HARAMAYA UNIVERSITY
SCHOOL OF GRADUATE STUDIES
SERO-PREVALENCE OF HEPATITIS B VIRUS INFECTIONS AND
ASSOCIATED
FACTORS
AMONG
PREGNANT
WOMEN
ATTENDINGANTENATAL CLINIC AT DEDER HOSPITAL, EASTERN
ETHIOPIA
MPH Thesis
Abdi Umare
August, 2015
Haramaya, Ethiopia
HARAMAYA UNIVERSITY
SCHOOL OF GRADUATE STUDIES
SERO-PREVALENCE OF HEPATITIS B VIRUS INFECTIONS AND
ASSOCIATED FACTORS AMONG PREGNANT WOMEN ATTENDING
ANTENATAL CLINIC AT DEDER HOSPITAL, EASTERN ETHIOPIA
A Thesis Submitted to the College of Health and Medical Sciences, School of
Graduate Studies, and Haramaya University
In Partial Fulfillment of the Requirements for the Degree of
Masterin Public Health
Abdi Umare
Major Advisor: BerhanuSeyoum (PhD, Assistant Professor)
Co-Advisor: TesfayeGobana (MPHM, PhD, Associate Professor)
August, 2015
Haramaya, Ethiopia
STATEMENT OF THE AUTHOR
By my signature below, I declare and affirm that this thesis is my own work. I have followed
all the ethical and technical principles of scholarship in the preparation, data collection, data
analysis and compilation of this thesis. Any scholarly matter that is included in the thesis has
been given recognition through citation.
This thesis is submitted in partial fulfillment of the requirements for a MPH degree at
Haramaya University. The Thesis is deposited at the University Library and is made available
to borrowers under the rules of the library. I solemnly declare that this thesis has not been
submitted to any other institution anywhere for the award of any academic degree, diploma, or
certificate.
Brief quotations from this thesis may be made without special permission provided that
accurate and complete acknowledgement of the source is made. Requests for permission for
extended quotations from or reproduction of this thesis in whole or in part may be granted by
the head of the school or department when in his or her judgment the proposed use of the
material is in the interests of scholarship. In all other instances, however, permission must be
obtained from the author of the thesis.
Name: Abdi Umare
Date: 12/6/2015
School/Department: GeneralPublic Health Signature: _________
i
BIOGRAPHICAL SKETCH
My name is Abdi Umare, I was born in 10/1/1983. I completed my primary school at Chiro
number one and secondary schools at Cherchercomprehensive secondary school which also
found in Chiro, West Hererge, and Eastern Ethiopia. After completion of my secondary
school, I joined Jimma University in the year 2004. I completed my Bachelor of Science
Degree studies in Medical Laboratory Technology in July 13/2006. After graduation of my
first degree, I was employed inDeder district hospital and I am working there.
In July 2013, I joined school of graduate studies, Haramaya University through self-sponsorto
pursue my post graduate studies in the program of General Public Health, which this volume is
in partial fulfillment.
ii
ACKNOWLEDGMENT
With all respect I would like to thank my advisors; major advisor Dr. BerhanuSeyoum and CoAdvisor: Dr. TesfayeGobana for their valuable comments, support, guidance and inspiration
towards the preparation and completion of this research project.Also I would like to thank the
College of Health Sciences, School of Graduate Studies, Haramaya University.
I am grateful to extend my deep thanks and genuine appreciation to MrTamirat H/Meriyam for
his unreserved support and commitment during serological screening at the laboratory of
Ethiopian Red Cross Society Blood Bank, Harar branch. Also thanks to this great
humanitarian organization.
Last but not least, my heartfelt thanks go to all my friends and my family who have partly
made their contribution through the whole processes of this thesis.
iii
Acronyms and Abbreviations
AIDS:Acquired Immunodeficiency syndrome
ANC: Antenatal care
DPT:Diphtheria, pertusis and Tetanus
ELISA:Enzyme linked Immunosorbent Assay
HBcAg: Hepatitis B core Antigen
HBeAg: Hepatitis B envelop Antigen
HBsAg: Hepatitis B Surface Antigen
HBV: Hepatitis B Virus
HCV: Hepatitis C Virus
HIV: Human Immunodeficiency Virus
HRP: Horse Radish Peroxidase
STI: Sexually Transmitted Infection
TMB:Tetramethylbenzidine
WHO: World Health Organization
iv
Table of Content
STATEMENT OF THE AUTHOR ..................................................................................................i
BIOGRAPHICAL SKETCH .......................................................................................................... ii
ACKNOWLEDGMENT ............................................................................................................... iii
Acronyms and Abbreviations .........................................................................................................iv
Table of Content .............................................................................................................................. v
ABSTRACT ................................................................................................................................. vii
1.
INTRODUCTION .................................................................................................................... 1
1.1.
Background ....................................................................................................................... 1
1.2. Statement of the Problem ...................................................................................................... 2
1.3. Significance of the Study ...................................................................................................... 3
1.4. Objectives ............................................................................................................................. 4
1.4.1. General Objectives ......................................................................................................... 4
1.4.2. Specific Objectives ......................................................................................................... 4
2. LITERATURE REVIEW ............................................................................................................ 5
2.1. Prevalence of HBV in Pregnant Women .............................................................................. 5
2.2. Factors Associated with Infection of HBV ........................................................................... 7
Diagram.1. Conceptual Framework ........................................................................................... 10
3. MATERIALS AND METHODS .............................................................................................. 11
3.1. Study Area .......................................................................................................................... 11
3.2. Study Period ........................................................................................................................ 11
3.3. Study Design ....................................................................................................................... 11
3.4. Source Population ............................................................................................................... 11
3.5. Study population ................................................................................................................. 11
3.6. Inclusion Criteria ................................................................................................................ 11
3.7. Exclusion Criteria ............................................................................................................... 12
3.8. Sample Size Determination ................................................................................................ 12
3.9. Sampling Procedure ............................................................................................................ 12
3.10. Data collection methods.................................................................................................... 13
3.10.1. Blood sample collection and storage ............................................................................. 13
v
3.10.2. Serological test for detection of HBsAg ........................................................................ 14
3.11. Study Variables ................................................................................................................. 14
3.12. Data Quality Control ......................................................................................................... 14
3.13. Method of Data Analysis .................................................................................................. 15
3.14. Ethical consideration......................................................................................................... 16
4. RESULTS .................................................................................................................................. 17
4.1. Socio-demographic characteristics of the study participants .............................................. 17
4.2. Prevalence of Hepatitis B Virus Infection .......................................................................... 17
4.2. Associated factors with hepatitis B virus infection ............................................................ 19
5. DISCUSSION............................................................................................................................ 22
5.1. Limitation of the study ........................................................................................................ 28
6. CONCULOSION AND RECOMMENDATION ..................................................................... 29
6.1. Conclusion .......................................................................................................................... 29
6.2. Recommendation ................................................................................................................ 29
7. REFERENCES .......................................................................................................................... 30
8. APPENDIX ............................................................................................................................... 36
Appendix A. Participant Information Sheet and Consent Form ................................................ 36
Appendix B. Translated ‘Participant Information Sheet and Consent Form’ in Afan-Oromo .. 38
Appendix C. Questionnaire........................................................................................................ 40
Appendix D. HIV Test Results Collection Formats .................................................................. 42
Appendix E. HBsAg Test Results Recording Formats .......................................................... 43
Appendix F. Translated Questionnaire in Afan Oromo ......................................................... 44
Appendix G. The principle, procedure and interpretations of test results ................................. 46
Appendix H. Curriculum Vitae .................................................................................................. 48
Appendix I. APPROVAL SHEET ............................................................................................ 50
vi
ABSTRACT
Hepatitis B virus (HBV) infection is one of the leading causes of liver diseases which are
serious public health problem worldwide. Recent estimates have placed HBV in the top 20
causes of human mortality which caused 686 000 deaths in a year. Women who are infected
with HBV can transmit the infection to their infants. Neonates who contract the HBV infection
have about 90% risk of developing chronic liver disease. This study was conducted to
determine the prevalence of HBV infection and associated factors among pregnant women
attended antenatal care (ANC) clinic at Deder Hospital, eastern Ethiopia.
A hospital based cross sectional study was conducted from March 18, 2015 to May 15, 2015
among pregnant women those attended ANC clinic for routine pregnancy follow-up.
Information about socio-demographic and other explanatory variables were collected through
face to face interview using a pre-tested questionnaire. Venous blood sample was collected
from each study subject and serum was tested for HBsAg by an enzyme linked
immunosorbent assay (ELISA) test kits according to manufacturer’s guideline. Statistical
analysis was computed by SPSS version 16. Binary logistic regression analysis was used to
examine the association between explanatory variables and hepatitis virus infections. Odds
ratio with 95% CI was used as a measure of strength of association and p-value less than 0.05
was considered as statistically significant.
The prevalence of HBV infection was 6.9%. In multivariate analysis, history of abortion
(AOR 10.9; 95% CI: 2.2-53.9), nose piercing (AOR 9.1; 95% CI: 1.34-61.79), surgical
procedure (AOR 12.8; 95% CI: 1.68-97.06) and history of multiple sexual practices (AOR
16.8; 95% CI: 3.18-89.06) were significantly associated with HBV infection.
Conclusion: This study determined that the prevalence of HBV infection among pregnant
women in this study area was 6.9% and identified some factors which were significantly
associated with this viral infection. Hence, Screening for HBV infection should be included as
a part of routine tests for all pregnant women during antenatal care. Health education
programs; on mode of transmission of HBV, high-risk behaviors and method of preventions,
should be instituted within antenatal care clinic as it can help to raise the awareness of
mothers.
Keywords: -Sero-prevalence,Hepatitis B Virus,HBsAg, Pregnant Women.
vii
1. INTRODUCTION
1.1.Background
Hepatitis B infection is caused by the hepatitis B virus (HBV), an enveloped DNA virus that
infects the liver and causes hepatocellular necrosis and inflammation (WHO, 2015) which are
serious public health problem worldwide (Adibi P et al., 2012). It is 50–100 times more
contagious than Human Immune Deficiency Virus (HIV) (Verma R et al., 2011).Many of the
carriers are not realizing that they are infected with the virus and thus HBV is referred as a
“silent killer”(Pungpapong S et al., 2007).
Geographical distribution of hepatitis B infection in worldwide varies from region to region
and it was categorized as; low prevalence of HBsAg (<2%) (North America, Western
Europe);Lower intermediate (2–4.99%) (Eastern Mediterranean region and some European
region); higher intermediate (5–7.99%) (Western Pacific region and some African countries);
high (>8%) (sub-Saharan Africa and some countries in the Western Pacific region)(WHO,
2015; Schweitzer A et al., 2015).
Viral hepatitis infection during pregnancy presents a unique set of management issues(EASL,
2012) and aspects of care that must be considered(Maureen M, 2009). There are 2 modes of
transmission, in countries of high HBV endemicity the usual mode of transmission is vertical
from mother to infant either through intrauterine or during perinatal period (Han L et al,
2011). Where as in areas of low endemicity the most common mode of transmission is
horizontal in adulthood(Goldstein S, et al, 2005), usually through sexual transmission and the
use of contaminated needles in medical procedures or injection drug use.
Worldwide, it is estimated that 2 billion people have been infected (WHO, 2009) and 240
million are chronic carriers of HBV surface antigen (WHO, 2015). Each year approximately
600,000 individuals die of complications such as acute liver failure, cirrhosis and
hepatocellular carcinoma (WHO, 2009; Verma R et al., 2011). Recent estimates have placed
HBV in the top 20 causes of human mortality which caused 686 000 deaths in one year of
2013 (GBD, 2015). Approximately 75% of carriers are found in Asia (Murad et al., 2013) and
hepatocellular carcinoma is ranked among the top 3 causes of death in males, especially in
1
South-East Asia (Goldstein S, et al, 2005). The second largest numbers of people living with
chronic HBV live in Africa which accounted for over 75 million individuals (Schweitzer A et
al., 2015).
Perinatal and early childhood transmissions are the main routs of HBV infection in high and
intermediate endemic areas (WHO, 2009), with up to 90% of them are at risk of developing
chronic liver disease (Schweitzer A et al., 2015). Therefore prevention of perinatal
transmission of HBV is an essential strategy to tackle the burden of the disease. Universal
HBV infant immunization would prevent up to 75% of global deaths from HBV-related causes
(WHO, 2009). Adding a birth dose, which the first dose of HBV vaccine is administered
within the first 24 hours of birth, would prevent perinatal transmission in up to 84% of
infants(Goldstein S, et al, 2005) and had numerous advantages and cost effectiveness (Lee C
et al., 2006).
In an effort to reduce Hepatitis B infection, Ethiopia like many other countries, has adopted
the WHO recommendation by integrating hepatitis B vaccination into national immunization
schedule, whereby hepatitis B vaccine is given to infants in combination with diphtheria,
pertussis, tetanus (DPT) and Haemophilus influenza-b as pentavalent at 6th, 10th and 14th
weeks of age (FMoH, 2010). But delaying the birth dose results in an increased risk of HBV
infection and hence, the first dose should be given within 24 hours of delivery(WHO, 2009).
The risk of transmission decreases dramatically in the setting of universal HBV screening
prenatally, immunoprophylaxis given to infants born to HBV infected mothers and hepatitis B
vaccine administered both to high risk mothers and to all newborn infants(WHO, 2009; Robert
D.
and Jeanne S. 2013). Antenatal screening for HBsAg to all pregnant women and
vaccination of their babies at birth has been recommended widely, yet it is not a routine
practice in most health settings of Ethiopia.
1.2. Statement of the Problem
Ethiopia is among high intermediate prevalence of HBsAg (5–7.99%) countries in the
world(WHO, 2015) and it was estimated that around 5 253 468 of people living with chronic
HBV in the general population of Ethiopia (Schweitzer A et al., 2015). However, data on the
2
epidemiology of HBV infection in Ethiopia are scarce, and those available are mostly from
Northern part of the country. In earlier time survey of Ethiopian blood donors 8% and 14.4%
of prevalence were reported by (Kefene H et al., 1988) and (Lakew, 1983) respectively from
northern Ethiopia. In recent studies the prevalence of 4.9% and 3.8% were determined among
pregnant women in Dessie referral hospital and Bahir Dar city, respectively (Mohammed S et
al., 2014; Yohannes Z et al., 2014). Similar study also in this area which was conducted to
determine the sero-prevalence of sexually transmitted infections (STIs) among antenatal care
attendees and reported as 7.3% was accounted for HBV infection (Tiruneh M, 2008).
Although these few studies indicated that hepatitis B infection among pregnant women is
important public health problem which needs to be addressed, but as noted from their finding
the magnitudes of the prevalence have varied even within the same administrative region of
the country. Also the associated factors with hepatitis B virus infections were varied
inconsistently between these mentioned previous study reports. Thus in addition to
determining the prevalence, associated factors with HBV infection also needed to be
determined at different setting of geographic area in order to design appropriate preventive
measures.
However, any data about the prevalence of HBV infection and its determinant factors among
pregnant women hardly available at all in eastern Ethiopia and particularly in Deder district.
Given that HBV infection leads to serious public health problem, it is important that its
epidemiology should be continuously assessed (Eke AC et al., 2011). So it is obvious that
epidemiological information is necessary to inform prevention and control priorities.
1.3. Significance of the Study
As epidemiological data on HBV infection are important to health program managers and
planners, the finding results of this hospital based study will be used by Deder hospital
administrative body to plan on the methods of prevention to halt transmission in the
community as well as to treat and support those are already affected by this viral infection.
Case managers, in maternal and children’s health program, may use this data to provide health
education or counseling for pregnant mothers on the modes of transmission and methods of
3
prevention. Also they will use these data to mobilize and coordinate the resources that are
important to implement appropriate testing, vaccination and medical treatment programs for
hepatitis B virus infection.
Therefore this study will provide data on the magnitude and associated factors with HBV
infection among ANC attendees which further will come out with recommendations for health
care providers and health care program managers whether or not there is a need to prioritize
this health problem due to hepatitis B virus among pregnant women those are living around
Deder hospital catchment area.
1.4. Objectives
1.4.1. General Objectives
To determine the prevalence of HBV infection and associated factors among pregnant women
attended antenatal care clinic from March 18, 2015 to May 15, 2015 at Deder hospital,
EasternEthiopia.
1.4.2. Specific Objectives
1. To determine the prevalence of HBsAg among pregnant women attended
antenatal care clinic from March 18, 2015 to May 15, 2015 atDeder Hospital.
2. To identify associated factors with hepatitis B infection among pregnant women
attendedantenatal care clinic from March 18, 2015 to May 15, 2015 at Deder
Hospital.
4
2. LITERATURE REVIEW
2.1. Prevalence of HBV in Pregnant Women
It is estimated that almost 50% of the cases of chronic HBV infection resulted from vertical
transmission or acquired in early childhood, especially in endemic areas (Petrova M and
Kamburov V, 2010). About 5% of mothers worldwide are chronic HBV carriers (WHO, 1999)
with the prevalence range from 0.6% in low prevalence areas to over 20% in areas with a high
incidence in the Far East and Africa (Mohebbi SR et al., 2011).
In Sub-Saharan Africa HBV prevalence among pregnant women is high in the western region
and varies between 6.2% and 16% with preponderance toward the upper end(Gasim et al.,
2013). In Nigeria the prevalence rate of 16.5% (Kolawole et al., 2012) for hepatitis B surface
antigen in pregnant women with the highest prevalence of 23.3% was recorded for 30–34
years age group. The same study in Ghana, the overall HBsAg positive rate was
10.6%(Younmo C et al., 2012), which varied among districts, ranged from 2.2% to 13.8% of
prevalence.
Among southern region of Africa, the highest prevalence reported from South Africa, which is
4.6% where as in the rest countries in this region of Africa published studies on HBV in
pregnancy are scarce and this area lies in the zone of moderate endemic when considering the
general population with an estimated prevalence between 2% and 2.9%(Gasim et al., 2013).
Studies that were conducted in Northern Africa reported the highest prevalence of 10% among
pregnant women in Mauritania (Mansour W et al., 2012) followed by 6.7% in Egypt, while it
was least prevalent in Libya (1.5%), followed by Algeria (1.6 %) and Tunisia (4%) (Gasim et
al., 2013).The central and eastern region of Africa characterized by having similar prevalence
of HBV among pregnant women and among general population, and most countries fall in the
moderate to high endemic zone(WHO, 2009); the highest prevalence (37%) was reported
from Somalia in 1987(Gasim et al., 2013). The seroprevalence of HBsAg among pregnant
women in Tanzania was reported to vary between 3.5% and 6.3% (Sabria R, 2014), whereas
5
studies in a neighboring country of Ethiopia reported that 5.6% and 9.3%from Sudan and
Kenya respectively(Okoth F et al., 2006; Elsheikh RM et al., 2007).
Ethiopia was reported to be one of the countries with high intermediate endemicity levels of
chronic HBV infection(WHO, 2015). In earlier time a survey of Ethiopian blood donors shows
that occurrence of HBsAg was 8%(Kefene H et al., 1988) andsimilarly, the study in northwest
Ethiopia reported that HBsAg was detected in 14.4 % of blood donors(Lakew, 1983). A
community-based sero-epidemiological survey of Addis Ababa was conducted to inform on
the transmission dynamics and control of HBV infection. HBsAg prevalence was 7%(Abebe
A, et al, 2003), and overall sero-prevalence (any marker), rose steadily with age to over 70%
in 40-49 year olds, which implies significant childhood and adult transmission.
In the research study to determine the prevalence and significance of sexually transmitted
diseases among Ethiopian women attending antenatal care (ANC) in Addis Ababa hospitals,
the prevalence of HBsAg among pregnant women was 5%(Duncan ME et al., 1995).
Moreover, a recent study on sero-prevalence and transmission of Hepatitis B virus among
delivering women and their new born in selected health facilities of Addis Ababa reported
3.0% of mothers were positive for HBsAg(Tegegne D et al., 2014), even though it is lower
than the previous study report,yet according to WHO standards it indicate intermediate
prevalence.
Relatively many studies on sero-epidemiology of HBV prevalence among pregnant women in
Ethiopia have been previously done in Northern part of the country. The study that was
conducted on sero-prevalence of sexually transmitted infections (STIs) among antenatal care
attendees in Gondar (Northwest Ethiopia) reported as 7.3% was accounted for HBV(Tiruneh
M, 2008), where as in more recent studies in this region of Ethiopia determined the prevalence
of 4.9% and 3.8% in Dessie referral hospital and in Bahir Dar city, respectively(Mohammed S
et al., 2014; Yohannes Z et al., 2014).Moreover, a study from Southern Ethiopia reported a
sero-prevalence rate of 6.1% (Ramos JM et al., 2011); where there are scarce published
studies on HBV among pregnant women in this region which is also similar for eastern part of
Ethiopia.
6
2.2. Factors Associated with Infection of HBV
A variety of risk factors have been found to be associated with high prevalence rates for HBV;
however, the emphasis on these risk factors varies greatly from one country to another. As
HBV is a blood-borne virus, blood and its products remain major causes of HBV transmission.
Sexual and parenteral routes(Gasim et al., 2013) also reported as main routes of HBV
transmission. Studies from Nigeria have reported that HBV infection was found to be
associated mainly with blood transfusion among pregnant women (Yakasai A et al., 2012). In
contrast to the above-mentioned findings, studies of HBV infection in pregnant women in
Sudan, Yemen, and Mauritania have failed to show any evidence of blood transfusion being a
factor for transmission(Elsheikh R et al., 2007; Mansour W et al., 2012; Murad A et al.,
2013).However, previous history of blood transfusion was reported as significant risk factor
among pregnant women in Bahir Darcity, Northwest Ethiopia( Yohannes Z et al., 2014)
Maternal screening programs and universal active and passive immune-prophylaxis of
newborn have reduced dramatically the HBV transmission rates by 95% (Petrova M and
Kamburov V, 2010) ; Vertical transmission of HBV is defined as positivity at6–12 months of
life for the hepatitis B surface antigen (HBsAg) or of HBV-DNA in an infant born to an
infected mother(Yin Y et al., 2013). In fact, detection of the infection when the child is 6
months old correlates with infection when the child is one year old and indicates chronicity of
the infection. Without prophylaxis, the risk of HBV vertical transmission is high. The risk is
highest in HBsAg and HBeAg-positive mothers (transmission rate:70%–90%), and low for
HBsAg-positive but HBeAg-negative mothers (transmission rate:10%–40%)(Goldstein et al.,
2005; Yin Y et al., 2013); also the risk of trans-placental transmissionis known to be increased
among HBeAg positive mothers as well as those with high HBsAg titer and HBV DNA level
(Bai H et al., 2007).
In some studies socio-demographic factors such as age, education level, and gravidity have
been found not to be significant factors associated with transmission of HBV(Elsheikh RM et
al., 2007; Mansour W et al., 2012; Murad A et al., 2013), however, some reports have stated
7
that history of multiple partners and becoming sexually active at an early age is a risk factor as
has been found among Nigerian pregnant women (Rabiu KA et al., 2010).
Similar finding was reported in Ethiopia, Dessie referral hospital and Jimma Zone. Cross
sectional study was conducted in Dessie;multivariate analysis showed that history of nose
piercing (AOR 18.1; 95%CI 2.9-114, P= 0.002) and history of having multiple sexual partners
(AOR 13.5; 95% CI 2.3-78, P =0.004) were significantly associated with HBV infection.
Nevertheless, there was no statistically significant association between gravidity status, home
delivery by traditional birth attendants and HIV status with that of HBV infection
(Mohammed S et al., 2014).Same study in Jimma showed that pregnant women who
experienced abortion had higher prevalence of HBsAg (7.3%) and the odds of having HBsAg
was more than twice with those pregnant women that had history of abortion (Mohammed A
and Solomon G/S, 2005). High parity, polygamy, multiple sexual partners and previous
history of sexually transmitted disease(Obi SN and Umeh S, 2006) were shown to be a
significant risk factors for HBV infection in Nigerian pregnant women.
As tattooing and body arts have become more prevalent in recent years, their popularity
increasing among young adults. Findings of the current systematic review and meta-analysis
indicate that tattooing is associated with hepatitis B transmission (Jafari S et al., 2012).
Since HIV and HBV share the modes of HIV transmission, it is plausible that HBV and HIV
co-infection can occur, and this has been documented. A study done among pregnant women
showed that one out of sixteen HIV infected had HBV infection as well(Santiago P et al.,
2005). Ethiopia being one of the countries with high burden of HIV infection and also found
inaregionclassified as high endemic area for HBV; the likelihood of HBV/HIV co infection is
highly anticipated(Asfaw N et al., 2011). The frequency of HBV and HIV co-infection
was19.0% in Northwest Ethiopia (Yohannes Z et al., 2014), and the prevalence of HIV
infection among HBsAg positive pregnant women was 33.3%.
Dental treatment can be included among the risk factors of HBV infection and it is more
important in developing countries where the rate of hepatitis infected individuals is
higher(Mahboobi N et al., 2013). Dentists and dental health care workers are at a high risk of
8
infection with both HBV and HCV during their daily occupational experiences (Stewardson
DA et al., 2002). Similarly, they can infect their patients by such agents if adequate infection
control policies are not applied(Mahboobi N et al., 2010)
Medical and surgical risk factors such as surgical procedures, home delivery, dental
procedures, and history of jaundice were all found not to be significant in some studies(Rabiu
K, 2010; Mansour W et al., 2012; Murad A et al., 2013), but the study in Northern Ethiopia
among pregnant women those came to hospital and health centers for ANC follow-up in Bahir
Dar administrative city,Previous history of blood transfusion (AOR = 3.7, 95% CI, 9.0214.84), body tattooing (AOR= 5.7, 95% CI, 1.24-26.50) and history of surgery (AOR = 11.1,
95% CI, 2.64-46.88) were significantly associated with HBV infection (Yohannes Z et al.,
2014).But in an Indian study found no association between HBsAg status and dental treatment
in a group of 71 HBV positive blood donors after multivariate analysis(Jagannathan L et al.,
2010).
A cross-sectional study carried out in Nigeria reported as there were statistically significant
relationships between HBV infection and previous history of tribal marks/tattoos (𝑥2 =27.39, P
= 0.001, df = 1), history of contact with previously infected HBV patients (𝑥2 =23.11, P =
0.001, df = 1) and those are health care workers by occupation of the pregnant women
(𝑥2=51.22, P = 0.001, df = 1) (Eke AC et al., 2011). However, a prospective cross-sectional
study performed involving pregnant women attending antenatal clinic at Gondar Health
Center, Co-infection of HBV, HCV and Treponemapallidum with HIV was observed but no
statistical association was noted (Tiruneh M, 2008).
9
-Medical treatment
-Admission to health facility
-Surgical procedures
-Blood transfusion
Socio-Demography
Characteristics
-Age
- Residence
-Marital status
- Occupation
-Educational status
Hepatitis B virus
infection
Behavior and practices
-Multiple sexual practices
-Traditional
invasive
procedures like; ear &
nose
piercing,
tattooing,home delivery
and abortion.
Diagram.1. Conceptual Frameworkshows factors related with Hepatitis B virus Infection.
(Source: Lesson from literatures)
10
3. MATERIALS AND METHODS
3.1. Study Area
Deder Hospital is located in Eastern Ethiopia, Eastern Hararghe Zone of Oromia Regional
State, in Deder Town. It is located approximately 458 km from the capital city of Ethiopia,
Addis Ababa. It was established around 1934 by American Mennonite Mission, and turned
into a government hospital in 1959. It serves as referral hospital for more than one million
people coming from four Woredas.It has 85 beds for inpatient and outpatient health care
services including antenatal care for pregnant women. The ANC clinic of the hospital serves
about 2100 pregnant women per year. The services delivered by the clinic includes assessment
of pre-existinghealth conditions (screening for anemia, syphilis, HIV), vaccination, nutrition
counseling, micronutrientsupplementation and early detection of pregnancy related
complications. (Derder Hospital Record and Documentation Department)
3.2. Study Period
The study was conducted from March 18, 2015 to May 15, 2015
3.3. Study Design
A hospital based cross sectional study was conducted.
3.4. Source Population
The source population was all pregnant women who attended ANC clinic at Deder Hospital
3.5. Study population
The study population was all pregnant women who attended ANC clinic for follow up
services at Deder Hospital during the study period.
3.6. Inclusion Criteria
Pregnant women who attended ANC clinic for the first time for the current pregnancy follow
upto avoid repeated inclusions during the study period and those had confirmed pregnancy.
11
3.7. Exclusion Criteria
We excluded women who came with incomplete, complete or missed abortions.Again,
thoseattended the clinic for more than one visit during thestudy periodbecause they were
already enrolled in the study.
3.8. Sample Size Determination
Sample size was determined using single population proportion formula by considering 7.3%
prevalence of HBVamong pregnant women in Gonder HC(Tiruneh, 2008), 95% CI and a 3%
margin of error.
n= Z2p (1-p)/ ε2
Where n =expected minimum sample
Z = standard deviation of the normal distribution, corresponding to 95% confidence=1.96
P= considered proportion
ε= maximum likely error taken as 3%
Accordingly, a total of 318 study participants were included (including 10% non-response
rate)
3.9. Sampling Procedure
All mothers attended the ANC clinic in week days at regular working time have been
consecutively enrolled until the desired sample size is reached. As a routine service delivery
procedure of the ANC clinic, all pregnant women those came for follow up care, were triage
and assigned to the clinic. According to their registration order at the triage place, they were
informed to come in one by one to ANC class for follow up service.Then, after the purpose
and risks of the study were explained they were asked for participation in the study.Clinical
investigations; blood pressure measurement, counseling and screening for human
immunodeficiency (HIV) were provided as routine service for pregnancy follow up in ANC
clinic. Moreover,blood sugar, hemoglobin, blood group and screening for syphilis were
provided as routine investigation for all pregnant women inthe hospital’slaboratory
department. A unique mark was put on cards of all enrolled mothers to avoid potential
repeated inclusions in the study during their subsequent visits.
12
3.10. Data collection methods
All nurses working in Deder hospital ANC clinic were trained by the principal investigator on
how to collect information about socio-demographic and other possible factors for HBV
infection. After a written consent was obtained from each study subjects, information
concerning socio-demographic and other possible factors for HBV infectionswere collected
through face to face interview using a pre-tested standard questionnaire which adapted from
the WHO “protocol for assessment of hepatitis B infection in antenatal patients” (WHO,
1990). After interviewed each study subject was sent to laboratory department with request
form for routine investigation as well as for drawing blood sample for this study purpose. At
the end of each working day record review was conducted at ANC clinic as a secondary data
source for HIV status of all participants.
Every day afternoon, at the end of working time, all filled questionnaires were checked for its
completeness, unrecorded data and unlikely responses were manually cleaned up by principal
investigator. Any questionnaires with such indication were suspended to be excluded unless
otherwise re-interviewing was possible later on at the time of they came back for next
appointment of ANC follow up within the study period.
3.10.1. Blood sample collection and storage
Three milliliter of venous blood was collected with plain tube following standard operational
procedures by trained laboratory technologist from each study subject. The blood specimen
was allowed to clot at room temperature for 30miniute and centrifuged at 3000rpm for at least
20 minutes at room temperature to get clear serum.The separated serum was transferred into
cryo-tube and stored in deep freeze at (-20°C) until transported for analysis. This storage
temperature was monitored continuously by inserted thermometer. The specimens were
transported in a cool box to Red Cross Society blood Bank, Harar branch, for Serological
analysis, and analyzed within the same day of arrival to avoided pre-analytical problem which
could be occurred due to multiple freeze-thawcycles. The whole processes of specimen
collection, storage, transportation and testing were done according to standard operational
procedure (SOP) of test kit manufacturer. (DialabELISA for HBsAg, Product Insert)
13
3.10.2. Serological test for detection of HBsAg
HBsAg ELISA Kit of Dialab(Austria) was used for detection of HBsAg in serum of the study
subjects. The DiaLabHBsAg ELISA Kit is an enzyme-linked immunosorbent assayfor
qualitative detection of HBsAg in human serum and plasma.It is intended for screening of
blood donors and diagnosis of patients related to infection with HBV. This test kithas
approximately99.9% and99.75% of sensitivity and specificity respectively, when performed
according to the instructions of the manufacturer. (Dialab ELISA for HBsAg, Product Insert)
Thus, in our study, the screening tests were performed as instructed by the manufacturer.The
details about the principle of the test, procedure and interpretations of the test results were
written at the appendix G.
3.11. Study Variables
3.11.1. Dependent variable: In this study, the dependent variable was sero-status of study
participant for HBsAg test.
3.11.2. Independent variables: The independent variable were; age, residence, marital status,
educational status, occupation, tattooing, home delivery, parity, gravidity, history of blood
transfusion, history of abortion, admission to health facility, history of surgical procedure, ear
and nose piercing, history of multiple sexual practice, history of STI and HIV status.
3.12. Data Quality Control
The questionnaires, which were originally developed in English have been translated in to
Afan Oromo and again translated back into English by language experts to ensure its
consistency. Before data collection, a pre-test was done to check the validity and acceptability
of the questionnaires in that same ANC clinic before formal study project was started among
30 pregnant women; however, those pregnant women were not included in the study sample.
Finally, some changes and modifications were made from the pretesting.
All initially reactive serums were retested again in duplicate to confirm the result according to
the test kit’s manufacturer guideline.
14
3.13. Method of Data Analysis
After data collection was completed, each questionnaire was checked and pre-coded
sequentially.The data were entered into Epi-Data version 3.1 and then transferred to SPSS
version 16 for analysis. Descriptive analysis such as means, standard deviations and
proportions were used to summarize, examine and determine the socio-demographic and
behavioral characteristics of study participants as well as the prevalence of HBV. Binary
logistic regression analysis was done to determine the association between explanatory
variables and the outcome variable.
Firstly, the association between independent factors and prevalence of HBV infection were
analyzed for each variable one by one in bivariate logistic regression analysis usingcrude odds
ratio with 95% CI; except for variables those have a cell with zero value.Under educational
status of study participants, thesecondary and tertiary sub-groupswere merged because they
have got very small value per individual cell.
“Enter” method of variable selection, in which all variables in a block are entered in a single
step, was used to construct a regression model.So, all explanatory variables, that with a pvalue less than or equal to 0.2 in the bivariate analysis were included in the multivariate
logistic regression model to identify variables which were associated independently.But the
only exception was made for two variables which were“history of abortion” and “place of
abortion”.Becauseplace of abortion was assessed only for those had history of abortion and
then at the time of data analysis for odds ratio, pregnant women those did not have history of
abortion, were used as a common reference groupforboth variables.So it was decided to enter
these two variables into the model alternatively and then the final model,which included only
the “history of abortion” with the rest other explanatory variables those have got p-value less
than or equal to 0.2 in the bivariate analysis, was used to assess which variables were
associated independently with outcome variable.Thus, AdjustedOdds ratio (AOR) with 95%
CI was used to determine the predictors of the outcome. In all statistical tests p-value less than
0.05 was considered as statistically significant.
15
3.14. Ethical consideration
Ethical clearance for the study wasobtained from Institutional Research Ethics Review
Committee (IHRERC) of the College of Health Sciences of Haramaya University. A written
letter which was obtained from the coordinator of School of Graduate Studies was submitted
to the Deder Hospital. The purpose of the study was explained to the officials of Deder
Hospital. A similar letter written by Deder Hospital administration was given to hospital’s
ANC clinic case team leader where the purpose of the study was explained to all member of
that department. Informed written consent was obtained from each study participants after
explaining the purpose of the study prior to the data and sample collection. Their serological
test result was available during their next consecutive ANC follow up for those wanted to
know the result. Positive pregnant women for HBsAg screening test were consulted to
physicians for further investigation and their liver function tests were done in the hospital’s
laboratory. Furthermore, they were concerned for especial follow up during the rest full course
of pregnancy, delivery and postnatal care for all those were volunteers and collaborative.
16
4. RESULTS
4.1. Socio-demographic characteristics of the study participants
A total of 318 pregnant women were participated in this study andtheir ages varied between 15
and 40 years with a mean age of 25.6±5.7 years. The majority of the study subjects (56.9%)
were living in rural. Two hundred ninety nine (94%) of them were married and 86.2% were
Oromo by ethnicity. One hundred thirty two (41.5%) of the participants did not attend formal
education and one hundred seventy (53%) were housewives and only eight (3%) were health
workers by occupation. (Table.1.).
Table.1. Socio-demographic characteristics of pregnant women attending ANC clinic at Deder
hospital, 2015 (n = 318)
Characteristic
Age
Residence
Marital Status
Ethnicity
Educational Status
Occupation
<= 20
21-25
26-30
31+
Urban
Rural
Single
Married
Divorced
Widowed
Oromo
Amhara
Gurage
Siltie
Number
88
112
66
52
137
181
5
299
7
7
274
30
9
5
Percentage (%)
27.6
35.2
20.8
16.4
43.1
56.9
1.6
94
2.2
2.2
86.2
9.4
2.8
1.6
No formal education
Primary school
Secondary & above
Farmer
Health worker
Housewife
Daily Laborers
Others
132
119
67
88
8
170
14
38
41.5
37.4
21.1
28
3
53
4
12
4.2. Prevalence of Hepatitis B Virus Infection
Out of 318 serums specimen 24 was positive at the first testing procedure. As it was
recommended by test kit manufacturer, any initially reactive samples should be retested in
duplicate (appendix G). So that, all 24 samples were retested in duplicate and 22 of them
17
remained reactive. The rest two samples were retested for the third time and resulted as none
reactive again. Therefore, it was decided that both of them should be considered as negative
for HBsAg. Thus, the overall prevalence of HBsAg was 6.9% (22/318).
By their age category, relatively the highest prevalence, 8% (9/112), was observed among 2125 years age group whereas the lowest prevalence, 5.7% (5/88), was within 15-20 years age
group. Among the residential category, higher prevalence of 8.8% (12/137) was recorded in
urban dweller pregnant women while lower prevalence (5.5%; 10/181) was observed under
rural category. The distribution of HBsAg in relation to marital status, the highest prevalence
was recorded among pregnant women who were single (20%), while none of divorced women
was infected(Table 2).
In this study, theprevalence of HBV infection increased with educational status of study
participants throughout the entire sub-groups.Regarding occupational status the highest
prevalence was recorded among health worker which is accounted for 37.5% of infection. In
relation to gravidity about 7.8% HBsAg positive pregnant women were pregnant for two and
more times. HBsAg was not detected among those have history of blood transfusion and
negative HIV/AIDS results were reported for all study participants.
Table.2.Prevalence of HBV among pregnant women attending ANC clinic at Deder Hospital,
2015 (n = 318).
Variable
Age
Residence
Marital Status
Ethnicity
HBsAg Status
Positive n(%)
Negative n(%)
<= 20
21-25
26-30
31+
Urban
Rural
5(5.7)
9(8)
5(7.6)
3(5.8)
12(8.8)
10(5.5)
83(94.3)
103(92)
61(92.4)
49(94.2)
125(91.2)
171(94.5)
Single
Married
Divorced
Widowed
Oromo
Amhara
1(20)
20(6.7)
0(0)
1(14.3)
19(6.9)
3(10)
4(80)
279(93.3)
7(100)
6(85.7)
255(93.1)
27(90)
Gurage
Siltie
0(0)
0(0)
9(100)
5(100)
18
Educational Status
No formal education
Primary school
Secondary & above
7(5.3)
8(6.7)
7(10.4)
125(94.7)
111(93.3)
60(89.6)
Occupation
Farmer
Health worker
Housewife
Daily Laborers
Others
6(6.8)
3(37.5)
9(5.3)
1(7.1)
3(7.9)
82(93.2)
5(62.5)
161(94.7)
13(92.9)
35(92.1)
Gravidity
Primigravida
Multigravida
3(4.1)
19(7.8)
70(95.9)
226(92.2)
Parity
Nullipara
Multipara
3(3.7)
19(8.1)
79(96.3)
217(91.9)
History of blood
transfusion
Yes
No
0(0)
22(6.9)
2(100)
294(93.1)
HIV/AIDS status
Positive
Negative
0(0)
22(6.9)
0(0)
294(93.1)
4.2. Associated factors with hepatitis B virus infection
Socio-demographic characteristic of pregnant women and exposure to different risk factors
were considered as potential factors for HBV infection, so that they were assessed and
determined by using bivariate and multivariate logistic regression accordingly. In bivariate
binary logistic regression, none of the socio-demographic variables were significantly
associated with HBV infection. Other factors, like home delivery by traditional birth attendant
and ear piercing were not significantly associated with HBV infection. On the other hand,
different categories of some socio-demographic and other explanatory variable like marital
status, ethnicity, blood transfusion and HIV/AIDS status, do have zero cell values, so that it
was impossible to conduct logistic regression analysis (Table 3).
Among pregnant women those had history of abortion, 22.7% (17/75) were positive for
HBsAg and significantly associated with infection caused by the HBV (COR 13.9, 95% CI
4.94-39.38; P < 0.001). Further assessment was conducted on those experienced abortion for
their place of abortion to see whether they have different strength of association or not with
infection of HBV by taking those had not history of abortion as a reference group. In that way,
19
place of abortion was significantly associated with this viral infection, abortion at home (COR
19.8, 95% CI 6.26-62.81; P < 0.001) and abortion at health facility (COR 9.8, 95% CI 2.9432.62; P < 0.001).
Fourteen, out of the 22 pregnant women with history of nose piercing, were positive for
HBsAg (Table 2). Bivariate logistic regression analysis showed that history of body tattooing
(COR 8.6, 95% CI 3.42-21.34; P < 0.001) and history of uvulectomy or/and tonsillectomy
traditionally (COR 5.5; 95% CI 1.98-15.34; P = 0.001) were significantly associated with
HBV infection. Similarly, pregnant women those had history of admission to health facility
(COR 18.5; 95% CI 6.49-52.57; P < 0.001) , surgical procedure (COR 16.8; 95% CI 5.3852.50; P < 0.001), tooth extraction (COR 2.8; 95% CI 1.03-7.62; P = 0.04), STI (COR19.8;
95% CI 7.57-51.99; P < 0.001) and having history of multiple sexual practice (COR 25.5;
95% CI 9.24-70.49; P < 0.001) had a higher risk for HBV infection.
Moreover, under multivariate logistic regression some of the factors were found to be
significant predictors of HBV infections.Pregnant women who had history of abortion were 10
times (AOR 10.9; 95% CI 2.2-53.9, P = 0.003) more likely of being infected by HBV than
pregnant women who had no history of abortion. Additionally, when place of abortion
assessed, pregnant women those had abortion at home had a higher risk of being infected
(AOR 14.2; 95% CI 2.2-92.5; P = 0.005) and those had abortion at health facility (AOR 8.6;
95% CI 1.4-53; P = 0.02) than pregnant women those had no history of abortion at all. Having
history of nose piercing were 9 times (AOR 8.9; 95% CI 1.34-59.39; P = 0.025) more likely to
be infected by HBV than pregnant women who had no history of nose piercing.
Similarly, history of surgical procedure was significantly associated with HBV infection
(AOR 13.3; 95% CI 1.7-103.8; P = 0.014) and Pregnant women those had history of multiple
sexual practices were 16 times (AOR 16.8; 95% CI 3.2-87.9; P = 0.001) more likely of being
infected by HBV than those had no history of multiple sexual practices. However, at
multivariate logistic regression, there was no statistically significant association between body
tattooing, traditional uvulectomy or/and tonsillectomy, history of admission to health facility,
tooth extraction and history of STI.
20
Table.3.The association of explanatory variables withHBV infection,among pregnant women
attending ANCcilinic at Deder Hospital, 2015(n = 318).
Variables
HBsAg Status
Positive n (%)
Age (year)
<= 20 5(5.7)
21-25 9(8)
26-30 5(7.6)
31+ 3(5.8)
Residence
Urban 12(8.8)
Rural 10(5.5)
Educational Status
Crude Odds Ratio
Negative n(%)
COR (95% CI)
83(94.3)
103(92)
61(92.4)
49(94.2)
1
1.450 (.468-4.494)
1.361 (.377-4.908)
1.016 (.233-4.439)
125(91.2)
171(94.5)
1.642(0.688-3.920)
1
Adjusted Odds Ratio
P-value
P-value
*
0 .519
0.638
0 .983
*
0.264
*
No formal
education
Primary school
Secondary &
above
Occupation
Farmer
Health worker
7(5.3)
125(94.7)
8(6.7)
7(10.4)
111(93.3)
60(89.6)
1.287(0.452-3.663)
2.083(0.699-6.208)
6(6.8)
3(37.5)
82(93.2)
5(62.5)
1
8.2(1.568-42.870)
0.013
Housewife
9(5.3)
161(94.7)
0.764(0.263-2.220)
0.621
DailyLaborers
1(7.1)
13(92.9)
1.051(0.117-9.453)
0.964
Others
3(7.9)
35(92.1)
1.171(0.277-4.951)
0.830
Gravidity
Primigravida
Multigravida
3(4.1)
19(7.8)
70(95.9)
226(92.2)
1
1.962(0.564-6.825)
Parity
Nullipara
Multipara
AOR (95% CI)
1
0.636
0.188
*
*
0.29
*
4(4.8)
18(7.7)
79(95.2)
217(92.3)
1
1.638(.538-4.989)
0.385
*
Home delivery by traditional birth attendant
Yes 13(8.2)
146(91.8)
No 9(5.7)
150(94.3)
History of abortion
Yes 17(22.7)
58(77.3)
No 5(2.1)
238(97.9)
Place of abortion
At home 10(29.4)
health facility 7(17.1)
Not at all 5(2.1)
Ear Piercing
Yes 21(7.6)
No 1(2.3)
1.484(0.616-3.578)
1
0.379
13.952(4.943-39.378)
1
0.000
10.9(2.2-53.9)
1
0.003
24(70.6)
34(82.9)
238(97.9)
19.833(6.263-62.805)
9.8(2.944-32.621)
1
0.000
0.000
14.2(2.2-92.5)
8.6(1.4-53)
1
*
0.005
0.020
254(92.4)
42(97.7)
1.654(0.373-7.335)
1
0.508
21
Nose Piercing
Yes
No
Tattooing
Yes
No
14(63.6)
8(2.7)
8(36.4)
288(97.3)
30.00(10.042-89.625)
1
0.000
8.9(1.3 59.39)
1
0.025
11(26.2)
11(4)
31(73.8)
265(96)
8.548(3.424-21.339)
1
0.000
2.9(0.59-15.1)
1
0.185
5.506(1.977-15.336)
0.001
3.2(0.65-16.16)
0.152
Uvulectomy or/and tonsillectomy traditionally
Yes
No
17(13.1)
113(86.9)
5(2.7)
183(97.3)
1
1
History of hospital or HC admission
Yes
No
17(27)
46(73)
5(2)
250(98)
18.478(6.495-52.569)
0.000
1
3.2(0.73-14.45)
0.122
1
History of surgical Procedure
Yes
7(46.7)
No 15(5)
History of tooth extraction
Yes 6(14.6)
No 16(5.8)
History of STI
Yes 14(36.8)
No 8(2.9)
History of multiple sexual practice
Yes 16(36.4)
No
6(2.2)
8(53.3)
16.8(5.376-52.502)
288(95)
0.000
1
13.3(1.7-103.8)
0.014
1
35(85.4)
261(94.2)
2.796(1.026-7.62)
1
0.04
1.8(0.32-9.72)
1
0.514
24(63.2)
272(97.1)
19.833(7.566-51.992)
1
0.000
3.2(0.7-14.29)
1
0.129
28(63.6)
25.524(9.242-70.486)
16.8(3.2-87.9)
0.001
268(97.8)
1
1=reference group, *=not significant at bivariate logistic regression analysis
22
0.000
1
5. DISCUSSION
The results of our study indicated that the prevalence of HBsAg among antenatal clinic
attenders in Deder Hospital is 6.9% and; history of abortion, nose piercing, surgical procedure
and history of multiple sexual practices were identified as significantly associated factors with
HBV infection independently.
According to established criterion, the prevalence of HBV among pregnant women in this
study is classified as high inter-mediate (5–7.99%) (WHO, 2015; Schweitzer A et al., 2015).
This finding is comparable with those among pregnant women from southern Ethiopia 6.1%
(RamosJM et al., 2011) and 7.3% among antenatal clinic attendees in Gondar Health Center,
northwest Ethiopia (Tiruneh M, 2008). But it is higher than 4.9% of prevalence in Dessie
referral hospital and 3.8% in Bahir Dar city (Mohammed S et al., 2014; Yohannes Z et al.,
2014).
This study result also revealed that a lower prevalence than the reports from earlier time
survey of Ethiopian blood donors (Kefene H et al., 1988) which was 8%. Similar study in
northwest Ethiopia reported in 14.4 % of blood donors (Lakew, 1983)which might be due to
lower awareness of the population towards HBV infection in that period. Moreover this
variation may be due to differences in sampling method, geographical variation, differences in
cultural practices, sexual behavior and practices, and differences in the test methods employed
to detect HBV infection. Because our study population consisted of only women able to access
antenatal care clinic at a tertiary hospital, so the prevalence reported here may have
underestimated the true prevalence.
In spite of we used highly sensitive and highly specific ELISA test kit in our study relative to
rapid test kit that was used in many of the studies cited from the literature, screening for
HBsAg alone does not fully reflect the epidemiology of this viral infection. So we did not
screen for other serological markers of HBV infection in our study such as anti-HBs and antiHBc antibodies, which are indicators of previous exposure to HBV infection. If these markers
were assayed for, the actual sero-prevalence rate would most probably be much higher than
the present reported figure.
23
Comparing to other African countries, our result is lower than 16.6% reported from Nigeria
among pregnant women (Kolawole O et al., 2012), 10.6% from the same study in Ghana
(Younmo C et al., 2012) and Yemen 10.8% (Murad A et al., 2013). Whereas the figure of
6.9% from our study, is however higher than (1.5%) in Libya, Algeria (1.6 %) and Tunisia
(4%) (Gasim, et al., 2013). In addition to cultural and behavioral differences; thesevariations
might be attributable to the differences in prevalence of HBV infection among their respective
total population because the prevalence of HBV infection in pregnant women reflects that in
the general population. In such a way it was well documented that;even though the wholeof
sub-Saharan Africa falls into the high endemicity category in general population (Kiire CF,
1996) but the western region of Africa are the most endemic area (Gasim et al., 2013). Where
as in the northern part of Africa the prevalence is relatively low also in general population
(WHO, 2009).
Socio-demographic factors such as age, residence, marital status, education level, and
gravidity have been found not to be significant factors associated with infection of HBV in
this study group. Similar findings were noted in the study of Nigeria, Mauritania and Yemen
(Rabiu K, 2010; Mansour W et al., 2012; Murad A et al., 2013).
Even though it is not statistically significant, in most epidemiological studies on HBsAg, there
has been a link between ages and HBV infection. The age of acquiring the infection is one of
the major determinants of the prevalence rates of HBsAg(WHO, 2009). In this study, HBsAg
was the highest among the 21-25 age groups and closely followed by 26-30. This is
consistence with the study by (Eke AC et al., 2011) in Nigeria which was highest among 2024 age groups. This can be explained as one mode of transmission of HBV is horizontally
through blood and other body fluids thus obviously these age groups are expected as more
sexually active and relatively they have more chance of multiple sexual practices. The other
possible reason may be, because these age groups are accounted for higher proportion than
other age categories to present for antenatal care in this study setting.Therefore, those were
positive to HBsAg test,are likely to be picked up by the screening tests as it was resulted from
this study.However, in our study as it was not statistically significant, it might happen by
chance.
24
But differently in other studies, the proportion was higher in the age group greater than 30
years old as compared to younger age group women less than 30 years old in Dessie referral
hospital (Mohammed S, et al 2014) and similar finding was reported from Jimma, south
western Ethiopia (Mohammed A and Solomon G.S, 2005) which indicated that 30-34 years
and greater than 40 years old had higher prevalence of HBV infection. The possible reason for
this variation, other than the difference in risk behaviors and practices of study participants, it
could be due to relatively only small numbers of pregnant women were participated in the
upper agerange of the study subjects. So that, even the smaller number of positive cases for
HBsAg in this age group, could inflate the age specific prevalence.
Although the level of education is known as the determinant factor for HBV infection with a
reverse pattern (Mohammed S et al., 2014), which might be due to that those have higher
educational status are expected to have higher awareness thus less likely to be infected, but in
our study the prevalence was increased with educational status. However, some findings
similarly with ours, showed no significant differences among different sub-group of
educational status such as those from Nigeria (Eke AC et al., 2011) and Sudan (Elsheikh RM
et al., 2007). On the contrary, other study conducted in Desse referral hospital, northern
Ethiopia, showed that pregnant women who had no formal education had a higher risk of
acquiring HBV than those had formal education (Mohammed S et al., 2014).
Some important predisposing factors to HBV infection such as occupation, home delivery, ear
piercing and blood transfusion failed to be related significantly to status of HBVin this study;
whereas some others like body tattooing, uvulectomy(or tonsillectomy), admission to hospital
or health center, tooth extraction and history of STI were significantly related at bivariate
analysis but failed when controlled for potential confounders under multivariate analysis. This
is a common finding as other studies have indicated that the inconsistency of these risk factors
and so, screening pregnant women on the basis of risk factors, that may be of little help in the
detection of HBsAg and prevention of neonatal transmission(Yakasai A et al., 2012). This was
supported by the findings in Bahir Dar city, Ethiopia (Yohanis Z et al., 2014) where body
tattooing and blood transfusion were reported as significantly related with HBV infection but
history of tooth extraction failed to do so whereas the study in Dessie referral hospital,
25
Ethiopia (Mohammed S et al., 2014) noted that having history of blood transfusion and home
delivery were not related with HBV infection.
As HBV is a blood-borne virus, blood and its products remain major causes of HBV
transmission(Gasim et al., 2013) but in our study positive case for HBsAg was not detected
which may be due very low study participants who have history of blood transfusion.
Moreover, associated factors with this viral infection varied greatly from one country to
another. When studies from Nigeria have reported that HBV infection was found to be
associated mainly with blood transfusion among pregnant women (Yakasai A et al., 2012), but
in contrast, studies on HBV infection among pregnant women in Sudan(Elsheikh R et al.,
2007),Yemen(Murad A et al., 2013) and Mauritania(Mansour W et al., 2012) have failed to
show any evidence of blood transfusion being an associated factor with this virus
transmission. This difference might be explained by better safety precautions being taken for
blood transfusion, where screening for the HBsAg is properly practiced.
Since HIV and HBV share the modes of transmission, it is plausible that HBV and HIV coinfection can occur. Ethiopia being one of the countries with high burden of HIV infection and
also found in a region classified as high endemic area for HBV(Asfaw N et al., 2011); the
likelihood of HBV/HIV co infection is highly anticipated, but in our case, no pregnant women
with positive HIV/AIDS test result report which is not common in many other studies. One
possible reason could be that, in our study, the result of HIV/AIDS of those pregnant women
were collected from ANC registration book as a secondary data which is probably vulnerable
for poor quality of screening and recording practices in that department. In contrast to our
finding frequency of 22.6% from Dessie hospital and 19% from Bair Dar city, northern
Ethiopia and 0.6% from Southern Ethiopia, HBV and HIV co-infection was reported
(Mohammed S et al., 2014; Yohanis Z et al., 2014; Ramos JM et al., 2011). In all of these
studies, screening of HIV was conducted for that research purpose simultaneously with
HBsAg screening.
Multivariate logistic regression analysis showed that history of abortion, nose piercing,
surgical procedure and history of having multiple sexual practices were retained as significant
26
determinant factors for HBV infection. Similar finding was reported from Dessie Hospital,
northern Ethiopia, except for surgical procedure (Mohammed S et al., 2014).
In our study, having history of abortion increased the risk of having HBV infection more than
ten times as compared with those who had no such experience. Additionally, further
assessmentwas conducted among those have history of abortion to determine whether there
was a difference between conducting abortion at home or at health facility, and came out with
the result of increased the risk of having HBV infection 14 times for those conducted at home
and 8 times for those conducted at health facility when they compared with those who had no
history of abortion. This imply that, although abortion is a significant associated factor for
HBV infection among this study participant, the risk is more increased when it is conducted at
home, may be due to less knowledge and practice of infection preventionduring abortion and
related activities where unsterilized equipment are more likely to be used. Similar to this
current study, having history of abortion was reported as significantly related to HBV
infection, from north western and south western part of Ethiopia(Mohammed A and Solomon
G/S, 2005;Yohannes Z et al., 2014).
The association of HBV infection and abortion could be related to the fact that abortion is
directly related to sexual activity. Thus sexually active women have a higher chance of getting
the infection especially those have history of multiple sexual partners. Although it is too far to
compare with current studies, there was a report from Addis Ababa, Ethiopia;abortion was
directly related to sexually active women andexposure to a heterosexual partner (Duncan ME
et al., 1995). The history of having multiple sexual practices was also assessedin our study and
revealed that the odd of infection of pregnant women in this study was 16 times than their
counterpart. There were also other reports that documented similar findings in Dessie referral
hospital and in Nigeria (Rabiu KA et al., 2010; Mohammed S et al., 2014).
History of surgical procedure was one of thefactors which significantly associated with this
viral infection. The Study conducted in Bahir Dar, Ethiopia reported the result which in line
with this finding (Yohannes Z et al., 2014). But other studies from Dessie referral hospital,
Ethiopia, Nigeria, Mauritania and Yemen were all found not to be significant (Mohammed S
et al., 2014; Rabiu KA 2010; Mansour W et al., 2012; Murad A et al., 2013). Thepossible
27
routes for infection during an operation: may be from infected surgeon to a patient, from
contaminated surgical instruments andfromHBV-positivepatienttoanotherpatient (Li X et al.,
2012).These can be attributable to poor practice of infection prevention in some health
facilities which could be addressed by administering nosocomial infections control programs
that promote and maintain a safe work environment.
Moreover, in regions with high prevalence of HBV, body piercing in harmony with other
risk behaviors may plays a role in the increased infection (Jafari S et al., 2012). History of
nose piercing was found to be significant predictors of HBV sero-prevalence among pregnant
women in our study.Similarly it was reported in the study from Dessie hospital, Ethiopia
(Mohammed S et al., 2014). In nose piercing practice, sharing of needles(or other sharp
materials), may posethe risks for HBV transmission.
5.1. Limitation of the study
It is obvious that this study is not free from limitations. Our findings were based on only
HBsAg serological marker which might have under estimated the true prevalence which could
have been obtained if we were able to use other markers such as anti-HBs and anti-HBc
antibodies. Additionally, we could not determine the extent of perinatal transmission of HBV,
because the prevalence of HBeAg was not assessed among HBsAg sero-positive pregnant
mothers for the reason of lack of reagent kit and resource constraints.
Another important point to be considered is that this study was conducted in only one hospital
among 318 pregnant women; therefore, its generalizability to all pregnant women is limited.
Moreover, when assessing the association between exposure to predisposing factors for HBV
infections and status of HBsAg, limitations of the cross-sectional study design have to be
taken into consideration.
28
6. CONCULOSION AND RECOMMENDATION
6.1. Conclusion
This study determined the prevalence of HBV infection among pregnant women in Deder
district was 6.9%; which is an intermediate prevalence according to the WHO classification
criteria that require routine screening of HBV infection in all pregnant women during
antenatal care. History of abortion, nose piercing, surgical procedure and history of having
multiple sexual practices were identified as significantly associated determinant factors for
HBV infection.
6.2. Recommendation
This study showed that HBV infection is serious public health issue in this study area, which
needs to be addressed. Screening for HBV infection should be included as a part of routine
tests for all pregnant women during antenatal care. Prenatal counseling on HBV infection
should be instituted within antenatal care clinic as it could help to raise the awareness of
motherson the mode of transmission and all possible factors for infection. To prevent healthcare-related transmissions of HBV requires a comprehensive approach that includes
implementing nosocomial infections prevention, and commitment of all surgical teams to
promote and maintain safety precautions for better working environment.
Further study, which is multi-sector or population based, should be conducted to be
generalized; and that included other serological markers in addition to HBsAg such as antiHBs and anti-HBc antibodies, which are more efficient for accurately estimating disease
frequency in a population. Moreover, all HBsAg positive mothers should be tested for HBeAg,
which helps to estimate the frequency of HBV carriers in population due to prenatal infection.
29
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35
8. APPENDIX
Appendix A. Participant Information Sheet and Consent Form
My name is…………………………I am working as a data and sample collector for the study
being conducted in this hospital by Abdi Umare who is studying for him Master’s degree at
Haramaya University, the College of Health Sciences. I kindly request you to lend me your
attention to explain you about the study and being selected as the study participant.
The study/project title: - Sero-prevalence of Hepatitis B Virus Infections and Determinant
Factors among Pregnant Women Attending Antenatal Clinic at Deder Hospital
Purpose/aim of the study:-. Determine the Sero-prevalence of Hepatitis B Virus Infections and
Determinant Factors among Pregnant Women. Thus, the study will avail information that
helps the health care providers and managers on the actual magnitude of HBV infection and
associated risk factors among pregnant women those have ANC follow up in this hospital. The
outcome of this study will send a signal to the health care providers and managers about the
importance of routine HBsAg screening and providing proper care for infected mothers and
their children.
Procedure and duration:-You are among the study subject selected purposely (i.e. not by
applying random sampling methods) to participate in this study. Once you have agreed to
enroll in the study, I will be interviewing you using a questionnaire to provide me with
pertinent data that is helpful for the study and to have blood drawn about 3ml (three
teaspoonful) for HBV testing. The interview and blood sample collection will take about 15
minutes, so I kindly request you to spare me this time for the interview.
Risks and benefits:-The risk of being participating in this study is very minimal, but only
taking few minutes from your time. No extra blood sample will be drawn other than that
drawn for routine investigation to antenatal care follow up.In case of any emergency health
problem due to fearing of blood collection and clotting disorder (may be difficult to stop your
bleeding) we are ready to give you first aid and to consult the nearby physician if there is any
indication for further support. There would not be any direct payment for participating in this
36
study. But the findings from this research may reveal important information for the local
health planners and to some extent may for you as well as your baby.
Confidentiality: - Your name will not be written in this format and never be used in
connection with any of the information you are going to tell me.
Rights: -You are not obliged to answer any question that you do not want to answer and your
blood sample; you may end this study at any time you want to.
If you have any question please you can contact me by phone mobile 0912690742 or Deder
Hospital phone number 0253330008 or you can call to The Institutional Health Research
Ethics Review Committee (IHRERC), The College of Health and Medical Science, Harar
Campus (Haramaya University), Phone number 0256685197
Declaration of informed voluntary consent:
I have read/ was read to me the participant information sheet. I have clearly understood the
purpose of the research, the procedures, the risks and benefits, issues of confidentiality, the
rights of participating and the contact address for any queries. I have been given the
opportunity to ask questions for things that may have been unclear. I was informed that I have
the right to withdraw from the study at any time or not to answer any question that I do not
want. Therefore, I declare my voluntary consent to participate in this study with my initials
(signature) as indicated below.
Signature of participant: _______________ Signature of data collector ________________
37
Appendix B. Translated ‘Participant Information Sheet and Consent Form’ in AfanOromo
Odeffannoo fi guca walii-galtee hiramaattoota qorannoof dhihaatan.
Maqaan koo____________________________________ jedhama.
Kaniin dhufe obbo Abdi Umare Univarsitii haramayaatti sagantaa barnoota digrii lammaffaa
(maastariitiif) haal-duree barbaadamu guutuuf qorannoo hojjachuuf karoorfamee keessatti
miseensa garee kanaati. Kanaaf isinis qorannoo kana iraatti akka hirmaattaniif waan
filatamtaniif odeeffanno barbaadamu akka naaf kennitaniif xiyyeeffannoon xinnoo na wajjiin
turtaniif kabajaanin isin gaafadha.
Mata duree qorannichaa:- Babal’insa dhukkuba tiru vaayrasii hepataaytas B jedhamuun dhufu
fi sababa faalama dhukkubichaaf ka’umsa tahan haadholii ulfa garaa qaban irratt gaggeefamu.
Kaayyoo qoranichaa:- babal’insaa dhukkuba kanaatiifi wantoota faalama dhukkuba kanaatiif
sababa tahan haadholii ulfaa keessatti
odeeffanno gahaa qabachuun barbaachisaadha.
Kanaafuu qorannoon kun odeeffanno kana waan gumaachuuf kunuunsa haadholiifi daa’imaaf
godhamu keessatti idoo guddaa qaba. Bu’an qorannoo kanaa ogeessa fayyaatiis tahe
hooggantoota fayyaatiif mutii tajaajila kanaa maal tahuu akka qabu murteessuuf akka
ka’uumsatti kan fayyaduudha.
Adeemsaa fi turtii qorannichaa:- As keessatti waan filatamtaniif odeeffannon isin kennitan
galma gahiinsa hojii kanaatiif iddoo guddaa waan qabuuf akka na deeggartan isin gaafachaa
gaafileen isin gaafadhuuf gucni qophaawe waan jiruuf isin gaafileef deebii sirri tahe naaf
laattu. Gaafin qophaa’e gabaabaa waan taheef yeroo gababaa daqiqaa 10 hin caalle qofa
isinirraa fudhata.
Midhaa fi Bu’aa:-
As keessatti hirmaachuuf midhaan isinirra gahu dandahu baaye’ee
xiqqaadha. Yeroo gabaabaa fi dhiiga qorannoof oolu miiliilitira 3 hin caalle qofa. Tarii rakkoo
sodaa dhiigaa fi dhiigni keessan dhaabbachuu diduu wajjiin wal-qabatuun dhufuu danda’uuf
ogeessi fayyaa gargarsa isinii kennuu danda’ kan qophaa’e ta’uu isinii mirkaneessina.
38
Iccitii fi Mirga:- maqaan keessan guca kana gubbatti kan hin barreeffamnee fi odeeffaanoon
isin naaf kennitan kun kessan tahuu namni biraa beekuu hin dandahu. Gaafilee deebisuu hin
barbaanne kamiyyuu akka deebisuu hin dirqamnee fi yeroo babaaddeetti guutumaa guututti
qorannichaa kessaa bahuuf mirga guutuu qabda.
Gaafii qabdan hundaaf bibilli koo Mob, 0912690742 Wajj, 0253330008 fi dabalataan kan
yunivaristii haramayaa garee dhimmii kun ilaaluu bilbila waajjiraa 0256685197 fayyadamuu
dandeessu.
Labsii Walii-galtee
Odeffannoo xalayaa kana irra jiran hunda dubbisee/naaf dubbifamee;- adeemsi, kaayyoon,
faaydaan, miidhaan, mirgaafi dirqamni kiyya hundi naaf galee jira. Kanaaf fedhii kiyyaan
qorannoo kana keessatti hirmaachuuf mallattoo kiyya kanaan mirkaneesseetin jira.
Mallattoo hirmaataa___________
Mallattoo nama odeeffanno kana guutee________
39
Appendix C. Questionnaire
Questionnaire Number_______
Date of interview___________
Interviewer Name__________________________
Pregnant woman’smedical registration number (MRN)____________
Socio-demographic information
1, How are you old now (in years) ?_______________
2, where are you living? (Tick only one)
Urban
3, What is your marital status? (Tick only one)
Widowed
Single
Rural
Married
Divorced
4, What is your educational Level (Tick only one)
No formal education at all
Primary education (1-8 grades)
Secondary education (9-12 grades)
Tertiary (above grade 12)
5, What is your ethnicity? (Tick only one)
Oromo
Gurage
Amhara
Siltie
Others_________________
6, What is your occupational status? (Tick)
Housewife
Daily Laborers
Others__________________
40
Farmer
Health care worker
Gynecological history (Write or Tick)
7, How many times you have been pregnant (including current pregnancy) ?_____
Question number 8.1 and 8.2 are for Parity
8.1, How many babies did you have live birth ? ______
8.2, how many still birth did you
have (delivery of died baby after 7th month of pregnancy)?___
9, Have you ever delivered at home by traditional birth attendant?
10, Do you have history of abortion?
NO
11, If yes, where was the place of abortion?
NO
YES
YES (if NO, go to question #12)
Home
health facility
Risks for Hepatitis B virus infection(Please tick only one)
12. Did you have ear piercing practice
NO
13. Did you have nose piercing practice
YES
NO
14. Did you have got your body tattooing
YES
NO
YES
15. Did you have been treated with blood transfusion
NO
16. Do you have history of hospital admission
NO
YES
17. Do you have history of tooth extraction
NO
YES
18. Do you have history of surgical procedure
NO
YES
YES
19. Do you have history of cutting of uvula or tonsillectomy traditionally
20. Do you have previous history of sexually transmitted infection?
21. Ever does your partner have had another partner other than you?
22. Did you have other sexual partners since being sexually active?
41
NO
NO
NO
NO
YES
YES
YES
YES
Appendix D. HIV Test Results Collection Formats
Participant’s
Identification HIV Test Result
Number
42
Appendix E. HBsAg Test Results Recording Formats
Participant’s Identification
HIV Test Result
Number
43
Appendix F. Translated Questionnaire in Afan Oromo
Gaafilee Qorannoo Sakatta’ins Faalama Dhukkuba Tiruu (Hepatitis B virus infection) kan
Haadholii Ulfaa irratti godhamuuf Dhihaate
Lakkofsa guca gaaffii_______
Guyyaa gaafii fi debisaa______________
Maqaa qorataa________________________
Lakkoofsa kaardii wal’aansaa_____________
Odeeffannoo bu’ura haala jireenya walii-galaa
1, Umriin kee meeqa(waggaan)?_______
2, Idoon jireenya keeti issa?
Magaalaa
Badiyyaa
3, Haalli gaa’ila keetii? (deebii ishii keessati tuqi)
Hin heerumne
Heerume
Kan du’e
Diigame (hiikaa)
4, Sadarkaa barnootaa keeti hangami?
Barnoota idilee kan hin qabne
Sadarkaa 1ffaa (kutaa 1-8)
Sadarkaa 2ffaa (kutaa 9-12)
Sadarkaa 3ffaa (kutaa 12 ol)
5, Sabni kee malii?
Oromoo
Guraagee
Amaara
Silte
Kan biraa_____________
44
6, Hojiin kee maali?
Qotee bulaa
Haadha warraa
Ogeessa fayyaa
Hojii guyyaa (kan idilee hin tahin)
Kan biraa___________
Seenaa haala hormaataa (da’umsaa) wal-qabatee
7, Inni kun ulfa meqafaadha ykn si’a meeqa daa’ima garaatti qabatte?_____
Gaaffiin 8.1 fi 8.2 lakkoofsa daa’imman lubbuufi lubbuu malee dhalatan ibsa.
8.1, Kan lubbuun dhalatan meeqa ?________
8.2, kan garaa keessatti du’anii dhalatan(umrii ulfaa ji’a 7ffaa booda ?___
9, Ogeessaaadaatiinmanattidhalteebeektaa?
10, Ulfisirraabaheebekaa ?
11, Yoobaheejiraate, essaatti ?
Lakkii
Eeyyee
Eeyyee(yoolakkiita’egaragafi #12 darbi)
Lakkii
Manajirenyaatti
Manayaalaatti
Wantootadhukkubatiruu
kanaanfalamuufsababatahankanneenasiigadiraawwatteebeektaa?
12, Gurrakeeuratteebeektaa ?
13, Funyaankeeyoo ?
Lakkii
(HBV)
Eeyyee
Lakkii
Eeyyee
14, Tumaafaayaqaamaatumatteebeektaa?
Lakkii
Eeyyee
15, Wal’aansadhiigafudhacuusiifgodhameebeektaa?
Lakkii
Eeyyee
16, Ammadurahospitaalaciifteeyaalamteebeektaa?
Lakkii
Eeyyee
17, Ilkaanbuqqafatteebeektaa?
Lakkii
18, Wal’aansabaqaqsaniiyaluugodhatteebeektaa?
45
Eeyyee
Lakkii
Eeyyee
19, Waanlaagaamuratteebeektaa?
Lakkii
Eeyyee
20, Dhukkubaqaamasaalaadukkubsatteebeektaa?
Lakkii
Eeyyee
21, Abbaanwarraakeesimleemichuu biraa niqabaa?
Lakkii
Eeyyee
22, Atiyooergagaa’la geese michuu biraa godhatteebeektaa?
Lakkii
Eeyyee
Appendix G. The principle, procedure and interpretations of test results
PRINCIPLE: This HBsAg ELISA kit uses antibody sandwich ELISA method in which
polystyrene micro-well strips are pre-coated with monoclonal antibodies specific to HBsAg.
Patient’s serum or plasma sample is added to the micro well together with a second antibody
conjugated with horse radish peroxidase (HRP) and directed against a different epitope of
HBsAg. During incubation, the specific immune-complex formed in case of presence of
HBsAg in the sample, is captured on the solid phase. After washing to remove sample serum
proteins
and
unbound
HPR-conjugate,
chromogen
solution
containing
tetramethylbenzidine(TMB) and urea peroxide are added to the wells. In presence of the
antibody-antigen-antibody (HRP) “sandwich” immune-complex, the colorless chromogens are
hydrolyzed by the bound HRP-conjugate to a blue color product. The blue color turns yellow
after stopping the reaction with sulphuric acid. The amount of color is measured
which is
proportional to the amount of antigen in the sample. Wells containing samples negative for
HBsAg remained colorless.
Procedure
1. Numbering wells: set the strips needed in strip –holder and number sufficient number
of wells including three Negative controls, two positive controls and one Blank
2. Add 50ul of positive controls, Negative control and specimen into their respective
wells. Note: use a separate disposal pipette tip for each specimen, Negative control and
positive control to avoid cross-contamination. Add 50 ul HRP-conjugate to each well
except the Blank and mix by tapping the plate gently.
46
3. Incubating: Cover the plate with the plate cover and incubate for 60 minutes at 37c. it
is recommended to use water tank to assure the temperature stability and humanity
durng incubation if dry incubator is used, do not open the door frequently.
4. Washing:After the end of the incubation, remove and discard the plate cover. Wash
each well 5 times with diluted wash buffer. Each time allow the micro wells to soak for
30-60 seconds. After the final washing cycle, turn the strips plate down onto blotting
paper or clean towel, and tap the plate to remove any remainders.
5. Coloring:Dispense 50ul of substrate solution B and after that 50ul of substrate solution
A in to each well including the Blank, and mix by tapping the plate gently. Incubate
the plate at 37 c for 15 minutes avoiding light. The enzymatic reaction between the
chromogen solution and the HRP-conjugate produces blue color in positive control and
HBsAg positive sample wells.
6. Stopping Reaction: using a multichannel pipette or manually add 50ul stop solution in
to each well and mix gently. Intensive yellow color develops in positive control and
HBsAgpositive sample well.
7. Measuring the Absorbance: calibrate the plate reader with the Blank well and read
the absorbance at 450nm. If a dual filter instrument is used,set the reference
wavelength at 630nm. Calculate the cut-off value and evaluate the results.
(note:read the absorbance within 5 minutes after stopping the reaction )
Interpretation of result
Each micro- plate must be considered separately when calculating and interpreting
results of the assay, regardless of the number of plates concurrently processed. The
results are calculated by relating each sample optical density (OD)value to the Cut-off
value (C.O) of the plate. If the Cut-off reading is based on single filter plate reader, the
results must be calculate by subtracting the Blank well OD value from the print report
values of samples and controls. In case the reading is based on dual filter plate reader,
do not subtract the Blank well OD from the print report values of samples and controls.
Negative Results:samples giving an absorbance less than the Cut- off value are
considered as negative,which indicates that no hepatitis B surface antigen has been
detected with this HBsAg ELISA kit. Therefore the patient is probably not infected
with hepatitis B virus.
47
Positive Result:sample giving an absorbance greater than or equal to the cut-off value
are considered as initially reactive, which indicated that HBV surfaces antigen has
probably been detected with this HBsAg ELISA kit. Any initially reactive sample
should be retested in duplicates. Repeatedly reactive samples could be considered
positive for HBsAg therefore the patient is probably infected by HBV.
Appendix H. Curriculum Vitae
Contact Detail
Name:
Abdi Umare Abdi
Sex:
Male
Date of Birth:
10/01/1984
Place of Birth:
Chiro, West Hararge Zone, Oromia, Ethiopia
Marital Status:
Married
Nationality:
Ethiopian
Address:
Deder Hospital
Phone
Mob.0912690742
Office: 0253330008
P.O.Box: 28
E-mail:
umareabdi@gmail.com
2. Personal profile
I am working enthusiastic with laboratory professional. I am eager to learn new skill and
environment and I am recognized by hospital Management.
3. Professional Qualification
Bachelor of Science in Medical Laboratory Technologist, Graduated on July 6, 2006
48
4. Key area of Experience
In Deder hospital since oct.2006 till now at different time as;Laboratory department head
Quality officer
Medical Director of the Hospital
CEO of the Hospital
5. TRAINING ON:TOT Training on Hematology, clinical chemistry, and CD4
Foundation of laboratory leadership and management
AFB smears microscopy and EQA(external quality assessment)
DBS sample collection, packaging, and transportation
Infection prevention
BSC, KPI (key performance indicator) and HMIS (Tulane University& RHB)
Drug and therapeutic committee(MSH/SPS, PFSA)
Medical supply and laboratory reagent(PFSA)
Laboratory Quality Management System
Training on AFB microscopy by LED microscopy
6. COMPUTER SKLLS
Certify on Ms-word, Excel, Access & PowerPoint
Experience in use of Microsoft word, excel, internet & e-mail
7. LANGUAGE
speaking
writing
reading
Afanoromo
excellent
excellent
excellent
Amaharic
exellent
exellent
exellent
English
good
exellent
excellent
8. REFERENCE
49
Mr. Mohamed Abdurehman CEO of Deder Hospital/Deder, 0913929565
Dr. HabtamuBeyene Medical Director Deder Hospital/Deder, 0911553591
Mr. GemachuTofik (MSC public Health) I-CAP, Jimma, 0920463533
Appendix I. APPROVAL SHEET
SCHOOL OF GRADUATE STUDIES
HARAMAYA UNIVERSITY
Sero-prevalence of hepatitis B virus infections and associated factors among pregnant women
attending antenatal clinic at Deder hospital, Eastern Ethiopia
Submitted by:
Abdi Umare
Name of Student
_____________
August 28, 2015
Signature
Date
Approved by:
1. DrBerhanuSeyoum
Name of Major Advisor
_______________
________________
Signature
2. DrTesfayeGobena
_______________
Name of Co-Advisor
Signature
3. ___________________
Name of Chairman, DGC
4. ___________________
Name of Dean, SGS
Date
________________
Date
__________________
Signature
__________________
Signature
50
________________
Date
________________
Date
5. ___________________
Name of Chairman, CGS
__________________
Signature
51
________________
Date