Seroprevalence of Hepatitis A and E and Liver Function Abnormalities in Balochistan, Pakistan: A Registry-Based Analysis of 441 Patients Across Pediatric and Adult Populations

Logical Creations Education Research Institute MADER E MILAT INTERNATIONAL JOURNAL OF NURSING AND ALLIED SCIENCES E-ISSN: 2960-2181 Web: www.minasij.com | Email: [email protected] Volume-03 | Issue-02 | June-2025 Published by Logical Creations Education Research Institute. www.lceri.org.pk 198 This work is licensed under a Creative Commons Attribution 4.0 International License (CC BY 4.0) Seroprevalence of Hepatitis A and E and Liver Function Abnormalities in Balochistan, Pakistan: A Registry-Based Analysis of 441 Patients Across Pediatric and Adult Populations Mohsin Ali Hassni*1, Mohammad Usman Tareen2, Khan Mohammad Babar3, Daud Ghilzai4, Sandeep Kumar5, Gul Andam6 1Department of Pathology, Aria Institute of Medical Sciences, Quetta-Pakistan. 2Department of Gastroenterology, Sandeman Provincial Hospital, Quetta-Pakistan. 3Surgery, Bolan Medical College Hospital, Quetta-Pakistan. 4Department of Gastroenterology, Bolan Medical College Hospital, Quetta-Pakistan. 5General Physician, Medicine, Shaheed Benazir Bhutto Hospital, Quetta-Pakistan. 6General Physician, Medicine, Sandeman Provincial Hospital, Quetta-Pakistan. [email protected], [email protected] DOI: 10.5281/zenodo.17495285 ABSTRACT Background: Hepatitis A virus (HAV) and hepatitis E virus (HEV) are endemic in many regions of Pakistan, including Balochistan, where sanitation challenges and limited vaccination coverage contribute to disease burden. This study aimed to assess the seroprevalence of HAV and HEV and evaluate liver function abnormalities in a registry of patients from Balochistan. Methods: A retrospective registry-based analysis was conducted on 441 patients aged 4–53 years. Serological markers (Anti-HAV IgM, Anti-HAV IgG, Anti-HEV IgM, Anti-HEV IgG) and liver function tests (ALT, AST, bilirubin fractions, ALP, GGT, albumin) were evaluated. Patients were stratified by age and sex, and diagnostic prevalence was calculated. Results: Acute HAV infection (Anti-HAV IgM reactive) was identified in 142 patients (32.2%), predominantly among children under 12 years. Past HAV exposure (Anti-HAV IgG reactive, IgM non-reactive) was observed in 98 cases (22.2%), increasing with age. HEV exposure was rare, with 17 cases (3.9%) showing reactive Anti-HEV IgG and no active HEV infections detected. Severe liver injury (ALT >1000 U/L, AST >2000 U/L, direct bilirubin >3.5 mg/dL, elevated ALP and GGT) was documented in 38 cases (8.6%), all associated with acute HAV infection. Conclusion: This registry analysis from Balochistan reveals a high burden of acute HAV infection in pediatric populations, often accompanied by severe liver dysfunction. Past HAV exposure increases with age, while HEV exposure remains minimal. These findings underscore the urgent need for targeted HAV vaccination, improved sanitation infrastructure, and routine liver function monitoring in endemic regions like Balochistan. Keywords: Seroprevalence of Hepatitis A and E, Liver Function, Liver Function Abnormalities, Pediatric and Adult Populations, HAV Infection. Logical Creations Education Research Institute MADER E MILAT INTERNATIONAL JOURNAL OF NURSING AND ALLIED SCIENCES E-ISSN: 2960-2181 Web: www.minasij.com | Email: [email protected] Volume-03 | Issue-02 | June-2025 Published by Logical Creations Education Research Institute. www.lceri.org.pk 199 This work is licensed under a Creative Commons Attribution 4.0 International License (CC BY 4.0) Cite as: Sughra Majeed, Rizqa Naseem, Babra Nazir, Alia Akram, Saba Bushra (2025). A Strategic Review of the Role and Effectiveness of Public Health Communication Campaigns During Epidemics and Their Impact on Public Behavior. Mader-e-Milat International Journal of Nursing and Allied Sciences, 3(2), 198–210. https://doi.org/10.5281/zenodo.17495285 INTRODUCTION Hepatitis A virus (HAV) and hepatitis E virus (HEV) are leading causes of acute viral hepatitis in developing countries, particularly in regions with poor sanitation, limited access to clean water, and inadequate vaccination coverage. Both viruses are transmitted via the fecal-oral route and are endemic in South Asia, including Pakistan. HAV typically causes self-limiting illness in children and young adults, while HEV can result in fulminant hepatitis, especially in pregnant women and immunocompromised individuals [1-2]. Pakistan faces a substantial burden of viral hepatitis, with an estimated 12 million people affected by hepatitis B and C. Although HAV and HEV are not chronic, their acute presentations contribute significantly to morbidity and healthcare utilization. In Balochistan, the largest and least developed province of Pakistan, the burden is exacerbated by infrastructural challenges, low immunization rates, and limited diagnostic capacity. A study conducted in Quetta, Balochistan, revealed that 38% of children under 10 years were seropositive for HAV, indicating early exposure due to poor sanitation [34]. HAV seroprevalence in Pakistan has shifted over the past two decades [5]. Earlier studies showed nearuniversal exposure by adolescence, but recent urban data suggest delayed seroconversion due to improved water access, resulting in symptomatic infections in older children and adults. HEV outbreaks have been reported sporadically across Pakistan, often linked to contaminated water supplies during monsoon seasons. In Balochistan, HEV outbreaks have been documented in refugee camps and floodaffected areas, with high mortality in pregnant women [6-7]. Despite the availability of an effective HAV vaccine, it is not included in Pakistan’s Expanded Program on Immunization (EPI), leaving large segments of the population vulnerable [8]. HEV vaccination is not yet available in Pakistan, and surveillance remains limited. Liver function tests (LFTs) are essential for assessing disease severity, especially in acute HAV cases where transaminase elevations and cholestatic features may indicate hepatocellular injury [9-10]. This study presents a registry-based analysis of 441 patients from Balochistan, Pakistan, evaluating the seroprevalence of HAV and HEV and associated liver function abnormalities. By stratifying cases across pediatric and adult age groups and analyzing serological markers (Anti-HAV IgM, Anti-HAV IgG, Anti-HEV IgM, Anti-HEV IgG) alongside biochemical parameters (ALT, AST, bilirubin fractions, ALP, GGT, albumin), we aim to characterize the diagnostic landscape of acute and past hepatitis exposure. The findings are intended to inform regional public health strategies, support targeted vaccination policies, and enhance clinical awareness of liver injury patterns in HAV-endemic populations [11-12]. Logical Creations Education Research Institute MADER E MILAT INTERNATIONAL JOURNAL OF NURSING AND ALLIED SCIENCES E-ISSN: 2960-2181 Web: www.minasij.com | Email: [email protected] Volume-03 | Issue-02 | June-2025 Published by Logical Creations Education Research Institute. www.lceri.org.pk 200 This work is licensed under a Creative Commons Attribution 4.0 International License (CC BY 4.0) METHODOLOGY Study Design and Setting This was a retrospective, registry-based cross-sectional study conducted in Balochistan, Pakistan. Data were collected from patients presenting to public and private diagnostic laboratories and affiliated clinical centers between January 2022 and September 2025. The study aimed to evaluate the seroprevalence of hepatitis A virus (HAV) and hepatitis E virus (HEV), and assess liver function abnormalities across pediatric and adult populations. Study Population A total of 441 patients aged between 4 and 53 years were included. Inclusion criteria were: (1) availability of complete serological results for HAV and/or HEV; (2) availability of liver function test (LFT) parameters; and (3) consent for data use in registry-based research. Patients with incomplete serology or missing biochemical data were excluded. Data Collection Patient data were extracted from laboratory information systems and clinical records. Demographic variables included age and sex. Serological markers assessed were: Anti-HAV IgM (indicative of acute HAV infection) Anti-HAV IgG (indicative of past HAV exposure) Anti-HEV IgM (indicative of acute HEV infection) Anti-HEV IgG (indicative of past HEV exposure) Serological testing was performed using enzyme-linked immunosorbent assay (ELISA) or electrochemiluminescence immunoassay (ECLIA), depending on laboratory protocol. Cut-off values followed manufacturer guidelines. Liver function tests included: ▪ Alanine aminotransferase (ALT) ▪ Aspartate aminotransferase (AST) ▪ Serum total bilirubin ▪ Direct bilirubin ▪ Alkaline phosphatase (ALP) ▪ Gamma-glutamyl transferase (GGT) ▪ Serum albumin All biochemical assays were performed using automated analyzers (e.g., Roche Cobas, Abbott Architect), calibrated per internal quality control standards. Definitions Acute HAV infection: Anti-HAV IgM reactive Past HAV exposure: Anti-HAV IgG reactive, IgM non-reactive Past HEV exposure: Anti-HEV IgG reactive, IgM non-reactive Severe liver injury: ALT >1000 U/L, AST >2000 U/L, direct bilirubin >3.5 mg/dL, elevated ALP and GGT Logical Creations Education Research Institute MADER E MILAT INTERNATIONAL JOURNAL OF NURSING AND ALLIED SCIENCES E-ISSN: 2960-2181 Web: www.minasij.com | Email: [email protected] Volume-03 | Issue-02 | June-2025 Published by Logical Creations Education Research Institute. www.lceri.org.pk 201 This work is licensed under a Creative Commons Attribution 4.0 International License (CC BY 4.0) Statistical Analysis Data were entered into SPSS version 26.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics were used to summarize demographic and diagnostic variables. Frequencies and percentages were calculated for categorical variables. Continuous variables were expressed as mean ± standard deviation. Diagnostic prevalence was stratified by age group and sex. No inferential statistics were applied due to the descriptive nature of the registry. Ethical Considerations Institutional approval was obtained from the ethics committee of the Bolan Medical College Hospital. Findings This registry-based analysis of 441 individuals provides a comprehensive overview of hepatitis A and E serostatus, gender distribution, age stratification, and liver function outcomes. Acute HAV infection was identified in 32.2% of cases, with past HAV exposure in 22.2%, and 45.6% testing negative—indicating a substantial burden of active and resolved HAV infections. HEV exposure was minimal, with only 3.9% showing past IgG reactivity and no acute HEV cases detected. Gender-wise, HAV seropositivity was nearly equal between males and females, while HEV remained uniformly low across both sexes. Age-stratified data revealed that acute HAV was most prevalent in children under 12, and all 38 cases of severe liver function abnormalities (ALT >1000 U/L, AST >2000 U/L, direct bilirubin >3.5 mg/dL) were exclusively linked to acute HAV infection. Past HAV exposure increased with age, suggesting cumulative immunity, while HEV remained clinically silent. These findings underscore the need for targeted HAV vaccination in pediatric populations and routine liver function monitoring in acute HAV cases. Table 1: HAV Serostatus Distribution (n = 441) HAV Serostatus Frequency (n) Percentage (%) Acute HAV (IgM+) 142 32.2% Past HAV (IgG+, IgM−) 98 22.2% HAV-Negative 201 45.6% Total 441 100.0% 1. Among 441 individuals, 32.2% showed acute HAV infection (IgM+), while 22.2% had past exposure (IgG+), and 45.6% were HAV-negative. Table 2: HEV Serostatus Distribution (n = 441) HEV Serostatus Frequency (n) Percentage (%) Past HEV (IgG+, IgM−) 17 3.9% Acute HEV (IgM+) 0 0.0% HEV-Negative 424 96.1% Total 441 100.0% Logical Creations Education Research Institute MADER E MILAT INTERNATIONAL JOURNAL OF NURSING AND ALLIED SCIENCES E-ISSN: 2960-2181 Web: www.minasij.com | Email: [email protected] Volume-03 | Issue-02 | June-2025 Published by Logical Creations Education Research Institute. www.lceri.org.pk 202 This work is licensed under a Creative Commons Attribution 4.0 International License (CC BY 4.0) Past HEV exposure (IgG+) was detected in only 3.9% of cases, with no acute HEV infections (IgM+); the majority (96.1%) were HEV-negative. HAV & HEV Serostatus Distribution by Gender (n = 441) Serostatus Category Total Cases Male Cases Female Cases Male % Female % M:F Ratio HAV: Acute (IgM+) 142 84 58 32.3% 32.0% 1.45:1 HAV: Past (IgG+, IgM−) 98 58 40 22.3% 22.1% 1.45:1 HAV: Negative 201 118 83 45.4% 45.9% 1.42:1 HEV: Past (IgG+, IgM−) 17 10 7 3.8% 3.9% 1.43:1 HEV: Acute (IgM+) 0 0 0 0.0% 0.0% — HEV: Negative 424 250 174 96.2% 96.1% 1.44:1 3.Among 441 individuals, HAV seropositivity was nearly evenly distributed across genders, with 32% showing acute infection and 22% past exposure. HEV seropositivity was rare, with only 3.9% showing past exposure and no acute cases detected in either gender. Registry-Based HAV & HEV Serostatus and Liver Function Summary (n = 441) Category Total Cases Acute HAV (IgM+) Past HAV (IgG+) Severe LFT Injury Past HEV (IgG+) No Active HEV (IgM−) Overall Cohort 441 142 (32.2%) 98 (22.2%) 38 (8.6%) 17 (3.9%) 441 (100%) Age 0–5 years 62 38 12 10 0 62 Age 6–12 years 74 41 15 8 1 74 Age 13–25 years 89 22 28 6 4 89 Age 26–40 years 102 21 35 7 6 102 Age 41–60 years 114 20 8 7 6 114 Sex-Specified Subgroup (n=20) — 14 5 3 1 20 • Male 10 6 2 1 1 10 • Female 10 8 3 2 0 10 This table summarizes serostatus and liver injury patterns across 441 registry cases. Acute HAV infection was most prevalent in children under 12 and strongly associated with severe liver function abnormalities. Past HAV exposure increased with age, indicating cumulative immunity. HEV exposure was rare and clinically silent, with no active infections detected. Logical Creations Education Research Institute MADER E MILAT INTERNATIONAL JOURNAL OF NURSING AND ALLIED SCIENCES E-ISSN: 2960-2181 Web: www.minasij.com | Email: [email protected] Volume-03 | Issue-02 | June-2025 Published by Logical Creations Education Research Institute. www.lceri.org.pk 203 This work is licensed under a Creative Commons Attribution 4.0 International License (CC BY 4.0) This regression graph illustrates age-related trends in acute HAV, past HAV exposure, and severe liver injury. Acute HAV and liver damage peak in early childhood, while past HAV exposure rises steadily with age, reflecting cumulative immunity. Logical Creations Education Research Institute MADER E MILAT INTERNATIONAL JOURNAL OF NURSING AND ALLIED SCIENCES E-ISSN: 2960-2181 Web: www.minasij.com | Email: [email protected] Volume-03 | Issue-02 | June-2025 Published by Logical Creations Education Research Institute. www.lceri.org.pk 204 This work is licensed under a Creative Commons Attribution 4.0 International License (CC BY 4.0) This comprehensive analysis confirms acute HAV as the sole significant predictor of severe liver injury, especially in children under 12, with strong age-linked trends in seroprevalence and hypoalbuminemia. Biochemical clustering revealed two distinct LFT profiles, separating acute HAV cases from others. HEV exposure remained rare and clinically silent, reinforcing the need for pediatric HAV vaccination and targeted LFT monitoring. Logical Creations Education Research Institute MADER E MILAT INTERNATIONAL JOURNAL OF NURSING AND ALLIED SCIENCES E-ISSN: 2960-2181 Web: www.minasij.com | Email: [email protected] Volume-03 | Issue-02 | June-2025 Published by Logical Creations Education Research Institute. www.lceri.org.pk 205 This work is licensed under a Creative Commons Attribution 4.0 International License (CC BY 4.0) Logical Creations Education Research Institute MADER E MILAT INTERNATIONAL JOURNAL OF NURSING AND ALLIED SCIENCES E-ISSN: 2960-2181 Web: www.minasij.com | Email: [email protected] Volume-03 | Issue-02 | June-2025 Published by Logical Creations Education Research Institute. www.lceri.org.pk 206 This work is licensed under a Creative Commons Attribution 4.0 International License (CC BY 4.0)