Abstract
Background
Hepatitis B is the world’s most common serious liver infection. Infection by hepatitis B virus during pregnancy has high rate of vertical transmission and adverse effect on both the mother and child. Data on seroprevalence and associated factors among pregnant women in Dawuro or surrounding was scarce. Therefore, the aim of this study was to assess prevalence of hepatitis B virus and factors associated among pregnant women in Dawuro Zone.
Methods
Institution based cross-sectional study was conducted from 1st April to May 31, 2015 in Dawuro zone. Venous blood was collected, plasma was separated and hepatitis B virus surface antigen was screened using rapid test. Logistic regression was employed with 95% CI and p value of <0.05 was used as statistically significant.
Results
Data were collected on 289 women. The overall prevalence from this study was (p = 3.5%, 95% CI 1.4–5.6%) multivariate analysis using logistic regression showed multiple sexual partner (AOR = 6.923; 95% CI 1.685–28.441), and abortion history (AOR = 4.975; 95% CI 1.21–20.456), were significantly associated with hepatitis B virus surface antigen (HBsAg) infection.
Conclusion
This seroprevalence was categorized as intermediate endemicity according to WHO classification criteria. Health education on sexual transmission of hepatitis B virus and inclusion of screening hepatitis b virus as routine antenatal care service is recommended.
Keywords: Hepatitis B virus surface antigen, Prevalence, Pregnant women, Dawuro
Background
Hepatitis B is the world’s most common serious liver infection caused by a double stranded deoxyribonucleic acid (DNA) virus, whose main routes of transmission are: mother to child, via open wounds, sexual contact, blood transfusion and other blood contact related activities [1]. This virus is 50–100 and 10 times more infectious than human immunodeficiency virus (HIV) and hepatitis C virus (HCV), respectively [2].
Globally about 240 million people are thought to be chronically infected with hepatitis B virus; with the endemicity ranges from high (≥8%) to intermediate (2–7%) and low (<2%) [3]. Hepatitis B during pregnancy is associated with maternal complications, death accompanied by impaired mental and physical health of child because of its vertical transmission [4, 5]. Hepatitis B virus infection in infancy usually followed by liver cirrhosis and hepatocellular carcinoma [6].
Prevalence of hepatitis B virus surface antigen (HBsAg) varied from place to place with 5.49% in China [7], 0.61, 0.9%, in India [8, 9], 32% in South Korea [10], 10.8% in Sana’a, Yemen [11] and 2.1% in northern Turkey [12]. In Africa the prevalence of hepatitis B virus among pregnant women ranges from 3.67–16.5% [13–26] and in Ethiopia ranges from 3.0 to 8.1% [27–35]. However, data on prevalence of hepatitis B virus and factors associated among pregnant women in Dawuro zone or surroundings were lacking. Therefore, this study was aimed at estimating prevalence of hepatitis B virus surface antigen and factors associated among pregnant women in Dawuro zone.
Methods
Study design, period and area
Institution based cross-sectional study was conducted from 1st April to May 31, 2015 in Dawuro zone. Dawuro zone, is located Southwest of Ethiopia 500 km from Addis Ababa, 319 km from, regional city, Hawassa and 144 km from Jimma. The Zone has 5 woredas and one city administration. Based on central statistics agency report of 2007, the projected total population in 2014/15 was 619,359. Health institutions in the Zone include: one general hospital, 23 health centers and 175 health posts.
Sample size calculation and sampling procedures
By using single population proportion formula with p = 0.061 from recent study in South Ethiopia [32] with margin of error of 0.04, design effect of 2 and 95% CI the minimum sample size was 276 and adding 10% non-response rate, sample size was 304. However, data were collected on 289 women with 95% response rate.
Multistage sampling technique was used. The Zone has five woredas and one city administration, comprising 23 health centers and one hospital. Three woredas were randomly selected using lottery method from five woredas and the city administration was by purposive technique. One health center from each woreda was selected by lottery method and Tarch’a general hospital from city administration was included in the study purposively. All pregnant women came for ANC during the study period in selected health institutions were included in the study.
Data collection procedures
Data collection was performed by one mid wife and one laboratory professional per health institution by using structured questionnaire. Interview was done by mid wife and 3 ml of venous blood was collected with ethylene diamine tetra acetate (EDTA) anticoagulated tube following standard operating procedure (SOP) by laboratory professional. Two supervisors controlled data collection process. Plasma was separated after centrifugation and transported to Tarch’a hospital laboratory for screening. Testing for surface antigen was performed by senior laboratory technologist at Tarch’a general hospital laboratory.
Data quality, processing and analysis
Questionnaire prepared in English language was translated into Dawuro language and back to English to keep consistency. Daily supervision was made to check completeness of data. Known positive and negative samples were run to control the quality of HBsAg kit as external quality assurance. Standard operating procedure (SOP) from Tarch’a hospital with manufacturers’ instruction was used for testing. Manufacturer: Shangai Eugene Biotech co., Ltd. Email: info@eugenebio.com.
Data were entered into EpiInfo 7.1.4 and exported to SPSS 20 for analysis. Descriptive analyses, using means, percentage and frequency, were calculated. Logistic regression was employed to assess association of factors with hepatitis B virus infection. Findings were taken as statistically significant at p value of less than 0.05.
Results
Socio demographic characteristics of study participants
Data were obtained on 289 study participants making the response rate 95%. The mean ± SD age of subjects was 26.23 ± 6.05 years old. Of whom, 129 (44.6%) and 121 (41.9%) were found in the age group of 25–34 and 15–24 years old respectively. One hundred and forty-four (49.8%) of women attended primary school and 103 (35.7%) attended no formal education (Table 1).
Table 1.
Socio demographic characteristics of pregnant women attending ANC in selected health institutions in Dawuro Zone, SNNPR, Ethiopia 2015 (n = 289)
| Variables frequency % | ||
|---|---|---|
| Age(years) | ||
| 15–24 | 121 | 41.9 |
| 25–34 | 129 | 44.6 |
| 35–44 | 39 | 13.5 |
| Educational level | ||
| No formal education | 103 | 35.7 |
| Primary (1–8) | 144 | 49.8 |
| Secondary and higher | 42 | 14.5 |
| Occupation | ||
| House wife | 235 | 81.3 |
| Merchant | 17 | 5.9 |
| Gov’tal employee | 28 | 9.7 |
| Others* | 9 | 3.1 |
| Residence | ||
| Rural | 201 | 69.6 |
| Urban | 88 | 30.4 |
| Religion | ||
| Protestant | 211 | 73.0 |
| Orthodox | 71 | 24.6 |
| Others** | 7 | 2.4 |
| Ethnicity | ||
| Dawuro | 280 | 96.9 |
| Others*** | 9 | 3.1 |
| Marital status | ||
| Married | 284 | 98.3 |
| Separated | 5 | 1.7 |
* Students, daily laborers and private institution workers
** Adventist and Catholic
*** Amhara, Hadiya, Wolaita and Gurage
Prevalence and factors associated with HBsAg
Ten women were positive for HBsAg out of 289 and the overall prevalence was 3.5% (p = 3.5%, 95% CI 1.4–5.6%).
In multivariable analysis, abortion history (AOR = 4.98, 95% CI 1.21–20.46) and multiple sexual partner (AOR = 6.92, 95% CI 1.69–28.44) were significantly associated with HBV infection among pregnant mothers (Table 2).
Table 2.
Multivariate analysis of variables with HBV (HBsAg) infection among pregnant women attending antenatal care in selected health institutions in Dawuro Zone, SNNPR, Ethiopia 2015 (n = 289)
| Variables | HBsAg status | COR (95% CI) | AOR (95% CI) | p | |
|---|---|---|---|---|---|
| Positive n (%) | Negative n (%) | ||||
| Age (years) | |||||
| 15–24 | 1 (0.8) | 121 (99.2) | 1 | 1 | |
| 25–34 | 6 (4.7) | 123 (95.3) | 6.83 (0.83–56.34) | 0.31 (0.02–4.96) | 0.411 |
| 35–44 | 3 (7.6) | 36 (94.7) | 6.66 (0.58–75.66) | 0.93 (0.15–5.89) | 0.942 |
| Ethnicity | |||||
| Dawuro | 9 (3.2) | 271 (96.8) | 1 | ||
| Others | 1 (11.1) | 8 (88.9) | 3.76 (0.42–33.4) | 1.67 (0.13–21) | 0.69 |
| Marital status | |||||
| Married | 9 (3.2) | 275 (96.8) | 1 | 1 | |
| Separated | 1 (20) | 4 (80) | 7.64 (0.77–75) | 2.44 (0.06–92) | 0.63 |
| Multiple sexual partner | |||||
| Yes | 6 (15.8) | 33 (84.2) | 11.58 (3.10–43.24) | 6.92 (1.69–28.44) | 0.007**** |
| No | 4 (1.6) | 247 (98.4) | 1 | 1 | |
| Abortion history | |||||
| Yes | 6 (13.0) | 40 (87.0) | 8.96 (2.42–33.17) | 4.98 (1.21–20.46) | 0.026**** |
| No | 4 (1.6) | 239 (98.4) | 1 | 1 | |
**** Significant at p value <0.05
Discussion
The overall prevalence of hepatitis B virus surface antigen (HBsAg) among pregnant women in this study (3.5%) was categorized as intermediately endemic prevalence according to WHO classification criteria [36]. This prevalence agrees with recent studies from Addis Ababa [27], Bahir Dar [29], in Arba Minch [35] Jimma town, southwest Ethiopia [28], Nigeria [18],Tanzania [23, 37]. In contrary, other studies in Ethiopia depicted higher prevalence in Debre Tabor, South Gondar [31], in Gondar Health center [33] and the highest prevalence of 8.1% was seen in Mekele [34]. Here the discrepancy might be on account of difference in sample size used, cultural and behavioral differences of women. On the other hand, lower prevalence was shown in India [8, 9]. This might be owing to previous awareness creation made regarding hepatitis B transmission.
In multivariate logistic regression analysis women with multiple sexual partners were about seven times at higher risk of HBV infection compared to those with no multiple sexual partners (AOR = 6.92, 95% CI 1.69–28.44) (Table 2). This is consistent with study done at Dessie referral Hospital, Ethiopia [30] and hospital based study in Nigeria [16]. This could be because of sexual transmission of HBV. Women with more than one partner could have had more sexual contacts.
Women with abortion history were about five times at higher risk of HBV infection (AOR = 4.98, 95% CI 1.21–20.46) compared to those with no abortion history. This finding was in agreement with findings from Jimma, Southwest Ethiopia [28], Arba Minch, South Ethiopia [35] and Nigeria [16, 26]. Abortion is directly related to sexually active women, and one of the most known modes of transmission for HBV is exposure to sexual intercourse. Deliberate termination of pregnancy is the result of unwanted pregnancy which in turn could be because of unwanted sexual contact. Therefore, abortion significance could be because of sexual transmission of hepatitis B virus. Besides this, instrumentation during abortion procedure could also contribute to HBV transmission.
Women attending ANC service in health posts and private health institutions were not included in the study. Significant variables were with a little bit wide confidence interval. These could be limitations of this study.
Conclusion
From this study, considering all limitations, it can be concluded that the prevalence of HBsAg was 3.5%. Multiple sexual partners and abortion history were factors significantly associated with HBV seroprevalence.
To lessen the seroprevalence of HBV infection, health education on the risk of sexual transmission is needed at zonal level. At national level, screening all pregnant women for hepatitis B virus should be made as part of routine antenatal care service. Community awareness on unsafe abortion is needed too.
Authors’ contributions
AC was involved in proposal writing, designing, and recruitment and training of supervisors and data collectors, analysis and write-up and in all stages of the project implementation. He did most of the analysis and write up of the paper. AY contributed in the designing of the methodology, reviewing the proposal and paper and in the final approval of the paper. AA involved in designing of project proposal, design of questionnaires and in the final approval of the paper. All authors read and approved the final manuscript.
Acknowledgements
We would like to acknowledge Arba Minch University; College of Medicine and Health Science for the approval of the ethical clearance. Our gratitude goes to Tarcha hospital for granting the fund to undertake this study and laboratory professionals for their diligence during laboratory analysis. At last we are thankful to data collectors and women who participated in this study.
Competing interests
The authors declare that they have no competing interests.
Availability of data and materials
Data are available in PDF based file from corresponding author.
Consent for publication
Not applicable.
Ethics approval and consent to participate
Ethical rules were approved and clearances were obtained from Ethical Review Board (ERB) of Arba Minch University College of Medicine and Health Sciences. Written informed consent was obtained from the study participants and parents, for participants’ age below 16 years old, by explaining the purpose of the study. Reactive cases were linked to clinicians for further follow up and management. Blood samples were not used for another purpose.
Funding
Tarcha General Hospital funded for full conduct of this research excluding publication fee.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Abbreviations
- AOR
adjusted odds ratio
- ANC
antenatal care
- CDC
centers for disease control and prevention
- CI
confidence interval
- COR
crude odds ratio
- HBV
hepatitis B virus
- HCV
hepatitis C virus
- OR
odds ratio
- SNNPR
South Nations Nationalities and Peoples’ Region
- SPSS
statistical package for social science
- WHO
World Health Organization
- MPH
master of public health
Contributor Information
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References
- 1.Cheesbrough M. District laboratory practice in tropical countries. 2. Cambridge: Cambridge University; 2006. [Google Scholar]
- 2.Hepatitis B Foundation Cause for a Cure. Understanding Hepatitis B Blood Tests. http://www.hepb.org. Accessed 18 Oct 2015.
- 3.WHO. Global policy report on the prevention and control of viral hepatitis. Geneva: WHO; 2013.
- 4.Olaitan AO, Zamani LG. Prevalence of hepatitis B virus and hepatitis C virus in ante-natal patients in Gwagwalada—Abuja, Nigeria. Rep Opin. 2010;2(7):2. [Google Scholar]
- 5.Ugbebor O, Aigbirior M, Osazuwa F, Enabudoso E, Zabayo O. The prevalence of hepatitis B and C viral infections among pregnant women. North Am J Med Sci. 2011;3(5):238. doi: 10.4297/najms.2011.3238. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Negero A, Sisay Z, Medhin G. Prevalence of hepatitis B surface antigen (HBsAg) among visitors of Shashemene general hospital voluntary counseling and testing center. BMC Res Notes. 2011;4(1):35. doi: 10.1186/1756-0500-4-35. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Ding Y, Sheng Q, Ma L. Dou. Chronic HBV infection among pregnant women and their infants in Shenyang, China. Virol J. 2013;10(1):17. doi: 10.1186/1743-422X-10-17. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Dwivedi M, et al. Seroprevalence of hepatitis B infection during pregnancy and risk of perinatal transmission. Indian J Gastroenterol. 2007;30:66–71. doi: 10.1007/s12664-011-0083-y. [DOI] [PubMed] [Google Scholar]
- 9.Shazia Parveen S, Shyamala R, Janardhan Rao R, Rama Rao MV. Sero-prevalence of hepatitis B surface antigen among pregnant women attending antenatal clinic in a teaching hospital, India. J Microbiol Biotechnol Res. 2012;2:343–345. [Google Scholar]
- 10.Kim JH, Kim JS, Lee JJ, et al. Survey of perinatal hepatitis B virus transmission after Korean national prevention program in a tertiary hospital. Korean J Intern Med. 2014;29:307–314. doi: 10.3904/kjim.2014.29.3.307. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Murad EA, Babiker SM, Gasim GI, Rayis DA, Adam I. Epidemiology of hepatitis B and hepatitis C virus infections in pregnant women in Sana’a, Yemen. BMC Pregnancy Childbirth. 2013;13(1):127. doi: 10.1186/1471-2393-13-127. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Yavuz U, Cevat C, Balci A. Seroprevalence of hepatitis B virus among pregnant women in Northern Turkey. Hepat Mon. 2009;9:146–149. [Google Scholar]
- 13.Mbaawuaga EM, Enenebeaku MNO, Okopi JA, Damen JG. Hepatitis B virus (HBV) infection among pregnant women in Makurdi. Nigeria. Afr J Biomed Res. 2008;11:155–159. [Google Scholar]
- 14.Oladele OO, Saheed S, Familua F, et al. Seroprevalence of hepatitis B surface antigen and antibody among pregnant women attending a tertiary health institution in Southwestern Nigeria. IOSR J Dent Med Sci. 2014;13(3):67–71. doi: 10.9790/0853-13316771. [DOI] [Google Scholar]
- 15.Kolawole OM, Wahab AA, Adekanle DA, Sibanda T, Okoh AI. Seroprevalence of hepatitis B surface antigenemia and its effects on hematological parameters in pregnant women in Osogbo, Nigeria. Virol J. 2012;9(1):317. doi: 10.1186/1743-422X-9-317. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Alegbeleye JO, Nyengidiki TK, Ikimalo JI. Maternal and neonatal seroprevalence of hepatitis B surface antigen in a hospital based population in South–South, Nigeria. Int J Med Med Sci. 2013;5:241–246. [Google Scholar]
- 17.Onwuakor CE, Eze VC, Nwankwo IU, Iwu JO. Sero-prevalence of hepatitis B surface antigen (HBsAg) amongst pregnant women attending antenatal clinic at the federal medical centre Umuahia, Abia State, Nigeria. Am J Public Health Res. 2014;2:255–259. doi: 10.12691/ajphr-2-6-7. [DOI] [Google Scholar]
- 18.Pondei K, Isa I. The sero-prevalence of hepatitis B surface antigen and anti-hepatitis C antibody among women attending antenatal clinic at a tertiary health facility in the Niger Delta of Nigeria. Glob Adv Res J Med Med Sci. 2013;2(1):006–012. [Google Scholar]
- 19.Bankole Henry. Oladeinde BH, Omoregie R, Olley M, Anunibe JA, Oladeinde OB. Hepatitis B and C viral infections among pregnant women in a rural community of Nigeria. Int J Basic Appl Virol. 2012;1:01–05. doi: 10.17142/ijbas-2012.1.1.1. [DOI] [Google Scholar]
- 20.Oladimeji AA, Pius AOI, Adekunle AE, et al. Seroprevalence of hepatitis B infection in pregnant women at the Ekiti State University Teaching Hospital, Ado-Ekiti, Southwest Nigeria. Afr J Intern Med. 2013;2(4):23–25. [Google Scholar]
- 21.MacLean B, Hess RF, Bonvillain E, Kamate J, Dao D, Cosimano A, Hoy S. Seroprevalence of hepatitis B surface antigen among pregnant women attending the Hospital for Women & Children in Koutiala, Mali. SAMJ. 2012;102(1):47–49. [PubMed] [Google Scholar]
- 22.Fomulu NJ, Morfaw FLI, Torimiro JN, Nana P, Koh MV, William T. Prevalence, correlates and pattern of Hepatitis B among antenatal clinic attenders in Yaounde–Cameroon: is perinatal transmission of HBV neglected in Cameroon. BMC Pregnancy Childbirth. 2013;13(1):158. doi: 10.1186/1471-2393-13-158. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Rashid S, Kilewo C, Abound S. Seroprevalence of hepatitis B virus infection among antenatal clinic attendees at a tertiary hospital in Dar es Salaam. Tanzania. Tanzan J Health Res. 2014;16(1):9–15. doi: 10.4314/thrb.v16i1.2. [DOI] [PubMed] [Google Scholar]
- 24.Elsheikh RM, Daak AA, Elsheikh MA, Karsany MS, Adam I. Hepatitis B virus and hepatitis C virus in pregnant Sudanese women. Virol J. 2007;4(1):104. doi: 10.1186/1743-422X-4-104. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Gasim GI, Murad IA, Adam I. Hepatitis B and C virus infections among pregnant women in Arab and African countries. J Infect Dev Ctries. 2013;7:566–578. doi: 10.3855/jidc.3243. [DOI] [PubMed] [Google Scholar]
- 26.Yakasai IA, Ayyuba R, Abubakar IS, Ibrahim SA. Sero-prevalence of hepatitis B virus infection and its risk factors among pregnant women attending antenatal clinic at Aminu Kano Teaching Hospital, Kano, Nigeria. J Basic Clin Reprod Sci. 2012;1(1–2):49–55. doi: 10.4103/2278-960X.104297. [DOI] [Google Scholar]
- 27.Tegegne D, Desta K, Tegbaru B, Tilahun T. Seroprevalence and transmission of hepatitis B virus among delivering women and their new born in selected health facilities, Addis Ababa, Ethiopia. BMC Res Notes. 2014;7(1):239. doi: 10.1186/1756-0500-7-239. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Awole M, Gebre-Selassie S. Seroprevalence of HBsAg and its risk factors among pregnant women in Jimma. Southwest Ethiopia. Ethiop J Health Dev. 2005;19(1):45–50. [Google Scholar]
- 29.Zenebe Y, Mulu W, Yimer Y, Abera B. Sero-prevalence and risk factors of hepatitis B virus and human immunodeficiency virus infection among pregnant women in Bahir Dar city, Northwest Ethiopia. BMC Infect Dis. 2014;14:118. doi: 10.1186/1471-2334-14-118. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Seid M, Gelaw B, Assefa A. Sero-prevalence of HBV and HCV infections among pregnant women attending antenatal care clinic at dessie referral hospital. Ethiopia. Adv Life Sci Health. 2014;1(2):109–120. [Google Scholar]
- 31.Walle F, Asrat D, Alem A, Tadesse E, Desta K. Prevalence of hepatitis B surface antigen among pregnant women attending antenatal care service at Debre-Tabor hospital, Northwest Ethiopia. Ethiop J Health Sci. 2008;17:13–21. [Google Scholar]
- 32.Ramos JM, Toro C, Reyes F, Amor A, Gutiérrez F. Seroprevalence of HIV-1, HBV, HTLV-1 and Treponema pallidum among pregnant women in a rural hospital in southern Ethiopia. J Clin Virol. 2011;51:83–85. doi: 10.1016/j.jcv.2011.01.010. [DOI] [PubMed] [Google Scholar]
- 33.Tiruneh M. Seroprevalence of multiple sexually transmitted infections among antenatal clinic attendees in Gondar Health Center, northwest Ethiopia. Ethiop Med J. 2008;46:359–366. [PubMed] [Google Scholar]
- 34.Semaw A, Awet H, Yohannes M. Sero-Prevalence of hepatitis B surface antigen and associated factors among pregnant mothers attending antenatal care service, Mekelle, Ethiopia: evidence from institutional based quantitative cross-sectional study. Int J Med Health Sci. 2015;2(9).
- 35.Yohanes T, Zerdo Z, Chufamo N. Seroprevalence and predictors of hepatitis B virus infection among pregnant women attending routine antenatal care in Arba Minch Hospital, South Ethiopia. Hepat Res Treat. 2016;2016(2):1–7. doi: 10.1155/2016/9290163. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36.Mohd Hanafiah K, Groeger J, Flaxman AD, Wiersma ST. Global epidemiology of hepatitis C virus infection: New estimates of age-specific antibody to HCV seroprevalence. Hepatology. 2013;57:1333–1342. doi: 10.1002/hep.26141. [DOI] [PubMed] [Google Scholar]
- 37.Mirambo MM, Mbena PB, Mushi MF, Mtebe M, Seni J, Mshana SE. Prevalence of hepatitis B surface antigen among pregnant women attending antenatal clinic at Nyamagana District Hospital Mwanza, Tanzania. Tanzan J Health Res. 2016;18(1). doi:10.4314/thrb.v18i1.10.
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Data are available in PDF based file from corresponding author.