Assessment of Hepatitis B Virus and Associated Risk Factors
Among Pregnant Women Attending Antenatal Care at Arsi
University Asella Referral and Teaching Hospital, Ethiopia
Nigatu Tumsa1, Tulu Degefu1, Zerihun Belay2
Adama Science and Technology University School of Applied Natural Sciences,
Applied Biology Program.
Abstract
Hepatitis B virus is a public health problem worldwide. Vertical transmission from
mother to baby is an important route of transmission for hepatitis B virus infection.
Consequently, screening pregnant women and realizing the sero-prevalence of
hepatitis B virus during pregnancy is vital to prevent the infection of new born baby
from positive mother. The objective of this study was to assess the sero-prevalence
of hepatitis B virus among pregnant women and to identify potential risk factors
associated with the infection. The study was conducted from January to May, 2016
using data from pregnant women attending the antenatal care unit of Arsi University
Asella Referral and Teaching Hospital, Arsi Zone,Oromia Regional State, Ethiopia.
Blood samples were collected from 454 pregnant women and tested for hepatitis B
surface antigen using rapid strip test which is a qualitative solid phase two site
sandwich immunoassay. A pre-structured questionnaire was used to collect socio-
demographic data and to find out possible risk factors. The overall study subjects
with hepatitis B surface antigen positive were 44(9.7%). Most 301(66.3%) of study
participants live in urban and 442(97.4%) were married. The socio-demographic
status of the participants shows that high hepatitis B surface antigen positivity was
among the urban 29(65.9%) and those who were house wife. All except the
gestational age of 3
rd
trimester (p<0.05) the participants demographic
characteristic had no significant association with Hepatitis B Virus. None of the risk
factors had statistically significant association with hepatitis B virus (P>0.05). It
can be concluded that high prevalence of hepatitis B virus among pregnant women
was found in this study as compared to the previous studies in different regions of
Ethiopia. This high prevalence indicates the importance of implementing preventive
measures including vaccination to women in the child bearing age as they are at
increased risk of acquiring HBV compared to the general population.
Key words: Hepatitis B virus, pregnant women, prevalence, risk factors
1. INTRODUCTIO
Hepatitis B virus is the most
serious types of viral hepatitis
which can lead to chronic liver
disease and put people at high risk
of death from cirrhosis of the liver
and liver cancer. Globally, over 350
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Ethiopian Journal of Science and Sustainable Development (EJSSD)
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million people are affected with
hepatitis B virus (HBV) infection
and over 1 million die annually of
HBV-related chronic liver disease
(Teresa and Wright, 2006).
Although the major source of
HBV is blood and blood products
it is also found in semen, saliva,
tears, breast milk, vaginal and
menstrual secretions and amniotic
fluid. Transmission occurs
through contaminated blood and
blood components by transfusion,
needle sharing, tattooing and
through very close personal
contact involving the exchange of
semen, saliva and vaginal
secretions and child birth
(Lavanchy, 2004). Population at
risk include health care personnel,
intravenous drug users,
hemophiliacs, infants born to
HBsAg positive mothers, renal
dialysis patients, sexual partners of
HBV carriers and individuals with
multiple sexual partners (CDC,
2014).
The major mode of
transmission of hepatitis B virus is
mother to child (Teresa and
Wright, 2006). It has been reported
that 10–30% of HBsAg positive
pregnant mother transmit the virus
to their babies. However, mothers
who are positive for both HBsAg
and HBeAg have chance of
transmitting HBV to their new
born is 70-90 % (Kwon and Lee,
2011). Up to 90% of the newborns
born from these mothers go on to
develop chronic hepatitis B caused
by HBV if they do not receive
hepatitis B virus immunoglubulin
and hepatitis B vaccine at birth
(Apuzzia et al., 2012).
HBV is the leading cause of
chronic liver disease and liver-
related deaths worldwide with the
majority of these causes occurring
in Africa and Asia, where HBV
prevalence is higher than 8 %
(Hoffmann and Thio, 2007). The
global prevalence of chronic HBV
infection varies widely from high
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(>8%) to intermediate (2-7%) and
low < 2% (Custer et al., 2004). The
prevalence of HBV is estimated at
8 % in West Africa and 5-7% in
Central Eastern and Southern
Africa (Su, 2010).
Hepatitis B virus is endemic
in Africa next to Asia, with a sero-
prevalence rate of between 8 and
20% (Elizabeth and Ramsey,
2011). In Ethiopia, Hepatitis B is
endemic with an average
prevalence of 10.8 %. However, it
is likely to be underreported due to
the lack of diagnostic facilities and
appropriate surveillance systems
(Fassil Shiferaw et al., 2016). In
Ethiopia studies have shown that
wide geographic and socio-
economic variation in hepatitis B
prevalence, ranging between 5.7
and 10.8 % (Asfaw Negero et al.,
2011). The sero-prevalence of
HbsAg is found to be as high as
14.4% in blood donors
(Rahlenbeck et al., 1997). Earlier
hospital-based studies showed that
hepatitis B accounts for 12 % of
hospital admissions and 31 % of
deaths in Ethiopian hospitals
(Tsega, 2000).
In a study that was done to
define the mode of transmission of
HBV infection in Ethiopia showed
that 5% of pregnant women were
reported to be positive for HBsAg
(Tsega et al., 1988). In another
study which was done to
determine the sero prevalence of
HBsAg and its risk factors among
pregnant women in Jimma
southwestern Ethiopia was 3.7%
(Mohammed Awole and Solomon
Gebresilasie, 2005). Recent
studies at public hospitals in
Ethiopia by Tsegaye Yohanes et
al.(2016) and Yeshi Metaferia et
al. (2016) showed that the
prevalence of HBV infection
among pregnant women was
intermediate (2-7.8 %).
Apart from a dearth of
information, concerning the
prevalence of HBV infection
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among pregnant women in
Ethiopia, the existing data are also
differing from region to region. In
addition, viral hepatitis screening
services are not widely available
except for the occasional
mandatory medical checkups for
work or travel purposes. The
magnitude of the problem is so
high that over 5.2% million people
are estimated to be living with
chronic HBV infection among the
general population of Ethiopia
(Ott et al., 2012). Knowing the
prevalence of HBV specifically
during pregnancy is vital for the
reason that major mode of
transmission is prenatal and the
best way of assessing the
prevalence in general population is
its prevalence in pregnant mothers.
So screening of all pregnant
mothers is critical to know the
burden of the problem and to
indicate the prevalence of HBV in
Ethiopia including the central
regions of the country.
By considering the existing
scarcity of information about HBV
infection in highly risk groups
especially pregnant women the
current study was conducted to
determine the prevalence of HBV
among pregnant women and risk
factors associated with hepatitis B
infection among pregnant women
attending antenatal care at Arsi
University, Asella Referral and
Teaching Hospital, Central
Ethiopia.
2. MATERIALS AND METHODS
2.1. Study area
The research was conducted
at Arsi University Asella Referral
and Teaching Hospital, Ethiopia.
Asella is found in Oromia
Regional State, central Ethiopia, at
a distance of 178 km southeast of
capital city Addis Ababa.
According to CSA (2007), Asella
town has a total population of
74,268 of whom 37,337 are male
and 36,931 are females. The
hospital is a referral and teaching
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hospital serving people coming
from all over 22 weredas in Arsi
zone. It gives antenatal care
service for more than average 20
pregnant women daily. The
hospital is with two laboratory
rooms, one for MCH and the other
for the other patients attending the
hospital.
2.2. Study population and design
A cross sectional hospital
based study was conducted among
pregnant women attending
antenatal care at Arsi University,
Asella Referral and Teaching
Hospital and voluntary to
participate in the study by giving
blood sample for screening HBV
infection and to respond
questionnaires during study
period. Sampling size was
calculated with single proportion
formula by taking Hepatitis B
surface antigen prevalence from
other studies conducted among
pregnant women 4.5%
(Kothari,2004) 2% error of
margin and 10 % non -response
rate
(𝑍𝛼/2)2𝑃(1−𝑃)
N= ,
𝑑2
(Where N=sample size; P =
Proportion of HBsAg prevalence
reported in similar study noted
above (4.5%); d=2% error of
margin; Z α/2 =Standard normal
probability for 95% CI (1.96).
2.3. Data collection and laboratory
investigation
A pre-tested structured
questionnaire was delivered to
volunteer pregnant women to obtain
socio-demographic information
including maternal age, gestation age,
occupation, educational status,
living area and other information
on risk factors for transmission of
HBV including a history of
previous blood transfusion, place
of previous birth, any surgical
procedure, tattooing, and hospital
admission by data collectors. The
questionnaires were first prepared
in English then translated into
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Afan Oromo and Amharic.
After completion of the
questionnaire, about 5ml of blood
sample was aseptically collected
by venipuncture from each
participant into sterile plane bottle.
The blood samples were left to
form clots at room temperature,
after which they were centrifuged
for 10 minutes at 200 revolutions
per minute (rpm) to separate serum
or plasma from clot. Sample
testing was done using rapid strip
test which is one step test that
utilizes the principle of rapid
chromatographic immunoassay
for the qualitative detection of
Hepatitis B surface antigen in
serum or plasma (Blumberg,
1971).
The separated serum was
allowed to equilibrate to room
temperature (15-300C).To perform
the laboratory test the foil pouch
was opened and remove the strip.
The strip was deepened in to the
serum for at least 5 seconds until it
was thoroughly wet and reaches
the level indicated by the arrows
on the strip. The strip was removed
from the specimens and placed on
a flat dry surface until the red lines
appeared. The result was read in
15 minutes. Interpretation of the
result was made as follows.
Positive: Two distinct red lines
appear, one line should be in the
control region(C) and another line
should be in the test region (T).
Negative: one red line appears in
the control region (C).No apparent
red or pink line appears in the test
region (T). Invalid: control lines
failed to appear due to insufficient
specimen volume or incorrect
procedural techniques. In that case
the procedure was repeated with a
new test strip.
2.4 Data analysis
The sero-prevalence of HBsAg
was expressed in percentages in
the study group and results were
presented in tables. Data was
entered and analyzed using the
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statistical software SPSS version
21. Chi-square test and bivariate
logistic regression analysis were
used to determine the association
between dependent variables and
the independent variables. The
result was considered statistically
significant at P<03.
3. RESULTS
3.1 The Socio-demographic
characteristics of the
participants
This study included 454
pregnant women attending the
antenatal care unit of Arsi
University Asella Referral and
Teaching Hospital during the
period of January, 2016 to May,
2016. Out of the total participants,
197 (43.4%) were in the age group
23-27, followed by 125 (27.5%) in
the age group 28-32, 96 (21.16%)
in the age group 18-22, 29 (6.4%)
in the age group 33-37 and 7
(1.5%) were in the age group 38-
42(Table.1).
Most of the study subjects
were from urban 301(66.3%) and
almost near to the total number of
the study participants were
married 443 (97.5%). The
majority of the study participants
were house wives 77(17.0%) and
about half of these women had an
education level of less than
secondary school (Table 1).
3.2 The risk factors of HBV
infection
The risk factors included in
this study were history of blood
transfusion, hospital admission,
surgical procedure, multiple
sexual practice, female genital
mutilation and body tattooing.
Most of the participants
408(89.9%) had no history of
blood transfusion. Of the total,
333(73.3%) were not admitted in
hospital. Of the total, only
36(7.9%) of the pregnant women
had history of surgical procedure.
But majority of the participants
439(96.7%) had no history of
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multiple sexual practice.
Similarly, 282(62.1%) of the
pregnant women had no genital
mutilation and only 25(5.5%) had
tattoo on their body (Table 2).
Table 1. The socio-demographic characteristics of pregnant women attending
the antenatal unit at Arsi University Asella Referral and Teaching
Hospital, 2016.
Socio-demographic characteristics Frequency Percentage (%)
Age group
18-22 96 21.1
23-27 197 43.4
28-32 125 27.5
33-37 29 6.4
38-42 7 1.5
Resident
Urban 301 66.3
Rural 153 33.7
Marital status
Single 11 2.4
Married 443 97.5
Educational status
Illiterate 71 15.6
1-8 157 34.6
9-12 142 31.3
Diploma 65 14.3
Degree and above 19 4.2
Gestational age
1st trimester 46 10.1
2nd trimester 104 22.9
3rd trimester 304 67.0
Abortion status
Yes 87 19.2
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No 367 80.8
Place of previous delivery
No birth 197 43.4
Home 80 17.6
Health institution 177 39
Screened for HBV
Yes 274 60.4
No 180 39.6
Vaccination for HBV
Yes 19 4.2
No 435 5.8
Total=454(100%) under each variable
Table 2. The risk factors characteristics of the participant women attending
the antenatal unit at Arsi University Asella Referral and Teaching
Hospital, 2016
Variables Frequency Percent
History of blood transfusion
Yes 46 10.1
No 408 89.9
Hospital admission
Yes 121 26.7
No 333 73.3
Surgical procedure
Yes 36 7.9
No 418 92.1
Multiple sexual activity
Yes 15 3.3
No 439 96.7
Body tattooing
Yes 25 5.5
No 429 94.5
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Female genital mutilation
Yes 172 37.9
No 282 62.1
3.3. Sero-prevalence of HBV in
pregnant women by socio -
demographic characteristics
Among 454 pregnant women
tested for HBsAg, 44(9.7%) were
positive for HBsAg (Table 3). The
sero-prevalence of HBsAg in
relation to age showed that the
highest prevalence of HBsAg
15(34.1%) were in the age group
of 23-27, followed by 14 (31.8%)
in the age group of 28-32, and 12
(27.3%) was in the age group of
18-22. Majority of pregnant
women 29(65.9%) positive for
HBV were in urban and all of
44(100%) positive mothers were
married. High number of HBsAg
positive 27(61.3%) were in
elementary and high school
educated. With regard to
occupation HBsAg positivity was
highest 29 (65.9%) among house
wife and most 24(54.5%) of
HBsAg positive mothers were on
3rd trimester followed by 12
(27.3%) on 2nd trimester (Table 3).
3.4. The Association between
prevalence and risk factors of
hepatitis B virus
The expected risk factors
associated with exposure to
HBsAg were determined by
comparing the significant
association (P<0.05) of HBsAg
detection for study participant as
shown in Table (4). None of the
risk factors had been found to be
associated with HBsAg sero-
positivity (P>0.05). However,
almost most of the study
participants were exposed to at
least one HBV infection risk
factors. Among 454 pregnant
women tested 172 (37.9%) had
history of female genital
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mutilation of these 20(45.5%)
were positive for HBsAg which
was the highest prevalence among
risk factors. Out of 121(26.6%)
who were admitted to hospital 14
(31.8%) were positive for HBV. A
total of 46(10.1%) had history of
blood transfusion of these 3(6.8%)
were positive for HBsAg, 36
(7.9%) had surgical procedure of
these only 2(4 .5%) were positive
for HBsAg. 15(3.3%) had multiple
sexual activity out of these only
3(6.8%) were positive. Pregnant
women who had body tattoo were
25(5.5%) among these only
2(4.5%) were positive for
Hepatitis B surface antigen.
Table 3. Sero-prevalence of hepatitis B virus (HBsAg) by socio-demographic
characteristics of the participant women attending the antenatal unit
at Arsi University Asella Referral and Teaching Hospital, 2016.
Variables
BsAg positivHBsAG (+)
Freq. freq. %)
HBsAg (-)
Freq. (%)
X2 P value
Age
18-22 12 27.3 84 20.5
34.1
23-27 15 182 44.4
2.589
28-32 14 31.8 111 27.1 0.912
33-37 2 4.5 27 6.6
38-42 1 2.3 6 1.5
Resident
Urban 29 65.9 272 66.3 0.003
0.433
Rural 15 34.1 138 33.7
Marital
status
Single 0 0 11 2.7
1.323
Married 44 100 398 97.1
In
relationsh
ip
0.998
0 0 1 0.24
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Educatio
nal status
Illiterate
1-8
9-12
Diploma
Degree &
above
Occupati
on
Employed
House
wife
Daily
labor
Student
Self
employer
Gestation
al age
1st
trimester
2nd
trimester
3rd
trimester
Abortion
status
3.829
4.643
0.132
0.011
3.390 0.119
11 25 60 14.6
14 31.8 143 34.9
13 29.5 129 31.5
4 9.1 61 14.9
2 4.5 17 4.1
7 15.9 70 17.1
29
2
65.9
4.5
281
11
68.5
2.7
0.678
0.806
1 2.3 8 2
5 11.4 40 9.8
8 18.2 38 9.3
12
27.3
92
22.4
24
54.5
280
68.3
Yes 13 29.5 74 18.1
No
Place of
31
70.5
336
82
previous
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Birth
No birth 20 45.5 177 43.2
Home 13 29.5 67 16.3
Hospital 11 25 166 40.5
Screened
for HBV
6.424
0.1
37
Yes 22 50 252 61.5
No 22 50 158 38.8
Vaccinati
on for
HBV
Yes 0 0 19 4.6
No 44 100 391 95.4
2.182 0.101
2.128
0.998
*Total sample=454(100%), positive=44(100) Negative=410(100) under each variables
Table 4. Bivarate assessment of risk factors for hepatitis B virus (HBsAg)
positivity
Variables
Frequency
(%)
HBsAg.
+ve (%)
X2 P-value
History of blood
transfusion
46(10.1) 3(6.8) 0.588 0.156
History of multiple
sexual activity
15 (3.3) 3(6.8) 1.665 0.998
Surgical procedure 36(7.9) 2(4.5) 0.764 0.188
Hospitalization 121(26.7) 14(31.8) 0.665 0.063
Female genital
mutilation
172(37.9) 20(45.5) 1.186 0.243
Body tattooing 25(5.5) 2(4.5) 10.160 0.330
No risk factor 40(8.8) 0(0)
Total 454(100) 44(100%)
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4. DISCUSSION
In this study the overall
prevalence of HBsAg in pregnant
women was 9.7%. According to
HBV prevalence classification of
WHO (2011), the finding of this
study has showed high endemicity
of HBV infection (≥8%) among
tested pregnant women. This
investigation implies that the
pregnant women are at high risk
for transmission of the disease.
The seroprevalence found in this
study was comparable with the
findings of previous studies in
Sub-Saharan countries such as
10.2% in Cameron (Noubiap et al.,
2015), 8.2% in northeast Nigeria
(Olokoba et al., 2011) and in Mali
8% (Maclean et al., 2012).
Contrary to these, it was higher
than the study conducted in
different regions of Ethiopia in
Addis Ababa 3% (Dessie Tegegne
et al., 2014), in Jimma , southwest
Ethiopia 3.7% (Mohammed
Awole and Solomon Gebresilasie,
2005), in Bahir-dar , northwest
Ethiopia 3.8% (Yohanis Zenebe et
al., 2014), Arba minch general
hospital 4.3% (Tsegaye Yohanes
et al.,2015) and in Addis Abeba in
three teaching hospitals 4.5%
(Sisay Kirba, 2014).
However, it was lower than
the study reported in university of
Benin, Nigeria in which the
prevalence of HBV infection
among pregnant women was
12.5% (Ugbebor et al., 2011), in
Zaria 18.2% (Luka et al., 2008), in
Makurdi, Nigeria 11%
(Mbaawuage, 2008) and in Taiwan
15.5% (Lin, 2008). The difference
in prevalence might be due to
geographic variations and
different sample populations
(Vazquez-Martinez et al., 2003),
difference in socioeconomic status
and traditional practices.
In developed nation where
regular screening and vaccination
of HBV is provided for pregnant
https://www.ncbi.nlm.nih.gov/pubmed/?term=Tegegne%20D%5BAuthor%5D&cauthor=true&cauthor_uid=24731794
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women low prevalence rate (<2%)
was reported (0.14 %-0.97%) in
USA (Euler et al., 2003), (1.65%)
in Mexico (Vazquez –Martinez,
2003) and (1.6%) in Saudi Arabia
(Alrowaily et al., 2008). A study
conducted by Ding et al. (2013)
indicates that the prevalence of
HBsAg among pregnant women in
Shenyang, China was lower than
the overall prevalence in China
because the transmission from
mother to child can be prevented
by administration of
immunoprophylaxis with HBIG
and HBV vaccine.
The present study also
revealed that the socio-
demographic characteristics of the
pregnant women did not show
significance association with the
prevalence of HBV infection
except the gestational age (P=
0.011). The highest sero-
prevalence of HBV infection was
found in those pregnant women at
the third trimester as compared to
first and second trimesters. This
was similar with other studies
conducted elsewhere in Ethiopia
(Zelalem Desalegn et al. 2016;
Yeshi Metaferia et al., 2016).
In this study, age was found to
have no significant associations
with HBV infection. However,
other studies showed higher
prevalence among women
between the ages of 23 to 32
(Tsegaye Yohanes et al., 2016;
Nyamusi et al., 2017). This is
expected because majority of
women in the child bearing age are
in their twenties. Moreover,
though not significant higher
prevalence of HBsAg 29(65.9%)
was reported from urban area
which is similar to in Sudan
(Abdallah et al., 2011) and in
Rwanda (Nyamusi et al., 2017).
However, contrary to this other
study in southern Ethiopia (Yeshi
Metaferia et al., 2016) showed
higher prevalence of HBsAg
among pregnant mothers from
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rural area than the urban
counterparts.
This study revealed that none
of the expected risk factors were
significantly associated with sero-
positivity for HBsAg (Table 4).
However the female genital
mutilation was the highest in the
percentage of the prevalence of
HBsAg 20 (45.5%) which
indicates that traditional practicing
of unsterilized instruments for
genital mutilation may increase
the risks of infection than other
risk factors. Elsewhere in the
previous reports, other factors
such as blood transfusion, body
tattooing, multiple sexual activity
and surgery were potential risk
factors for HBV infection
(Yohanis Zenebe et al.,2014:
Yeshi Metaferia et al., 2016). This
variation might be attributing to
cultural, being aware on
prevention and transmission,
educational and behavioral
differences for the risk factors of
HBV infection.
5. CONCLUSION
In conclusion, in this study,
the prevalence of HBsAg among
pregnant mothers attending Arsi
University Asella Teaching
Hospital was high according to
WHO criteria. All of the
demographic characteristics of the
participants had no significant
association with HBV infection
except for the gestational age
which shows the significant
prevalence in the 3rd trimester
compared to other factors. The
high prevalence of HBsAg among
pregnant women in this study
indicates the importance of
implementing preventive measures,
including vaccination to women in
the child bearing age as they are at
increased risk of acquiring HBV
compared to the general
population.
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ACKNOWLEDGEMENTS
We are very grateful to the
pregnant women who showed
willingness to participate in the
study and to the staff of Arsi
University Asella Referral and
Teaching Hospital.
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