti-hepatitis C antibody (HCVab). However, the majority of these have reported a variety of rates, depending on their study population, which limits the generalizability of their results to the general population. On the other hand, cultural diversity in the different cities of Pakistan also necessitates the performing separate population-based studies in the various regions.
A review study conducted by Huma et al 19 on prevalence and risk factors of HBV and HCV in general population of Pakistan and showed an overall prevalence in adults 2.4% for HBV and 3.0% for HCV. Another study conducted by Javed et al 20 reported an overall prevalence of 2.8% for HBV and 3.19% for HCV in general population of NWFP.
A similar study conducted on the dental patients visiting Bacha Khan Medical & Dental College 21 showed a prevalence of 7.75% for HCV and 7.0% HBV with no significant difference in males and females. This ratio is quite higher than we found in our study. However, there is statistical significance among gender based prevalence in HBV as well HCV.
Another study conducted at dental sector of Ayub Medical College Abbottabad, 22 showed total infection with HBV & HCV as 4.1% which is quite lower than our findings. The percentage of female was higher that correlates with our findings. However, in above mention studies HCV is more prevalent than HBV.
Another study conducted by Dilhan et al in Istanbul 23 on dental patients showed almost similar prevalence of HBV i.e. 2.3% but a lower prevalence of HCV i.e. 0.1%. However, males were more prone to be infected in contrast to our study.