Hepatitis B surface antigen was measured by enzyme immunoassay in a random sample of 1258 healthy pregnant women attending the ante-natal clinics of St. Luke’s Hospital, Malta and Gozo General Hospital, Gozo, and 364 intravenous drug users attending the detoxification centre, SLH. Eight of the pregnant women and ten of the drug addicts were positive for the surface antigen, accounting for a prevalence of 6/1000 and 30/1000 for each cohort, respectively. This would be consistent with low/intermediate prevalence rate in accordance with WHO criteria.peer-reviewe

Attard Montalto, E.

Mamo, Julian

Portelli, Alfred V.

English

OAR@UM

25 -Maltese Medical Journal, 1996; 8 (1): 25-27 A11 rights reserved. Hepatitis 8 prevalence in two Maltese sub-populations E. Attard Montalto*, A. Portellj**, J. Mamo*** ABSTRACT: Hepatitis B surface antigen was measured by enzyme immunoassay in a random sample of 1258 healthy pregnant women attending the ante-natal clinics of St. Luke's Hospital, Malta and Gozo General Hospital, Gozo, and 364 intravenous drug users attending the detoxification centre, SLH. Eight of the pregnant women and ten of the drug addicts were positive for the surface antigen, accounting for a prevalence of 6/1000 and 30/1000 for each cohort, respectively. This would be consistent with low/intermediate prevalence rate in accordance with WHO criteria. *Department of Pham1acy, University of Malta. Msida **Department of Pathology, SI. Luke's Hospital, G'Mangia ***Department of Public Health, University of Malta, Msida Correspendence: A. Portelli, Department of Pathology, SI. Luke's Hospital, G'Mangia Keywords: hepatitis E, pregnant women, drug addicts, prevalence. This article is based 011 a paper read at the //1 Maltese Medical School Conference, 29th Nov-2lld Dec /995. Introduction Hepatitis B is an important cause of acute and chronic infection of the liver with a long incubation period of approximately 2-4 months 1.2. Hepatocellular damage is mediated by the cellular immune response of the host to the hepatocytes3. Persistence of the virus occurs in about 10% of adults .and in as many as 90% of infants due to their underdeveloped immune system4. The hepatitis B carrier state is defined as the presence of hepatitis B surface antigen (HBsAg) in the serum for more than six months 1•5• There are approximately 200 million carriers worldwide, who provide a reservoir for the disease, and who have an increased risk of cirrhosis and hepatocellular carcinoma 1.4.5. There is a spectrum of disease from subclinical infection to an acute icteric illnessI.2. The virus is primarily transmitted via the parenteral route, thus placing intra-venous drug abusers at risk. In addition, the infection may be transmitted sexually, perinatally and possibly, by close contact due to non-sexual exchange of body f1uids 3.6 . The only previous work on hepatitis B, known to the authors, to have been carried out in Malta, was a study on Maltese blood donors 7• In this study, blood donors constituted two sUb-populations: one largely composed of relatives of hospital patients who required blood, while the other consisted essentially of voluntary donors many of whom were already screened and therefore selectively tending to be negative. The prevalence of hepatitis in the first group was reported as 2.8% and in the latter, as 0.6%. The author of that study commented that both results may be overestimates because the ELlSA method then used may have given a relatively high false positive rate and no further confim1atory tests were done. The author recommended a further study with confim1atory tests. Aims The aim of our study was to determine the prevalence of hepatitis B surface antigen within the sub-populations of pregnant women and intra-venous drug abusers. Although pregnant women are a selected population, they are likely to represent a healthy cohort within the general population, whereas, intravenous drug abusers represent a high risk group. It is probable therefore, that the results obtained would indicate that the approximate overall prevalence within the general Maltese population would lie within this range. Materials & Methods Serum samples were collected from pregnant women who were routinely screened for hepatitis B over a period of two years (January 1992 to December 1993). One thousand, two hundred and fifty-eight pregnant women aged 14 to 56 years (median of 29 years) were selected at random from those attending the "booking visit" at ante-natal clinics, SI. Luke's Hospital (SLH), Malta and Gozo General Hospital (GGH), Gozo. SI. Luke's Hospital is the only general hospital in Malta and the majority of births in Malta take place in this hospital. Hence, the random population chosen during the booking visit was considered representative of the population of pregnant women in Malta. In addition, 364 newly admitted drug addicts aged 16 to 52 years (median: 25) attending the detoxification centre, SLH, Malta within this two year recruitment period were tested anonymously for the presence of HBsAg. The prevalence of intra-venous drug abusers at the time of the study was unknown. However, according to unpublished figures (SEDQA) the estimated prevalence today, is about 600. Therefore, given the probability that there were less cases then, the -E. Attard Montalto et al. 26 number investigated (364) is a fair representative sample. An enzyme immuno assay, (Auszyme® Abbott Laboratories) was used to detect HBsAg levels in concentrations of ~ 0.lng/mI6. A positive EIA reaction was repeated and if the repeat test was also positive a confirmatory neutralization test was carried out. Student's Hest was used to determine significant association or difference between the age of seropositive and seronegative individuals within both cohorts. Results Of the 1258 pregnant women tested, eight were found to be positive for the surface antigen resulting in a prevalence of HBsAg of 6 per 1000 women within this cohort. There was no significant difference between the ages of the seropositive and seronegative women. Ten of the 364 drug abusers were positive for HBsAg indicating an approximate prevalence of 30/1000. There was a significant difference between the mean age of the seropositive (32.4 years) and seronegative (26.41 years) drug addicts at P<0.025%. Discussion Malta is an island nation with a population of approximately 360,000. It is geographically surrounded by areas of intermediate endemicity carrier rates, including southern Italy, Northern Africa and the Middle East. WHO considers an intermediate prevalence rate to lie between 2 - 7%8 and so by applying a prevalence of approximately 4% to Malta, it would be expected that 14,400 persons would be carriers of this infection. In order to carry out a comprehensive evaluation of the entire Maltese . population, the use of invasive serological techniques would have rendered such a study extremely difficult. For this reason the subpopulations of pregnant women and drug addicts were chosen. Pregnant Women Population The prevalence of 6/1 000 with hepatitis B antigen positivity in this cohort was low compared with the higher rates present in neighbouring countries. This study population sample was large enough for this rate to be considered a valid representation of that of all pregnant women attending St. Luke's Hospital and therefore on the island. Perinatal transmission of HBV represents one of the most efficient modes of hepatitis B transmission and approxin1ately 90% of HBeAg carrier mothers infect their infants in this way9. As a result, 85 to 90% of infected infants will themselves become chronic carriers probably as a result of their immature immune system which is unable to eliminate the surface antigens5.9.lo. Serological studies involving women of child bearing age are a useful scientific guide for the estimation of risk of infection to infants by perinatal transmission8. In this study, eight previously undetected HBsAg positive women were identified and their offspring were immunized within 48 hours of birth, thereby preventing future complications related to the infection9.I I. Indeed the administration, concurrently, of immunoglobulin (HBIG) preparation and the vaccine to infants of HBsAg positive mothers, within 48 hours and not later than 7 days of birth, prevents the development of carrier states in all but 5% of such exposed infants3,4,9,1l. A second dose of the vaccine is then administered at 1-2 months of age, and a third at 6-18 months of age ll . The aim of immunization is the protection against HBsAg carrier status and thus reduction of carcinoma associated with the chronic infection. Drug Abuse Population This study has shown that an approximate 30/1000 drug addicts in Malta were positive for the surface antigen. This value is considerably higher than the prevalence of HBsAg shown within the cohort of pregnant women, and confirms the high risk of this infection in drug abusers in Malta 12 . However, when compared with the prevalence of HBsAg of 38% within a similar addict popUlation in Stockholm13, the prevalence in Malta was approximately 3%. Due to the fact that information regarding drug addicts is withheld to preserve anonymity, it was not possible to trace data about exposure to other risk factors. For this reason it was assumed that these persons contracted the infection as a result of their lifestyle involving drug abuse. The mean age of seropositive drug addicts was significantly greater than that of their seronegative counterparts. Recently, the detoxification centre in Malta has provided patients with free syringes so as to avoid the sharing of contaminated equipment, thereby reducing the spread of infection. Also a public education programme about hepatitis B and its modes of transmission has resulted in an increased awareness of the risks associated with this lifestyle. Older drug abusers may have been exposed to these risk factors for a longer period of time as compared to younger persons, and as in other countries with a low to intermediate prevalence carrier popUlation, hepatitis B infection increases with age. However, as the study only looked at addicts attending the detoxification centre at SLH, it may not be representative of the drug abusing population on the island as a whole. Conclusion These two serological studies have provided prevalence rates of two extremes of the Maltese population. It may be assumed that the overall prevalence lies somewhere between the rate for pregnant women and that of the sub-popUlation of drug addicts . From this, one may assume that the overall popUlation prevalence rate lies between 1 % and 3% which is a low or low-intermediate endemicity rate as set by WHO. References 1. 	 Zuckennan AI, Zuckerman I & Harrison T. Viral hepatitis - the alphabet so far; Int I of Cl in Virol 1993; 6: 1-8. 2. 	 Cook Gc. Infections involving the liver and biliary system; communicable and tropical diseases, 101-115. 3. 	 McCollum RW. Viral hepatitis, epidemiology and control, 1989. 4. 	 Smithkline Beecham Biologicals Documenta: New prospects for control of Hepatitis B, 1989. 27 Hepatitis B prevalence in two Maltese sub-populations 5. 	 Maynard M. Hepatitis B vaccine: Current progress and strategies for utilisation. New developments with human and veterinary vaccines, 157-168. 6. 	 Hoofnagle JH & DiBisceglie AM. Serological diagnosis of acute and chronic viral Hepatitis; Seminars in liver disease, 1991; 1I(2): 73-83. 7. 	 Farrugia A. Incidence of Hepatitis B surface antigen in Maltese blood donors - results comparing different test systems, pp54-61, in Camilleri M (ed)., Clinical Gastroenterology in Malta. Malta, 1987. 8. 	 WHO: Immunisation. WHO EPI/Gen/88.5: 4-23. 9. 	 Emest JM et al. Intrapartum Hepatitis B screening in a low-risk population. Amer J of Obs and Gynae 1990; 978-980. 10. 	 Beasley et al. Hepatology, 3(2): 135-141. 11. 	 Committee on Infectious Diseases: Universal Hepatitis B Immunisation. Amer Acad of Paediat 1992; 89(4): 795­800. 12. 	 Zuckemlan AJ. Immunisation against Hepatitis B. Br Med Bulletin, 1990; 46: 383-398. 13. 	 Sobeslavsky o. Prevalence of markers of Hepatitis B virus infection in various countries: a WHO Collaborative Study. Bulletin of the World Health Organisation 1980; 58(4): 621-628. Hospices and hospitals St Anne House, Senglea (Ospizio Sant Anna) The Ospizio is situated on the Senglea Wharf facing Vittoriosa. Opened in 1794, in the house bequeathed by Nicola and Maddalena Dingli, it originally housed women from Senglea and Siggiewi, Nicola Dingli's native village. In 1889 it was taken over by the Franciscan Sisters of Malta who ran it for over 70 years . The building became unsuitable for its purpose and in 1980, the Archpriest of Senglea, Fr. John Sladden, assisted by Canon Vincent Camilleri, decided to build a new hospital on the site. 1lle new building, designed by Architect Joseph Borg Constanzi, was inaugurated in 1987 and can take 30 inmates. Two lions from the old building, holding the stems of the Dingli and Comelio families, have been incorporated in the front gate. Since 1987 it has been administered by Movement Umanita Gdida which is a branch of the Focolare movement. Acknowledgement The assistance of Mrs Mildred Falzon, administrator of Dar Sant Anna is gratefuly acknowledged. References 1. 	 Bonnici Alexander: Dar Sant·Anna Ghall-Anzjani tl-Isla 1987 Parocca ta" l-Isla. pp40. 2. 	 Guillaumier Alfie: L-Isla. Bliet u Rhula Maltin 1987 12:333. 3. 	 Zahra L: Senglea - "Invicta Civitas" Civilisation 1988: 38:1064 c. Camilleri The copyright of this article belongs to the Editorial Board of the Malta Medical Journal. The Malta Medical Journal’s rights in respect of this work are as defined by the Copyright Act (Chapter 415) of the Laws of Malta or as modified by any successive legislation. Users may access this full-text article and can make use of the information contained in accordance with the Copyright Act provided that the author must be properly acknowledged.  Further distribution or reproduction in any format is prohibited without the prior permission of the copyright holder. This article has been reproduced with the authorization of the editor of the Malta Medical Journal (Ref. No 000001)  

Alfie: L-Isla. Bliet u Rhula Maltin

Committee on Infectious Diseases: Universal Hepatitis B Immunisation. Amer Acad of Paediat

Dar Sant·Anna Ghall-Anzjani tl-Isla

Immunisation against Hepatitis B. Br Med Bulletin,

Incidence of Hepatitis B surface antigen in Maltese blood donors - results comparing different test systems, pp54-61,

Intrapartum Hepatitis B screening in a low-risk population.

Senglea - &quot;Invicta Civitas&quot; Civilisation

Hepatitis B prevalence in two Maltese sub-populations

https://www.um.edu.mt/library/oar/bitstream/handle/123456789/246/mmj1996%20080125.pdf?sequence=1&isAllowed=y

Hepatitis B prevalence in two Maltese sub-populations

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