Hepatitis B is an important public health concern in both developing and developed countries affecting approximately 3.5 billion of the world's population and additionally ≥ 400 million are chronic carriers [1–4]. It has been estimated globally that each year ~1-2 million people die from HBV related complications such as chronic hepatitis, cirrhosis hepatocellular carcinoma (HCC) [2–8]. HBV is endemic in the Pakistani population with a rate of 3% HBV carriers in the country. Although the rate of exposure to HBV in Pakistan is not fully confirmed, Awan et al (2010) reported ~38% prevalence with a 4% carrier rate and 32% with anti-HBV surface antibodies by natural conversion [3].

The highest concentrations of infectious HBV are in blood, serum and serum-derived body fluids, such as semen and saliva [9]. It has been reported earlier in 2002 that the hepatitis B virus can live for several days in dried blood on table surfaces, needles, syringes and razors [10, 11]. HBV transmission has been observed by percutaneous or mucosal exposure to infected blood and body fluids [12]. Transmission also occurs via the use of unsterilized dental and surgical instruments, shaving from barber, reuse of needle for nose and ear piercing, reuse of disposable syringes and sharing needles with drugs addicts, sharing personal things such as razors, toothbrushes, and nail cutters, sexual and prolonged close personal contact with infected personnel [13]. High prevalence of HBV was observed in geographical areas of low economic status, which underscores the importance in controlling this disease because ~67.5% of the Pakistani population belongs to rural areas of low economic status [14, 15].

This study was planned to evaluate the presence of HBV in internally displaced persons (IDPs) due to war against terrorism in Malakand Division, a backward rural area in Pakistan. The study also evaluated the potential risk factors predisposing this population to HBV. It is anticipated that this study will help in creating awareness among the people about the potential risk factors in order to avoid the possible transmission of hepatitis B infection.

The purpose of this study was to investigate the prevalence of HBV in IDPs in the Malakand Division. This is one of the most backward and historically important rural areas of northern Pakistan. Most of the earlier studies conducted up to date in Pakistan have been focused on urban areas only. It has been confirmed by earlier studies that most HBV positive subjects belonged to the rural areas of low economic status [14]. More than 67.5% of the Pakistani population lives in rural areas [15]. It has been well documented that HBV infection is more prevalent in these low socioeconomic settings [14]. Because of this, a few years ago the Government of Pakistan launched a very effective immunization program against HBV to eliminate this silent killer from the country. Unfortunately that was limited to only urban areas, which is one of the main reasons, that the incidence of HBV is increasing in these localities. The present study might be helpful to draw the attention of local and international organizations towards these areas. The Malakand Division was taken as model because all its districts have very low literacy rate, are far-off from basic health facilities and are affected by tiresome and natural disasters (e.g. earthquake, floods).

The present study has confirmed about 21.05% prevalence of HBV in the surveyed population of IDPs. High prevalence of HBV was observed in IDPs from district Malakand and Dir (L) as compared to district Swat, Buner and Shangla. There were approximately three times as many males as females with HBV infection. Regarding gender-wise prevalence the frequency distribution of hepatitis B infection was found as higher in males (78.5%) as compared to the females (21.5%). It appears that male gender is playing an important role in the acquisition of HBV infection and might be caused by the higher exposure to the outside environment as compared to females who most of the days live at their houses. Barber shaving, homosexuality (male to male contact), and drug use are very common in these areas which strengthens the arguments for such high incidence of HBV among males. Similar results with 78.04% males and 21.95% of females HBV infections were observed by Shazi and Abbas during the comparison of risk factors associated with hepatitis B and C infection in patients at a liver stomach clinic Karachi [16]. High prevalence results of HBV in males compared to females have been observed in earlier studies in Pakistan [15, 17]. Similar results have also been obtained in Bangladesh where the researchers reported high prevalence in males (67.86%) than females (32.14%) [18]. The aforementioned prevalence in men reflect the increased frequency of high risk behavior which might include multiple sexual partners, drug use and barber shaving as compared to women.

In almost all the age groups found to be affected, the prevalence rises gradually with age. High risk of infection was found in the older subjects as compared to the younger ones. The higher prevalence among older age groups may be attributed to the more frequent exposure to risk factors and prolonged HBV infection. This study has identified many of the significant risk factors for HBV infection. In this study, barber risk presented a major route of transmission because this exposure frequency was markedly higher (32%) in male individuals who routinely shaved with community barbers. Janjua and Nizamy (2004) reported that 46% of the barbers in Pakistan reuse blades, concluding that the possibility of transmission increases with the frequency of reused blades [19]. According to one study conducted by Usman and his colleagues in 2003, the most frequent risk factor contributing to HBV infection is barber risk and it accounts for 47.6% of the infection [17]. The statistics of their results deviate from our study because the trend has changed substantially during the last few years and barbers have become more aware about HBV infection and have started using disposable blades and razors.

The contaminated dental instruments also play an important role in HBV infection because of the presence of HBsAg in the saliva of acute and chronic hepatitis B patients [20]. According to our findings, patient with prior history of dental treatment were mostly in their old ages (~41%). Most of the patients were from low economics status and were attended by local medical practitioners. In fact these practitioners mostly do not possess equipment for proper autoclaving, and some are illiterate and do not know what autoclaving is. Thus the lack of proper sterilization techniques and reuse of contaminated dental equipment might be a reason for such high rate of prevalence in these areas. These results are also supported by shazi and Abass (2006) who observed similar results (43.9%) for the dental risks [16]. Usman et al (2003) reported a high percentage (60%) of HBV patient with prior history of dental surgery as compared to current study [17]. Another predisposing risk factor of hepatitis B infection with previous history of surgery was positive in 15% of the patients. Similar results of 21.9% and 21.43% were reported by Shazi and Abass (2006) and Khan et al (2007) [16, 21].

Sharing personal items (72.5%) such as tooth brushes, sewak (miswak), and shaving razors and frequent household contact (51.5%) have also been identified as major risk factors for HBV infection. Tanveer and colleagues in 2008 reported that there is a high habit (37.5%) of sharing personal belongings in the infected persons that could account for the high risk of infection [22]. It is likely that the high prevalence reported in household contacts in Pakistan may be due to the fact that they would be exposed to the same community risk factors as the index patients, rather than intra-household transmission per se. In contrast, HBV intra-familial transmission is well documented outside of Pakistan, and HBV is far more infectious as compared to HCV or HIV [23–25]. Skin tattooing and sexual contact with hepatitis positive partner contribute 11% and 3.5% in the spread of HBV infection respectively.

The study revealed the seroprevalence of HBV among the various age groups along with the risk factors. High prevalence was observed in males as compared to females. The infection was more common in the older groups. We have also identified the major risk factors in this study which include barber shave, dental equipment & procedures, sharing personal items (e.g. tooth brash, sewak) and household contacts. Timely identification of people suffering from HBV infection is mandatory to control its rapid spread. Stringent aseptic measures should be adopted during surgical and dental procedure. More emphasis should be given to the preventive measures which include screened blood transfusion, safe sexual practice, use of disposable syringes and razors and proper disposal of contaminated materials. Importantly the Government authorities and non government organizations (NGOs) should take aggressive steps to educate and create awareness among the local population about the possible risk factors to avoid the transmission of HBV infection and extend the benefits of immunization to rural areas.

Fawad Khan (M.Phil Molecular Biology), Haji Akbar (M. Phil Molecular Biology), Hayat Khan (M.Phil Molecular Biology) and Khuram Shehzad (MS Bioinformatics) are PhD scholars. Mahmood Akhtar Kayani (PhD Cancer Genetics) is HoD department of Biosciences, COMSATS, institute of IT, Islamabad, while Muhammad Idrees (PhD Molecular Biology) is Principal Investigator at CEMB, University of the Punjab, Lahore