Sero-Prevalence of HBsAg, HBeAg and Associated Factors among Chronic Liver Disease Patients in Amhara National Regional State, Northwest Ethiopia

Background: The main causative agents of Chronic liver diseases (CLD) are hepatitis B and C viruses and excessive alcohol consumption. Hepatitis B virus (HBV)-infected patients with a positive hepatitis e-antigen (HBeAg) indicates highly infectious and a significantly elevated risk of transmitting HBV and developing serious CLD such as cirrhosis and hepatocellular carcinoma.

Objective: This study is to assess the prevalence of HBsAg, HBeAg, and associated risk factors among chronic liver disease patients in Amhara Regional State, Ethiopia.

Methods: A cross-sectional study design was conducted among CLD patients who visited governmental hospitals from June to August 2024. Socio-demographic and associated risk factor data were collected using a structured questionnaire. Five ml of blood was collected from each study participant. ELISA and Maglumi HBeAg kits were used to detect HBsAg and HBeAg, respectively. A p-value < 0.05 was considered statistically significant.

Results: A total of 188 participants with the mean age of 38.11 years were involved in this study. The majority of the participants were males 119 (63.3%). The prevalence of HBsAg among CLD patients was 50.5% (95/188) (95% CI; 43.2-57.9). The prevalence of HBeAg among HBV infected CLD patients was 37.9% (95% CI; 28.1 48.4). High rate of HBV infection and HBeAg were detected among male participants 58.8% (70/119) and frequent alcohol consumption 57.5% (69/120).  Multiple sexual partner (AOR=3.37(95% CI=1.62-6.99)) and a history of contact with jaundiced patients (AOR=6.1 (95% CI=1.99-18.5)) had a statistically significant association with HBV infection. 

Conclusion: HBV is a major contributing cause of CLD in our study setting.  About 38% of CLD patients were highly infectious and at risk of developing the diseases. We recommended that educate communities about HBV transmission route and risk factors, screening and vaccination of the high-risk group are desirable to reduce the transmission and the developing of the diseases.

A liver disease is any disease that affects liver. Unlike acute liver failure, this happens suddenly, liver diseases progress slowly over time. The most common causes of chronic liver diseases (CLD) worldwide are related to viral hepatitis, alcohol, and non-alcoholic fatty liver disease [1].  Viral hepatitis remains a major cause of CLD and liver cancer in many parts of the world, especially in lower and middle-income countries. Chronic hepatitis B is the most common cause of CLD in East Asia and Sub-Saharan Africa [2, 3]. According to the World Health Organization (WHO), the 2024 global hepatitis report states that 254 million people are living with chronic HBV infection and causing 1.1 million deaths per year [4].  In the WHO African Region, 65 million people are chronically infected [5]. 

According to WHO report 2024, approximately 87 % of HBV infections are not detected at diagnosis, and these instances remain potential causes of viral transmission which leads to liver cancer or cirrhosis [4, 6]. In low-income settings, most people with liver cancer present indications late in the course of the disease and die within months of diagnosis [7]. 

There are different serological markers used in the diagnosis of hepatitis B, each with different epidemiological and clinical significance. Hepatitis B surface antigen (HBsAg) can be detected in the serum of infected individuals within 4-6 months. Hepatitis B e-antigen (HBeAg) appears shortly after HBsAg positivity [8, 9, 10]. The hepatitis B e-antigen test is crucial for determining the level of active viral replication and infectivity in individuals with chronic hepatitis B. A positive result indicates high viral replication and a greater risk of transmitting the virus [11]. 

The Centers for Disease Control and Prevention recommends hepatitis B testing for people born in countries with 2% or higher HBV prevalence [12]. In contrast, on the African continent, only 2% of persons infected with HBV were diagnosed. Early diagnosis and prevention of HBV infection transmission are essential for its elimination [13].

In Ethiopia, the prevalence of HBV infection was 7.4% in 2016 [14] and 6% in 2019 [15], 6.9% in 2024[16]. Meanwhile, in our study setting, in addition to late comer for diagnosis of liver diseases, they were waiting for long time without treatment because of limited number of setting where HBV DNA testing is available. HBeAg -positive individuals are considered highly infectious and a significantly elevated risk of transmitting HBV and developing serious CLD such as cirrhosis and hepatocellular carcinoma (HCC), especially if treatment is delayed.  Even if, the prevalence of HBeAg among CLD patients with HBV not well reported, accurate estimates of the epidemiologic burden of HBV infection and HBeAg are crucial for effective healthcare strategies, developing guideline and prevention of HBV infection. Therefore, the current study aim was to assess the prevalence and associated risk factors of HBsAg and HBeAg among chronic liver disease patents in Amhara National Regional State, North West-Ethiopia.

A liver disease is any disease that affects liver. Unlike acute liver failure, this happens suddenly, liver diseases progress slowly over time. The most common causes of chronic liver diseases (CLD) worldwide are related to viral hepatitis, alcohol, and non-alcoholic fatty liver disease [1].  Viral hepatitis remains a major cause of CLD and liver cancer in many parts of the world, especially in lower and middle-income countries. Chronic hepatitis B is the most common cause of CLD in East Asia and Sub-Saharan Africa [2, 3]. According to the World Health Organization (WHO), the 2024 global hepatitis report states that 254 million people are living with chronic HBV infection and causing 1.1 million deaths per year [4].  In the WHO African Region, 65 million people are chronically infected [5]. 

According to WHO report 2024, approximately 87 % of HBV infections are not detected at diagnosis, and these instances remain potential causes of viral transmission which leads to liver cancer or cirrhosis [4, 6]. In low-income settings, most people with liver cancer present indications late in the course of the disease and die within months of diagnosis [7]. 

There are different serological markers used in the diagnosis of hepatitis B, each with different epidemiological and clinical significance. Hepatitis B surface antigen (HBsAg) can be detected in the serum of infected individuals within 4-6 months. Hepatitis B e-antigen (HBeAg) appears shortly after HBsAg positivity [8, 9, 10]. The hepatitis B e-antigen test is crucial for determining the level of active viral replication and infectivity in individuals with chronic hepatitis B. A positive result indicates high viral replication and a greater risk of transmitting the virus [11]. 

The Centers for Disease Control and Prevention recommends hepatitis B testing for people born in countries with 2% or higher HBV prevalence [12]. In contrast, on the African continent, only 2% of persons infected with HBV were diagnosed. Early diagnosis and prevention of HBV infection transmission are essential for its elimination [13].

In Ethiopia, the prevalence of HBV infection was 7.4% in 2016 [14] and 6% in 2019 [15], 6.9% in 2024[16]. Meanwhile, in our study setting, in addition to late comer for diagnosis of liver diseases, they were waiting for long time without treatment because of limited number of setting where HBV DNA testing is available. HBeAg -positive individuals are considered highly infectious and a significantly elevated risk of transmitting HBV and developing serious CLD such as cirrhosis and hepatocellular carcinoma (HCC), especially if treatment is delayed.  Even if, the prevalence of HBeAg among CLD patients with HBV not well reported, accurate estimates of the epidemiologic burden of HBV infection and HBeAg are crucial for effective healthcare strategies, developing guideline and prevention of HBV infection. Therefore, the current study aim was to assess the prevalence and associated risk factors of HBsAg and HBeAg among chronic liver disease patents in Amhara National Regional State, North West-Ethiopia.

A hospital-based cross-sectional study was conducted from June to August 2024 at Felege Hiwot Comprehensive Specialized Hospital (FHCSH) and Tibebe Ghion Specialized Hospital (TGSH), Bahir Dar, Ethiopia. Bahir Dar is the capital city of the Amhara National Regional State in the Federal Democratic Republic of Ethiopia. It is about 570 km away from Addis Ababa.

The sample size was calculated using a single population proportion formula by considering a 34.8% prevalence of HBV among CLD patients at the University of Gondar Comprehensive Specialized Hospital Northwest, Ethiopia [17], a 95% confidence interval and a 5% margin of error.  Accordingly, the sample size was (1.96)2(0.348) (0.652)/ (0.05)2 =348.6

But total chronic liver disease who had followed up in gastrointestinal clinic in our study sites was 382. We used correction formula; ni=n/1+ 1-n/N. n=348.6, N=382, ni=182.52.  We added 10% non-response; the final sample size was 201.

Socio-demographic data: age, sex, marital status, educational status and occupation, and other risk factors like multiple sexual partners, frequent alcohol consumption, family history of CLD, previous history of hospital admission, Ear piercing, and dental extraction were collected using a structured, pre-tested questionnaire. Five ml of venous blood was collected from each study participant. Samples were left at room temperature for 30 minutes to facilitate clotting and centrifuged at 3000 rpm for 5 minutes to get clear serum for serological analysis.  HBsAg was detected using a sandwich enzyme-linked immunosorbent assay (ELISA) test kit (Biomedical Engineering Co., Ltd. Shenzhen, China), with a stated specificity of 99.78% and sensitivity of 100%. HBsAg-positive participants were subsequently tested for HBeAg using Maglumi HBeAg kit (Biomedical Engineering Co., Ltd. Shenzhen, China), which has the specificity and sensitivity 100% as per the manufacturer’s recommendation [ 18].

Data were analyzed using the Statistical Package for Social Sciences (SPSS) version 27 software. Statistical significance for dependent and independent variables was measured using bivariate and multivariate analysis, and p-value < 0>

Socio-demographic characteristics of the Participants

A total of 188 study participants with 93.5% response rate were involved in this study. The mean age of the study participants was 37.7 (SD ± 12.34) years. The majority of the participants were males119 (63.3%), in the age categories of 35- 44years 58 (30.9%), urban dwellers116 (61.67 %), married 142(75.5%), and 67 (35.6%) farmers. Considering educational status 70 (37.2%) of study participants were complete higher education (Table 1).

Prevalence of HBsAg among chronic liver diseases patients

The prevalence of HBsAg was 50.5% (95/188) (95% CI; 43.2-57.9).  High rate of HBV infection was detected among male participants 58.8% (70/119), ≥55 years old participants 65% (13/20), urban dwellers 50.9% (50/116), and married participants 56.3% (80/142). Considering occupational status 55% (37/67) of them were farmer participants (Table1). 

Table 1: Socio-demographic characteristics of Participants among Chronic Liver Disease Patients in Amhara regional state, Ethiopia, 2025

Associated Factors for Hepatitis B infection among chronic liver disease patients

During bivariate analysis, sex, age, occupational status, ear piercing, dental extraction, shaving, previous hospital admission, family history of jaundice, marital status and frequent alcohol consumption were significantly associated with HBV infection (P < 0 AOR=3.37(95% CI=1.62-6.99)). AOR=6.1 CI=1.99-18.5)). AOR=11.4 CI=1.69-72.7)).  AOR=12 CI=1.77-83.3))>

Table 2: Bivariate and Multivariate analysis on association risk factors with HBV infection among chronic liver disease patients in Amhara regional state, Ethiopia, 2025

AOR: Adjusted Odds Ratio, COR: Crude Odd Ratio.

Prevalence of HBeAg   among HBsAg positive chronic liver disease patients

The prevalence of HBeAg among HBV infected CLD patients was 37.9% (95% CI; 28.1 48.4). The highest prevalence rate of HBeAg was observed in the age group 35-44 years (51.4%) followed by the age group 45-54 years (38.9%).  About 42.9% of HBeAg positive participants were males, 44.4% rural residence, and 41% of the participants had history of frequent alcohol intake (Table 3).

Table 3: Prevalence of HBeAg among HBsAg positive chronic liver disease patients in Amhara regional state, Ethiopia, 2025

Chronic liver disease is an important medical and public health problem worldwide and is one of the leading causes of morbidity and mortality [19]. The risk factors for CLD may vary in different populations. In developing countries, predominant causes of CLD are alcohol consumption, hepatitis B, hepatitis C, malnutrition, and toxins [20]. Determining the causative agent of liver diseases and detection of HBeAg are very essential for management of the patient and prevention of HBV infection transmission. As far as our knowledge, this is the first study determining the prevalence of HBeAg among chronic liver disease patients in Amhara region, Ethiopia.

The current study demonstrated that 95/188 (50.5 %) with (95 % CI=43.2-57.9) of the study participants were positive for HBsAg. This finding is higher than those recorded in other site:  Gondar (34.8 %) [21], in selected hospitals Addis Ababa (34.2 %) [22], in public health hospital Addis Ababa (35.8 %) [23], in South East Ethiopia (22.3%) [24], in Sheikhpura, Patna, India 29.5% [25], in India 21.42% [26], South Tamil Nadu 9.6% [27], in Northern Pakistan (38.2%) [28]. On the other hand, this study finding is line with study reported in Addis Ababa (55.9) [29] and in India 47.5% [30]. But this study finding is less than study reported in Sidama, Ethiopia [31], Dhaka, Bangladesh 64% [32]. The high prevalence in the current study might be due to HBV being a major risk factor for CLD in our study setting. And also indicates patients presenting with signs of liver diseases are at a higher risk of also having HBV. Therefore, HBV infection is endemic in Ethiopia and early screening and treat the population might be important to prevent the transmission. 

Regarding predisposing factors, this study demonstrated that study participants who had history of contact with jaundiced patients and had multiple sexual partners were significant association with HBV infection. This finding is in agreement with study done in across the country: [16, 17,21, 22, 33].   The significant association confirms that the virus is transmitted through close contact with infected individuals and their body fluids. This consistence finding across different studies in Ethiopia suggest that contact with jaundiced patients and had multiple sexual partners being prevalent mode of transmission. The overall result shows the necessity of public health imitative to educate communities about HBV transmission route and risk factors.

Even though, male and history of frequent alcohol consumption didn’t show significant association during multivariate logistic regression analysis, more prevalence HBV infection as well as HBeAg were found among male study participants and who had history of frequent alcohol consumption. This finding is supported by different studies conducted across the country and abroad; in different part of Ethiopia [21, 31, and 33) in Eritrea [34], in Nigeria [35], in India [26], in Mumbai, India [36], in Pakistan [37]. This might be due to behavioral and hormonal factors play a crucial factor for being male higher infected with HBV [38]. Frequent alcohol consumption contributes to a higher prevalence and more sever diseases progression through increasing viral replication and weakened the immune response. 

Detection of HBeAg indicates a high level of active viral replication and infectivity and is a strong indicator of active liver diseases or risk for HCC (39). This study is showed that the prevalence of HBeAg among HBV infected CLD patients was 37.9% (95% CI; 28.1 48.4). This magnitude is higher than the magnitude reported from studies in India 0.28% [40] and Nigeria 6% [35]. 

Even though a direct comparison was difficult due to difference in study population, the prevalence of HbeAg in this study was higher as compared to previous studies done in abroad the country: Cambodia 92 (17.9%) (41), in Botswana 3(18.8%) (42), in Tanzania 9(2%) (43,), in Eritrea 7 (3.9%) (34). On the other hand, the current study result is agreement with a study conducted in across the country: in Yirgalem hospital Ethiopia 13/34(38.8%) (44), a study conducted in Hawassa among patients scheduled for surgery 34.2% (45). This difference might be due to variation in the endemicity of HBV infection, the predominant mode of transmission, immune tolerance phase, and genotype variation among countries. As HBeAg is a marker of active viral replication, consistence higher prevalence of HBeAg in Ethiopia indicates a substantial ongoing risk of transmission within the country both horizontal and vertical. 

Limitation of the study

HBV DNA was not performed. Thus, HBeAg negative patients with high replication were not detected, although these patients have the highest risk for developing cirrhosis and HCC.

The prevalence of HBV infection was high among CLD patients. This indicates that HBV infections were the main risk factors for liver diseases patients in our study setting. About 38% of CLD patients were highly infectious and at risk of developing HCC. 

Contact with jaundiced patients, and having multiple sexual partners were predisposing factor for HBV infection. We recommended that educate communities about HBV transmission route and risk factors, a routine testing for those who have contact with CLD patients, screening of sexually active population and vaccination are necessary to control the transmission of the diseases.

Abbreviations

CLD: Chronic Liver Diseases, 

HBeAg: Hepatitis B envelope antigen, 

HBsAg; Hepatitis B surface Antigen, 

HBV:  Hepatitis B virus, 

HCV:  Hepatitis C virus, 

HIV: Human Immuno Deficiency Virus, 

WHO: World Health Organization

Ethics approval and consent to participant

Ethical approval was obtained from the Institutional Review Board of College of Medicine and Health Sciences.  After we explained about the purpose of the study, informed written consent was obtained from each study participants.  For each confirmed HBsAg and HBeAg results was given to the responsible clinician.

Consent for publication

Not applicable.

Availability of data and materials

All data are included in the manuscript.

Funding

This research was funded by the National Institute for Health Research (NIHR) (PSIA2020-3073) using United Kingdom (UK) Aid from the UK Government to support global health research, as part of the EDCTP2 Programme supported by the European Union

Competing interests

The authors declare that they have no competing interests

Authors' contributions

MD conceived the research topic and objectives, wrote the draft of the manuscript.

AA, GA, HT, MM, DA, DA and AA participated in the designing of the study, data analysis, and statistical analysis and interpreted the result. ST, YS and SW were involved in revising the manuscript for its scientific content. All Authors read and approved the final manuscript.

Acknowledgements

The authors would like to thank to Nurse and Medical laboratory staff of our study site health institution, Amhara public health institute, study participants, data collectors, Bahir Dar University, Felege Hiwot Comprehensive Specialized Hospital and the funder (the National Institute for Health Research (NIHR) (PSIA2020-3073) using United Kingdom (UK) Aid from the UK Government to support global health research, as part of the EDCTP2 Programme supported by the European Union).