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Background objectives: Blood transfusion is a life-saving
intervention in patient management. However, risks are involved which may lead
to transmissions of hepatitis B and hepatitis C from donors to recipients. This
study aimed at determining the prevalence, knowledge and risk factors
associated with hepatitis B and hepatitis C infection. It also described the
existing knowledge about infection impact and spread of HBV and HCV.
Methodology: This was descriptive type of study design adopting purposeful sampling
technique.
Where every 6th voluntary blood donor was selected. Six millilitres (ml)
blood samples was drawn from 384 voluntary blood donors aged 18-65 years.
Chemiluminescent micro particle immunoassay technology was used to determine
present of HBsAg and anti-hepatitis C in serum.
Results: There were 384 participants whose analysis recorded 1.0 % HBV prevalence
and 0.3 % HCV. The prevalence of HBV was significant in both male and female
voluntary blood donors VBD (χ2=9.88, df=2, P = 0.007). However, it was
insignificant for HCV (χ2=1.871,df=1,P=0.349).Intravenous drug use was a major
risk factor identified for HCV and HBV infection. Most voluntary blood donors
64% and 71 lack knowledge about hepatitis B and HCV respectively in terms modes
of transmission, general information and risks of infection.
Conclusion: Despite strict selection targeting low risk groups there was 1.3%
expression of HBV and HCV. Only 34% respondents had sufficient knowledge about
hepatitis B and HCV transmission. Modes. Intra venous drugs was a major risk
for HCV and HBV infection.
Keywords: Hepatitis, Rrisk, Kknowledge, Ttransmission
INTRODUCTION
Blood transfusion a life-saving intervention in patient management [1].
However, risks are involved which may lead to transmissions of hepatitis B and
hepatitis C viral infections from donor to recipient [2]. Hepatitis B virus and HCV are common
infection and complications which result from blood transfusion [3,4]. The
seroconversion is approximately 2% for HCV and 6-60% for HBV in cases of being
a blood recipient [5]. Standard
reliable results coupled with a working quality management system reduce errors
and risks of transmitting infection to blood recipients.
Interventions, such as standardized screening of donated blood, use of regular
voluntary blood donors, and exclusion of high risk blood donors improve quality
and availability of safe blood. Unnecessary transfusion and inappropriate
utilization of blood contribute to Transfusion transmissible infection in
developing nations [6].
Transfusion transmissible infections can be monitored and reduced if Reduction can also be achieved by having data on HBV and HCV prevalence, knowledge and risks. Two billion people are exposed to Hepatitis B virus, 350 million develop chronic Hepatitis B and over two million annual death according to World Health Organization estimates There are 177.5 million estimated infection of Hepatitis C in the world, half of infected people are in Africa [7,8]. African countries including Kenya have difficulties to access safe and adequate blood attributed to lack of quality manage-ment systems, policies, standardized protocols and non-applicable use of confirmatory tests like polymerase chain reaction and Nucleic acid test. Hepatitis status un-awareness, lack of standardized and centralized screening methods in Kenya make blood a potential source of TTIs. This is against WHO recommendations that require all countries to have working quality management systems and to implement centralized and standard blood screening policy as envisioned by WHO. Standardized and centralized screening of donated blood gives precise and reliable results.
The aim of this study was to establish the
prevalence of hepatitis B and HCV, risks and existing knowledge among Kenyan
voluntary blood donors. In Kenya Hepatitis B
virus prevalence is estimated to be at 5-8% in the general public [9]. Whereas transmission
prevalence of 3.2% and 2.4% HCV and HBV
respectively [10] was reported in Nyeri satellite among voluntary blood
donors. The prevalence of HCV was reported to be less than 1% (Karoney et al.,
2013) in Kenya, review of Africa hepatitis infection.
In Sub-Sahara Africa the established risk
ratio is 2.5 and 4.3 of HCV and HBV infection respectively of every 1000 units
of transfused blood [12]. This ratio may be as a result of relaxing stringent
rules used for selecting blood donors, unreliable blood screening techniques.
Other issues like inappropriate utilization of blood brought about by policies
that do not describe or guide on correct use of blood.
Lack of awareness to past and recent
infection and latency stages of HBV and HCV complicates selection of health
voluntary blood donars. The risk ratio of transmitting HBV through blood
transfusion are potentially high in HBV latent infection. In Sub Saharan Africa
12.5% patients who receive blood transfusion are at a risk of post transfusion
infection like Hepatitis B and Hepatitis C [13]. Such trends creates lasting
reservoirs for infectious diseases such as HCV and HBV in the general
population. New infection has negative impact on the economy and puts pressure
on medical care, increase dependency and loss of productive persons.
Centralized and standardized screening of blood greatly improves quality and
safety of blood; however, the contrary happens without established standards.
To ensure quality and safe supply of blood there must be standards that must be
complied by both private and public transfusing facilities. During window
period the results of HBsAg assay are negative however detection of HBV DNA
reduces transmission of HBV during acute window period. The disappearance of
HBsAg in chronic occult HBV infection can lead to transfusion of HBV. To help
reduce infection transfer, latent screening and confirmatory tests are critical
as a screening component.
METHODS
Study
design
Across sectional, descriptive type
of study design was adopted. The
study population were voluntary blood donors whose data were collected from
March 2017 to June 2017 within Nairobi. A total 2135 blood donors volunteered
whereas only 384 were enrolled. Basically, donors must be 18-65 years, be in good health, a
pre donation haemoglobin (Hb) of ≥ 12.5g/dl. Be ≥ 50 kgs and satisfy risk
assessment section on the questionnaire. They also must have had a snack in
last six hours and without history of fainting in last one month. All voluntary
donors who did not meet above condition were excluded.
Laboratory diagnosis of Hepatitis B and Hepatitis
C virus
Diagnosis of HBV and Hepatitis C virus depended on the detection of HBsAg
and anti HCV in blood donor’s serum. Chemiluminescent micro particle
immunoassay technology (CMIA), with flexible assay protocols referred to as
chemiflex was used, for the quantitative determination of HBsAg in serum.
Chemiluminescent micro particle immunoassay was used to determine the present
of antibodies and analyte in the samples. This reaction was measured as
relative light units (RLUs), which means relationship exists between HBsAg in the
sample and the RLUs detected.
Diagnosis of HCV also depended on the
detection of anti HCV in blood donor’s serum. Chemiluminescent micro particle
immunoassay technology (CMIA), with flexible assay protocols referred to as
chemiflex was used, for the quantitative determination of anti-HBC in human
serum.
The CMIA then measures the chemiluminescent
emission over a predefined time period to quantitate the analyte concentration
to determine qualitative interpretation or cut off. Resulting reaction is
measured as RLUs, that is direct relationship exists between the amount of
anti-HCV in the sample and the RLUs detected.
ETHICAL CONSIDERATIONS
Ethical approval was given by Kenyatta
University Ethics and research Committee (KUERC). Permission to use donor
results was given by the director Kenya National blood transfusion. For
confidentiality and integrity, each volunteer blood donor signed a consent form
was assigned a unique identification code and was assured that information
collected will not be made public.
DATA
ANALYSIS
The data was analyzed using Chi-square test with a confidence (CI) interval of 0.05. Demographic characteristics was analyzed using percentages and frequencies. The ages were placed in 5 groups with age difference of 10 years. Chi-square test was used to find the significance difference between voluntary donors infected by hepatitis age groups and knowledge about hepatitis transmission. The relationship in the occurrence of hepatitis in voluntary blood donors was found to be significant at P=0.05 for all test at 95% CI. Results analysis was done using Statistical Packages for Social Statistics (SPSS) version 23.
RESULTS
Demographic characteristics of voluntary blood donors
A total of 384 voluntary blood donors aged 18
to 65 years and categorized into 18-25, 26-35, 36-45, 46-56, 56-65 years
participated in the study. The mean age was 25.12 years with a SD of 6.963.
There were 65.1% male and 34.9% female participants. More than half 68.2%
participants were 18-25 years, 22.1% were 26-35 years, 7.3% were 36-45 years
and 2.3% were 46-55 years. There was a reduction in number of voluntary blood
donors with advance in age. Majority, 89.3% voluntary blood donors had college
or tertiary education, 8.9% secondary education, 0.8% primary education (Table
1).
Prevalence of Hepatitis
B virus and HCV among voluntary blood donors at RBTC-Nairobi
The overall
prevalence of both HBV and HCV was at 1.3% among voluntary blood donors (Table
2).
Prevalence of HBV
and HCV in male and female voluntary blood donors at RBTC Nairobi
There were
250 male and 134 female voluntary blood donors enrolled. The study recorded a
prevalence of 0.8% HBV in male and 1.5% in female VBDs. Prevalence of HCV was
0.3% among male and female voluntary blood donors (Table 3).
Seropositivity of ant HBsAg was significant in both female and male VBD (χ2=9.88,
df=2, P=0.007). Seropositivity of ant HCV was insignificant in both female and
male VBD (χ2=1.871, df=1, P=0.349). (Table 3).
Association of predictor variables (Risks)
with HBV and HCV infection among voluntary blood donors at RBTC- Nairobi
Out of 384
voluntary blood donors 1.3% had history of exposure to unsafe injection while
98.7% had no exposure history to unsafe injection. Six (1.6%) VBDs had been
exposed to unprotected sex, 98.4% not exposed to unprotected sex (χ2=0.800,
df=1, P=0.004). Thirty, (7.8%) voluntary blood donors had used non-medical
drugs like cocaine and marijuana (χ2 =1.658, df =1, P= 0.198). Five
(1.3%) VBDs had contact or stayed together with people with yellow eyes.
Consent to sex in exchange for money as a risk, at least 1% VBDs gave or
received money in favor of sex (χ2 =0.974, df =1, P= 0.003). At
least 3.1% VBDs consented to sex with someone whose HBV and HCV status was
unknown to them (χ2 =0.130, df =1, P= 0.718). In conclusion 4.4% of
voluntary blood donors had more than one sexual partner which meant risk to
self and infecting others.
Knowledge about Hepatitis
B among voluntary blood donors
A standardized questionnaire with eleven
closed end questions whose response were analysed to establish how much
knowledge was there among voluntary blood donors was used. The respondents were
allowed to mark “Yes”, “No and “Don’t Know” to respond to questions. From their
responses, 51.25 % voluntary blood donors, were aware HBV was acquired through
unsafe injections whereas 48.75% being unaware. In the same study, it was noted
that only 32.55 % voluntary blood donors were aware that HBV was a lifelong
infection whereas over 67.44% were unaware. It was also found out that most
voluntary blood donors 71.35 % were not informed about or being aware of HBV
complicating to liver cancer and cirrhosis. The study recorded that there were
only 36.72% of the respondents aware of HBV vaccine availability. Treatment
could cure hepatitis B infection however only 42.19%) voluntary blood donors
knew HBV could be cured if treated. This study noted that there were only 31%
of the respondents who were aware of Hepatitis B transmission via sharing of
contaminated syringe and needles.
This study also recorded that only
38.8%voluntary blood donors knew HBV was transmitted from mother to child.
Whereas majority 61.2% were not informed or not aware. In overall, majority 235
(61.19%) respondents had not been informed how perinatal HBV transmission
occurs. Another common mode of HBV transmission was via unprotected sex;
however, only 35.7% voluntary blood had information about this form of
transmission. Transmission of HBV can also occur through transfusion of not
properly screened blood and its products. At least 144 (37.7%) voluntary blood
donors knew HBV was transmitted through transfusion of blood and blood
products. In overall, the general knowledge about hepatitis B virus was below
average as only 36% respondents were found to have sufficient information about
HBV modes of transmission. Majority 64% respondent’s lack general knowledge
about HBV.
Current existing general knowledge about
Hepatitis C among voluntary blood donors at RBTC-Nairobi
A standardized
questionnaire with 11 closed end questions was used to collect information
whose data was analyzed to establish how much knowledge was available about
HCV. The respondents marked “Yes”, “No and “Don’t Know” to respond to the
questions. The findings were, only (37%) voluntary blood donors acknowledged
that HCV was a virus and it’s a viral infection.
Out of 384, only 70
(10.70%) voluntary blood donors acknowledged that HCV was a lifelong infection.
However, most respondents (89.3 %) had insufficient information or knowledge,
how HBV was a lifelong infection.
Out of 384, 76
(19.8%) voluntary blood donors acknowledged that HCV could lead to liver cancer
or liver cirrhosis, however, 80.2% voluntary blood donors were not able to
acknowledge that HCV could lead to liver cancer or cirrhosis. This was be
attributed to lack information on how HCV infection leads to liver cancer or
liver cirrhosis.
This study recorded
that there were 39.52% voluntary blood donors aware that HCV was transmitted by
being transfused with contaminated blood and blood products. However overall
majority 233 (60.67%) VBDs lack knowledge or information how this occur when
all transfused blood is screened.
Hundred and twenty
nine (33.59%) voluntary blood donors acknowledged that HCV could be cured if
treatment was given. However, majority (66.40%) VBDs knew that HCV was not
curable.
Out of 384 only 93
(24.22%) voluntary blood donors acknowledged that HCV had signs and symptoms
however, majority 226 (58.85%) had no idea or any knowledge. Respondents’
knowledge about HCV infection was below expected levels among voluntary blood
donors. Only 27.48% voluntary blood donors had excellent knowledge, whereas
71.2 % had poor knowledge about HCV transmission.
This study noted that 18% voluntary blood donors
thought that HCV could be transmitted via faecal oral route while majority 82%
knew that transmission does not occur this way.
DISCUSSION,
CONCLUSION & RECOMMENDATIONS
Kenya National
Blood Transfusion Service (KNBTS) depends on voluntary blood donors for blood.
From this study most voluntary blood donors were below 35 years whose majority
were aged 18-25 years at68.2%. The results compare well with [14], in Ghana
where 50.2 % voluntary blood donors were below 35 years, 64.4% were 19 to 35
years [15] and below 35 years in Gabon. Number of donors aged above 36 years
was only 9.6%. The results compare well
to that of [16], where less than 10% voluntary blood donors were >40 years
of age this contrast with over 40- 45% voluntary blood donors aged above 40 to
50 years in the USA [17]. In this study males formed majority (64.8%) voluntary
blood donors compared to female (25.2%) voluntary blood donors. Most females
were deferred due to low hemoglobin, body physiological changes and pregnancy
[18]. They are prone to vasovagal reactions which affects their experience as
blood donors. Deferral to donate diminishes likelihood of donor return,
especially for first-time blood donors or longer period allowed before next
donation.
Women have
difficulties when blood is withdrawn and fear adverse and vasovagal reaction
during or after donation than men. Materials used in blood donation such as
needles, sight of blood and the feeling of discomfort make women defer
themselves from blood donation. Fewer women give blood because it is not their
relative who needs blood [19]. Less men were deferred giving an opportunity to
most of them being allowed to donate because their hemoglobin was ok and
willingness to donate. Men are more individualistic unlike women who are
altruistic. In Ghana [20] reported 2.05% female and 97.95% male donors. The
difference in respondents was attributed to difference in study design, number
of participants and entry criteria used. Geographical location may also affect
outcome due to different believes and myth about blood. The selection criterial
used and type of population approached impact on respondents. Some religion and
myth about blood affect number of voluntary blood donor turnout. Low level of
both hepatitis B and HCV could be attributed to level of education. However,
this contradicts the finding of this study where the general knowledge among
respondents about HBV and HCV 37%. This indicates an existing gap which need to
be filled by educating the public on both Hepatitis B and HCV.
Prevalence of
Hepatitis B and HCV among voluntary blood donors at Regional Blood Transfusion
Center, Nairobi
This study
recorded, 1.3% prevalence of hepatitis B and hepatitis C among voluntary blood
donors, 1.0 % and 0.3% respectively for Hepatitis B and Hepatitis C. Prevalence
of of 1.5% HBV was recorded among voluntary blood donors aged 18-25 years.
Prevalence of hepatitis B in this age group was higher than overall prevalence
of HBV. This results indicated that HBsAg carriage is higher among young
people. Early infection may complicate in both HBV and HCV leading to liver
cancer and liver cirrhossis. Prevalence of HBV and HCV was not significant
(χ2=1.882, df=3, P=0.597). Low prevalence of both HCV and HBV at RBTC Nairobi
was probably attributed to strict selection and health talk segment given to
potential VBDs before blood donation. In addition, low risk groups which
include faith-based organization, institution, schools colleges and disciplined
forces are used. Low prevalence can also be attributed to self-exclusion as a
result of pre-donation counselling and 100 % voluntary blood donation.
More so, Kenya is classified by WHO as low
prevalence country. In this study 90.6%
voluntary blood donors had tertiary education; however, this did not reflect on
how much knowledge was available about HBV and HCV infection. It is believed
educated people make informed decision and understand the risks and control
measures of infection. In addition, they also engage in positive
health behaviors that protect their lives. In a study at Mbagathi hospital [21]
said that education play a major role and has a big impact on spread and
control of infection. The
finding are inconsistent with report from a study by [22] which
reported more than half 2.1% HBV in the general population. Kamande et al., [10] reported a 2.4 % HBV,
Madhushree et al., [23]
reported 0.4% HBV in India. In Uganda
Hladik et al., [24] reported 3%
HBV and 0.6% HCV, Varsha et al.,
[25] reported 1.79%. In Eritrea Siraj et
al., [26] reported a 2.0%, 0.7% HBV and HCV respectively. The results are inconsistence to
those of Asundula et al. [21] which reported HBV of 3.8% among pregnant women
at Mbagathi hospital in Kenya. The results are also inconsistence to those of
Jean et al. [16] which reported HBV of 3.9% among general population in Rwanda.
Results
variation could be attributed to differences in geographical regions, different
types of risk groups and the means of exposures involved. It could also vary
depending on prevalence of hepatitis in the general population. The differences
could also be attributed to study design, study population and the criteria for
inclusion or exclusion. Globally there is variation in sero-prevalence of HCV,
with lowest prevalence in United States (0.1%) and highest in Egypt 24.8%. In Morocco,
Baha et al. [27] reported 0.62%
HCV and 0.96% HBV prevalence, Fathi et
al. [28] in Jordan. More so, there is concerted efforts to immunize every newborn child by
the government which may have reduced this prevalence.
Risk factors
associated with Hepatitis C infection among voluntary blood donors
Among the
risks that were identified and associated with hepatitis C were; use of illicit
drugs like marijuana and cocaine. At least 30 (7.8%) voluntary blood donors had
used these drugs. However, this was insignificant (χ2=0.085, df=1, P=0.922) in terms of prevalence
or infection by hepatitis C among voluntary blood donors. Promiscuity, 3.9%,
3.1% sexual activity with people of unknown hepatitis background, 1.8 % sharing
of contaminated needles and syringes. Contact with people having signs of
infection by hepatitis 1.3%, 1% giving or receiving money to get sexual favors.
Most risks were associated with peer pressure, social environment, belief that
marijuana has medicinal value, curiosity and low perception of harm. The
participant who had used nonmedicinal drugs had first used them while in school
or college. This pattern suggested peer pressure influence to start doing
drugs. Frequency in type of risks differ depending on the geographical location
and also target population. The most
significant risks in this study were engaging in unprotected sex, sex with
multiple partners (χ2=1.849,
df=2, P=0.039, χ2=0.829,
df=1, p=0.046) respectively. More so unsafe injection (χ2=02.233, df=2, p=0.027) and sexually transmitted infection (χ2=0.908, df=1, p=0.013) were
significant risks to HBV infection.
Existing general knowledge about hepatitis B
infection among voluntary blood donors at RBTC-Nairobi
In this study we described the
knowledge regarding HBV transmission modes, HBV infection, HBV risk factors,
HBV signs and symptoms among voluntary blood donors at RBTC, Nairobi. Kenya. We
also described the knowledge regarding HBV based on information known to
voluntary blood donors. This information was whether HBV was a viral infection,
lifelong infection, if it can be cured or treated and about prevention by
vaccination. The knowledge among voluntary blood donors was evaluated by
distributing a questionnaire with 11 closed end question about HBV. The respondents were required to mark “Yes”,
“No” or “Don’t know”.
It was generally observed that
majority voluntary blood donors had poor knowledge regarding HBV treatment, was
it a viral infection, lifelong infection and if it had a vaccine. There were
only 34% voluntary blood donors with satisfactory knowledge whereas 66% had
unsatisfactory knowledge. In regard to knowledge about HBV transmission, 38.2%
of the voluntary blood donors had satisfactory knowledge, however, majority
61.8% had poor or unsatisfactory knowledge. This gives a picture about the
extent of ignorant that exist about HBV transmission. The parameters that were
considered were transmission via contaminated needles and syringes, unprotected
sex, perinatal, transfusion contaminated of blood and blood products.
Unprotected sex among adults has been known to be a common route of HBV
transmission, however, in this study, 64.8% respondents disagree to this fact.
More so, 48.7% of the respondents wrongly thought that HBV was transmitted via
the feco-oral route.
Sharing of contaminated needles and syringe
are well known modes of HBV transmission, however only 31% respondents agreed
and 69% of the respondents disagreed with this fact. Transfusion with
contaminated blood and blood products and through mother to child (perinatal)
are other methods. However, 37.5 % and 38.8% voluntary blood donors
respectively agree that HBV can be transmitted via this means. This results
compare well with other studies
[29]. This could be because, information
about viral infection relating to HBV is not well known. They
also compare well with other
studies among pregnant women [30]. This results was attributed to insouciant
knowledge about HBV, barrier to eliminating its transmission among pregnant
mothers. Scientists
[31] reported that perinatal transmission of hepatitis B is mostly in mothers
with detectable HCV RNA in peripheral blood by PCR.
CONCLUSION
Despite strict selection and targeting low
risk groups there is 1.3% expression of HBV and HCV (1.0% and 0.3%
respectively) among voluntary blood donors. Intravenous drug use was a major
risk factor for HCV and HBV infection among voluntary blood donors. There was
lack of general knowledge and transmission of both HBV and HCV among voluntary
blood donors was poor. There were only 34% respondents with sufficient general
knowledge and sufficient knowledge about hepatitis B and HCV modes of
transmission.
RECOMMENDATIONS
Establish a functioning blood
donor data bank of all seronegative voluntary blood donors and encourage repeat
donations by Kenya National Blood Transfusion Service. Promoting and
rehabilitation of drug addiction could help reduce HBV or HCV transmission.
Promoting public Education and awareness on HBV and HCV transmission,
progression and lay down strategies to reduce infection to be implemented by
the Kenya National Blood Transfusion Service (KNBTS).
FURTHER
STUDIES
Carry out a country wide study in both
voluntary blood donors and general public on prevalence and knowledge and risks
about hepatitis B and hepatitis C viruses. Secondly to carry out genotyping in
both HCV and HBV among voluntary donors in Nairobi region.
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