Performance Evaluation of Determine HBsAg 2 Rapid Card Test for the Detection of Hepatitis B Surface Antigen in Clinical Samples

INTRODUCTION

Hepatitis B virus (HBV) remains a critical public health problem with notable morbidity and mortality.¹ Approximately, more than 250 million people are chronic HBV carriers,¹ with a considerable regional variation of hepatitis B surface antigen (HBsAg) positivity ranging from low (2%) to high (8%) endemicity prevalence.² In India, the prevalence of HBsAg positivity ranges between 3 and 4.2%, with an estimated 40 million HBV carriers.³ The Global Health Sector Strategy (GHSS), endorsed by the World Health Organization (WHO), underscores the importance of scaling up diagnosis and testing for Hepatitis B to achieve the overall aim of elimination of viral hepatitis by 2030.¹ The focus is to reach populations and communities to improve screening, testing, and treatment for Hepatitis B. Among HBV markers, HBsAg is the most frequently used marker used to test HBV infection.⁴ Rapid diagnostic testing is an effective method to screen large communities cost-effectively.⁵ Despite the availability of effective vaccines and advancements in HBV diagnosis and treatment strategies, early access to testing is still a hurdle in low and middle-income countries. Although the routinely used enzyme-based immunoassays (EIA) for HBsAg detection have good sensitivity and specificity,⁶ the requirement of dedicated lab infrastructure, trained personnel and high cost limits its use in resource-limited settings. Therefore, rapid diagnostic tests (RDT) for HBV may be a powerful gateway to improve patient access to diagnosis and treatment services, critical components of an effective cascade-of-care response. Point-of-care (POC) testing, which includes RDTs, performed at or near the patient site could provide timely results, resulting in rapid diagnosis and faster clinical decision-making. In this study, the clinical performance of Determine HBsAg 2 card test (Alere Medical Co. Ltd [Now Abbott]), a qualitative lateral flow immunoassay was compared with that of current routinely used ARCHITECT qualitative HBsAg assay (chemiluminescent immunoassay-based technology, Abbott Diagnostics, IL, US) for the detection of HBsAg in clinical serum samples.

MATERIALS AND METHODS

RESULTS

Out of 120 patient serum samples used in the study: 46 were confirmed HBsAg-positives and 74 were confirmed HBsAg-negatives (Flowchart 1). The population’s median age was 44 years (IQR: 36–51 years). The male-to-female ratio was 9:1. The baseline demographics of the study population are depicted in Table 1. Out of 46 confirmed HBsAg-positive samples, 39 (84.7%) samples were tested positive by Determine HBsAg 2 test. All the samples with discordant results were further subjected to HBsAg Quantitative assay. Among the 7 HBsAg confirmed positive samples, which showed as “false-negative” by Determine HBsAg 2 assay, were tested positive by HBsAg quantitative assay. Among the HBsAg-negative samples (n = 74), all samples showed 100% concordance with the Determine HBsAg 2 test. So, overall, a sensitivity of 84.7% (95% CI: 71.13–93.66%) and specificity of 100% (95% CI: 95.14–100%) was seen for the Determine HBsAg 2 card test in comparison to the reference assay (Table 2).

DISCUSSION

The present study intended to evaluate the clinical performance of the Determine HBsAg 2 card test for the qualitative detection of HBsAg compared with ARCHITECT HBsAg Qualitative II as the reference assay. Determine HBsAg 2 card test is a simple, rapid lateral flow immunoassay which provides test results within 30 minutes. The test results did not vary at 15 minutes and 30 minutes. Of 74 confirmed HBsAg-negative samples, a 100% concordance was seen between the test and reference assay. Among 46 true HBsAg-positive samples, 39 (84.7%) samples were positive in the Determine HBsAg 2 test. All the 7 positive samples that showed negative results by Determine HBsAg 2 card test were found to have low (≥0.05 IU/mL but ≤0.1 IU/mL) HBsAg levels as detected by a third test, HBsAg quantitative assay. As claimed by the manufacturer, the analytical sensitivity of the Determine HBsAg 2 assay is 0.1 IU/mL. This explains the disparity in results among those 7 samples, as the antigen levels were beyond the detection limit of the Determine HBsAg 2 assay. Therefore, overall, a sensitivity of 84.7%, a specificity of 100%, and a diagnostic accuracy of 99.5% were observed for the Determine HBsAg 2 test. Despite advances in diagnostics and treatment for HBV, low access to diagnostic services remains a significant challenge. Accurate, reliable, and affordable POC assays are needed for mass testing of the general public. Currently, in-use Rapid HBsAg card tests show good clinical sensitivity and specificity^5,8 but show low accuracy due to poor analytical sensitivity (2–10 IU/mL).^5,6 This leads to “missed” HBV cases and increased transmission rates. HBV can remain “silent” inside the liver for years and with increasing age, may cause liver-related complications, leading to decreased quality of life and healthcare costs. Therefore, the need of the hour is to screen as many individuals as possible, especially in endemic and hyperendemic zones, which are “hotspots” for hepatitis B infection. Although the current chemiluminescent-based qualitative and quantitative HBsAg assays with good sensitivity and specificity are available,^9,10 cost and technical expertise make them less accessible in low and middle-income countries. Therefore, accurate and affordable card tests with lower limit-of-detection (LoD) are good alternatives for rapid diagnosis of HBV infection. One such card test evaluated by a previous study¹¹ and this current study showed that Determine HBsAg 2 assay could improve the detection of HBV-infected individuals with lower HBsAg levels, preventing the spread of infection to other contacts. This would enable more and more individuals to enter the cascade-of-care process. In addition, this Determine HBsAg card test can be helpful for public health epidemiological and surveillance programs where good and inexpensive assays are indispensable. A limitation of this study includes the retrospective nature of the study design, so, large sample size studies with patient categories covering different genotypes and mutants would give a better scenario to assess the diagnostic performance of this assay.

CONCLUSION

The Determine HBsAg 2 assay has the probability to render a quick and reliable diagnosis at the point‐of‐care for early testing of HBV-infected individuals with low levels of HBsAg, which allows them to receive timely care and treatment, further mitigating the chances of progression to severe liver disease.

ORCID

Anushka Soni https://orcid.org/0000-0002-4964-2544

Ekta Gupta https://orcid.org/0000-0002-5237-216x

REFERENCES

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