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TRANSACTIONSOF THE ROYAL SOCIETY OF TROPICAL MEDICINE AND HYGIEN E (1995) 89,167-170

167

Prevalence of hepatitis B and C viruses in healthy Indonesian blood donors

H. A. Sulaiman, Julitasari2, Annie Sie3, Masri Rustam4, W. Melani4, A. Co&n3 and G. B. Jennings3

Medical

Faculty, University of Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia;

Directorate General, Communicable

Disease Control and Environmental Health Ministry of Health, Jakarta, Indonesia;

3US Naval Medical Research Unit No. 2,

Jakarta, Indonesia; 41ndonesian Blood Bank Service, Jakarta, Indonesia

Abstract

Blood samples were collected from 7572 healthy volunteer blood donors from 21 of the 27 Indonesian prov-

inces, and tested for antibodies to hepatitis C virus (anti-HCV) using the new second-generationenzyme imm-

unosorbent assay, and also tested for hepatitis B surface antigen (HBsAg). We detected anti-HCV in 2.1% of

the blood donors. No statistically significant difference was found between males and females or between lo-

cations, but there was a statistically significant increasing likelihood of anti-HCV prevalence with increasing

age. HBsAg was found in 8.8% of the 3839

tested

donors. There was no statistically significant difference

between sexesor age groups, but there was a statistically significant higher prevalence in the islands of Su-

lawesi and eastern Indonesia. Only 7 individuals, from 5 locations, were both anti-HCV and HBsAg posi-

tive. Based on responses o a questionnaire, a history of surgery, blood transfusion, intravenous medication,

and acupuncture were identified as risk factors for the presenceof anti-HCV. No such risk factor was identi-

fied for HBsAg prevalence. The combined data suggest separate modes of transmission for the 2 viruses,

and indicate the need for continued surveillance for these agents n Indonesian blood banks.

Keywords: hepatitis B, hepatitis C, prevalence in blood donors, Indonesia

Introduction

Hepatitis B virus (HBV) causesacute and chronic he-

patitis and hepatocellular carcinoma (ROBINSON, 1985).

Hepatitis C virus (HCV) has been associatedwith acute

hepatitis and hepatic cirrhosis

(CHEN

et al., 1990), and

may be a cause of hepatocellular carcinoma

(DAZZA

et

al.,

1993). These agents therefore pose a serious threat to

the safe collection of blood for blood bank systems.

Numerous studies have documented the prevalence of

these viruses in developed countries

(KUHNL et

al.,

1989; STEVENS et al., 1990), but less s known about de-

veloping countries where cost is a major factor in deter-

mining which assaysare available for blood bank screen-

ing programmes. The obvious value of such testing is a

decreasedprevalence of associateddisease n blood reci-

pients

(ALTER

et al.,

1986).

thogens from donors, and to identify any risk factor(s)

associated with seropositivity. The assessment evealed

HCV and HBsAg to be potential threats, especially in

certain areasof the archipelago.

A previous assessmentof HBV prevalence in Indone-

sia, conducted in 1981, was limited to Jakarta, the na-

tional capital, and found 10% of the blood donors posi-

tive for hepatitis B surface antigen (HBsAg) (MBOI et al.,

1981). A more recent report, limited to the provincial

capital of South Sulawesi, identified 7.1% of the blood

donors as HBsAg seropositive

(AMIRUDIN

et al., 1991).

The same report detected HCV antibodies (anti-HCV) in

3.1% of the blood donors, a much higher proportion

than that in other countries

(DAWSON

et al.,

1991;

JANOT et al., 1989). The importance of these agents in

Indonesia was shown recently by SULAIMAN et al. (1991).

Among acute hepatitis cases, 6.4% were associatedwith

HBV and 2.8% had anti-HCV. However, HBsAg was de-

tected in 36.5% o f liver cirrhosis cases and anti-HCV in

73.9%, while 58.6% of hepatocellular carcinoma cases

were positive for HBsAg and 34.2% for anti-HCV.

Both of these Indonesian HCV studies were performed

using the anti-HCV first-generation enzyme immunoas-

say (EIA) which tested for a single HCV antigen. A

newer, second generation HCV EIA has been developed,

and incorporates antigens from 3 separateHCV proteins

~LAI et al., 1992). This new assavhas imoroved sensitiv-

ity and specificity (ALTER, 1992j and its&useshould pro-

vide more accurate data on HCV prevalence.

Indonesia is the fourth most populous country in the

world, comprising over 13 000 islands stretching nearly

5000 km along the equator. The major islands are

Java/Bali, Sumatra, Kalimantan, Sulawesi, and Eastern

Indonesia, including Irian Jaya. The blood bank service

is responsible for the safe collection of blood throughout

the archipelago. This study was conducted to determine

the risk to the blood bank system of blood-borne pa-

Address for correspondence: Dr A. L. Corwin, US NAMRU-2,

Box 3, Unit 8132, APO Al96520-8132 , USA.

Materials and Methods

Subjects

Seven thousand, five hundred and seventy-two blood

donors (6732 male, 755 female, and 85 unknown) were

sequentially surveyed at 24 blood bank services in 21 of

the 27 Indonesian provinces, from November 1992 to

February 1993. Blood donations in Indonesia are entirely

voluntary, with no commercial gain. The number of

samples collected at each site was proportional to the

population of the province. Ages of the study population

ranged from 11 to 76 years (meankstandard deviation

32.91+10.02 years). The mean age of males (33.04k9.97

years) was significantly higher than that of females

(31.79+ 10.48 years) (P


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168

Table 1. Age distribution of hepatitis C virus and

HBsAg positive blood donors screened throughout

Indonesia, November 1992-February 1993

Age group

(years)a

1 -20

21-30

31-40

41-50

5 -70

Anti-hepatitis C

positive HBsAg positive

61597 (1.0%) 231316 (7.3%)

3312944 (1.1%) 14111467 9.6%)

22/2087 (1.1%) 8811092 8.1%)

55/1351 (4.1%) 511626 (8.0%)

451436 (10.3%) 191241 (7.9%)

x>;o904~4

x2=3*37

P=O.5030

aRespondents not revealing their age or sex were not

included in calculations.

by the exact and normal methods. x2 tests with Yatess

correction were performed when comparing multiple

proportions from mutually exclusive sample groups. Stu-

dents t test and analysis of variance were used to deter-

mine the significance of differences between mean

values.

Table 2. Prevalence of hepatitis C virus aad HBsAg among blood

donors in Indonesia, by location, November KM-February 1993

Anti-hepatitis C virus HBsAg

No. of

No. positive/ No. of

No. positive/

Location

cities

no. tested

cities

no. tested

Java/Bali

9 11214487 (25%) 3

9911793 (55%)

Sumatra

5

2011186 (1.7%) 2 271382 (7.0%)

Kalimantan

121800 (1.5%) 3

281597 (4.7%)

Sulawesi :

131700 (1.8%) 3

871694 (12.5%)

Eastern

Indonesia

3 41399 (1.0%) 3

97/373 (26%)

x2=8.2, P=O.O8

x2=187.6,

PO.O5) (the 95% CI for the difference between the

means was -11.1 to 2.33). In contrast, the mean age of

HBsAg positive males (33 years) was significantly

(P40 years of age (5.6%) was significantly higher

(P


3/4

169

HBsAg and the risk of HCV infection.

Discussion

These findings show the risk to the Indonesian blood

bank system of blood-borne pathogens from their volun-

teer donors. Our findings of a 2.1% anti-HCV prevalence

in Indonesian blood donors is much higher than that re-

ported from western countries (using a first generation

EIA), 0.42%-0.9%

(KUHNL

et

al.,

1989; STEVENS

t al.,

1990). A report from Japan documented a similar pre-

valence (0.56%) (TANAKA

et al.,

1992). However, de-

veloping south-east Asian countries have a higher pre-

valence. Thai blood donors had an anti-HCV prevalence

of 2.3% in a small number of samples tested (POOVO-

RAWAN t al.. 1991). while a studv of healthv subiects in

Singapore found 1.70/o o be positive for an&HCV (YAP

et al., 1991). Cultural differences or cross reactivity with

region-specific anti

ens might explain this observed vari-

ation between deve oped and developing countries; how-

:

ever, such common agents as dengue and Japaneseence-

phalitis virus have not been shown to cross-react with

HCV (DAWSON t al., 1991). The finding of higher HCV

prevalence in areas with ~1 million population suggests

that the new urban lifestyle of a developing nation mayexpose city dwellers to risk factors associatedwith HCV

infection. Further studies are needed to explain the

underlying reason or the higher prevalence.

ALLAIN et al. (1992) have reported the need for confir-

matory testing of samples found to be positive for anti-

HCV by EIA. Unfortunately, we did not perform confir-

matory recombinant immunoblot testing, a technique

commonly used for this purpose. DAWSON t al. (1991)

and ALBERTI

et al.

(1991) reported that this additional

testing confirmed 26O/0o 47% of samples positive by

EIA samnles as true HCV infections. However. both of

those stuhies used a first generation anti-HCV EIA. Our

study used the second generation assay and thus should

have found fewer false oositives (AACH et al.. 1991). Re-

gardless of this, our finding of 2.1% anti-H& ire-

valence is significant, and warrants continued screening

by the Indonesian blood bank system.

Only 7 of 3839 (0.18%) individuals screened or both

HBV and HCV markers were positive for both; thus it

seems unlikely that the 2 viruses are transmitted to In-

donesian blood donors in an identical manner. HBV is

transmitted sexually and vertically (ROBINSON, 1985),

and both agents can be transmitted by blood, but uncer-

tainties remain regarding the transmission of HCV

(EVERHARTet al., 1990; REESINK

et

al.,

1990;

KAO

et

at., 1992). In our study, anti-HCV and HBsAg pre-

valence was essentially equal in the 2 sexes, but there was

a difference in prevalence between age groups (Table 1).

Anti-HCV was more prevalent in the older age groups, a

finding similar to that in other studies (SCOTT et al.,

1992; TANAKA et al., 1992). This is compatible with ex-

posure later in life, perhaps via one of the risk factors

identified in Table 3. Alternatively, repeated exposure

during the course of life may be necessary to elicit an

antibody response detectable by the EIA. HBsAg pre-

valence, on the other hand, was constant th roughout the

5 age groups. This may indicate that the prevalence of

HBsAg is due to exposure early in life, i.e. through verti-

cal transmission. These conclusions are consistent with

there being different means of transmission of the 2

viruses.

The prevalence o f HBsAg in the blood donors, though

lower than previously reported for Jakarta (MBOI et

al.,

1981), was alarmingly high in many areasof the Indone-

sian archipelago. A significantly higher prevalence of

HBsAg was detected among blood donors from Sulawesi

and Eastern Indonesia than in the rest of the Indonesian

archipelago. Whether some cultural difference exists be-

tween these areas and the remainder of Indonesia which

might cause the higher prevalence is unknown; however,

the data suggest that factors associated with a less intens-

ively

urban lifestyle (populations


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170

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Received 6June 1994; revised 16 August 1994; accepted for

publication 25 August 1994

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