Vol. 2 No. 1, 2009 Correct.pmd

Introduction:
Although hepatitis C virus (HCV) related chronic liver
disease is common in our clinical practice, unfortunately
there is lack of representative population study in
Bangladesh regarding the prevalence of the virus. This
present study is among the handful where the sero-
prevalence of HCV in our population has been studied.

Except for the work by a Japanese group, that reported
5% prevalence of HCV in Bangladesh1, others reported
extremely low prevalence of HCV in Bangladesh2. This
gives the impression that the impact of HCV in Bangladesh
is negligible. On the other hand a British study has shown
that 45.3% and 56% of British-Bangladeshi patients with
chronic liver diseases and hepatocellular carcinoma
respectively have been infected with HCV3. There are also
published data from Bangladesh identifying HCV to be
the etiological agent in 24.1% of patients with chronic
liver diseases in Bangladesh4. All these diversifying
reportings make it essential to revisit the prevalence of
HCV in this country, especially among the apparently
healthy individuals.

Epidemiology of Hepatitis C Virus in Bangladeshi General Population
Mamun-Al-Mahtab1, Salimur Rahman2, Fazal Karim3, Graham Foster4, Susannah Solaiman5

1Assistant Professor, 2Professor, Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh, 3Consultant
Medicine, Dhaka Mohanagar Hospital, 4Professor, 5Research Fellow, Digestive Diseases Research Centre, Bart’s and the London Queen Mary’s
School of Medicine and Dentistry, London, UK.

Abstract
Background: Hepatitis C virus is encountered sporadically in Bangladesh. It results in a wide range liver diseases, with
asymptomatic acute hepatitis rarely at one end to HCC at the other end of the spectrum. Methods: 1018 individuals of
different age groups and sex with varied religious, educational and social backgrounds were tested for anti-HCV by
ELISA. Before testing, blood samples were preserved at -20°C. The study was conducted in a semi-urban location on
the outskirts of Dhaka. Results: 0.88% tested positive for anti HCV. None of them tested positive for HBsAg. There
was a male predominance and those who tested positive were mostly between 17 and 50 years of age. Major risk factors
for exposure to HBV appeared to be injudicious use of injectable medications, treatment by unqualified, traditional
practitioners, mass-vaccination against cholera and smallpox, barbers and body piercing. Conclusion: HCV remains an
important cause of morbidity and mortality in Bangladesh.

Key words: HCV, prevalence, general population, Bangladesh.

[BSMMU J 2009; 2(1): 14-17]

Correspondence to : Dr. Mamun-Al-Mahtab, Assistant Professor,
Department of Hepatology, Bangabandhu Sheikh Mujib Medical
University, Shahbag, Dhaka-1000, Bangladesh, Email:
shwapnil@agni.com

Materials and methods
The study was conducted in the Savar area on the outskirts
of Dhaka in May 2007. The area has a large industrial
base. The leading export processing zone of the country
is also situated here. People from all over the country stay
and work in different industrial and other installations in
this area. Moreover, due to its proximity and excellent
communication with Dhaka city, many people from
different parts of the country reside here and commute to
Dhaka daily for work and business. It was therefore
assumed that the study population was representative of
the Bangladeshi population.

Before the samples were collected, several meetings were
held with local political, social, religious and business
leaders in order to ensure community participation and
full cooperation. We arranged mass propaganda to
encourage people to participate in the study. During Jumma
prayers, Imams (i.e. Muslim priests) urged the common
people to participate in the study. Extensive broadcasting
was done and posters and banners were erected in key
locations. 20 graduate physicians were employed to obtain
consent from the participants and fill in a pre-designed
questionnaire for each individual. 10 phlebotomists
collected blood, maintaining all aseptic precautions, while
a group of 5 laboratory technicians were involved in

sample preservation. Large number of volunteers were
employed to ensure smooth execution of the exercise.

The sample size was 1018. Prior, informed, written consent
was obtained from every participant. A questionnaire was
filled in for each individual.

All samples were stored at -20°C and tested for anti-HCV
by ELISA (Abbott, USA).

Results
In all, 1018 individuals were included in the study.
Participants of either sex, between 1 to over 50 years of
age, with different religious, social, professional and
educational backgrounds, donated blood voluntarily for
the study (Table I). The completed questionnaire contained
detailed information on relevant demographic data and
risks of possible exposure to HCV (Table II).

Table I
Demographic characteristics of study population

Age distribution Age in Yrs. Nos. %

0-16 0 0

17-50 9 100

50+ 0 0

Sex distribution Sex Nos. %

Male 6 66.66

Female 3 33.34

Religion of study population Religion Nos. %

Muslim 6 66.66

Hindu 3 33.34

Christian 0 0

Education level Level Nos. %

No Education 0 0

Primary 3 33.34

High School 6 66.66

College 0 0

University 0 0

Table-II
Risk factors for HCV positivity

Risk factor Nos. %
Yes No. Yes No.

Blood Transfusion 0 9 0 100
Dental Procedure 0 9 0 100
H/O Jaundice 0 9 0 100
< 6 months - - - -
> 6 months - - - -
Sutures 0 9 0 100
Surgery 0 9 0 100
I/V Infusion 0 9 0 100
Abscess Drainage 0 9 0 100
Urinary Catheterization 0 9 0 100
Blood Donation 0 9 0 100
Endoscopy 0 9 0 100
Injection/EPI Immunization 0 9 100 0
Vaccination (Smallpox, Cholera) 6 0 0 100
Treatment from Quack 6 3 66.66 33.34
Shaving/Haircut in Barber Shop 3 6 33.34 66.66
Tooth Brush Sharing 0 9 0 100
Body Piercing 3 6 33.34 66.66
Tattooing 0 9 0 100
I/V Drug Abuse 0 9 0 100
Alcohol 0 9 0 100
Multiple Sexual Partners 0 9 0 100
Family H/O Hepatitis 3 6 33.34 66.66
Family H/O Liver Disease 3 6 33.34 66.66
Acupuncture 0 9 0 100
Circumcision 3 6 33.34 66.66
By Surgeon 0 - 0 -
By Hajam 3 - 100 -
Pregnancy 3 0 100 0
1 No. 0 - 0 -
2 Nos. 2 - 66.67 -
3 Nos. 1 - 33.33 -
4 Nos. 0 - 0 -
5 Nos. 0 - 0 -
6 Nos. 0 - 0 -
Abortions 1 2 33.33 66.67
1 No. 1 - 100 -
2 Nos. 0 - 0 -
Miscarriages - - - -
1 No. - - - -
2 Nos. - - - -
Forceps/Ventouse Deliveries - - - -
1 No. - - - -
2 Nos. - - - -
Deliveries by Caesarean Section 1 2 33.33 66.67
1 No. 1 - 100 -
2 Nos. 0 - 0 -
Breast Feeding 2 1 66.67 33.33

HCV in Bangladesh Mamun-Al-Mahtab et al

Of the participants 0.88% (9/1018) tested positive for anti-
HCV. All who tested positive were in the age group of 17-
50 years. Males predominated over females. 66% (6/9)
positive subjects were males and the remaining 33 % (3/
9) were females.

66% (6/9) were Muslims and rest 33% (3/9) Hindus. 66%
(6/9) had high school education, while 33% (3/9) received
primary education. None had any history of jaundice. The
risk factors for exposure to HCV are listed in Table II.
None had co-infection with hepatitis B virus (HBV).

Discussion
The study reveals that in our population the highest
prevalence of HCV is among young adults and middle-
aged individuals with a male predominance. This favours
horizontal transmission as the principal mode of
transmission of the virus, as we could not identify anyone
positive for anti-HCV in the 0-5 years age group.

The most important risk factor for exposure to HCV as
revealed by this study is treatment by ‘quacks’ (i.e. non-
qualified traditional medical practitioners) including
circumcision by ‘hajams’ (i.e. traditional rural practitioners
skilled in carrying out circumcision) and delivery by ‘dhais’
(i.e. traditional birth attendants) who are unaware of the
consequences of unhygienic and unsterile interventions.
Since these people still provide the backbone of primary
health care in our rural areas, educating them properly
regarding sterilization and hygiene is important. Injectable
drug abuse however is not a major problem in our country,
possibly due to religious beliefs and social norms.

While, as predicted, barbers appear to be responsible to
some extent for transmission of the virus, surprisingly
dental procedures, contrary to our usual belief, do not
appear to pose a significant threat. The traditional practice
of ear and nose piercing by our women is also an important
route of HCV transmission and thus extra care is warranted
before one goes for a hair cut or pierces a tissue.

At one time, before the discovery of the mode of
transmission of HCV, mass-vaccinations against cholera
and smallpox were carried out in Bangladesh and involved
repeated use of the same needle. Although it resulted in
the eradication of smallpox and in control of cholera, it
seems to be taking its toll now, as a significant proportion
of the study population who tested positive had a history
of such vaccination. This is similar to the resultant rise in
HCV infection in Egypt following mass-vaccination
against schistosomiasis.

The prevalence of HCV as revealed by this study is similar
to that reported in the Indian sub-continent where the figure

varies between 1%-5%5. The Indian sub-continent is in
the intermediate prevalence zone of the virus. The lowest
prevalence of HCV is seen in UK and Scandinavia where
it is 0.01%-0.1% and is slightly higher in USA (0.2%)
and Western Europe (0.5%). Higher percentages have been
reported from Eastern Europe, Middle East and the
Mediterranean5. HCV poses a huge burden on the health
of Bangladeshis, being a leading cause of all forms of
chronic liver diseases next only to HBV6, 7. This is similar
to the experience in India8, 9, Pakistan10 and Nepal11, 12.
HCV also ranks to be a leading cause of HCC in
Bangladesh13 as well as in the region including India8 and
Pakistan14.

Historically, Bangladesh has been a hyper-endemic area
for viral hepatitis. Patients with hepatitis are encountered
in Bangladesh round the year and epidemics due to
hepatitis A and E viruses (HAV and HEV) have broken
out on several occasions in the last century.

This study, which was mainly aimed to find out the
prevalence of HCV in Bangladesh may not be a truly
representative one in regard to sample size, but at the same
time it is one of the earliest as well as best designed
epidemiologic studies in Bangladesh for HCV and shows
that a small percentage of our population are infected with
the virus. Our data contradicts the 0% or 5% prevalence
of HCV among our population as reported by earlier
researchers4, 1. However our observation is in line with
our clinical experience in Bangladesh, where HBV
infection and HBV related chronic liver disease patients
are encountered much more commonly than those caused
by HCV. The reason for reportings of such low or high
prevalences of HCV by our predecessors is not exactly
known, but sample size, sensitivity of anti-HCV ELISA
kit used etc. may have influenced their data.

Although the prevalence of HCV is not high in our
population, given that we have a population of more than
140 million in Bangladesh, the total number of HCV
infected individuals in this country is understandably very
high. This deserves special attention as voluntary blood
donation is getting popular in Bangladesh, but there is
still serious concern regarding screening of donated blood
for HCV, especially in the non-government setting. Studies
carried out among combined injectable drug users and
heroin smokers in Bangladesh report of HCV prevalence
in them to be as low as 7% to as high as 77% in different
parts of the country15. Since these people are the principal
source of commercial blood donation in the country, anti-
HCV screening must therefore be strictly implemented, if
we are to avoid a deadly epidemic that may not be too far
away. The other issue that needs to be addressed to prevent

BSMMU J Vol. 2, Issue 1, January 2009

spread of HCV is to ensure screening patients for the virus
before any surgical or dental procedure, a practice that is
equally important, but almost not existent in Bangladesh.

Acknowledgement
We are grateful to Square Pharmaceuticals Ltd., Dhaka,
Bangladesh, for an un-restricted grant for this study.

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HCV in Bangladesh Mamun-Al-Mahtab et al