PREVALENCE OF HEPATITIS B AND C AMONG PREGNANT WOMEN ATTENDING ANTENATAL CARE
ABSTRACT
Background: Hepatitis B is the inflammation of the liver caused by the Hepatitis B virus. The risk of maternal transmission of Hepatitis B infection in pregnancy and a peri-natal period is dependent on the maternal Hepatitis B envelop antigen (HBeAg).
A positive HBeAg mother has between a 70-90% chance of transmitting the virus to the unborn child. This study sought to determine the prevalence of and predictors of Hepatitis B among pregnant women in Uyo. The study also assessed pregnant women’s awareness about Hepatitis B transmission and prevention. Methods: A cross-sectional study was undertaken. Pregnant women were evaluated using a structured questionnaire to collect information on their socio-demographic characteristics and awareness of Hepatitis B virus (HBV) transmission and prevention. Pregnant women were screened for Hepatitis B virus sero-markers, using a commercial rapid diagnostic test, with three milliliters of blood for the Hepatitis B profile. Assessment of awareness was done using a Hepatitis B basic awareness summary score.
Results: Of the 183 pregnant women screened 20.22% (37/183) tested positive for
HbsAg, 7.10% (13/183) for HbeAg, 18.58% (34/183) for HbcAb, 1.64%(3/183) for HbsAb and 10.38% (19/183) for HbeAb. The type of marital relationship was significantly associated with HBsAg positivity and HBeAg positivity. The majority of pregnant women 78.7% are aware of Hepatitis B transmission and prevention.
Recommendation and Conclusion: This study has demonstrated a high prevalence of HBsAg and HBeAg and the majority 78.14% (143/183) are not aware of mother-to-unborn child transmission of Hepatitis B among pregnant women. Pregnant women should be screened for HbeAg before delivery and vaccines should be affordable and available. More educational programs on the mode of HBV transmission and methods of prevention should be introduced at the antenatal care (ANC) level.
Keywords: Prevalence, Hepatitis B virus infection, pregnant women, Uyo, awareness, Hepatitis B envelop antigen, Hepatitis B surface antigen, Hepatitis B surface antibody.
CHAPTER ONE
1.0 INTRODUCTION
1.1 BACKGROUND
The inflammation of the liver caused by the Hepatitis B virus can lead to Hepatitis B disease which can be life-threatening to the person infected. Cirrhosis and liver cancer are the cause of death of a person suffering from chronic Hepatitis B infection thereby making it a public health issue(World Health Organization, 2017). Sexual contact is the major transmission route for Hepatitis B infection in low-endemicity areas amongst high-risk adults while perinatal transmission accounts for the transmission of Hepatitis B virus (HBV) in high-endemicity areas (Hou et al., 2005).
The most effective way to prevent Hepatitis B Virus transmission to newborns is through the effective identification of HBV-positive pregnant women (Borgia et al., 2012). Screening asymptomatic people is an important instrument in disease detection, prompt diagnosis, and intervention, particularly at an early stage of the disease. This may improve the health outcome as well as a better understanding of the transmission pattern of the disease(Parveen et al., 2012).
It is very common for infants to develop chronic Hepatitis B if it is transmitted from an infected mother and usually, this occurs before the age of 5 years (WHO, 2017). Chronic HBV infection goes through three to four phases depending on the immunity of the individual. The immune-tolerant phase is the first phase followed by the immune clearance or immunoactive phase, then no replicative inactive phase which may lead to a rebirth of the phases. About 87-90% of patients infected with HBV may either develop immunity or become chronic carriers, which may lead to the risk of developing liver cirrhosis or liver cancer (Ott et al., 2012).
To prevent mother-to-child transmission, a child born to a mother positive for Hepatitis B surface antigen should receive the Hepatitis B vaccine and the Hepatitis B immune globulin within 12 hours of birth, that child will be 85-95% protected from Hepatitis B virus(Center for Disease Control and Prevention, 2015). Those who acquire HBV infection at birth or during childhood do not usually experience symptoms. Therefore it is necessary to target the risk group of people who are likely to acquire the infection for screening (Sarin et al., 2016).
Chronic Hepatitis B is endemic in Sub-Saharan Africa and Asia with an estimated prevalence of 5% and 10% respectively in the adult population (WHO, 2017). Ghana has been categorized among the areas of the world with a high prevalence (≥8 %) of chronic HBV The rate of chronic Hepatitis B virus infection in 2013 was 12.92 %, but some experts also put it at 10 to 15% (Schweitzer et al., 2015). Women in their reproductive age with chronic HBV infection remain a major source of the continued spread of the virus. Therefore there is a need for screening of pregnant women to detect the virus in prenatal care to enable early intervention (Abdi, 2015).
Hepatitis B screening is among the routine tests recommended for all pregnant women when they visit the antenatal clinic in Ghana. The risks of maternal complications of Hepatitis B virus are inducing premature labor and intra-ventricular, intrapartum, and postpartum hemorrhages. In the case of infants, there are usually poor outcomes like stillbirths and neonatal deaths, jaundice, anorexia, malaise, acute and chronic liver disease, and impaired mental and physical health (Abongwa, et al., 2016).
1.2 PROBLEM STATEMENT
There are several mechanisms in place to check the Hepatitis B status of women who are attending antenatal clinics to identify Positive HbsAg mothers so that measures can be put in place to prevent transmission of the Hepatitis B virus to the unborn child (Kiyshi et al., 2015). Hepatitis B virus is often acquired in adolescence or adulthood through sexual contact or drug use by injection in the United States and Western Europe. This is different in Ghana and Africa where a majority of HBV is acquired through vertical transmission from mother to child and horizontal transmission from child to child usually in pre-schools (Luuse et al., 2017). In Africa where there is scare scarcity of health resources, lack of education, and data, making a diagnosis and monitoring the infection is a major problem. Furthermore, stigma and discrimination are also invisible challenges in helping the interventions for the prevention and treatment of HBV (O’Hara et al., 2017).
Hepatitis B virus can persist at room temperature for at least seven (7) days with viral replication occurring. Hepatitis B virus can be spread from one person to another through an infected person’s sore that sheds the virus into the environment. Contact with the contaminated environment/surface while having an open lesion makes a person susceptible to infection with the virus(Nelson, Easterbrook, & Brian, 2017). Hepatitis B virus comes second to tobacco as the most common carcinogenic agent and a major cause of liver cirrhosis and liver cancer. Moreover, they usually have poor outcomes in terms of morbidity and mortality (Okonkwo et al., 2017).
According to WHO (2015), less than 5% of people with chronic Hepatitis infections know their status. Women may know their status only when they are pregnant and this makes it a major public health challenge. Maternal Hepatitis B envelop antigen (HBeAg) is an important factor in the maternal transmission of HBV infection during pregnancy. A positive HbeAg mother has a 70-90% rate of transmission and less than 10% if she is HbeAg negative (Eke et al., 2016). It is necessary to differentiate between a low replicative patient and a risk of progressive disease. A Hepatitis B virus deoxyribonucleic acid (DNA) more than 2000 IU/ml is considered as a risk of progression to disease. According to Sarin et al. (2016), patients who are positive for HBsAg and with DNA≥1000 IU/ml are at a high risk of reactivation of the virus.
The World Health Organization has made Hepatitis a major community health
consent, by drafting strategies to deal with viral Hepatitis globally, with strategies to eliminate viral Hepatitis by 2030 (WHO, 2017). The Upper West Region has the highest prevalence of 18% within the West Africa sub-region (GNA, 2006).
Hepatitis B immune globulin (HBIG) which is used to prevent mother-to-child transmission is very expensive and therefore, rarely available, and more over the logistics of storage is a major challenge in most health facilities. Antivirals should be considered for HBV-infected mothers to reduce perinatal transmission(Chotun et al., 2017). In 2015, only 9% of Hepatitis B virus-infected individuals had been tested where sub-Saharan Africa, and out of that, only 8% were on treatment. Treatment for Hepatitis B infection should be made easily available and accessible to the general population (Aberra et al., 2017).
1.3 JUSTIFICATION
The double-stranded DNA virus is among the viruses that cause severe liver infections.
This virus can easily be spread from infected mother to unborn child, through infected open wounds, unprotected sex, infected blood transfusion, and other infected blood-contact-related activities. The Hepatitis B virus is 50-100 more contagious than the human immunodeficiency virus (HIV) (Chernet et al., 2017).
Most infections of Hepatitis B usually occur during 22 weeks of gestation and seven days after birth and at this stage there are no symptoms, thereby leading to the development of chronic infection by children. Therefore, screening of pregnant women is very necessary (Etame Sone et al., 2017). Every pregnant woman must test for Hepatitis B regularly whether previously vaccinated or tested. This can be done during a prenatal visit. Pregnant women who are not screened prenatally and those involved in risky behavior should be tested on the day of admission for delivery at the hospital and maternity home (Kumar et al., 2012). The prevalence of HBV can easily be estimated in a given population by an active screening of pregnant women for HbsAg. This will give dependent data to prevent mother-to-unborn child transmission (Eke et al., 2011). It is very important to know that geographical differences account for the differences in the seroprevalence and risk-related factors with HBV infection which may lead to designing suitable preventive measures for different settings (Umare et al., 2016).
Furthermore, Hepatitis B infection can be effectively managed through reliable data on the prevalence of infections in the general population, mindful of mother-to-child transmission only if the mother is positive for HBsAg (Abongwa, et al., 2016). According to Adjei et al. (2016), newborn babies born to HBV-infected mothers in the Eastern Region of Ghana were not given Hepatitis B immunoglobulin (HBIG) after the health facilities screened the pregnant women for HbsAg. It was only the routine vaccines that were given to the newborn babies whether the mother was positive or negative. Previous studies on Hepatitis B infection among pregnant women were done in southern parts of Ghana but there is no documented data for the upper west region.
The presence of HbsAg in blood is a hallmark of diagnosis of Hepatitis B virus infection. In regions where there is poor or lack of resources, conducting this test may not be readily available to the entire population including pregnant women. This practice may lead to pregnant women not knowing their status before labor (Siaket al., 2014). More importantly, given that horizontal transmission largely accounts for the spread of the infection among infants, there is a need for further research in the northern parts of Ghana to provide evidence to guide and support policy formulation for the eradication of viral Hepatitis by 2030, by the World Health Organization’s target. The majority of HBV transmission is from mother to child transmission. Therefore those positive for HBV must be made aware of their status and let them understand the possibility of transmission of the virus to their unborn child (Han et al., 2017). Women of reproductive age are a channel of infection and therefore they become chronic with the Hepatitis B virus (Abdi et al., 2015).
1.4 OBJECTIVES
1.4.1 GENERAL OBJECTIVE
The general objective of this study was to determine the prevalence and predictors of the Hepatitis B virus among pregnant women attending antenatal care (ANC) in Uyo.
1.4.2 SPECIFIC OBJECTIVES
- To determine the prevalence of HBsAg among pregnant women in Uyo.
- To assess the awareness of Hepatitis B transmission and prevention among pregnant women in Uyo.
- To determine the prevalence of HBeAg among pregnant women in Uyo.
- To determine, HBcAb (Anti-HBc) HbeAb and HbsAb among pregnant women in Uyo.
1.5 CONCEPTUAL FRAMEWORK OF HEPATITIS B
The framework explains the influence of various risk factors associated with Hepatitis B infection among pregnant women. The risk of one being infected is influenced directly or indirectly by the following factors: Medical interventions, Traditional practices, Biological factors, Risky behaviors, unawareness of HBV, and irregular screening. It can be argued that the most important aspect of Hepatitis B transmission to pregnant women is through a medical intervention such as blood transfusion. If a woman has ever been transfused with blood that is not well screened (infected with Hepatitis B virus), then there is a likelihood of being infected through the blood transfusion.
It is known that risky behaviors such as having multi-sexual partners and intravenous drug usage put one higher on the ladder of being infected with the Hepatitis B virus. For example, a person is likely to be infected with Hepatitis B virus if he or she engages in unprotected sex with an infected person.
Moreover, if a person is not aware of the Hepatitis B virus mode of transmission and methods of prevention he or she may be engaged in risky behavior, for example, having multiple sex partners. Traditional practitioners of female genital mutilation and tribal marks have the possibility of transmitting HBV to their clients if the instruments used are not well sterilized. If a pregnant woman is HIV positive, she has a high possibility of transmitting the virus to the child. More importantly, if there are irregular screenings at the facility level could miss out on positive Hepatitis B surface antigen. This may also lead to the high prevalence of Hepatitis B in the community.
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