Studies on the serological markers for hepatitis B virus infection among type 2 diabetic patients

Abstract Background Hepatitis B infection is a public health concern globally. HBV can be associated with type II diabetes mellitus, as HBV outbreaks have been observed among diabetics in healthcare facilities. This study evaluates the prevalence of HBV infection among patients with type II diabetes mellitus. Method A total of one hundred and eighty (180) diabetic patients and one‐hundred non‐diabetics (Controls) were recruited for this study. Structured questionnaires were administered to the consented participants to obtain relevant data. Sera samples obtained were screened using the HBsAg ELISA kit; CTK Biotech, Inc, while the 5 panel kit—rapid diagnostic test, was used to assay for serological markers. Questionnaires were used to obtain relevant information and demographic data. Result Overall prevalence of HBV infection among diabetes patients was 13.3%. Breakdown showed 9 (5.0%) seropositivity was obtained among male subjects compared to 15(8.3%) recorded among the females, P = .834; P < .05. Subjects aged 41‐50 years recorded, 7(3.9%) positivity P = .774; P > .05. Educational status of participants showed 22 (12.2%) positivity among subjects with tertiary level of education P = .032; P < .05). Risk factors considered showed that 5(2.8%).seropositive subjects were alcoholic consumers (P value = .9711; P > .05). Result among non‐diabetics (Control) subjects showed (4%) seropositivity among the male subjects compared to (5.0%) seropositivity recorded among the female subjects (P = .739; P > .05). Conclusion There is an indication of higher risk of HBV infection among type 2 diabetic patients when compared to non‐diabetics. There is the need for more research on this area of study, to further validate the association between HBV infection and Diabetes Mellitus.


Hepatitis B virus (HBV) is one of the most common chronic infec-
tions worldwide and the leading cause for hepatocellular carcinoma (HCC) worldwide. 1 Based on WHO report, one-third of the world population estimated at about 2 billion individuals are HBV-infected, including studies showing that about 240 million individuals are chronic carriers. 2 Transmission of this virus occurs via exchange of bodily fluid such as blood, semen, and perinatal transmission.
Hepatitis B has been majorly associated with hepatocellular carcinoma, cirrhosis, and chronic hepatitis, and this makes it identifiable as a major health issue in various developing countries. 3 An increased rate of this disease occurrence has been recorded in regions like East Asia and sub-Saharan Africa where 5%-10% of adults in these locations come up with chronic hepatitis infection as compared to other areas. 4 Hepatitis virus is a member of the Hepadnaviridae family, possessing a small, enveloped DNA virus called the "Australia antigen" and later referred to as hepatitis B virus. Studies have shown that HBV has contributed to the increased morbidity rate worldwide.
This virus is known to cause about 50% of cases of hepatocellular carcinoma and 30% of cases of cirrhosis globally. 5,6 Further studies showed that the hepatitis B surface antigen (HBsAg) was known to be present in patient's serum. 7 This surface antigen is present on the outer envelope alongside an inner nucleocapsid consisting of hepatitis B core antigen (HBcAg). 8 Diagnosis of this virus is done by blood screening for the surface antigen. To enable most precise diagnosis and to determine the infectious rate, the diagnosis and follow-up of chronic hepatitis B virus (HBV) infection relies on laboratory viral biomarkers.
There are two major categories of HBV biomarkers. The first one is serology, a term comprising the detection and quantification of viral antigens and viral specific antibodies, and the second is nucleic acid testing (NAT) for the detection and quantification of HBV genome and its RNA transcripts. 9 The spread of this virus is rapidly on the increase globally; as large numbers of individuals are unaware of the ravaging effect of this virus nether do they know their status mostly in identified endemic regions. Complications can occur after prolonged infection with this virus and due to its asymptomatic nature. Transmission of the virus can easily occur without adequate precaution.. 10 Based on the increasing prevalence of HBV, various studies have been carried out on this virus with less information on its association with diabetic patients. HBV outbreaks have been observed among diabetics in healthcare facilities and nursing homes.
Diabetic patients are vulnerable to hepatotropic infections as a result of recurring hospitalization and blood screening. 11 Studies carried out by the National Health and Nutrition Examination Survey revealed an increased prevalence of hepatitis B among diabetic patients as compared to non-diabetic patients. Diabetic patients, due to their defective levels of T lymphocytes are vulnerable to viral infections as a result of an immune compromised system.

| Study area and population
The study was conducted at the Federal Teaching Hospital Ido-Ekiti which is a tertiary health institution. The study population comprised of randomly selected confirmed diabetic patients attending the outpatient department of the Teaching Hospital.

| Inclusion and exclusion criteria
Individuals confirmed for type 2 diabetes mellitus diabetes were recruited for the study. Persons who showed no interest in the study and are not diabetic were excluded from the study.

| Questionnaire and sample size
The sample size for research work was obtained from one-hundred and eighty (180) volunteers, and the recruits were properly informed about the study and their consents obtained. Well-structured questionnaires were used to collect demographic data and other pertinent information.

| Sample collection and processing
Aseptic collection of three to five (3-5) mL of blood from each diabetic patient was done. At room temperature, blood samples were left undisturbed to allow clotting. Thereafter, sera obtained were dispensed into a clean, dry cryovial and stored at −20°C prior use.
Screening of the sera was done for antibodies to HBV with the use of ELISA kits (Fortress Diagnostic Limited), while the 5 panel kit-rapid diagnostic test, was used to assay for serological markers. Standard procedures were strictly adhered to during the assaying process.

| Sample processing
Sera samples obtained were screened for HCV antibodies using ELISA technique according to the manufactures manual. The 5 panel kit-rapid diagnostic test, was used to assay for serological markers serum ALT was also assayed for, according to manufacturer's manual. Hepatitis B ELISA and ALT kits were stored in the refrigerator at 4°C prior to use. Sera samples were analyzed at Landmark University Medical Laboratory.

| Data analysis
Filled questionnaires were crosschecked manually for correct entry of data. The data were analyzed using the SPSS software package, and chi-square test was used to compare several variables while the critical level for statistical significance was set at P = 5% (.05).
The result based on educational status of subjects screened, the prevalence of 2 (1.1%) was recorded among subjects with a minimum of primary educational status. The prevalence of 3 (1.7%) was recorded among those with secondary level of education, while 18 (10.0%) positivity was recorded among individuals with tertiary level of education (Table 5).
Based on the demographic factors, a prevalence of 9 (5.0%) was recorded among subjects engaging in trading, while 11 (6.1%) prevalence rate was recorded among civil workers, 3 (1.7%) prevalence among industrial workers, and 1 (0.6%) prevalence was recorded among subjects who were students, P = value of .240; P > .05 (Table 6).
On the basis of risk factors among subjects screened, 2.8% prevalence was recorded among alcohol consumers, while 1.7% prevalence was recorded among individuals with history of tribal mark/ tattoos. 1.7% positivity was recorded among individuals with history of sharing sharp objects (Table 7).
Based on clinical history of subjects screened, 2.8% prevalence was recorded among individuals with family history of HBV infection, compared to 2.2% prevalence was recorded among care givers ( Table 8).
The assay carried out on the positive samples, using the 5-panel kit, showed that 37.5% positivity was recorded among individuals with HBsAg, and 8.3% was recorded for subjects with HBsAb.
However, 4.2% positivity was recorded for subjects with HBeAg, 45.8% positivity was noted for subjects with HBeAb, and 54.2% positivity was recorded among subjects with HBcAb. (Table 9).

| D ISCUSS I ON
HBsAg positivity was more prevalent among diabetic patients (13.3%), compared to the non-diabetic subjects (9%). Although this difference was statistically insignificant, it was of clinical importance. The result obtained from the sera samples screened among diabetic patients showed a prevalence rate of 13.3%.This result is comparable to the study carried out at Ahmadu Bello University, Zaria among diabetes where HBV prevalence of 12.5% was recorded. 12 Our findings also correspond with a national survey carried out in Nigeria where the prevalence of 12.2% was recorded. 13 A study done in Taiwan also showed a related prevalence of 13.5% among diabetic patients. 14 However, the result obtained from this research was higher in comparison with a study carried out in China and Turkey which recorded 3.8% and 5.1% prevalence among diabetic patients, respectively. 15

TA B L E 5 Distribution of HBV among diabetics Based on Educational qualification
rate among widows than individuals of other marital status 22,23 ( Table 4). This could be as a result of the sexual promiscuity of  preferable serologic test to establish a history of previous infection. Earlier studies (Zhang et al,30 ) reported that improvement in vaccination strategies could be attributed to upsurge in HBsAb positivity, which should increase the confidence of the population on the immunization process as a safe guard against HBV infection.

| CON CLUS ION
In conclusion, this study found that the risk of HBV infection after the onset of T2DM recorded no significance statistical difference compared to risk factors among patients without the T2DM.
However, individuals infected with T2DM had a higher incidence rate of HBV in all the age ranges studied when compared to non-

ACK N OWLED G M ENTS
The author deeply acknowledges the Management of the Landmark University Medical Center for the opportunity to use the Medical Laboratory department to assay our samples. Staffs of the FTC Ido Medical Laboratory Department are also deeply appreciated.

DATA AVA I L A B I L I T Y S TAT E M E N T
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.