Prevalence of anti-HCV Antibodies Among Healthy Asymptomatic Indian Blood Donors and the Current Role of anti-HBc Screening as a Surrogate Marker for HCV Infection
Hepatitis B virus (HBV) and hepatitis C virus (HCV) infections account for a bulk of acute and chronic liver diseases world-wide. Since, both the viruses share similar risk factors and modes of transmission, a combined HBV and HCV infection is frequently encountered especially in the HBV endemic areas. Until lately anti-HBc antibodies were considered as surrogate marker for HCV infection. But with the development of advanced tests for HCV detection the role of anti-HBc in this regard stands uncertain.
Published on: Mar 4, 2016
Transcripts - Prevalence of anti-HCV Antibodies Among Healthy Asymptomatic Indian Blood Donors and the Current Role of anti-HBc Screening as a Surrogate Marker for HCV Infection
Prevalence of anti-HCV Antibodies Among Healthy
Asymptomatic Indian Blood Donors and the Current Role
of anti-HBc Screening as a Surrogate Marker for HCV
It is the prime responsibility of a Blood Transfusion
Service (BTS) facility to offer its patients the safest possible
blood for transfusion that is free from various Transfusion
Transmissible Infections (TTI’s). Although measures such
as adoption of strict donor selection criteria, encouragement
and maintenance voluntary non remunerative pool of blood
donors and temporary or permanent deferral of those with
high risk behaviors judged by the use of questionnaire are a
routine practice globally, the final decision on whether or
not to use a blood/blood product for transfusion relies on the
results of infectious marker tests. In India, it is mandatory to
test for HIV, HBsAg, anti HCV, Malarial Antigen and
syphilis. The use of sensitive screening methods that may
detect infectious agents during the ‘window period’ such as
nucleic acid testing further adds to blood safety.
Hepatitis B virus (HBV) and hepatitis C virus (HCV)
infections account for a bulk of acute and chronic liver
diseases world-wide [1-2]. Since, both the viruses share
similar risk factors and modes of transmission, a combined
HBV and HCV infection is frequently encountered
especially in the HBV endemic areas. It has been shown that
a dual HBV and HCV infection is associated with a more
severe liver disease, and is at an increased risk for
progression to hepatocellular carcinoma (HCC) .
Individual literature on the prevalence of HCV as well
as the Hepatitis B core antibody in different populations
world over is readily available, however not many have
studied the two in conjunction with each other. Presence of
298 Apollo Medicine, Vol. 7, No. 4, December 2010
PREVALENCE OFANTI-HCVANTIBODIESAMONG HEALTHYASYMPTOMATIC INDIAN
BLOOD DONORS AND THE CURRENT ROLE OF ANTI-HBC SCREENING AS A
SURROGATE MARKER FOR HCV INFECTION.
, Aakanksha Bhatia*, NL Rosamma** and Minimol***
#Director,*Registrar, **Senior Technologist, ***Technologist, Department of Transfusion Medicine,
Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi 110 076, India.
Correspondence to: Dr RN Makroo, Director, IndraprasthaApollo Hospitals, Sarita Vihar, New Delhi 110 076, India.
Hepatitis B virus (HBV) and hepatitis C virus (HCV) infections account for a bulk of acute and chronic liver
diseases world-wide. Since, both the viruses share similar risk factors and modes of transmission, a combined
HBV and HCV infection is frequently encountered especially in the HBV endemic areas. Until lately anti-HBc
antibodies were considered as surrogate marker for HCV infection. But with the development of advanced
tests for HCV detection the role of anti-HBc in this regard stands uncertain.
Key words: Combined HBV and HCV infection, Anti HBc antibodies, Surrogate marker.
anti-HCV and anti-HBc antibodies in absence of
detectable HBsAg by ELISA has been reported in blood
donors in variable frequencies. Although blood units in
such cases are definitely discarded, these cases create a
dilemma where donor notification is concerned. Until
lately anti-HBc antibodies were considered as surrogate
marker for HCV infection. But with the development of
advanced tests for HCV detection the role of anti-HBc in
this regard stands uncertain .
Patients with HCV-related chronic liver disease (CLD)
frequently show markers of previous HBV infection.
Moreover, they may carry occult HBV infection. It has
been shown that co-infection with hepatitis delta virus or
HCV results in down regulation of HBV replication and a
reduction in antigen synthesis . It was initially believed
that the HCV core protein inhibits HBV replication and
gene expression. Bellecave, et al.  on the contrary
showed that HBV and HCV can replicate in the same cell
line without in vitro interference. Thereafter other indirect
mechanisms of viral interference mediated by innate and/
or adaptive host immune responses were proposed [8,9].
MATERIALS AND METHODS
All donors who donated blood at the Indraprastha
Medical Corporation Limited Blood Bank, Indraprastha
Apollo Hospital, New Delhi from January 2006 to
December 2010 were enrolled in the study. The donors
were apparently healthy adults between the ages of 18-60
years. All donors were subjected to a pre test counseling
which was done by qualified staff trained to screen donors
299 Apollo Medicine, Vol. 7, No. 4, December 2010
for blood donation as per the Drug and Cosmetics act.
Donors who did not fulfill the general criteria for blood
donation, paid and commercial donors and those with a
history of high risk behavior were deferred from donating
blood at our institution and hence, excluded from the study.
Post donation all donor blood samples were tested for
the presence of anti-HBc antibodies using Enzyme Linked
Immuno SorbentAssay (ELISA). Third generation ELISA
kits (MonolisaTM Anti-HBc PLUS, BIO-RAD) using fully
automated EVOLIS walk away system (BIO-RAD) were
used for testing. For anti-HCV antibodies, third generation
ELISAkits (MUREXANTI-HCV (VERSION 4) MUREX
BIOTECH.) were used from January 2006 till October
2010. From October 2010 till December 2010 SP-
NANBASE C-96 3.0 kits from GENERAL
BIOLOGICALS CORP. were introduced.All samples that
tested positive by ELISA were repeat tested in duplicate
using the same ELISA kit. Only repeat reactive samples
were labeled as ‘POSITIVE’.
Nucleic acid testing (NAT) was done for all donor
samples using the TMA (Transcription Mediated
Amplification). The Procleix Ultrio Assay, a qualitative in
vitro nucleic acid amplification test from Chiron
(Novartis), for the detection of human immunodeficiency
virus type 1 (HIV-1) RNA, hepatitis C virus (HCV) RNA,
and hepatitis B virus (HBV) DNA was performed and The
Procleix HIV-1, HCV, and HBV Discriminatory Assays
were run for the reactive cases. ELISA and NAT results
were compiled, tabulated and analyzed.
A total of 99,131 donors were included in the study and
tested for anti-HCV and anti-HBc antibodies by ELISA.
The year wise distribution of blood donors and marker
positivity is shown in Table1.
From 2006 till 2010, anti-HCV antibodies were
detected in 406 donors, with an average of 81 cases per
year. These constitute an average of 0.41% of the total
donors tested. Anti-HBc antibody on the other hand was
detected in 10,169 donors (average of 10.25%) irrespective
of the HBsAg status. Ninety Six (0.09%) showed positivity
for both anti-HCV and anti-HBc antibodies. In three out of
these 96 donors HBsAg was detected indicating a clear cut
case of dual infection of HBV and HCV. However, in the
remaining 93 donors only anti-HCV and anti-HBc
antibodies were detected (Fig.1).
All the 96 cases were subjected to NAT. The initial
Procleix Ultrio assay was reactive in 44 cases.
Discriminatory assays confirmed the presence of HCV
RNA in 42 out of these 44 cases, while the remaining two
were diagnosed having HBV DNA. Retrospective analysis
revealed that in one of these two cases HBsAg was detected
in ELISA, while the other one was only positive for anti
HBc antibody besidesAnti HCV.
A retrospective evaluation of the NAT positive cases
also revealed that there were merely 4 cases in the five year
study period where anti HBc positivity in absence of anti
HCV yielded HCV RNA in NAT. Further in 3 out of these
four ELISAalso showed HBsAg positivity.
Hepatitis C is a leading cause of transfusion related
hepatits, the transmission primarily being parenteral. It is
common in drug addicts, recipients of blood products, and
patients on haemodialysis. It is also observed commonly in
health care workers as well as healthy voluntary blood
Hepatitis C virus (HCV) infection rate is about 3% with
over . More than 3.5 million new cases are diagnosed
Table 1 Year wise distribution of anti-HCV and anti-HBc marker results
Year Total number of Number of donors Number of donors Number of donors
donations reactive for anti-HCV reactive for anti-HBc positive for both anti-HCV
antibodies by ELISA antibodies by ELISA antibodies by ELISA and anti-HBc
2006 18278 75 (0.41%) 2012 (11.01%) 26(0.14%)
2007 19664 75 (0.38%) 2013 (10.2%) 16 (0.08%)
2008 21068 86 (0.41%) 2098 (9.95%) 15 (0.07%)
2009 20605 86 (0.42%) 2145 (10.41%) 22 (0.11%)
2010 19515 84 (0.43%) 1901 (9.74%) 17 (0.09%)
TOTAL 99131 406(0. 41%) 10169 (10.25%) 96(0.09%)
Apollo Medicine, Vol. 7, No. 4, December 2010 300
well as HIV infection until the development of advanced
screening tests for anti HCV antibodies and for HCV RNA.
Current studies reveal that anti-HBc testing does not
identify additional donors capable of transmitting HCV
infection when such donors are also screened by the more
advanced and sensitive anti-HCV tests. It has been long
argued that anti-HBc testing does help in detection of at
least a few additional donors infected with hepatitis B,
which are either in the window period or have a very low
level of antigenemia. Despite these potential benefits of
anti-HBc screening, the present test for anti-HBc gives
many false positive results. This not only leads to
unnecessary wastage of blood units that are otherwise
suitable for transfusion but also creates unwarranted
anxiety and apprehension among donors who are provided
with confusing test results and are subjected to needless
medical expense .
In our study we detected 96 donors who were positive
for both, anti-HCV and anti-HBc antibodies, 93 of them
being negative for HBsAg by ELISA. These results can be
explained in several ways. False positive results may
account for a handful of such cases. Similarly donation
during the “window period” following acute HBV
infection, remote infection with HBV without persistent
viremia, and remote infection with persistent “occult”
infection in addition to persistent HCV infection will also
give such test results.
Nucleic acid testing, however showed presence of HCV
RNA only in 42 out of these 96 cases, while HBV DNA was
identified in 2 cases. The remaining cases where NAT was
non reactive may indicate either a false positive ELISA
result or a case where HCVviremia has been cleared.There
In this study we detected anti-HCV antibodies by
ELISA in 406 donors, constituting an average of 0.41% of
the total. This is fairly comparable to existing Indian
[11,12] as well as western literature [13,14] with a few
exceptions [15,16] where a relatively higher prevalence
was reported. Over a period of these five years the HCV
prevalence at our centre has remained low with percentage
positivity ranging from 0.38% in 2007 to 0.43% in 2010.
These results are possibly due to the strict screening criteria
that are being enforced in our centre, and deferral/rejection
of donors giving positive history of jaundice, high risk
behavior or any other history suggestive of the same.
The transmission of hepatitis B following transfusion of
blood/blood products containing the hepatitis B core
antibody was first described by Hoofnagle in 1978 .
HBsAg is the most commonly used marker for HBV
infection in donated blood and in many countries including
India, anti-HBc is not a mandatory screening test.Anti-HBc
has been found to be an excellent indicator of occult HBV
infection during the ‘core window’ period. However, with
the introduction and institution of more advanced
techniques for Nucleic Acid Testing like TMA or PCR,
those are able to amplify and detect the HBV DNA, the role
of anti-HBc antibody in donor screening is being
questioned by users across the globe.
In India, the incidence of anti-HBc amongst blood
donors ranges from 11-29% [18,19]. For reasons essentially
similar to those implicated in low HCV prevalence,
positivity rates for anti-HBc antibodies in our study are
slightly lower, the average being 10.32%.
Anti-HBc was a popular surrogate marker for HCV as
Fig 1 Year wise distribution of anti-HCV and anti-HBC antibody results in blood donors
301 Apollo Medicine, Vol. 7, No. 4, December 2010
were only four cases (0.004%) where HCV RNA was
identified in the absence of anti- HCV and presence of anti
HBc antibody, 3 of which were also reactive for HBsAg.
From these results it is clear that the importance of anti HBc
as a surrogate marker for HCV infection cannot be
As we have already mentioned, patients with HCV-
related chronic liver disease (CLD) frequently show
markers of previous HBV infection. Moreover, they may
carry occult HBV infection. Like dual HBV and HCV
infection, occult HBV infection in chronic hepatitis C could
also aggravate the disease severity. Suppression of HBV
replication by HCV in acutely or chronically infected
patients is well-described phenomenon. Liaw, et al 
found that HCV infection might suppress HBV or even
eliminate HBV. The mechanisms accounting for the
suppression of HCV on HBV were investigated by Shih,
et al . Their findings suggest that HCV may directly
interfere with HBV replication and furthermore identified
the HCV core protein as a repressor of HBV production.
HBV-HCV co-infection is characterized by “viral
interference,” whereby the replication of one virus is
suppressed by another [22-24]. In the phenomenon of viral
interference, usually one virus remains dormant while the
other replicates actively. HCVreplication is generally more
dominant, leading to low levels of HBV DNA serum
[22,26-28] and liver [20,29].
The prevalence of anti-HCV and anti-HBc antibodies
individually are fairly comparable to the existing Indian and
western literature. Cases positive for both these antibodies
but lacking HBsAg may indicate dual HBV and HCV
infection, chronic HCV infection with occult Hepatitis B or
a false negative result among others. Besides in this era of
highly sensitive ELISAand NAT, the role of the hepatitis B
core antibody as a surrogate HCV marker is doubtful.
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