Skip to main content
NCBI home page
Bulletin of the World Health Organization logoLink to Bulletin of the World Health Organization
. 2018 Aug 29;96(11):750–759. doi: 10.2471/BLT.18.208603

Hepatitis B and C virus seroprevalence, Burkina Faso: a cross-sectional study

Séroprévalence du virus de l'hépatite B et de l'hépatite C au Burkina Faso: une étude transversale

Seroprevalencia del virus de la hepatitis B y C, Burkina Faso: un estudio transversal

الانتشار المصلي لفيروسي الالتهاب الكبدي "ب" و"جـ"، بوركينا فاصو: دراسة متعددة القطاعات

布基纳法索乙型肝炎和丙型肝炎病毒血清阳性率：一项横断面研究

Серораспространенность вирусов гепатита B и C в Буркина-Фасо: эпидемиологическое исследование

Nicolas Meda a, Edouard Tuaillon b, Dramane Kania c, Adama Tiendrebeogo d, Amandine Pisoni e, Sylvie Zida c, Karine Bollore e, Isaïe Medah a, Didier Laureillard f, Jean Pierre Moles g, Nicolas Nagot b, Koumpingnin Yacouba Nebie h, Philippe Van de Perre b, Pierre Dujols b,✉
PMCID: PMC6239015  PMID: 30455530

Abstract

Objective

To estimate population-wide hepatitis B and C seroprevalence using dried blood spot samples acquired for human immunodeficiency virus (HIV) surveillance as part of the 2010–2011 Demographic and Health Survey in Burkina Faso.

Methods

We used the database acquired during the multistage, clustered, population-based survey, in which 15 377 participants completed questionnaires and provided dried blood spot samples for HIV testing. We extracted sociodemographic and geographic data including age, sex, ethnicity, education, wealth, marital status and region for each participant. We performed hepatitis B and C assays on 14 886 HIV-negative samples between March to October 2015, and calculated weighted percentages of hepatitis seroprevalence for each variable.

Findings

We estimated seroprevalence as 9.1% (95% confidence interval, CI: 8.5–9.7) for the hepatitis B surface antigen and 3.6% (95% CI: 3.3–3.8) for hepatitis C virus antibodies, classifying Burkina Faso as highly endemic for hepatitis B and low-intermediate for hepatitis C. The seroprevalence of hepatitis was higher in men than in women, and varied significantly for both with age, education, ethnicity and region. Extremely high HCV-Ab seroprevalence (13.2%; 95% CI: 10.6–15.7) was identified in the Sud-Ouest region, in particular within the youngest age group (15–20 years), indicating an ongoing epidemic.

Conclusion

Our population-representative hepatitis seroprevalence estimates in Burkina Faso advocate for the inclusion of hepatitis serological tests and risk factor questionnaire items in future surveys, the results of which are crucial for the development of appropriate health policies and infection control programmes.

Introduction

Viral hepatitis is a global health challenge worldwide, particularly in low- and middle-income countries.1 Hepatitis B virus (HBV) is estimated to affect around 75 million people in Africa, including 1.9 million in Burkina Faso.2 HBV is the most frequent cause of acute hepatitis and chronic liver disease.3,4 Despite the introduction of HBV vaccines in the Expanded Programme on Immunization (EPI) in 2006, incidence is increasing.2 Further, 10–33 million individuals in West Africa are estimated to be affected by hepatitis C virus (HCV).5 These HBV and HCV infections are the main contributors to the hepatocellular carcinoma burden in Africa.3,6

Control of the HCV epidemic is envisioned when the new direct antiviral agents, reported to cure most HCV-infected patients within 12 weeks of treatment,7 become available in low-income countries. Precise epidemic knowledge based on reliable nationwide representative surveys8 is therefore essential to estimate the number of HCV-infected subjects requiring treatment and to evaluate the efficiency of any future treatment programme. Data from relevant surveys are also required to estimate the number of people living with chronic HBV and therefore the resources required for treatment.9

Robust epidemiological studies on viral hepatitis at the national level are however lacking.8 Most existing studies were conducted at different periods on specific populations (e.g. pregnant women or blood donors), and do not report estimations of age, sex, or demographic-specific prevalence.10–13 When included in systematic reviews and meta-analyses of population-wide prevalence,2,8,14–19 such studies lead to biases and large estimation intervals, and overlook the demographic and geographic heterogeneity of the epidemics.8

The Demographic and Health Surveys (DHS) Program20 conducts large, multistage, clustered, population-based surveys in low- and middle-income countries. By collecting and analysing accurate and representative data on population and health, including blood sample collection (dried blood spot) and storage on filter papers for human immunodeficiency virus (HIV) testing, one can evaluate the impact of existing health programmes and develop strategies for improvement. Here, we demonstrate how these surveys provide an opportunity for affordable hepatitis testing and epidemiological studies. Using the DHS database and dried blood spot samples acquired from May 2010 to January 2011, we estimate the viral hepatitis B and C seroprevalence in the HIV-negative adult population of Burkina Faso.

Methods

Survey

The Institut National de la Statistique et de la Démographie conducted the fourth Burkina Faso DHS in 2010.21 Following the structure of previous surveys,20 the survey aimed to acquire representative data on households, men and women, and adopted a two-stage, stratified clustered design22 in determining which households were to be sampled. In the first stage of the survey, 574 administrative demographic zones were selected from the total of 13 989 within Burkina Faso with a probability dependent upon the number of households within that zone. In the second stage, households within selected demographic zones were selected at random with a uniform probability; a total of 14 947 households were included in the survey. Questionnaires were completed by both male and female interviewers recruited by the Institut National de la Statistique et de la Démographie.21 Interviewers attended a 6-week training course at the institute, where they were educated on the different features of the survey including general methodology, logistics, the subjects covered in the questionnaire and blood sampling procedures.

Survey subpopulation

Due to their perceived status as main carer, women were considered best placed to provide information on the health of household members and living conditions. All women aged 15–49 years either living in each of the 14 947 households or having stayed there overnight were therefore invited to complete a questionnaire. Among the households, one household out of two within each demographic zone was selected at random (7475 households) for men aged 15–59 years to be interviewed. Agreement to provide a blood sample was sought from all interviewed men and from the interviewed women who were living in the same households as male participants. After signing an informed consent form, a total of 8293 women and 7084 men formed the subpopulation that completed the questionnaire and provided a blood sample.

Ethics

All procedures performed as part of the study were conducted in accordance with the standards of the Ethics Committee for Health Research of Burkina Faso, while also meeting the principles expressed in the declaration of Helsinki. Free informed consent was obtained from every individual participant in the use of data and dried blood spot samples collected for further research. According to the Burkina Faso survey protocol, all data records were fully anonymous without any possibility of participant identification.

Blood sample processing

As part of the Burkina Faso DHS,21 dried blood spot samples (two to five per filter paper; Whatman 903 Protein Saver, Dassel, Germany) obtained by finger prick, were sent to the national blood transfusion centre in individual bags with dessicant and stored at −20 °C. Samples were punched into microtitration plates and analysed for HIV infection using an enzyme-linked immunosorbent assay (Vironostika HIV Uni-Form II plus O, Biomérieux, France). The positive samples and 10% of the negative samples were checked using a recombinant enzyme-linked immunosorbent assay (Enzygnost Anti-HIV 1/2 plus, Dade Behring Marburg GmbH, Germany). All discordant results were tested (InnoLia, Innogenetics, Belgium) once more to give a final result of 160 HIV-positive samples. HIV analysis exhausted a total of 491 samples, leaving 14 886 HIV-negative samples for hepatitis testing.

Hepatitis serology assays

We performed the hepatitis B and C assays on HIV-negative dried blood spot samples between March and October 2015. We tested for the presence of hepatitis B surface antigen (HBsAg) by eluting a punched disc of 6 mm in diameter overnight at ambient room temperature in 1.5 mL phosphate buffered saline, and using the Monolisa HBsAg Ultra assay (Bio-Rad, Hercules, United States of America). The sensitivity and specificity estimations of the test were 96.0% (95% confidence interval, CI: 77.7–99.8) and 100.0% (95% CI: 97.6–100.0), respectively.23,24 We detected the HCV antibody (HCV-Ab) by eluting a punch of 6 mm diameter overnight at ambient temperature in 2 mL of a buffer (two thirds phosphate buffered saline and one third manufacturer’s diluent), and using the Monolisa HCV AgAb Ultra assay (Bio-Rad, Marnes-la-Coquette, France). The sensitivity and specificity estimations of the test were 95.0% (95% CI: 83.1–99.4) and 100.0% (95% CI: 98.9–100.0), respectively23,25,26

Survey data extraction

We extracted several sociodemographic and geographic variables from the survey database, including: sex, age, declared ethnicity, educational achievement (none, primary, secondary or higher), household wealth index quintile (quintile of the nationwide wealth index distribution constructed from household assets scoring), marital status (including living with a common-law partner), residential area (name of region and whether urban or rural setting) and HIV status (positive or negative) according to the dried blood spot sample analysis in 2010. We also extracted the representativeness weighting data calculated by the survey statisticians,21 and used these data to estimate population-wide seroprevalence from the survey subpopulation.

Statistical methods

We performed statistical analyses with SAS software, version 9.2® (SAS Institute Inc., Cary, USA), using procedures for weighted survey samples. We used an adjusted F-test for qualitative variables. We also created the new variable “tested-couple” to describe two participants reported as living as a couple in the same household, who had both been tested for viral hepatitis markers. We considered our results significant for P-values ≤ 0.05, and present results with their 95% CI.

As our study sample contained only HIV-negative subjects, we conducted a complementary analysis to approximate the hepatitis prevalence in the overall population of 15 046 survey participants (14 886 HIV-negative and 160 HIV-positive). We allocated the upper limit of the published B and C hepatitis prevalence estimates (i.e. 15% for HBsAg in Burkina Faso27 and 9% for HCV-Ab in West Africa17) for the HIV-positive population (1.0% prevalence21) to these subjects.

Results

Sociodemographic data

Of the 14 886 HIV-uninfected subjects (Table 1), the mean age was 31.9 years (95% CI: 31.6–32.3) in men and 28.6 years (95% CI: 28.4–28.9) in women. A total of 10 017 participants (weighted %: 68.4; 95% CI: 67.5–69.2) had no educational achievement, 10 576 (72.1%; 5% CI: 71.2–73.0) were currently married or living with a partner, and 10 189 (72.5%; 95% CI: 71.7–73.2) lived in a rural setting.

Table 1. Estimated hepatitis seroprevalence, by sociodemographic and geographic data, Burkina Faso, 2010–2011.

Characteristic No. sampled HBV-positive
 HCV-positive
No. Weighted %a (95% CI) No. Weighted %a (95% CI)
All 14 886 1365 9.1 (8.5–9.7) 565 3.6 (3.3–3.8)
Men 6 830 723 10.5 (9.6–11.4) 286 3.9 (3.4–4.5)
Women 8 056 642 7.8 (7.1–8.6) 279 3.2 (2.8–3.7)
Age group, years
15–19 3 010 303 9.6 (8.3–10.8) 87 2.5 (1.9–3.1)
20–24 2 489 256 10.4 (9.0–11.9) 69 2.6 (1.9–3.3)
25–29 2 265 220 9.9 (8.5–11.3) 88 3.7 (2.8–4.6)
30–34 2 105 199 9.5 (8.1–11.0) 87 3.8 (2.9–4.8)
35–39 1 708 155 9.2 (7.6–10.7) 71 4.1 (3.1–5.1)
40–44 1 387 105 7.4 (5.9–9.0) 68 4.7 (3.4–5.9)
45–49 1 181 78 6.2 (4.6–7.7) 54 4.4 (3.1–5.7)
50–54 (men) 422 26 5.4 (3.1–7.8) 22 5.1 (2.8–7.5)
55–59 (men) 319 23 6.4 (3.6–9.3) 19 5.9 (3.1–8.7)
Education
None 10 017 866 8.6 (7.9–9.2) 422 4.0 (3.5–4.4)
Primary 2 492 249 10.1 (8.7–11.6) 96 3.7 (2.9–4.6)
Second or higher 2 377 250 10.1 (8.5–11.7) 47 1.6 (1.0–2.2)
Wealth index quintile
Poorest 2 568 217 8.5 (7.2–9.8) 154 5.4 (4.4–6.4)
Poorer 2 771 262 9.3 (8.1–10.6) 109 3.5 (2.7–4.2)
Middle 2 774 246 8.6 (7.4–9.8) 113 4.4 (3.4–5.4)
Richer 3 042 292 9.2 (7.9–10.4) 123 3.8 (3.0–4.7)
Richest 3 731 348 9.5 (8.2–10.8) 66 1.5 (1.0–2.0)
Marital status
Never married 3 918 411 10.4 (9.2–11.6) 109 2.3 (1.8–2.9)
Currently married 10 576 911 8.5 (7.9–9.1) 437 4.0 (3.5–4.4)
Previously married 392 43 12.0 (7.7–16.2) 19 4.5 (2.3–6.6)
Geographical setting
Urban 4 697 452 9.6 (8.4–10.8) 101 1.8 (1.2–2.3)
Rural 10 189 913 8.9 (8.2–9.5) 464 4.3 (3.8–4.7)
Region
Boucle du Mouhoun 1 309 109 7.9 (6.3–9.5) 41 3.0 (2.0–4.0)
Cascades 963 95 10.1 (8.2–12.0) 57 6.2 (4.6–7.8)
Centre 1 424 132 9.4 (7.6–11.2) 11 1.0 (0.3–1.7)
Centre-Est 1 009 107 10.3 (8.1–12.5) 35 3.8 (2.5–5.1)
Centre-Nord 1 024 89 8.0 (6.1–10.0) 36 3.9 (2.5–5.3)
Centre-Ouest 1 282 126 9.8 (7.9–11.7) 45 3.9 (2.6–5.1)
Centre-Sud 1 016 76 6.8 (5.1–8.6) 16 1.7 (0.8–2.6)
Est 1 186 127 11.0 (8.9–13.1) 41 4.0 (2.8–5.3)
Hauts-Bassins 1 388 125 9.1 (7.3–10.8) 53 3.7 (2.6–4.8)
Nord 1 090 77 6.6 (4.9–8.3) 41 4.0 (2.6–5.3)
Plateau-Central 1 100 91 8.4 (6.6–10.1) 31 3.0 (1.9–4.1)
Sahel 1 003 110 10.6 (8.5–12.7) 25 2.6 (1.5–3.7)
Sud-Ouest 1 092 101 8.9 (7.0–10.8) 133 13.2 (10.6–15.7)
Ethnicity
Bobo 606 49 7.8 (5.5–10.0) 38 6.2 (4.1–8.4)
Dioula 127 11 8.6 (3.1–14.2) 3 2.0 (0.0–4.3)
Fulfulde/Peul 1 157 111 9.2 (7.3–11.1) 34 3.0 (2.0–4.1)
Gourmantche 946 114 12.3 (9.9–14.6) 34 4.1 (2.7–5.5)
Gourounsi 721 71 8.7 (6.4–11.0) 24 3.4 (1.9–5.0)
Lobi 513 39 7.9 (5.3–10.5) 62 11.6 (8.2–15.0)
Mossi 7 659 624 8.2 (7.5–9.0) 178 2.4 (2.0–2.8)
Senoufo 855 102 12.5 (9.9–15.1) 57 5.5 (4.0–7.0)
Touareg/Bella 239 26 9.8 (6.2–13.3) 6 2.1 (0.6–3.7)
Dagara 495 60 11.2 (7.9–14.5) 70 13.2 (9.6–16.7)
Bissa 516 61 11.8 (8.7–14.8) 18 3.9 (1.9–6.0)
Other 1 052 97 8.8 (6.8–10.8) 41 3.6 (2.4–4.9)
Open in a new tab

CI: confidence interval; HBV: hepatitis B virus; HCV: hepatitis C virus.

a Percentages and CIs are weighted for population-wide representativeness using data calculated by 2010 survey statisticians.

Note: We estimated the seroprevalence from the 2010 Demographic and Health Survey.21

Seroprevalence

Countrywide, seroprevalence was estimated as 9.1% (95% CI: 8.5–9.7) for HBV, 3.6% (95% CI: 3.3–3.8) for HCV and 0.3% (95% CI: 0.2–0.4) for HBV–HCV coinfection.

HBV

The HBV seroprevalence was significantly higher in men (10.5%; 95% CI: 9.6–11.4) than in women (7.8%; 95% CI: 7.1–8.6). For both men and women, the prevalence varied significantly with age (P = 0.0002), level of education (P = 0.03), ethnicity (P = 0.004) and region of residency (P = 0.0029; Fig. 1; Fig. 2 and Table 1). The HBV seroprevalence within the Gourmantche and Senoufo ethnic groups was 12.3% (95% CI: 9.9–14.7) and 12.5% (95% CI: 9.8–15.1), respectively. This is significantly higher than the 8.2% (95% CI: 7.4–9.0) seroprevalence within the predominant Mossi ethnic group, who comprise 51.5% (7659/14 886; 95% CI: 50.4–52.5) of the population in Burkina Faso according to the 2010 survey. In men, lower seroprevalence was observed with increasing age (P for trend, 0.003) (Fig. 2). Among couples, the HBV seroprevalence was significantly higher (P = 0.02) for those whose partner was infected (11.7%; 95% CI: 8.4–15.1) compared with those whose partner was not infected (8.1%; 95% CI: 7.4–8.9).

Fig. 1.

Hepatitis B seroprevalence in Burkina Faso, 2010–2011

Note: We estimated the seroprevalence from the 2010 Demographic and Health Survey.21

Fig. 1

Open in a new tab

Fig. 2.

Hepatitis B infection by age and sex, Burkina Faso, 2010–2011

CI: confidence interval.

Note: We estimated the seroprevalence from the 2010 Demographic and Health Survey.21

Fig. 2

Open in a new tab

HCV

The seroprevalence of HCV infection was higher in men (3.9%; 95% CI: 3.4–4.5) than in women (3.2%; 95% CI: 2.8–3.7; Table 1). For both men and women, HCV seroprevalence varied with age (P = 0.024; Fig. 3), level of education level (P < 0.0001), ethnicity (P < 0.001) and wealth index quintile (P < 0.0001). It varied from 2.4% (95% CI: 2.0–2.8) in the Mossi ethnic group to 11.6% (95% CI: 8.2–15.0) in the Lobi and 13.2% (95% CI: 9.6–16.7) in the Dagara ethnic groups. HCV seroprevalence was significantly (P < 0.0001) higher in rural (4.3%; 95% CI: 3.8–4.7) than in urban (1.8%; 95% CI: 1.2–2.3) settings and varied with regions; Centre (1.0%; 95% CI: 0.3–1.7) or Centre-Sud (1.7%; 95% CI: 0.8–2.6) regions had the lowest seroprevalence, while Cascades (6.2%, 95% CI: 4.6–7.8) and Sud-Ouest (13.2%; 95% CI: 10.6–15.7) regions had the highest (Fig. 4). As for HBV, the HCV seroprevalence increased significantly (P < 0.0001) for those whose partner was infected (14.6%; 95% CI: 9.4–19.8) compared with those whose partner was not infected (3.7%; 95% CI: 3.2–4.1). In men, the seroprevalence was observed to increase with age (P for trend, < 0.001; Fig. 3).

Fig. 3.

Hepatitis C infection by age and sex, Burkina Faso, 2010–2011

CI: confidence interval.

Note: We estimated the seroprevalence from the 2010 Demographic and Health Survey.21

Fig. 3

Open in a new tab

Fig. 4.

Hepatitis C seroprevalence in Burkina Faso, 2010–2011

Note: We estimated the seroprevalence from the 2010 Demographic and Health Survey.21

Fig. 4

Open in a new tab

HCV–HBV coinfection

The seroprevalence of coinfection was lower in women (0.2%; 95% CI: 0.1–0.3) than in men (0.4%; 95% CI: 0.2–0.6), and varied across regions (Fig. 5). Among the population in which HCV-Ab was detected, the seroprevalence of HBsAg was 8.4% (95% CI: 6.4–10.4), significantly (P = 0.03) higher in men (10.7%; 95% CI: 7.6–13.7) than in women (6.1%; 95% CI: 3.4–8.7). Among the HBsAg-positive population, the seroprevalence of HCV-Ab was 3.4% (95% CI: 2.4–4.2) countrywide: 4.1% (95% CI: 2.7–5.4) in men and 2.5% (95% CI: 1.4–3.6) in women.

Fig. 5.

Coinfection of hepatitis B and hepatitis C in Burkina Faso, 2010–2011

Note: We estimated the seroprevalence from the 2010 Demographic and Health Survey.21

Fig. 5

Open in a new tab

Complementary analysis

When we included hepatitis seroprevalence estimates for HIV-positive participants, the population-wide seroprevalence of viral hepatitis did not change with a 9.1% HBsAg prevalence (95% CI: 8.5–9.7) and a 3.6% HCV-Ab prevalence (95% CI: 3.3–4.0).

Discussion

Systematic reviews2,8 have estimated HBV and HCV prevalence in Burkina Faso of 12.0% (95% CI: 11.7–12.4) and 6.1% (95% CI: 1.3–14.2), respectively, ranking the country as one of the most affected sub-Saharan countries.8 However, despite meta-analytic designs, these estimations are biased by homogeneity in population sampling. Our calculation of 9.1% HBV seroprevalence (95% CI: 8.5–9.7) and 3.6% HCV seroprevalence (95% CI: 3.3–3.8), based on a representative population sample in terms of sociodemographic and geographic characteristics, are much lower and have narrower CIs. Our data show that Burkina Faso should be classified as highly endemic for HBV (> 8%)4 and of low–intermediate prevalence for HCV (3–6%).17

Our HBV seroprevalence estimates were roughly uniformly distributed across the geographic regions, but a high degree of regional heterogeneity was observed for HCV; this demonstrates that the assumed epidemiological homogeneity between neighbouring countries used in meta-analyses8 is not valid at a national level. In the Sud-Ouest region, populated mostly by the Lobi (45.1%, 492/1092; 95% CI: 41.8–48.3) and Dagara (36.7%, 401/1092; 95% CI: 33.9–39.5) ethnic groups,21 HCV seroprevalence is 13.2%; this is close to that of Egypt (14.7%, 1636/11 126),28 currently considered the most-affected country in Africa. We also observed a different pattern of HCV age-specific seroprevalence in the Sud-Ouest region: as well as an increasing trend in seroprevalence with age, in common with the countrywide prevalence, a high seroprevalence of 12.9% (95% CI: 7.1–18.7) was estimated in the youngest age group (15–19 years).

Our study has some limitations. The 2010–2011 Burkina Faso DHS focused on the sociodemographic characteristics of the population and the prevalence and risk factors of HIV (e.g. a history of unprotected sex and/or multiple partners, or having undergone unsafe, medically invasive procedures during the previous 12 months). Although these risk factors of hepatitis infection are shared with that of HIV infection,17,29 the survey was not specific enough to measure hepatitis epidemiology; risk factors such as drug use, tattoos or cultural scarification (frequently carried out within the Lobi and Dagara ethnic groups), or hepatitis infection in a relative, were not considered. We therefore limited our analysis of hepatitis seroprevalence to one in terms of sociodemographic parameters only. Future surveys, especially in West Africa, should accommodate the current health challenges of hepatitis epidemiological knowledge and control.

Since the survey was conducted during 2010–2011 and included participants from age 15 years, we cannot investigate the effect of the introduction of the HBV vaccine in the EPI in 2006. However, in countries that have introduced routine infant HBV immunization, prevalence has been observed to fall.6

Hepatitis analysis of dried blood spot samples from HIV-negative participants only was a potential selection bias for countrywide prevalence assessment. Nevertheless, with a 1% HIV seroprevalence in Burkina Faso,21 our complementary analysis suggests that this bias had no effect on the estimated hepatitis prevalence. The method of determining HIV status within any DHS involves the collection of five dried blood spots per card from each survey participant, sufficient for both HIV (rapid test, confirmation test and viral load) and hepatitis testing if (i) the five blood spots are completely and correctly filled and (ii) sample punches are performed near the margin, allowing three punches per spot.

The HBV and HCV seroprevalence we report here reflect the situation in 2010 and cannot predict the current situation in 2018. However, these data represent a countrywide baseline against which the evolution of the epidemic can be measured in future surveys. From our estimate of HCV prevalence of 3.6%, and considering that 50% of the 15.6 million Burkina Faso population in 2010 was aged 15–59 years30 and that infection with hepatitis C resolves spontaneously in about 25% of the infected population,31 we estimate that about 210 600 HCV viraemic adults were in need of HCV therapy in 2010.

A final limitation of the study is the ethical conundrum of not returning results to the participants, which is contrary to the 2017 WHO recommendations.32 The survey protocol stipulated that the dried blood spot sampling and database would be totally anonymous without any possibility of participant identification; participants could therefore not be informed of HIV-seropositive results. In an attempt to overcome this situation, a list of the nearest health centres and a voucher for a free HIV test were given to each sampled participant. Since our study was conducted in 2015 and nested within the 2010–2011 survey, we were not able to replicate this procedure for hepatitis testing. This limitation does not alter our results or their public health interest, but advocates for free tests and treatments.

Our study benefited from the stratified clustered design of the DHS, a survey design which is similar to that of a national census.22 This design results in sample sizes of over 10 000 participants, which is considered the minimum to be wholly representative of the general population for health and demographic data, meeting the requirements for accurate epidemiological results.5

An additional benefit of the survey design is the possibility of identifying subregional variations; our discovery of the high level of HCV seroprevalence in the Sud-Ouest region, particularly in the youngest age group (15–20 years), suggests that the epidemic is still ongoing. Further studies are required to identify the transmission routes and understand the specific risk factors associated with this region.29,33,34

Another strength of our study is its feasibility and low cost. Hepatitis serology testing using dried blood spot samples is now recommended when collecting venous blood specimens is difficult (e.g. in epidemiological studies) and/or when the sample has to be tested away from where it was collected, as is the case in many low- or middle-income countries.35,36 The extra cost per subject for HBV and HCV testing during a survey is approximately 8 United States dollars (US$): US$ 2 for hepatitis serologic reagents (equivalent to a rapid diagnosis test34) and US$ 6 for basic laboratory fees.37

In conclusion, expanding DHS to include hepatitis testing is both affordable and achievable. Characterizing disease epidemiology and its evolution at nationwide and regional levels in sub-Saharan Africa is crucial for the development of appropriate health policies and infection control programmes.38 Our reliable hepatitis B and C seroprevalence data in Burkina Faso, and our identification of an ongoing epidemic in the Sud-Ouest region, advocate for the immediate inclusion of hepatitis serological tests and risk factor questionnaire items in future surveys.

Acknowledgments

We thank the Ministry of Health of Burkina Faso. We also thank Macro International, who worked closely with the Institut National des Statistiques et de la Démographie throughout the 2010 survey.

Funding:

The study was funded by the Institut National de la Santé et de la Recherche Médicale (INSERM) and French National Agency for Research on AIDS and Viral Hepatitis (ANRS), Paris, France (grant no. ANRS12270).

Competing interests:

None declared.

References

  • 1.WHO Global health sector strategy on viral hepatitis 2016–2021. Geneva: World Health Organization; 2016. Available from: http://www.who.int/hepatitis/strategy2016-2021/ghss-hep/en/ [cited 2018 Jul 22].
  • 2.Schweitzer A, Horn J, Mikolajczyk RT, Krause G, Ott JJ. Estimations of worldwide prevalence of chronic hepatitis B virus infection: a systematic review of data published between 1965 and 2013. Lancet. 2015. October 17;386(10003):1546–55. 10.1016/S0140-6736(15)61412-X [DOI] [PubMed] [Google Scholar]
  • 3.Perz JF, Armstrong GL, Farrington LA, Hutin YJ, Bell BP. The contributions of hepatitis B virus and hepatitis C virus infections to cirrhosis and primary liver cancer worldwide. J Hepatol. 2006. October;45(4):529–38. 10.1016/j.jhep.2006.05.013 [DOI] [PubMed] [Google Scholar]
  • 4.Villa E, Fattovich G, Mauro A, Pasino M. Natural history of chronic HBV infection: special emphasis on the prognostic implications of the inactive carrier state versus chronic hepatitis. Dig Liver Dis. 2011. January;43 Suppl 1:S8–14. 10.1016/S1590-8658(10)60686-X [DOI] [PubMed] [Google Scholar]
  • 5.Gower E, Estes C, Blach S, Razavi-Shearer K, Razavi H. Global epidemiology and genotype distribution of the hepatitis C virus infection. J Hepatol. 2014. November;61(1) Suppl:S45–57. 10.1016/j.jhep.2014.07.027 [DOI] [PubMed] [Google Scholar]
  • 6.Lemoine M, Thursz MR. Battlefield against hepatitis B infection and HCC in Africa. J Hepatol. 2017. March;66(3):645–54. 10.1016/j.jhep.2016.10.013 [DOI] [PubMed] [Google Scholar]
  • 7.Assefa Y, Hill PS, Ulikpan A, Williams OD. Access to medicines and hepatitis C in Africa: can tiered pricing and voluntary licencing assure universal access, health equity and fairness? Global Health. 2017. September 13;13(1):73. 10.1186/s12992-017-0297-6 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 8.Riou J, Aït Ahmed M, Blake A, Vozlinsky S, Brichler S, Eholié S, et al. ; HCV Epidemiology in Africa Group. Hepatitis C virus seroprevalence in adults in Africa: a systematic review and meta-analysis. J Viral Hepat. 2016. April;23(4):244–55. 10.1111/jvh.12481 [DOI] [PubMed] [Google Scholar]
  • 9.Policy brief: Guidelines for the prevention, care and treatment of persons with chronic hepatitis B infection. Geneva: World Health Organization; March 2015. Available from: http://www.who.int/hiv/pub/hepatitis/hepatitis-b-guidelines/en/ [cited 2018 Jul 22]. [PubMed]
  • 10.Collenberg E, Ouedraogo T, Ganamé J, Fickenscher H, Kynast-Wolf G, Becher H, et al. Seroprevalence of six different viruses among pregnant women and blood donors in rural and urban Burkina Faso: A comparative analysis. J Med Virol. 2006. May;78(5):683–92. 10.1002/jmv.20593 [DOI] [PubMed] [Google Scholar]
  • 11.Nagalo MB, Sanou M, Bisseye C, Kaboré MI, Nebie YK, Kienou K, et al. Seroprevalence of human immunodeficiency virus, hepatitis B and C viruses and syphilis among blood donors in Koudougou (Burkina Faso) in 2009. Blood Transfus. 2011. October;9(4):419–24. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12.Simpore J, Granato M, Santarelli R, Nsme RA, Coluzzi M, Pietra V, et al. Prevalence of infection by HHV-8, HIV, HCV and HBV among pregnant women in Burkina Faso. J Clin Virol. 2004. September;31(1):78–80. 10.1016/j.jcv.2004.06.001 [DOI] [PubMed] [Google Scholar]
  • 13.Zeba MTA, Sanou M, Bisseye C, Kiba A, Nagalo BM, Djigma FW, et al. Characterisation of hepatitis C virus genotype among blood donors at the regional blood transfusion centre of Ouagadougou, Burkina Faso. Blood Transfus. 2014. January;12 Suppl 1:s54–7. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 14.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. April;57(4):1333–42. 10.1002/hep.26141 [DOI] [PubMed] [Google Scholar]
  • 15.Madhava V, Burgess C, Drucker E. Epidemiology of chronic hepatitis C virus infection in sub-Saharan Africa. Lancet Infect Dis. 2002. May;2(5):293–302. 10.1016/S1473-3099(02)00264-5 [DOI] [PubMed] [Google Scholar]
  • 16.Barth RE, Huijgen Q, Taljaard J, Hoepelman AI. Hepatitis B/C and HIV in sub-Saharan Africa: an association between highly prevalent infectious diseases. A systematic review and meta-analysis. Int J Infect Dis. 2010. December;14(12):e1024–31. 10.1016/j.ijid.2010.06.013 [DOI] [PubMed] [Google Scholar]
  • 17.Rao VB, Johari N, du Cros P, Messina J, Ford N, Cooke GS. Hepatitis C seroprevalence and HIV co-infection in sub-Saharan Africa: a systematic review and meta-analysis. Lancet Infect Dis. 2015. July;15(7):819–24. 10.1016/S1473-3099(15)00006-7 [DOI] [PubMed] [Google Scholar]
  • 18.Shepard CW, Finelli L, Alter MJ. Global epidemiology of hepatitis C virus infection. Lancet Infect Dis. 2005. September;5(9):558–67. 10.1016/S1473-3099(05)70216-4 [DOI] [PubMed] [Google Scholar]
  • 19.Karoney MJ, Siika AM. Hepatitis C virus (HCV) infection in Africa: a review. Pan Afr Med J. 2013;14:44. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 20.The DHS Program. Rockville: ICF; 2018. Available from: http://dhsprogram.com [cited 2018 Jul 22].
  • 21.Enquête Démographique et de Santé et à Indicateurs Multiples du Burkina Faso 2010. Calverton: ICF International; 2012. French. http://dhsprogram.com/publications/publication-FR256-DHS-Final-Reports.cfm [cited 2018 Jul 22].
  • 22.Johnson TP. Handbook of health survey methods. Hoboken: John Wiley & Sons, Inc.; 2010. [Google Scholar]
  • 23.Lange B, Cohn J, Roberts T, Camp J, Chauffour J, Gummadi N, et al. Diagnostic accuracy of serological diagnosis of hepatitis C and B using dried blood spot samples (DBS): two systematic reviews and meta-analyses. BMC Infect Dis. 2017. November 1;17(S1) Suppl 1:700. 10.1186/s12879-017-2777-y [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 24.Kania D, Bekalé AM, Nagot N, Mondain AM, Ottomani L, Meda N, et al. Combining rapid diagnostic tests and dried blood spot assays for point-of-care testing of human immunodeficiency virus, hepatitis B and hepatitis C infections in Burkina Faso, West Africa. Clin Microbiol Infect. 2013. December;19(12):E533–41. 10.1111/1469-0691.12292 [DOI] [PubMed] [Google Scholar]
  • 25.Brandão CP, Marques BL, Marques VA, Villela-Nogueira CA, Do Ó KM, de Paula MT, et al. Simultaneous detection of hepatitis C virus antigen and antibodies in dried blood spots. J Clin Virol. 2013. June;57(2):98–102. 10.1016/j.jcv.2013.02.014 [DOI] [PubMed] [Google Scholar]
  • 26.Tuaillon E, Mondain AM, Meroueh F, Ottomani L, Picot MC, Nagot N, et al. Dried blood spot for hepatitis C virus serology and molecular testing. Hepatology. 2010. March;51(3):752–8. [DOI] [PubMed] [Google Scholar]
  • 27.Bado G, Penot P, N’Diaye MD, Amiel C, Hema A, Kamboulé EB, et al. Hepatitis B seroprevalence in HIV-infected patients consulting in a public day care unit in Bobo Dioulasso, Burkina Faso. Med Mal Infect. 2013. May;43(5):202–7. 10.1016/j.medmal.2013.04.001 [DOI] [PubMed] [Google Scholar]
  • 28.Mohamoud YA, Mumtaz GR, Riome S, Miller D, Abu-Raddad LJ. The epidemiology of hepatitis C virus in Egypt: a systematic review and data synthesis. BMC Infect Dis. 2013. June 24;13(1):288. 10.1186/1471-2334-13-288 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 29.Jayaraman S, Chalabi Z, Perel P, Guerriero C, Roberts I. The risk of transfusion-transmitted infections in sub-Saharan Africa. Transfusion. 2010. February;50(2):433–42. 10.1111/j.1537-2995.2009.002402.x [DOI] [PubMed] [Google Scholar]
  • 30.Sherbrooke University. Perspective monde. Population totale, Burkina Faso. Sherbrooke: Sherbrooke University: 2018. French. Available from: http://perspective.usherbrooke.ca/bilan/tend/BFA/fr/SP.POP.TOTL.html [cited 2018 Aug 13].
  • 31.Westbrook RH, Dusheiko G. Natural history of hepatitis C. J Hepatol. 2014. November;61(1) Suppl:S58–68. 10.1016/j.jhep.2014.07.012 [DOI] [PubMed] [Google Scholar]
  • 32.WHO guidelines on ethical issues in public health surveillance. Geneva: World Health Organization; 2017. http://apps.who.int/iris/bitstream/handle/10665/255721/9789241512657-eng.pdfhttp://[cited 2018 Jul 22].
  • 33.He J, Lin J. HCV prevalence during the age range of peak sexual activity. Lancet Infect Dis. 2017. February;17(2):131–2. 10.1016/S1473-3099(17)30003-8 [DOI] [PubMed] [Google Scholar]
  • 34.Pépin J, Labbé AC. Noble goals, unforeseen consequences: control of tropical diseases in colonial Central Africa and the iatrogenic transmission of blood-borne viruses. Trop Med Int Health. 2008. June;13(6):744–53. 10.1111/j.1365-3156.2008.02060.x [DOI] [PubMed] [Google Scholar]
  • 35.WHO Guidelines on hepatitis B and C testing: policy brief. Geneva: World Health Organization; 2016. http://www.who.int/hepatitis/publications/hepatitis-testing-recommendation-policy/en/ [cited 2018 Jul 22].
  • 36.Easterbrook PJ; WHO Guidelines Development Group. Who to test and how to test for chronic hepatitis C infection - 2016 WHO testing guidance for low- and middle-income countries. J Hepatol. 2016. October;65(1) Suppl:S46–66. 10.1016/j.jhep.2016.08.002 [DOI] [PubMed] [Google Scholar]
  • 37.Protto JP, Plasschaert S, Sartor F, Walckiers D. Biological testing for HIV, hepatitis B and C infections. PH/EPI reports no. 2004–011. Available from: https://www.wiv-isp.be/epidemio/epien/birn/biotest.pdf [cited 22 Jul 2018].
  • 38.Layden JE, Phillips R, Opare-Sem O, Akere A, Salako BL, Nelson K, et al. Hepatitis C in sub-Saharan Africa: urgent need for attention. Open Forum Infect Dis. 2014. September 17;1(2):ofu065. 10.1093/ofid/ofu065 [DOI] [PMC free article] [PubMed] [Google Scholar]

Articles from Bulletin of the World Health Organization are provided here courtesy of World Health Organization

RESOURCES