Hepatitis B Surface Antigen level and its Correlation with Age, Gender, and Liver Biomarkers


Dr. Zainab A. Hamid1, M. Sc Yasmeen J. Al-Bayaa2, Dr. Ali Hattem Hussain3

1,2Department of Microbiology, Baghdad Medical College, University of Baghdad, Baghdad-Iraq.

3Ph.D Medical Microbiology, Nursing Department, Technical College of Health,

Sulaimani Polytechnic University.

*Corresponding Author E-mail: zainabhamid96@gmail.com, dr.alihattem@yahoo.com



Background: Measuring the concentration of hepatitis B surface antigen (HbsAg) in HBV patients can be determined with immunoassay techniques. This study aimed to measure the HbsAg titers in chronic HBV patients and to assess its correlation with patients' ages, gender, and with the levels of liver enzymes and total serum bilirubin. Materials and Method: Fifty-eight chronic hepatitis B infected patients were enrolled in this study. Age and gender of the patients were recorded. HbsAg concentration was tested with automated Immunoanalyzer. The patients were also tested for ALT, AST, ALP, and TSB by automated chemistry analyzer. Results: All the chronic HBV patients have positive HBsAg titers above the negative cutoff (0.05U/L) with mean concentration equal to 3099.7U/L, and a range of 0.25-6005.2 U/L. The highest mean HbsAg concentration was in age group 50-59, while the least was in age group ≥60. There was weak negative insignificant correlation between HbsAg concentrations and ages of patients. Thirty one of the patients were males and 27 were females. The means of HbsAg concentrations between males and females were statistically not significant. The mean ALT concentration was 60.038U/L, for AST was 40.728U/L, for ALP was 113.722 U/L, and for TSB was 1.168mg/dl. The values of correlation coefficients (R) between HBsAg titers and the concentrations of ALT, AST, ALP, and TSB were 0.13, 0.11, 0.12, and 0.14, respectively. Conclusions: The HBsAg titers are positive among all chronic HBV patients, with a mean titer of 3099.7U/L and all of the values are below 10000.0U/L. The mean titers increase gradually with age to reach the peak in age group 50-59 years old then decline The age, gender, serum ALT, serum AST, serum ALP, and TSB all have weak insignificant correlations with HBsAg titers among chronic HBV patients. The serum ALT is the most commonly elevated liver biomarker in chronic HBV patients.


KEYWORDS: Hepatitis B virus, HbsAg concentration, liver biomarkers, ALT.




Hepatitis B virus (HBV) infection is a chronic dynamic disease. Liver cirrhosis and hepatocellular carcinoma (HCC) are the most annoying nightmares complications; these complications occur many years since the onset of infection and they are responsible of HBV fatalities that reach up to 500,000 cases per year1.


Chronic HBV infection is the presence of HBsAg for more than six months from the first positive HBsAg result; this group of HBV infection is the major cause of HBV morbidity and mortality2. HBsAg is an envelope HBV protein; it is a target for human immune system3, and it is the principle HBV marker for detection HBV infection in symptomatic patients and in HBV screening laboratory testing. Previously, the HBsAg testing was done to detect its positivity without measurement of its serum level. Recently, the quantitative measurement of serum HBsAg becomes a major test parameter in many laboratories using automated immunoanalyzers4.


The quantitative measurement of HBsAg can be a new parameter for determine the HBV infection status in regard to HBV transmissibility, its correlation with other biomarkers, disease progression, response to treatment, and/or possibility of developing complications5.    


The liver is the target of HBV infection, and liver injury is reflected by abnormal liver function test, among others, raise in total serum bilirubin (TSB) and elevation in liver enzymes especially, serum alanine transaminase (ALT), serum aspartate transaminase (AST), and alkaline phosphatase (ALP)6. Age and gender might affect the HBsAg concentration, the correlation of HBsAg titer with and age and gender can give better understanding of disease pathology and viral pathogenicity. Moreover, the correlation between HBsAg titer and liver biomarkers such as ALT, AST, ALP, and TSB can clarify the clinical course of HBV infection, which might improve the management of this infection.      


The main aim of this study is to quantitatively measure the serum HBsAg concentration in chronic HBV infected patients and to assess its correlation with age, gender, ALT, AST, ALP, and TSB.



Study Population:

In this retrospective study, 58 chronic HBV patients were enrolled. They were consulting the General Public Laboratory in Sulaimani city/Kurdistan region of Iraq. They were diagnosed as HBV patients for more than 6 months by physicians and confirmed by laboratory testing of HBV markers (HbsAg positive ≥ 6 months). The exclusion criteria involved any HBV infected patient with the first HbsAg positivity for less than 6 months, or chronic HBV infection with co-infection with HCV and/or HIV. The study extended between December 2019 and April 2020.



Age and gender for each patient was recorded and blood was collected from each participant by venipuncture, then serum was separated and stored at -20°C till tested. All sera were tested for HBsAg concentration (ADVIA Centaur® CP Immunoassay System, Siemens, Germany) with result less than 0.05 U/L was interpreted as negative. The patients were also tested for SGOT, SGPT, ALP, and TSB by automated chemistry analyzer, cobas c 311 (Roche/ Germany), with normal range of <37 U/L for SGOT, <40 U/L for SGPT, 53-128 U/L for ALP, and 0.3-1.2mg/dl for TSB. All tests were performed according to the manufacturers' protocols. The Microsoft Excel program version 2013 was used for data entry and analysis. P value of ˂ 0.05 was considered as statistically significant. The correlation coefficient was measured by internet-based software named Social Science Statistics. The study was done in line with Helsinki declaration regarding ethical principles, and the enrollment of chronic HBV infected patients was only for voluntary participants; then a signed informed consent was obtained from people participating in this study. The scientific committee of the Technical College of Health/ Sulaimani polytechnic University approved the study. 



All the chronic HBV patients have positive HBsAg titers above the negative cutoff (0.05 U/L). The mean HbsAg concentration among the study group, patients with chronic HBV infection, was 3099.7 U/L, with median titer of 3548 U/L and the range of HBsAg titer was 6005 U/L (0.25-6005.2 U/L), as demonstrated in table (1). Most of the patients (77.6%) have HBsAg concentrations between 1000 - <10,000 U/L, while none of them has HBsAg titer ≥10000.0 figure (1).


Table 1: The mean, median, range and mode, of HbsAg concentration among study group


Result U/L

Mean (Average)







All values appeared just once.

Geometric Mean









Figure 1: The distribution of study group according to their HBsAg concentrations (U/L)


The mean of patients' ages is 42.7 with highest frequency [15 (25.8%)] of patients was in age group ≥ 60 years, table (2). The highest mean HbsAg concentration was in age group 50-59, while the least was in age group ≥60, figure (2). The results revealed the presence of weak negative correlation (R is -0.1906) between HbsAg concentrations and ages of chronic HBV patients, these results were insignificant (The P-value is 0.153), figure (3).

Table 2: The distribution of chronic HBV patients according to age groups

Frequency (%)

Age group

5 (8.6%)


12 (20.7%)


12 (20.7%)


9 (15.6%)


5 (8.6%)


15 (25.8%)




Figure 2: The mean concentrations of HbsAg in different age groups


Figure 3: The correlation of HbsAg concentrations with ages of chronic HBV patients


Among the 58 chronic HBV patients enrolled in this study, 31 were males and 27 were females, with male: female ratio equal to 1.2:1. The mean HbsAg concentration was higher in males (3224 U/L) than in females (2957 U/L), however, these results were statistically not significant, p>0.05; though, the range of HbsAg concentrations is a little bit higher in males than females, table (3). 


Table 3: The statistics for HbsAg concentrations between both genders of study group




HbsAg concentration*

Mean (Average)










All values appeared just once.

All values appeared just once.










*P value>0.05


The mean ALT concentration (60.038 U/L) was above the accepted normal range, and the same for AST (40.728 U/L). The mean ALP concentration was 113.722 U/L, which is within the normal range and TSB is in the upper limit (1.168 mg/dl) of normal range; the medians and ranges for these four liver biomarkers are recorded in table (4).


Table 4: The means, medians, and ranges of liver biomarkers' concentrations

Parameter (unit)

Frequency of elevated titers (%)

Mean Concentration






45/58 (77.6%)







24/58 (41.1%)







13/58 (22.4%)






TSB (mg/dl)

18/58 (31%)







When the concentrations of HBsAg were correlated to the concentrations of ALT, the results showed weak positive correlation (R=0.13). The P-Value is 0.32, and the result is not statistically significant at p < .05, figure (4).


Figure 4: The correlation of serum HbsAg concentrations with ALT concentrations for chronic HBV patients

The correlation coefficient between HbsAg concentrations and their matching AST is equal to 0.11. Although technically a positive correlation, the relationship between them is weak. The P-value is 0.43. The result is not significant at p < 0.05, figure (5).



Figure 5: The correlation of serum HbsAg concentrations with AST concentrations in chronic HBV patients

The relationship between HbsAg concentration and ALP concentration revealed a weak positive correlation coefficient (R) equal to 0.12 and the relationship between these two variables is weak. The P-value is 0.37. The result is not significant at p < 0.05, figure (6).



Figure 6: The correlation of serum HbsAg with ALP of chronic HBV patients


The relation between TSB concentrations and HbsAg concentrations revealed irrelevant weak positive correlation (R = 0.14). The P-value is 0.31. The result is not significant at p < 0.05, figure (7).


Figure 7: The correlation of HbsAg with TSB among chronic HBV patients



This study is was achieved to reveal the important HBV marker, the HbsAg titer. Previously, HbsAg was used solely for the diagnosis of HBV, but with the development of new immunological techniques for quantification the HbsAg, it is now important to understand the relationship of HbsAg concentration with the laboratory and clinical aspects of HBV infection in order to recognize its clinical significance7.


There is no clear-cut reference grading system to distribute the HBsAg levels as low, intermediate and high titers; However, different researchers tried to allocate such levels of HBsAg titer ranges. Zi-zheng, et al8 regarded an HBsAg titer of <100 U/L as low titer while >1000 as high titer; if we agree this assumption, so 77.6% of HBV in the current study are of high titer. Moreover, Brouwer et al9 mentioned that a titer ˂100 U/L is equivalent to viral inactivity, thus most of patients in our study having active HBV infection.  

In the current study, the mean concentration of the HbsAg among patients with chronic HBV infection is nearly 3,099 U/L, with median of 3548 U/L and range of 6005 U/L, these results are much higher than that recorded by Brouwer et al9 as acceptable level of viral inactivity. In this regard, patients with titers more than 100 U/L are at increased risk of complications like liver fibrosis especially if there are additional cofactors like positive HBeAg.    


Seto and his co-workers10, found that the risk of liver fibrosis in HBeAg positive patients will increase if HBsAg >25,000 U/L, while in our study none of the patients has a titer above 10000.0 U/L which correlate with low risk of liver fibrosis. However, the presence of other cofactors that can injury the liver like chronic diseases, alcohol consumption, cigarette smoking, or high serum lipids will increase the risk of liver complications. Sometime HBV patients with low titers of HBsAg and without the presence of any other associated risk factor are still at risk of fibrosis11.   


The current study revealed a weak negative correlation between HbsAg concentrations and ages of chronic HBV patients; although these results were statistically not significant, they indicate a relative decrease in HbsAg concentration when the patient becomes older.  This feature is in accordance to the general fact that adults have mild disease and more probability to clear the body from HBV than younger age12.


The results showed that the frequency of HBV infection in males is a little bit more than in females, thus males are more prone to infection than females, this might be due to the activity, movement, and contact with other people that is more among males than in females in Sulaimani city. The results showed the mean HbsAg concentration is higher in males than in females, which might be due to protective effect of female hormones like estrogen13 or due to higher metabolic rate in male, which will prone more stress on liver14.


In this study, 77.6% of the patients have abnormally elevated titers of ALT; it is the most frequently recorded as abnormal liver biomarker among study group. The elevation in ALT indicates rise in inflammatory process and more injured hepatocytes15. The AST is less frequently elevated (40.1%) in chronic HBV than ALT; the mean concentration and range of AST levels are also less than their equivalents ALT levels; these results are against the results of Hasanjani Roushan et al.16 who found that AST is better indicator of the liver injury severity than ALT. The AST serum levels have also insignificant weak positive correlation with HBsAg level, which might indicate the presence of additional viral and/or human factors that contribute to HBsAg titer. Esmaeelzadeh et al.17, found serum ALT 75.6 IU/L, AST 60.5 IU/L, which is higher than that in ours; this might be due to different study groups, as they choose both active and inactive HBV infections while in our study we did not measure the HBeAg biomarker or HBV viral load to determine the viral activity.


The ALP is within the normal range, and TSB is in the upper limit of normal range; in chronic HBV infection, these two markers are less significant in predicting the liver injury unless there patient develop severe complications like biliary obstruction or sepsis18.


The results showed that HbsAg concentration has no significant correlation with the concentrations of liver enzymes or total serum bilirubin concentration. This might reflect the irrelevant effect of increase in HbsAg concentration on the health of the liver, thus increase in HBsAg concentration might not reflected increase in viral activity which in turn increase liver damage. The liver parameters have been regarded as a reliable and sensitive marker of liver disease and their concentrations are related to liver damage; and the HbsAg concentration is also a good indicator for liver damage but other cofactors like HBeAg or viral DNA are important to clarify the liver damage. However, Brouwer WP, found that HBsAg titer <100IU/ml is related to viral inactivity9.        



The HBsAg titers are positive among all chronic HBV patients, with a mean titer of 3099.7U/L and none of these results reach the titer of 10000.0U/L. The concentration of HBsAg is mostly high among patients with chronic HBV infection with wide range among patients; the mean titers increase gradually with age to reach the peak in age group 50-59 years old then decline; however, there is irrelevant weak negative correlation between HbsAg concentrations and the ages of patients. The gender has no significant influence on HBsAg concentration. The ALT has the most frequent elevated levels among liver biomarkers, followed by AST, TSB, and then ALP; however, all these four liver biomarkers have insignificant weak correlation with serum HBsAg titer.   



The authors declare that there are no conflicts of interest.



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Received on 14.08.2020           Modified on 15.10.2020

Accepted on 17.11.2020         © RJPT All right reserved

Research J. Pharm. and Tech. 2021; 14(8):4207-4211.

DOI: 10.52711/0974-360X.2021.00729