Prevalence and associated risk factors of hepatitis B virus infections among women of reproductive age in Juba, South Sudan
Introduction: Hepatitis B virus (HBV) is a partially double-stranded, enveloped virus with a circular DNA genome. This virus increasingly infects the population. Information on HBV infections in South Sudan is limited. This study aimed to examine the prevalence and major risk factors of HBV infections among women of reproductive age in Juba City, South Sudan.
Method: This study adapted a quantitative cross-sectional research design to assess prevalence and risk factors of HBV infections among these women. The study sites were seven health facilities in Juba. A validated semi-structured questionnaire was used to collect data from the 1808 randomly selected women. The study used EpiData software v4.7 to control data entry and Stata v15 for analysis. Chi squared tests and regression model were performed to determine association and likelihood respectively.
Results: Among the 1808 women, the burden of HBV infections was 11.2% and nearly half were unaware of their HBV status. The HBV infections were significantly associated with blood transfusion (p <0.001), surgical operations (p <0.001), and close contact with a case of HBV (p < 0.001). The women who had close contact with a case of HBV infections were 2.5 times more likely to be infected (OR: 2.487, 95% CI: 1.549 - 3.995). Women who had a history of surgical operations were more likely to be positive for HBV by 12.6% compared to those who had had no surgery (OR: 1.126, 95% CI: 0.614 - 2.067). The women who receive blood transfusions were more likely to be infected HBV (OR: 1.134, 95% CI 0.594 - 2.166).
Conclusion: The prevalence of HBV infections among these women was high and nearly half of them were unaware of their HBV status. It is associated with blood transfusion, surgical operations, and close contact with cases of HBV. The study recommends the improvement of tailored health promotion, antenatal HBV screening, birth dose vaccines.
Keywords: prevalence, associated risk factors, hepatitis B virus infections, women of reproductive age, Juba, South Sudan
Introduction
Hepatitis B virus (HBV) is a partially double-stranded, enveloped virus with a circular DNA genome. It belongs to Hepadnaviridae family of viruses. A first infection with HBV is considered as an acute infection. An infection lasting more than six months is defined as chronic infection. The transmission of HBV from mother to child during birth is known as vertical transmission. Horizontal transmission refers to the passage from one host to another (e.g. sexual contact with an infected person, blood transfusion).[1]
Globally, this virus infects 1.5 million people every year, accounts for 296 million chronic infections (3.8%), and 6 million children younger than five (0.9%) and 820,000 deaths. In Africa, the new cases of HBV infections are 990,000, the burden of HBV infections is 7.5% among the general population (82,300,000), among children younger than five years is 2.5% and deaths related HBV infections are 80,000.[2]
The magnitude of HBV endemicity in South Sudan has become a major public health problem. The burden of the infection among the South Sudanese general population is 22.4%.[3] Seropositivity of HBV among blood donors at the Blood Bank of Juba Teaching Hospital (JTH) is 18% and at the National Blood Bank is 8.2%.[4,5] The prevalence of HBV infections among pregnant women accessing health services at JTH stands ranges 6.3% to 11%.[6,7]
Conflicts have weakened the health system and the people’s health status, particularly among women and children.[8,9] Fragmented social structures exacerbate the transmission of HBV as do cultural patterns, e.g. inadequately sterilised tools used in ear piercing and tribal markings and eating together from common utensils.[7] Although many studies have been conducted on HBV prevalence and risk factors globally, few of them were conducted in South Sudan. This study was designed to examine prevalence and major risk factors of HBV infections among women of reproductive age in Juba City and to inform the relevant plans for policies, strategies, and practices.
Method
This study adapted a quantitative cross-sectional research design to assess prevalence and associated risk factors of HBV infections among these women at seven health facilities in Juba of South Sudan. These health facilities were Gumbo Primary Health Care Centre (PHCC), Gurei PHCC, Juba Military Referral Hospital (JMRH), Juba Teaching Hospital (JTH), Kator PHCC, Munuki PHCC, Nyakuron PHCC. The Cochran’s formula was adapted at 95% confidence level, 5% degree of accuracy, 15% non-response rate, design effect of 4, and variance of 50%. A sample size of 1808 women was calculated and was proportionally allocated to each health facility.
Women aged between 18 and 49 years and who accessed healthcare services were included and those who declined to participate in this study were excluded. A validated semi-structured questionnaire was used in collection of data.
The EpiData software version 4.7 was used to control data entry. Afterwards, the data were exported to Stata version 15 for analysis. Chi squared tests and regression model were performed to determine association and likelihood respectively.
Ethical approval was obtained from University of Juba Graduate College and the Ministry of Health Research Ethics Review Board. Participants consented to be included after being assured of confidentiality and privacy.
Results
A total of the 1808 women were interviewed of whom 925 (51.2%) had accessed HBV tests and 883 (48.8%) did not. The burden of HBV infections was 104 (11.2%) among these women.
The burden of this infection at the various sites is shown in Table 1. JMRH had the highest burden of HBV. Among the regions of South Sudan, Greater Bahr El Gazal region had the highest burden of HBV infections. Regarding the subnational levels, this burden was 14.5% in Eastern Equatoria, 25% in Abyei, 25% in Pibor, 33.3% in Northern Bahr El Ghazal. of Juba City Council Blocks, the burden was 5.8% in Munuki City Block, 13.3% in Juba City Block, 17.4% in Kator City Block (Table 1).
The women aged ≥ 45 years had the highest HBV infections (14.3%). Women who had attended formal education had a lower rate of infections compared to those who had not, that is, 10.3% and 16% respectively. Unemployed women had a higher burden of HBV infections than those who were employed. Whereas the unmarried women had 16.2% burden of HBV infections, the married ones had 10.7% burden of HBV infections (Table 1).
Table 1. The factors related to HBV infections among women of reproductive age
|
Variable |
HBV test results |
Total |
Chi-square test (p-value) |
|
|
Negative |
Positive |
|||
|
n (%) |
n (%) |
|||
|
Name of health facility |
13.106 (0.410) |
|||
|
JTH |
219 (91.6) |
20 (8.4) |
239 |
|
|
JMRH |
122 (83) |
25 (17) |
147 |
|
|
Gurei PHCC |
123 (92.5) |
10 (7.5) |
133 |
|
|
Nyakuron PHCC |
122 (91) |
12 (9) |
134 |
|
|
Gumbo PHCC |
113 (84.3) |
21 (15.7) |
134 |
|
|
Munuki PHCC |
62 (91.2) |
6 (8.8) |
68 |
|
|
Kator PHCC |
60 (85.7) |
10 (14.3) |
70 |
|
|
Age group |
0.070 (0.792) |
|||
|
< 32 years |
646 (88.6) |
83 (11.4) |
729 |
|
|
≥ 32 years |
175 (89.3) |
21 (10.7) |
196 |
|
|
Age group |
0.768 (0.857) |
|||
|
18 - 24 years |
293 (89.9) |
33 (10.1) |
326 |
|
|
25 - 34 years |
417 (88.3) |
55 (11.7) |
472 |
|
|
35 - 44 years |
99 (87.6) |
14 (12.4) |
113 |
|
|
≥ 45 years |
12 (85.7) |
2 (14.3) |
14 |
|
|
Residential area in Juba |
15.322 (0.002) |
|||
|
Juba |
52 (86.7) |
8 (13.3) |
60 |
|
|
Kator |
142 (82.6) |
30 (17.4) |
172 |
|
|
Munuki |
260 (94.2) |
16 (5.8) |
276 |
|
|
Others |
367 (88) |
50 (12 |
417 |
|
|
Residence |
13.402 (0.515) |
|||
|
Rural |
367 (88) |
50 (12) |
417 |
|
|
Urban |
454 (89.4) |
54 (10.6) |
508 |
|
|
Region of origin |
1.496 (0.473) |
|||
|
GER |
650 (88.6) |
84 (11.4) |
734 |
|
|
GBR |
62 (86.1) |
10 (13.9) |
72 |
|
|
GUR |
109 (91.6) |
10 (8.4) |
119 |
|
|
State of origin |
18.139 (0.112) |
|||
|
Central Equatoria |
464 (88.2) |
62 (11.8) |
526 |
|
|
Eastern Equatoria |
94 (85.5) |
16 (14.5) |
110 |
|
|
Western Equatoria |
92 (93.9) |
6 (6.1 |
98 |
|
|
Jonglei |
73 (91.3) |
7 (8.8) |
80 |
|
|
Lakes |
36 (90) |
4 (10 |
40 |
|
|
Unity |
18 (94.7) |
1 (5.3) |
19 |
|
|
Upper Nile |
14 (93.3) |
1 (6.7) |
15 |
|
|
Northern Bahr El Ghazal |
6 (55.6) |
3 (44.4) |
9 |
|
|
Warrap |
10 (90.9) |
1 (9.1) |
11 |
|
|
Western Bahr El Ghazal |
8 (100) |
0 (0) |
8 |
|
|
Pibor |
3 (75) |
1 (25) |
4 |
|
|
Abyei |
3 (75) |
1 (25) |
4 |
|
|
Ruweng |
1 (100) |
0 (0) |
1 |
|
|
Religion |
3.090 (0.213) |
|||
|
Christianity |
724 (88.9) |
90 (11.1) |
814 |
|
|
Islam |
96 (88.1) |
13 (11.9) |
109 |
|
|
Traditional Beliefs |
1 (50) |
1 (50) |
2 |
|
|
Formal education |
4.301 (0.038) |
|||
|
No |
131 (84) |
25 (16) |
156 |
|
|
Yes |
690 (89.7) |
79 (10.3) |
769 |
|
|
Main occupation |
1.007 (0.316) |
|||
|
Housewife |
552 (88) |
75 (12) |
627 |
|
|
Others |
269 (90.3) |
29 (9.7) |
298 |
|
|
Employment status |
0.206 (0.650) |
|||
|
Unemployed |
399 (88.3) |
53 (11.7) |
452 |
|
|
Employed |
422 (89.2) |
51 (10.8) |
473 |
|
|
Marital status |
2.869 (0.650) |
|||
|
Unmarried |
83 (83.8) |
16 (16.2) |
99 |
|
|
Married |
642 (89.2) |
78 (10.8) |
720 |
|
|
Separated/widow |
96 (90.6) |
10 (9.4) |
106 |
|
|
Type of marriage |
0.160 (0.690) |
|||
|
Monogamy |
444 (89.7) |
51 (10.3) |
495 |
|
|
Polygamy |
294 (88.8) |
37 (11.2 |
331 |
|
|
Parity |
2.036 (0.154) |
|||
|
≤ 3 |
517 (89.9) |
58 (10.1) |
575 |
|
|
> 3 |
304 (86.9) |
46 (13.1) |
350 |
|
|
Monthly family income |
5.577 (0.233) |
|||
|
≥ USD50 |
72 (94.7) |
4 (5.3) |
76 |
|
|
≥ USD100 |
210 (90.1) |
23 (9.9) |
233 |
|
|
≥ USD150 |
147 (88) |
20 (12) |
167 |
|
|
≥ USD200 |
230 (88.8) |
29 (11.2 |
259 |
|
|
≤ USD201 |
162 (85.3) |
28 (14.7) |
190 |
|
|
Use of mani-pedicure instrument |
0.002 (0.962) |
|||
|
Own instruments |
452 (88.8) |
57 (11.2) |
509 |
|
|
Common instruments |
369 (88.7) |
47 (11.3) |
416 |
|
|
Scarification or tribal marks |
1.724 (0.189) |
|||
|
No |
675 (89.4) |
80 (10.6) |
755 |
|
|
Yes |
146 (85.9) |
24 (14.1) |
170 |
|
|
Dental procedure |
0.054 (0.189) |
|||
|
No |
632 (88.9) |
79 (11.1) |
711 |
|
|
Yes |
189 (88.3) |
25 (11.7) |
214 |
|
|
Blood transfusion |
5.946 (0.015) |
|||
|
No |
706 (89.8) |
80 (10.2) |
786 |
|
|
Yes |
115 (82.7) |
24 (17.3) |
139 |
|
|
Surgical operation |
6.074 (0.014) |
|||
|
No |
694 (89.9) |
78 (10.1) |
772 |
|
|
Yes |
127 (83) |
26 (17) |
153 |
|
|
Close contact with hepatitis B case |
25.854 (<0.001) |
|||
|
No |
667 (91.5) |
62 (8.5) |
729 |
|
|
Yes |
154 (78.6) |
42 (21.4) |
196 |
|
|
Smoking shishia (tobacco) |
12.805 (<0.001) |
|||
|
Yes |
135 (80.8) |
32 (19.2) |
167 |
|
|
No |
686 (90.5) |
72 (9.5) |
758 |
|
|
Drinking alcohol |
4.952 (0.026) |
|||
|
Yes |
160 (84.2) |
30 (15.8) |
190 |
|
|
No |
661 (89.9) |
74 (10.1) |
735 |
|
|
Overall burden of HBV infections |
821 (88.8) |
104 (11.2) |
925 |
|
To determine the major risk factors associated with HBV infections among these women, the analyses by Chi-square test and of logistic regression were performed.
The Chi-square X2 identified that, of the sociodemographic characteristics, HBV infection was significantly associated with residential area (p =0.002), and formal education (p = 0.038) (Table 1). Furthermore, of the health behaviours, HBV infection was statistically associated with blood transfusion (p <0.001), surgical operations (p <0.001), close contact with a case of HBV (p < 0.001), smoking of shishia (p < 0.001) and drinking of alcohol (p < 0.001) (Table 1).
The statistically significant factors (independent variables) and HBV test results (dependent variable) were entered into logistic regression model. This was to determine the likelihood of the association. A preliminary analysis entailed that the statistical multicollinearity was realised with overall tolerance = 0.984. A review of standardized residual values highlighted that there were outliers which were kept in the dataset. Thus, the model was statistically significant, [X2 (9=925)=42.269, p <0.001], indicating that the model could differentiate study participants who had HBV positive test result from those who had a negative result. Subsequently, the model explained between 4.5% (Cox & Snell R2) and 8.8% (Nagelkerke R2) of the variance and correctly predicted 88.8% of the test results. As shown in Table 2, Juba residential area and use of tobacco had significantly contributed to the model.
Table 2. Predictors of HBV infections among women of reproductive age: Multivariable Analyses
|
Predictor |
B |
SE |
Wald |
df |
p-value |
OR (95% CI LL, UL) |
|
Residential area in Juba |
|
|
|
|
|
|
|
Juba* |
|
|
|
|
|
|
|
Kator |
0.177 |
0.423 |
0.176 |
1 |
0.675 |
1.194 (0.522, 2.734) |
|
Munuki |
0.353 |
0.259 |
1.862 |
1 |
0.172 |
1.423 (0.857, 2.363) |
|
Others |
-0.726 |
0.305 |
5.645 |
1 |
0.018 |
0.484 (0.266, 0.881) |
|
Formal education |
|
|
|
|
|
|
|
No* |
|
|
|
|
|
|
|
Yes |
0.392 |
0.258 |
2.298 |
1 |
0.13 |
1.479 (0.892, 2.454) |
|
Ever blood transfused |
|
|
|
|
|
|
|
No* |
|
|
|
|
|
|
|
Yes |
0.126 |
0.33 |
0.146 |
1 |
0.703 |
1.134 (0.594, 2.166) |
|
Surgically operated |
|
|
|
|
|
|
|
No* |
|
|
|
|
|
|
|
Yes |
0.119 |
0.31 |
0.148 |
1 |
0.701 |
1.126 (0.614, 2.067) |
|
Contact with case of HBV |
|
|
|
|
|
|
|
No* |
|
|
|
|
|
|
|
Yes |
0.911 |
0.242 |
14.206 |
1 |
<0.001 |
2.487 (1.549, 3.995) |
|
Ever used tobacco |
|
|
|
|
|
|
|
No* |
|
|
|
|
|
|
|
Yes |
0.272 |
0.311 |
0.766 |
1 |
0.382 |
1.313 (0.714, 2.414) |
|
Ever taken alcohol |
|
|
|
|
|
|
|
No* |
|
|
|
|
|
|
|
Yes |
0.055 |
0.298 |
0.035 |
1 |
0.853 |
1.057 (0.59, 1.894) |
|
Constant |
-2.454 |
0.191 |
165.089 |
1 |
<0.001 |
0.086 |
|
*Reference category |
||||||
Table 2 presents odds ratios (OR) analyses of HBV infections among the women. The women who had close contact with a case of HBV infections were 2.5 times more likely to be infected (OR: 2.487, 95% CI: 1.549 - 3.995). For every increase in odds of the women who smoke shishia, there is 31.3% likelihood of these women to be HBV infected (OR: 1.313, 95% CI: 0.714 - 2.414). Those who attend formal education were 1.5 times more likely to have negative HBV results than those who did not attend formal education (OR: 1.479, 95% CI: 0.892 - 2.454). Women who had a history a surgical operation were more likely to be positive for HBV at 12.6%.
Discussion
This study found that the overall burden of HBV infections was 11.2% among women of reproductive age. This burden is higher than the regional estimate (East Africa 6%) and also higher than other in-country studies (Juba Teaching Hospital, 11%; Bor State Referral Hospital, 8.6%.[6,10,11]) The study also identified that nearly half of these women were unaware of their HBV status. This might be due to the test of HBV infection being optional. Promoting the importance of antenatal hepatitis B testing is continuing. It is likely that this burden is a consequence of weak health systems.[8,9] Furthermore, fragmented social structures and cultural patterns may play a part in exacerbating the transmission of HBV.[7]
This study identified that HBV infection is associated with residential area, level of education and history of blood transfusion, surgical operations, close contact with other HBV infected persons, smoking of shishia and alcohol consumption. Our findings are consistent with previous studies: HBV infections in Ethiopia are associated with blood transfusion and with level of education in a Nigerian Study.[12,13]
Conclusion
The prevalence of HBV infections among women of reproductive age was high and nearly half of these women were not aware of their HBV status. It is significantly associated with, level of education, blood transfusion, surgical operations, close contact with HBV infected persons, smoking of shishia and alcohol consumption. Concerted efforts should be made to improve the provision of healthcare services incorporating tailored health promotion, antenatal HBV screening, birth dose vaccines, and continuing professional development for healthcare providers.
Conflict of interest: None
Sources of funding: None
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