Prevalence of hepatitis B virus infection and its associated factors in Ethiopia: a recent systematic review and meta-analysis

Abstract

Background

Hepatitis B virus (HBV) is one of the most common causes of chronic liver disease and is a growing concern in low-income countries, including Ethiopia. Different studies have been conducted on the prevalence of HBV infection among Ethiopian regions and population segments. Therefore, this systematic review was commenced to summarize these findings, deliver representative pooled data on the prevalence of HBV infection among Ethiopian administrative regions and population segments, and identify possible factors associated with HBV infection.

Methods

Electronic databases such as PubMed, African Journals Online, and Google Scholar were searched for published articles from July 9, 2019, to February 30, 2024. The data were exported to STATA version 15.1 for meta-analyses. The heterogeneity between the results of the primary studies was accessed using Cochran’s Q chi-square test and quantified with I² statistics. A random effect model was used to pool the prevalence of HBV infection.

Results

The overall pooled prevalence of HBV infection was 6.9% (95% CI: 6.1, 7.7). Among the subgroup analyses, the highest pooled prevalence of HBV infection was obtained from Harar city 9.6% (95% CI: 5.6, 13.5), followed by South Nations and Nationalities People Regions (SNNPR) 8.5% (95% CI: 7.4, 9.7). On the other hand, the pooled prevalence of HBV infection among waste handlers was high 12.6% (95% CI: 2.4, 27.6) followed by female commercial sex workers (FCSW) 10.9% (95% CI: 7.7, 15.2) and human immune deficiency virus (HIV) positive individuals 9.9% (95% CI: 7.2, 12.8). HBV infection was significantly linked to the following factors: those with multiple sexual partners, a family history of chronic liver disease, exposure to bodily fluids, HIV seropositivity, and sharp needle injury had Adjusted Odd Ratio (AOR):3.9 (95% CI: 2.62, 5.76), (AOR: 6.9 (95% CI:3.46, 10.53), (AOR:3.1 (95% CI: 2.01, 3.05), (AOR:7.7 (95% CI: 2.99, 19.93), (AOR:2.1 (95% CI: 1.58, 2.66) times a greater chance of infection, respectively.

Conclusions

The high pooled prevalence of HBV infection in Ethiopia indicates that the burden of HBV infection continues to be a public health concern. The Ethiopian Ministry of Health should develop a strategic plan for prevention and control of HBV infection transmission including awareness creation, scale-up screening programs, diagnosis, treatment, and care services to reduce the burden of HBV infection and eliminate it as a public health threat.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-025-11150-8.

Introduction

Hepatitis B virus (HBV) is the cause of hepatitis B, previously known as serum hepatitis, and began appearing in the 19 th and early twentieth centuries [1]. Currently, 3.0 million new infections occur per year globally, more than 350 million people are living with this disease, and over a million people have lost their life because of acute and chronic viral infections that cause cirrhosis and liver cancer [2]. Hepatitis B virus is a major cause of chronic hepatitis, cirrhosis, and hepatocellular carcinoma. Owing to its largely asymptomatic nature, hepatitis B is a silent epidemic; most people are unaware of its infection. According to the World Health Organization (2024) report, in 2022, an estimated 254 million people were living with chronic HBV infection, with 1.2 million new infections each year and 1.1 million deaths [3].

Currently, more than 60 million African people are living with chronic hepatitis B. Greater than 90% of people living with hepatitis B in Africa lack attention, which has resulted in more deaths from hepatitis in Africa than from acquired immune deficiency syndrome (AIDS), malaria or tuberculosis [3, 4].

The Disease Control and Prevention (CDC) recommends hepatitis B testing for people born in countries with 2% or higher HBV prevalence [5]. In contrast, on the African continent, only 2% of persons infected with HBV were diagnosed. Currently available antiviral drugs for the treatment of HBV are expensive and not curative. Early diagnosis and prevention of HBV infection transmission are essential for its elimination [6].

In Ethiopia, the pooled prevalence of HBV infection was 7.4% in 2016 [7] and 6% in 2019 [8].To eliminate HBV infection in Ethiopia, developing guidelines for the prevention and control of HBV infection transmission is crucial. Adequate budget allocation for prevention of HBV infection in all regions of Ethiopia and segment of population is challenging. Therefore, conducting systematic reviews and meta-analyses is important for identifying regions with high burdens of HBV infection and segmenting the population. Although two systematic reviews and meta-analyses were conducted in Ethiopia in 2016 [7] and 2019 [8], 50% of the articles used in the first systematic review were from primary studies conducted in Addis Ababa alone, and this review also included old articles, whereas the second systematic and meta-analysis included 60% of the articles from studies conducted in the Amhara region. In addition, both systematic reviews didn’t report the pooled prevalence of HBV infection in all Ethiopian administrative regions and the main risk factors associated with HBV infection. Hence, fully understanding the dynamics of the HBV infection burden in Ethiopia is difficult. Therefore, the current systematic review and meta-analysis was designed to generate comprehensive and representative information on HBV infection pooled prevalence and associated risk factors by searching for recent articles to address the gap in previous studies.

The updated systematic review and meta-analysis pooled national and regional state data was used to alarm local health sector planners, allocate adequate resources for the prevention and control of HBV infection transmission and identified gaps for future similar studies.

Materials and methods

The protocol of this study is recorded at the National Institute of Health Research (PROSPERO registration number CRD42024493993) https://www.crd.york.ac.uk/PROSPERO/view/CRD42024493993

Study setting

This review was conducted using primary studies in different administrative regions of Ethiopia. Ethiopia has twelve regional states; Afar, Amhara, Benishangul-Gumaz, Gambela, Harar, Oromoia, Somali, South Nations Nationalities and People, Tigray, Sidama, Southwest Ethiopia Peoples, and South Ethiopia with two separate self-governing administration (Addis Ababa and Dire Dawa) https://www.voaafrica.com/a/ethiopia-creates-a-12th-regional-state-/7168313.html

Article search strategy

We searched the following databases: PubMed, Hinari, African Journals Online (AJOL), Google Scholar, and Science Direct (SD). The search was performed via the following Medical Subject Headings (MeSH) search terms. “Viral hepatitis”, “prevalence”, “sero-prevalence”, “magnitude”, “Hepatitis B virus”, “HBV”, “hepatitis B surface antigen”, “HBsAg”, “risk factors”, associated factors, determinant” and Ethiopia separately or in combination by using the string terms AND and OR (S file 1). All published articles from July 9, 2019, to February 30, 2024, were retrieved and assessed for eligibility. The Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) 2020 statement checklist was utilized to conduct this systematic review and meta-analysis (Fig. 1)[9].

Fig. 1.

PRISMA flow charts: study selection

Eligibility criteria

The included studies met the following inclusion and exclusion criteria.

• ❖ Inclusion criteria: Articles had cross-sectional, or case‒control study designs, reported prevalence data or associated risk factors for HBV infection in Ethiopia, were published in English.

• ❖ Exclusion criteria: reviews, articles involving children and chronic liver disease (CLD) patients were excluded. reviews, articles involving children and chronic liver disease (CLD) patients were excluded.

Quality assessment

The authors critically appraised the studies independently via the Joanna Briggs Institute (JBI) quality assessment tool for prevalence studies [10]. The critical appraisal tool includes nine parameters that had yes, no, unclear and not applicable options: appropriate sampling frame, proper sampling technique, adequate sample size, study subject and setting description, sufficient data analysis, use of valid methods for the identified condition, valid measurement for all participants, use of appropriate statistical analysis, and adequate response rate. A score of 1 was assigned for a yes response; a score of 0 was assigned for no and unclear responses. The mean score was subsequently computed for each article. Studies below the mean score were categorized as poor, and studies above the mean score were categorized as good (S file 2) [10].

Article selection and data extraction

All articles identified through our search strategy were imported into EndNote version X9 software, and duplicate articles were removed. Based on their titles and abstract, two independent researchers (SE and DE) screened the identified articles. Risk factor variables were included in this meta-analysis if they were reported in at least two of the included studies and demonstrated a statistically significant association with HBV infection in at least one study.. Data extraction was conducted through Joanna Briggs Institute data extraction tool updated in 2024 [10] following a thorough review of abstracts and full texts. Data extraction tool used the Microsoft excel sheet through which data elements were captured. The excel extracted data includes name of the first author, year of publication, year of study, sample size, number of HBV-positive cases, administrative region, study group, screening method enzyme-linked immunosorbent assay, rapid diagnostic tests, sampling technique, study design and associated factors (multiple sexual partners, a family with chronic liver diseases, exposure to body fluid, tattooing, abortion, HIV, sharp needle injury, HBV vaccination, history of blood transfusion, and condom use) were extracted from each article. Two authors (SE and DE) independently extracted data from the full-text articles. When discrepancies occurred, a third evaluator (ET) was consulted, and inconsistencies were resolved by consensus.

Statistical analysis

The Excel-extracted data was subsequently imported into statistical software for data analysis (STATA) version 15 and utilized for conducting the meta-analysis. The random effect model was with a 95% confidence interval (CI) was used to determine the pooled prevalence and associated risk factors of HBV infection in Ethiopia Forest plots were used to show the prevalence and risk factors for HBV infection in Ethiopia with 95% CIs. Risk factors such as having multiple sexual partners, family history of chronic liver diseases, exposure to body fluids, tattooing, abortion, HIV, sharp needle injury, being vaccinated against HBV, a history of blood transfusion, and condom use were assessed for their association with HBV infection at the 95% CI.

Heterogeneity test

Heterogeneity of the primary studies was assessed using cochrance Q chi-square test and I² statistics. A p value of less than 0.05 was considered to indicate statistically significant heterogeneity. Based on I² statistical values < 25% considered as low heterogeneity, value between 25–50 considered as medium heterogeneity and value > 50% considered as high heterogeneity. In this review, a random effects model was used for analysis. Subgroup analysis was conducted to address any potential heterogeneity for pooled estimate of hepatitis B virus infection. A sensitivity analysis was conducted by systematically excluding one study at a time to ensure that no single study unduly influenced the results.

Publication bias

Publication bias was assesses by visual inspection of a funnel plot based on the shape of the graph. The funnel plot graph was asymmetrical, which we suggested the presence of publication bias. On the other hand objective assessment, egger’s regression test were used to assess publication bias, with a p value less than 0.05 considered indicative of a statistical significant publication bias.

Results

Study selection

A total of 780 articles were retrieved through an electronic search by using search terms, of which 698 articles were eligible for title and abstract assessment after the removal of 82 duplicate records. Out of the 698 articles screened for eligibility, 605 records were excluded by their title and abstract assessment. A total of 93 articles underwent full-text assessment for eligibility, and 21 studies were excluded for various reasons. Finally, a total of 72 studies that fulfilled the inclusion criteria were included (Fig. 1).

Characteristics of the included studies

In this systematic review and meta- analysis, a total of 72 articles with the overall sample size of 83,058 and 3741 positive cases that conducted on the prevalence of HBV infection and associated factors in Ethiopia. Seventy one articles were cross sectional study and one was a nested case–control study. Most of the regions of Ethiopia were represented in this systematic review and meta-analysis. Twenty-one studies, with a total sample size of 2401 and 357 positive cases, were conducted in the South Nations and Nationalities People Regions (SNNPR); nineteen studies, with a total sample size of 7419 and 432 positive cases from the Amhara region; fourteen studies, with a total sample size of 26,212 and 888 positive cases from the Oromia region; six studies, with a total sample size of 15,106 and 488 positive cases from Addis Ababa; six studies, with a total sample size of 22,426 and 848 positive cases from the Tigray region; three studies with a total sample size of 1769 and 178 positive cases from the Harar region; two studies, with a total sample size of 706 and 53 positive cases from the Gambella region; and one study with a total sample size of 589 and 50 positive cases from the Somali region.

Prevalence of HBV infection in Ethiopia

There was a wide difference in the prevalence of HBV infection among the studies included in this systematic review and meta-analysis. The lowest and highest HBV infection prevalence rates were obtained from studies conducted among healthcare workers (1.8%) [11] and waste handers (20.4%) [12] in the Oromia region. According to the random effects model, the overall pooled prevalence of HBV infection among 83,058 study participants was 6.9%, with a 95% CI: 6.1, 7.7) (Table 1).

Table 1.

Summary of research articles included in the systematic review and meta-analysis of HBV in Ethiopia 2024 (N = 72)

S.No	Authors	Year of publication	Region	Study group	D. Method	Sample size	Prevalence(95% CI)	SE	Q. assess ment
1	Tesfa et al., 2019[13]	2021	Harar	Health care worker	RDT	407	11.30(8.20,14.40)	1.57	Good
2	Abate et al.,2022[14]	2022	Oromia	Health care worker	RDT	438	9.60(6.80, 12.30)	1.41	Good
3	Beykaso et al., 2022[15]	2022	SNNPR	Healthy individual	ELISA	346	9.80(6.70, 13.00)	1.60	Good
4	Abebe et al., 2019[16]	2019	Harar	Healthy individual	ELISA	461	5.90(3.70, 8.00)	1.10	Good
5	Abebe &Alemnew 2020[17]	2020	Oromia	Blood donor	ELISA	17,810	3.10(2.80, 3.30)	0.13	Good
6	Abebe et al., 2021[18]	2021	Amhara	Healthy individual	ELISA	403	2.50(1.00, 4.00)	0.78	Good
7	Aliyo 2022[19]	2022	Oromia	Blood donor	ELISA	4193	2.10(1.60, 2.50)	0.22	Good
8	Ambaye et al.,2023[20]	2023	SNNPR	Healthy individual	RDT	416	6.50(4.10, 8.90)	1.21	Good
9	Asaye et al.,2022[21]	2022	SNNP	Pregnant women	RDT	375	5.90(3.50, 8.20)	1.22	Good
10	Assefa et al.,2023[22]	2023	Amhara	Pregnant women	RDT	422	13.0(9.80, 16.2)	1.64	Good
11	Atalay et al.,2021[23]	2021	SNNPR	Pregnant women	RDT	215	5.10(2.20, 8.10)	1.50	Good
12	Ayana et al., 2019[24]	2019	Harar	HIV positive	RDT	901	11.7(9.60, 13.70)	1.07	Good
13	Ayele et a.l,2020[25]	2020	Gambella	Refugees camp	RDT	453	7.30(4.90, 9.70)	1.22	Good
14	Ayele & Weldehanna [26]	2023	Amhara	Waste handlers	ELISA	276	5.10(2.50, 7.70)	1.32	Poor
15	Wondmagegn et al.[27]	2022	Amhara	FCSW	ELISA	194	11.9(7.30, 16.40)	2.32	Poor
16	Meseret et al. 2021[28]	2021	Amhara	HIV positivity	ELISA	81	21.0(12.1, 29.90)	4.53	Poor
17	Bafa & Egat 2020[29]	2020	SNNPR	Pregnant women	RDT	222	4.10 (1.50, 6.60)	1.33	Good
18	Bancha et al.,2020[30]	2020	SNNPR	Pregnant women	RDT	675	7.30(5.30, 9.20)	1.00	Good
19	Belay et al., 2020[31]	2020	SNNPR	Healthy individual	RDT	612	9.00(6.70, 11.30)	1.16	Good
20	Belay et al., 2022[32]	2022	SNNPR	Healthy individual	RDT	330	8.50(5.50, 11.50)	1.54	Good
21	Belete et al.,2023[33]	2023	Amhara	Diabetic patients	RDT	152	3.90(0.90, 7.00)	1.57	Poor
22	Beykaso et al.,2021[34]	2021	SNNPR	Healthy individual	ELISA	693	9.50(7.30, 11.7)	1.11	Good
23	Beykaso et al., 2021[35]	2021	SNNPR	Blood donor	ELSIA	417	9.80(7.00, 12.70)	1.46	Good
24	Biazin et al.,2019[36]	2019	AA	Healthy individual	RDT	454	3.70(2.00, 5.50)	0.89	Good
25	Chanko et al., 2021[37]	2021	Tigray	Pregnant women	RDT	240	9.20(5.50, 12.80)	1.87	Good
26	Dagnaw et al.,2020[38]	2020	Amhara	Pregnant women	ELISA	1121	4.60(3.40, 5.90)	0.63	Good
27	Daka D., et al., 2021[39]	2021	SNNPR	FCSW	ELISA	381	13.9(10.4%, 17.4)	1.77	Good
28	Gebreselassie et al.,2021[40]	2021	Amhara	Pregnant women	RDT	338	8.3(5.30, 11.20)	1.50	Good
29	Demissie et al.,2020[41]	2020	Oromia	Pregnant women	ELISA	363	6.10(3.60, 8.50)	1.26	Good
30	Eba et al.,2020[42]	2021	Oromia	Pregnant women	RDT	277	5.80(3.00, 8.50)	1.40	Good
31	Gebrehiwet et al.,2023[43]	2023	AA	PTB patients	ELISA	387	3.60(1.80, 5.50)	0.95	Good
32	Gebremariam et al.,2019[44]	2019	Amhara	Healthy individual	ELISA	332	4.50(2.30, 6.80)	1.14	Good
33	Gebretsadik et al.,2022[45]	2022	Amhara	Pregnant women	RDT	124	11.3(5.70, 16.90)	2.84	Poor
34	Gedy et al.,2021[46]	2021	SNNPR	Pregnant women	RDT	422	10.9(7.90, 13.90)	1.52	Good
35	Gedefaw et al.,2019[47]	2019	Amhara	Pregnant women	ELISA	338	4.70(2.50, 7.00)	1.15	Good
36	Gedefie et al.,2023[48]	2023	Amhara	HIV positivity	ELISA	222	10.4(6.40, 14.40)	2.05	Good
37	Gemechu et al.,2022[49]	2022	AA	Blood donor	PCRT	973	2.80(1.70, 3.80)	0.53	Good
38	Genetu et al.,2022[50]	2022	AA	Pregnant women	RDT	281	3.20(1.10, 5.30)	1.05	Good
39	Geta et al.,2022[51]	2019	Amhara	Health individual	ELISA	419	3.80(2.00, 5.70)	0.93	Good
40	Seyoum et al.,2022[52]	2022	AA	HIV positivity	RDT	873	6.00(4.40, 7.50)	0.80	Good
41	Getie et al.,2021[53]	2021	Amhara	TB patients	ELISA	145	3.40(0.50, 6.40)	1.51	Good
42	Goa et al.,2019[54]	2019	SNNPR	HIV positivity	RDT	442	8.10(5.60, 10.70)	1.30	Good
43	Goyetom et al.,2020[55]	2020	Tigray	Pregnant women	RDT	473	11.6(8.70, 14.50)	1.47	Good
44	Gundersen et al.,2020[56]	2020	Somali	Pregnant women	ELISA	589	8.50(6.20, 10.70)	1.15	Good
45	Kampe et al.,2023[57]	2023	Oromia	Pregnant women	ELISA	368	5.70(3.30, 8.10)	1.21	Good
46	kassaw et al.,2022[58]	2022	SNNPR	Pregnant women	ELISA	381	6.60(4.10, 9.00)	1.27	Good
47	Edosa et al.,2023[59]	2020	Amhara	Blood donor	ELISA	384	4.20(2.20, 6.20)	1.02	Good
48	Kenea et al.,2020[60]	2020	Oromia	Pregnant women	RDT	276	6.50(3.60, 9.40)	1.48	Good
49	Kumalo et al.,2022[61]	2022	SNNPR	Healthy individual	ELISA	220	6.80(3.50, 10.10)	1.70	Poor
50	Legesse et al.,2023[62]	2023	Tigray	Pregnant women	RDT	20,622	3.30(3.10, 3.60)	0.12	Good
51	Liebert et al.,2021[63]	2021	Amhara	Prison	ELISA	339	6.50(3.90, 9.10)	1.34	Good
52	Marama et al.,2020[64]	2020	SNNPR	Pregnant women	ELISA	435	8.70(6.10, 11.40)	1.35	Good
53	Mengstie et al., 2021[12]	2021	Oromia	Waste handlers	RDT	260	20.4(15.5, 25.30)	2.50	Good
54	Metaferia et al.,2021[65]	2021	Amhara	FCSW	RDT	360	7.50(4.80, 10.20)	1.39	Good
55	Million et al.,2019 [66],	2019	Amhara	Diabetic patients	RDT	305	8.50(5.40, 11.70)	1.60	Good
56	Mohammed et al.,2022[67]	2022	Amhara	Healthy individual	RDT	1080	2.70(1.70, 3.60)	0.49	Good
57	Nuru et al.,2020[68]	2020	Amhara	Pregnant women	RDT	384	4.70(2.60, 6.80)	1.08	Poor
58	Shiferaw et al.,2023[69]	2023	SNNPR	Pregnant women	RDT	320	6.90(4.10, 9.60)	1.42	Good
59	Solomon 2021[70]	2021	Oromia	Blood donor	ELISA	548	2.90(1.50, 4.30)	0.72	Good
60	Tadiwos et al.,2021[71]	2021	SNNPR	Pregnant women	RDT	479	9.20(6.60, 11.80)	1.32	Good
61	Tanga et lal.,2019[72]	2019	Gambella	Pregnant women	RDT	253	7.90(4.60, 11.20)	1.70	Good
62	Taye et al., 2019[73]	2019	Oromia	Pregnant women	ELISA	455	5.70(3.60, 7.80)	1.09	Good
63	Taye et al.,2019[74]	2019	SNNPR	Surgical patients	ELISA	422	9.00(6.30, 11.70)	1.39	Good
64	Teame et al.,2019[75]	2022	Tigray	HIV positivity	RDT	439	10.0(7.20, 12.80)	1.43	Good
65	Tesfu et al., 2023[76]	2023	AA	Pregnant women	RDT	12,138	3.00(2.70, 3.30)	0.15	Good
66	Tilahun et al.,2023[77]	2023	Tigray	Pregnant women	RDT	337	3.90(1.80, 5.90)	1.05	Good
67	Tsegaye et al.,2023[78]	2023	Tigray	Prison	RDT	315	7.90(5.00, 10.90)	1.52	Poor
68	Tsegaye et al.,2020[79]	2020	SNNPR	Cheka consumer	ELISA	511	18.2(14.9, 21.50)	1.71	Poor
69	Umer et al.,2023[80]	2023	Oromia	Pregnant women	RDT	300	8.00(4.90, 11.10)	1.57	Good
70	Woldegorigis et al., [81]	2019	SNNPR	Healthy individual	RDT	625	8.00(5.90, 10.10)	1.09	Good
71	Yigezu et al., 2022[82]	2022	Oromia	Blood donor	ELISA	359	3.60(1.70, 5.60)	0.98	Good
72	Yilma et al., 2021[11]	2021	Oromia	HealthCare orker	ELISA	457	1.80(0.50, 3.00)	0.62	Good
Pooled prevalence						83,058	6.9(6.1, 7.77)

AA Addis Ababa, SNNPR: South Nations and Nationalities People Regions’, ELISA Enzyme-Linked Immunosorbent Assay, RDT Rapid Diagnostic Test, PCRT Polymerase Chain Reaction Test, FSW Female Sex Worker, D. Method Diagnostic method, Q. assessment Quality assessment

Subgroup analysis of HBV infection in Ethiopia

Due to the heterogeneous nature of the included studies in this review we performed subgroup analysis to explore the causes of heterogeneity. We performed subgroup analysis based on: the study area (region), occupation types, living condition, immunity status, comorbidity status and pregnancy status.

Prevalence of HBV infection by region

In this systematic review and meta-analysis, six regions and 2 administrative cities were included. Accordingly, the pooled prevalence rate of HBV infection was 8.5% (95% CI: 7.4. 9.7) in SNNP, 9.6% (95% CI: 9.6, 13.7) in Harar, 3.6% (95% CI: 2.8, 4.4) in Addis Ababa, 5.1% (95% CI: 4.1, 6.2) in Oromia, 6.2%(95% CI: (4.9, 7.4) in Amhara, 7.5% (95% CI: 5.6, 9.4) in Gambella, 7.5% CI: 4.6, 10) in Tigray, and 8.5% (95%: 6.2, 10.7) in the Somali regional state. The highest and lowest pooled prevalence rates of HBV infection were obtained from Harar city (9.6%, 95% CI: 5.6, 13.5) and Addis Ababa city 3.6%, 95% CI: 2.8, 4.4) (Table 2).

Table 2.

Subgroup analysis of pooled HBV prevalence in Ethiopia, 2024

Subgroup	Subgroup category	Included Articles	Sample size	Positive case	Prevalence (95%CI)	Heterogeneity test(I2)	P-value
By Region	Amhara	19	7419	432	6.2 (4.9, 7.4)	82.0%	0.000
	SNNPR	21	4638	357	8.5(7.7. 9.4)	73.7%	0.000
	AA	6	15,106	488	3.6 (2.8, 4.4)	65.5%	0.013
	Oromia	14	26,212	888	5.1 (4.1, 6.2)	90.7%	0.000
	Tiray	6	22,426	848	7.5(4.6, 10)	93.0%	0.000
	Harar	3	1769	178	9.6 (9.6, 13.7)	87.7%	0.000
	Gambella	2	706	53	7.5 (5.6, 9.4)	4 0.0%	0.77
	Somali	1	589	50	8.5(6.2, 10.7)	-	-
By Job/occupation	Health care worker	3	1302	96	7.4 (0.8, 14.1)	96.0%	0.000
	FCSW	3	935	103	10.9 (7.7, 15.2)	76.9%	0.013
	Waste handers	2	536	67	12.6 (2.4, 27.6)	96.6%	0.000
	Cheka Consumers	1	511	93	18.2 (15.9, 21.2)	-	-
	Blood donors	7	24,684	744	3.4 (2.5, 4.2)	85.0%	0.000
By immunity against HBV infection	Healthy individual	13	6391	389	6.3(4.7,7.9)	86.6%	0.000
	Pregnant women	29	43,304	689	6.5(5.7, 7.2)	88.7%	0.000
	HIV positive patients	6	2958	277	9.9(7.2, 12.8)	82.3%	0.000
	PTB patients	2	532	19	3.6 (9 2.0, 5.1)	-	-
	Diabetic patients	2	457	32	6.2 (1.7, 10.7)	76.3%	0.040
	Surgical patients	1	422	38	9.0(6.3, 11.7)	-	-
Living condition	Prisoners	2	654	47	7.1 (5.1, 9.1)	-	-
	Refugee camp	1	453	33	7.3(4.9, 9.7)	-	-

AA Addis Ababa, SNNPR: South Nations and Nationalities People Regions’, FCSW Female Commercial sex worker

Pooled prevalence of HBV infection by job type

In this subgroup analysis, a total of sixteen articles were included. As shown in Table 2, the pooled prevalence rate of HBV infection among health care workers was 7.4% (95% CI: 0.8, 14.1), and it was 3.4% (95% CI: 2.5, 4.2) among blood donors, 10.9% (95% CI: 7.7, 15.2) among FCSW, 12.6% (95% CI: 2.4, 27.6) among Waste handlers and 18.2% (95% CI: 15.9, 21.2) among Cheka Consumers (Table 2).

Pooled prevalence of HBV infection among individuals with varying degrees of risk for acquisition and immunity to HBV infection

In this sub-group analysis, a total of fifty three articles were included. The pooled prevalence of HBV infection among healthy individuals was 6.3% (95% CI: 4.7, 7.9). The prevalence of HBV infection was high 9.9% (95% CI: 7.2, 12.8) in HIV-positive adults. The prevalence of HBV infection in pregnant women, pulmonary TB patients and diabetic patients were 6.5% (95% CI: 5.7, 7.2), 3.6% (95% CI: 2.0, 5.1), and 6.2% (95% CI: 1.7, 10.7), respectively (Table 2).

Risk factors for HBV infection in Ethiopia

In this meta-analysis, different risk factors have been assessed to evaluate their association with HBV infection. Factors such as: history of multiple sexual partners, family history of chronic liver diseases, body fluid exposure, history of tattooing, history of abortion, HIV infection, history of sharp needle injury, history of HBV vaccination, history of blood transfusion, and condom use, were assessed to determine their association with HBV infection.

Association of history of abortion with hepatitis B virus infection

In this sub-categorical analysis, seventeen studies were included for the assessment of history of abortion and HBV infection [23, 29, 37–42, 45, 50, 58, 64, 69, 71, 72, 76, 80]. Fourteen studies showed that a statistically significant association between history of abortion and HBV infection [23, 29, 37, 39, 41, 42, 45, 50, 58, 64, 69, 71, 72, 80]. The pooled meta-regression analysis revealed that a significant association was observed between abortion and HBV infection with the odds of: 3.97 (95% CI: 2.6, 6.3) (Fig. 2).

Fig. 2.

Association of history of abortion with hepatitis B virus infection

Association of blood transfusion with hepatitis B virus infection

In this sub-categorical analysis, thirty-three studies were included for the assessment of blood transfusion history and HBV infection [11, 12, 16, 21, 22, 29, 30, 32, 36, 38–41, 43, 45, 47, 48, 50, 56, 57, 60, 61, 64, 66, 68, 69, 71–74, 76, 79, 80]. Twelve studies were revealed a statistically significant association between a history of blood transfusion and HBV infection. The pooled meta-regression analysis revealed that a significant association between history of blood transfusion and HVB infection with the odds of 3.019 (95% CI; 2.04, 4.45) (Fig. 3).

Fig. 3.

Association of blood transfusion with hepatitis B virus (HBV) infection

Associations of needle stick injury and body fluid exposure with HBV infection

In this sub-categorical analysis, thirteen [11, 12, 16, 21, 26, 30, 36, 40, 43, 61, 72, 83, 84] and six [11, 12, 16, 40, 42, 72] studies were included for the assessment of needle stick injury with HBV infection and body fluid exposure with HBV infection, respectively. Six and four studies demonstrated statistically significant associations between a history of needle stick injury and body fluid exposure with HBV infection, respectively. Pooled meta-regression analysis revealed a statistically significant association between needle-stick injuries and body fluid exposure with HVB infection with the odds of 2.05 (95% CI: 1.58, 2.66) and 3.1 (2.01, 3.05) respectively (Fig. 4).

Fig. 4.

Associations of needle stick injury and body fluid exposure with HBV infection

Associations of family history of liver disease with HBV infection

In this sub categorical analysis, Eighteen studies on the evaluation of family history of liver disease with HBV infection were included in this sub-categorical analysis [21, 29–32, 34–36, 38, 40, 41, 54, 56–58, 76, 79, 85]. Twelve of these studies have demonstrated a statistically significant correlation between HBV infection and a family history of liver disease. A significant association between an HVB infection and a family history of liver disease was found by pooled meta-regression analysis. People with a family history of liver disease have 7 times the odds of having an HBV infection compare to for those without a family history of liver (95% CI:6.94, 3.46, 10.53) after adjusting other factors (Fig. 5).

Fig. 5.

Association of family history of liver disease with HBV infection

Associations of history of multiple sexual partners with HBV infection

For the evaluation of many sexual partners with HBV infection, thirty-one studies were included in this sub-categorical analysis [11, 12, 14, 16, 21, 23, 25, 29, 30, 32–36, 38, 40, 41, 43, 45, 48, 54, 56, 57, 60, 66, 68, 72, 73, 76, 79, 80]. A statistically significant association between a history of several sexual partners and HBV infection was found in twenty of these studies. A statistically significant association between exposure to several sexual partners and HBV infection was found by pooled meta-regression analysis. The probability of developing HBV infection was nearly four times the odds for those with several sexual partners than for those without multiple partner (95% CI:2.62, 5.76)) (Fig. 6).

Fig. 6.

Association of multiple sexual partners with HBV infection

Association of history of tattooing with HBV infection

To evaluate tattooing history with HBV infection, twenty eight studies were included in this sub-categorical analysis [12, 16, 22, 23, 25, 30, 31, 33, 34, 36–38, 40, 41, 43, 47, 48, 55–58, 60, 66, 74, 76, 79, 80, 85]. Twenty of these studies found a significant association between HBV infection and tattooing history. A statistically significant correlation between tattooing history and HVB infection was found by pooled meta-regression analysis. People with tattooing history have three times the odds off HBV infection than for those without tattooing history after adjusting other factors (95% CI:2.17, 4.09) (Fig. 7).

Fig. 7.

Association of tattooing with HBV infection

Associations of HBV vaccination, HIV infection and condom use with HBV infection

For the evaluation of HBV vaccination, HIV infection and condom uses on the risk of aquring HBV infection, four [12, 25, 36, 39], seven [16, 23, 29, 38, 55, 57, 71], and six [31, 32, 38, 39, 45, 47] studies were included to assess the risk of HBV infection, respectively. Three out of six studies, six out of seven, and one out of four were found statistically significant associations between HIV infection, HBV infection, and using condoms appropriately. HIV infection and HBV infection were found to be significantly correlated by pooled meta-regression analysis. HIV-positive individuals have nearly eight times the odds of HBV infection compared to HIV- negative individuals (95%CI:2.99, 19.93). There was no statistically significant correlation between condom use or HBV vaccination and HBV infection, according to the pooled meta-regression study (Fig. 8).

Fig. 8.

Associations of vaccination, HIV infection and condom use with HBV infection

Risk of publication bias

The results of this study were heterogeneous. To understand the cause of heterogeneity publication bias was assessed using the funnel plot that displays the presence of possible publication bias (S File 3). This bias might be due to missing of unpublished articles in the country. The other causes might be due to the inclusion of articles with different population nature for risk factor assessment of HBV infection. The sub-group analysis and sensitivity test were done to further explore the causes of heterogeneity (Table 2 and S Files 4). Additionally, the egger’s test demonstrated an evidence of publication bias (p < 0.05). Three studies were highly influence this study such as: Abebe &Alemnew 2020 [17], Aliyo 2022 [19[and Tesfu et al., 2023 [76]. We tried to observe the changes by analyzing by removing these articles from our data and the prevalence of HBV infection become 7.2% but to exclude these articles from the review the quality of the study was good and their sample size was very large. Therefore, we authors decided to include in this review.

Discussion

This review was conducted to determine the pooled prevalence and risk factors for HBV infection in Ethiopia. In this meta-analysis, the pooled prevalence of HBV infection was 6.9% (95% CI: 6.1- 7.4). This result is slightly higher than previous meta-analysis findings reported from Ethiopia 6.0% (95% CI: 5 to 6%) [8]. On the other hand, the current pooled prevalence is consistent with that of a review study reported in China 6.89% (95% CI: 5.84–7.95%) [86] but it is higher than that reported in Iran (2.2%) [87]. In contrast, our findings are lower than those reported from Cameron 10.6%, (95% CI 8.6% to 12.6%) [88]. The low and high prevalence rates of HBV infection might be due to differences in sample size and screening methods and differences in the endemicity of HBV infection and community awareness on infection prevention across countries.

In the current study, the pooled prevalence of HBV infection among pregnant women, health care workers, and HIV-positive patients were 6.5%, 6.5%, and 7.4%, respectively. This subgroup prevalence of HBV infection are also higher than those reported in previous systematic reviews from Ethiopia, which reported a 5% prevalence among pregnant women, health care workers, and HIV-positive patients [8]. Additionally, our review revealed a higher pooled prevalence of HBV infections among pregnant women than other similar previous reviews 4.7% (95% CI: 4. 0, 5.4) [89], 4.75% [90], and 5.78% [91]. The high prevalence reported in the current review might be due to the low vaccination coverage among health care workers, poor knowledge of the people to ward prevention of HBV infection transmission [92, 93].

In this systematic review and meta-analysis also analyzed pooled prevalence rate of HBV infection by region. The pooled prevalence rate of HBV infection was 8.5% in SNNP, 9.6% in Harar, 3.6% in Addis Ababa, 5.1% in Oromia, 6.2% in Amhara, 7.5% in Gambella, 7.5% in Tigray, and 8.5% in the Somali regional state. In this subgroup analysis pooled prevalence rate of HBV in all regions is higher than previous systematic review reported from Ethiopia, except Addis Ababa [8]. This result indicates HBV infection becoming health problem in Ethiopia. This might be due to awareness level and infection prevention practice in the community, involvement of stakeholders in infection prevention becoming decrease.

In the present meta-analysis, the pooled prevalence rate of HBV infection among blood donors was 3.4% (95% CL: 2.5, 4.6), which is relatively lower than the previously reported prevalence of HBV infection among blood donors in Ethiopia 4.91% (95% CI: 4.21, 5.60) [94]. This might be because the current study included a low number of articles compared with the previous study. However, the pooled prevalence of HBV infection among blood donors in this review is significantly greater than that reported in a review of Iranian blood donors 0.57% (95% CI:0.47, 0.67) [95], and it is also greater than the reported among Mediterranean and Eastern countries blood donors 2.03% (1.79, 2.26) [96]. The high prevalence of HBV infection in Ethiopia might be due to the endemicity of the virus in the country.

Among the HIV-positive participants, the pooled prevalence of HBV infection was 9.9% (95% CI: 7.2, 12.80). The current report is higher than the global reported 8.4% (95% CI: 7.9, 8.8) [97]. This might be due to the poor knowledge of the people to ward prevention of HBV infection transmission in our study sitting [92].

The pooled prevalence of HBV infection among health care workers was 7.4% (95% CI: 0.8, 14.1), which is higher than two studies from Africa 5.0% and 6.81% [98, 99], Asia 4.0% (1.0, 7.0) [198], and global reports 2.3% (95% CI: 1.9, 2.7) [100]. The high prevalence of HBV infection among health care workers in the current review might be due to the limited implementation of prevention and control methods and low vaccination coverage among health care workers [14, 101].

The pooled prevalence of the current review among pregnant women was 6.5% (95% CI: 5.7, 7.2). This result is consistent with a study reported from Nigeria, 6.49 (4.75, 8.46) [102], East Africa was 6.0% (95% CI: 6.0% − 7.0%) [103] but higher than that reported from Iran, 1.18% (95% CI: 0.09%−1.53%) [104]. This result indicates that HBV infection is endemic in Africa.

The present meta-analysis revealed that prior history of exposure to multiple sexual partners AOR: 3.88 (95% CI: 2.62, 5.76), family history of chronic liver disease AOR: 6.94 (95% CI: 3.46, 10.53), exposure to body fluid AOR: 3.1 (95% CI: 2.01, 3.05), tattooing AOR: 2.99 (95% CI: 2.17, 4.09), abortion history AOR: 3.97; (95% CI: 2.6, 6.3), and sharp needle injury AOR: 2.05 (95% CI:1.58, 2.66) were statistically associated with HBV infection. This result is consistent with previous systematic and meta-analysis conducted on pregnant women in Ethiopia [90, 91] and East Africa [103].

The odds of having HBV infection among individual who had multiple sexual partner were higher than those individual with didn’t have multiple sexual partner. This result is consistent with previous systematic and meta-analysis conducted on pregnant women in Ethiopia. This might be due to fact that multiple sexual partners increase the probability of encountering someone already infected with HBV. The odds of having HBV infection among individual with the history of blood transfusion were higher than who didn’t have history of blood transfusion. This might be due to less rigorous screening protocol may contribute to the high risk of HBV infection in those with blood transfusion history [105].

The odds of having HBV infection among individual with the history of abortion were higher than who didn’t have history of abortion. This result is consistent with previous systematic and meta-analysis conducted on pregnant women [106]. This might be due to use of unsterile material for abortion procedure and unprotected sexual intercourse may contribute to the high risk of HBV infection in those who had abortion history.

The odds of having HBV infection among individual with family history of chronic liver disease were higher than who didn’t have family history of chronic liver disease. This might be due to a combination factors like shared sharp material, close contact with body fluid within the household, generally, poor protective on HBV infection prevention may contribute to the high risk of HBV infection in those who had family history of chronic liver disease [92].

The odds of having HBV infection among individual with exposure to body fluid were higher than those who didn’t have exposure to body fluid. This might be due to the fact that HBV infection can spread through contact with infected body fluid like blood, saliva, vaginal fluid and semen [3].

Strengths and limitations

Strength

This systematic review and meta-analysis revealed the national pooled figure of HBV infection and associated factors in Ethiopia. All regions are included except the Afar region. In addition, it produced updated data on the pooled prevalence of HBV among different subgroups and regional states by including more relevant articles from previous publications.

Limitations

High statistical heterogeneity was observed in this review because of the inclusion of articles with different screening methods, sample sizes and exclusion of unpublished studies Moreover, the inclusion of a single study on cheka consumers, which reported a markedly high HBV prevalence relative to other findings, likely influenced the pooled prevalence of HBV infection, potentially leading to an overestimation.

Conclusion

The high pooled prevalence of HBV infection in Ethiopia clearly indicates that HBV infection continues to be a public health concern. In the subgroup analysis, the highest pooled prevalence rates of HBV infection (> 8%) were obtained in Harar and SNNP, among CFSW, waste handlers and HIV-positive patients. Having multiple sexual partners, abortion history, family history of chronic liver disease, exposure to body fluid, tattooing, and sharp needle injury among the risk factors contribute to HBV infection.

Ethiopian ministry of health should develop strategic plan for the prevention and control of HBV infection transmission for vulnerable populations like awareness creation strengthening screening programs, diagnosis, treatment and care services to reduce the burden of HBV infection and to eliminate it as a public health threats.

High statistical heterogeneity was observed in this review because of the inclusion of articles with different screening methods and sample sizes. In addition, only one study conducted among cheka consumer included in this review and the result is very high HBV compare to the other finding; this result might be influenced to increase the prevalence of pooled prevalence of HBV infection.

Abbreviations

AOR

Adjusted odd ratio

FCSW

Female Commercial Sex Worker

HBsAg

Hepatitis B surface antigen

HBV

Hepatitis B virus

HIV

Human immune deficiency virus

PRISMA

Preferred Reporting Items for Systematic Review and Meta-Analyses

PTB

Pulmonary tuberculosis

SNNPR

South Nations and Nationalities People’s Region

UK

United Kingdom

Authors’ contributions

All authors had an important involvement to the review reported. ST contributed in the conceptualization, research design, acquisition data and interpretation. ET contributed to the statistical analysis, MM, ST, ET, FM, DE and GK were participated in drafting and revising, AM, SW, NB,MA, BG and AK, were involved in supervising, and critically reviewing the articles, All the authors gave final approved of the review to published and agreed on the journal to which the review has been submitted..

Funding

This research was funded by the National Institute for Health Research (NIHR) (PSIA2020-3073) using United Kingdom (UK) Aid from the UK Government to support global health research, as part of the EDCTP2 Programme supported by the European Union.

Data availability

All the data generated or analyzed are included in the manuscript and supplementary file.

Data is provided within the manuscript or supplementary information files.

Declarations

Ethics approval and consent to participant

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.