Prevalence Of Hepatitis B Virus Among Pregnant Women Attending Antenatal Clinic At Primary Health Centre

Introduction

1.1 Background of the Study

Viral hepatitis is an international public health challenge, comparable to other major communicable diseases, including HIV, tuberculosis and malaria.Despite the significant burden it places on communities across all global regions, hepatitis has been largely ignored as a health and development priority until recently. It will no longer remain hidden, however, with the adoption of the resolution on the 2030 Agenda for Sustainable Development. Target 3 (three) is of particular relevance: it calls for specific action to combat viral hepatitis (Global Health Sector Strategy on viral hepatitis, 2016–2021).

Hepatitis is an inflammation of the liver that is caused by a variety of infectious viruses and non-infectious agents leading to a range of health problems, some of which can be fatal. There are five main strains of the hepatitis virus, referred to as types A, B, C, D and E. While they all cause liver disease, they differ in important ways including modes of transmission, severity of the illness, geographical distribution and prevention methods. In particular, types B and C leads to chronic disease in hundreds of millions of people and together are the most common cause of liver cirrhosis, liver cancer and viral hepatitis-related deaths.

An estimated 354 million people worldwide live with hepatitis B or C, and for most, testing and treatment remain beyond reach. Some types of hepatitis are preventable through vaccination (World Health Organization, 2016).

Nearly 300 million people worldwide live with Hepatitis B Virus (HBV), which resulted in an estimated 820,000 preventable deaths in 2019. The virus is most commonly spread from mother to child during birth and through contact with the bodily fluids of an infected person. Infection in infancy and early childhood leads to chronic hepatitis in about 95% of cases. The World Health Organization (WHO) recognizes HBV as a leading cause of death worldwide (WHO, 2016).Annual World Hepatitis Day campaign is one of nine flagship World Health Organization’s annual health campaigns to increase awareness and understanding of viral hepatitis. For World Hepatitis Day 2022, WHO focuses on the theme “Bringing hepatitis care closer to you” and calls for simplified service delivery of viral hepatitis services, bringing care closer to communities.Up-to-date national and sub-national data on infection levels in the community is key to measuring progress towards this goal. (WHO, 2022) A World Health Organization (WHO) study found that an estimated 4.5 million premature deaths could be prevented in low- and middle-income countries by 2030 through vaccination, diagnostic tests, medicines and education campaigns. WHO’s global hepatitis strategy, endorsed by all WHO Member States, aims to reduce new hepatitis infections by 90% and deaths by 65% between 2016 and 2030.Prevalence of HBV infection is classified by WHO as high (>8.0%), intermediate (2%–8%) and low (<2%). (World Health Organization, 2016).

A new Consolidated guidelines on HIV, viral hepatitis and STI prevention, diagnosis, treatment and care for key populations was published by World Health Organization. The guidelines are officially launched at the AIDS 2022 Conference in Montreal, Canada, in a satellite session entitled: Launching new WHO guidelines for key populations: Focus for impact.The guidelines outline a public health response to HIV, viral hepatitis and sexually transmitted infections (STIs) for 5 key populations (men who have sex with men, trans and gender diverse people, sex workers, people who inject drugs and people in prisons and other closed settings).

In China, The 13th five-year plan for economic and social development of the People’s Republic of China (2016–2020). Beijing: Central Compilation &Translation Press reveals that government have identified HBV as a significant health issue, and the virus is one of six major infectious diseases included in the latest 5-year Chinese national plan.

Substantial progress has been made over the past 20 years in implementing high national levels of coverage of interventions to prevent both horizontal transmission (infant HBV vaccination) and vertical transmission (birth-dose HBV vaccination within 24 hours of birth and hepatitis B immunoglobulin, Ig). The results of sequential national serosurveys in China reveal a reduction in the prevalence of HBsAg in children younger than 5 years from 9.7% in 1992, to 1.0% in 2006 and to 0.3% in 2014. (. Cui F, Shen L, Li L, Wang H, Wang F, Bi S, et al., 2017).

In 2014, the United States Preventive Services Task Force recommended screening of high-risk adolescents and adults, and pregnant women at their first prenatal visit for HBV infection to prevent transmission of HBV to vulnerable newborns and children. To reverse the trend, an HBV prevention protocol similar to that for the prevention of mother-to-child transmission of HIV is required. This protocol would increase HBV case detection rate and lead increased HBV contact tracing of household members, increased adequate HBV vaccination of infants at birth, and enable the evaluation of HBV vaccination uptake among infants.Hepatitis B virus (HBV) infection has shown an intermediate or high endemicity level in low-income countries over the last five decades. In recent years, however, the incidence of acute hepatitis B and the prevalence of hepatitis B surface antigen chronic carriers have decreased in several countries because of the HBV universal vaccination programs started in the nineties. Some countries, however, are still unable to implement these programs, particularly in their hyperendemic rural areas(World Journal of Gastroenterology, 2015).

The diffusion of HBV infection is still wide in several low-income countries where the prevention, management and treatment of HBV infection are a heavy burden for the governments and healthcare authorities (Rosa Z.,Adriana B., 2015). Overall, an estimated 10% of those chronically infected have been diagnosed (World Health Organization, 2021). Importantly, the vast majority of those diagnosed and on treatment live in the Americas, Europe, Asia, or the Western Pacific regions. 

In Africa, less than 2% are diagnosed and a paltry 0.1% are on treatment. This contrasts sharply with HBV prevalence in Africa, where it is endemic, with a 60% lifetime risk of acquiring HBV infection. An estimated 82 million people are chronically infected, representing one-quarter of the globally infected population. Based on the WHO viral hepatitis scorecard data made available online, Nigeria has 5.5% HBsAg seroprevalence in theSub-Sahara Africa.South Sudan has thehighest prevalence rate of 22.2%, Liberia 14.9%, Niger 11.6%, Benin 11.0%, Central African Republic and Mauritania records 10.2%, while countries with lowest prevalence include; Seychelles with 0.4%, Botswana 1.3%, Algeria 1.8%, Eritrea and Mauritius 1.9%(WHO Viral Hepatitis Scorecard;December, 2019). A total of 30 of the 47 WHO AFRO region countries have a HBsAg prevalence >5% and 70% of all new HBV infections occur in the WHO AFRO region. Moreover, more than two-thirds of the now 6.3 million children below the age of 5 who are hepatitis-B-surface-antigen-positive (HBsAg) reside in the WHO AFRO region (De V.,NayagamM.J., et al., 2021).

With over 20 million people estimated to be infected with Hepatitis B virus (HBV) infection, Nigeria has the largest number of people living with HBV infection in sub-Saharan Africa (SSA) and ranks third after China and India, globally. The 2018 Nigeria HIV/AIDS Impact and Survey reported the prevalence of HBV among persons aged 15–49 years is 8.6%, with the prevalence among males (11.1%) about twice that of females (6.1%). In Nigeria, HBV is the most common cause of liver cancer and the fourth leading cause of cancer deaths. Nonetheless, it has continued to be a silent epidemic, as most of the people infected are undiagnosed and do not access treatment and prevention services (Olakunde B. O., Adeyinka D. A., Olakunde O. A., Uthman O. A., Bada F. O., Nartey Y. A., et al., (2021).

1.2 Statement of Problem

Viral hepatitis during pregnancy is associated with high risk of maternal complications and pregnant women are known for depressed immunity, thus infection with Hepatitis B Virus is of clinical importance due to vertical transmission (i.e., mother to child). By 2030, the incidence of chronic hepatitis infection will have been reduced by 90% and there will be universal access to key prevention and treatment services.The world health organization’s global health sector strategy on viral hepatitis, is the first as a strategy thatcontributes to the achievement of the 2030 Agenda for SustainableDevelopment. 

It covers the first six years of the post2015 health agenda, 2016–2021, building on the Prevention and Control of Viral Hepatitis Infection: Framework for Global Action, and on two resolutions on viral hepatitis adopted by the World Health Assembly in 2010 and in 2014. The strategy addresses all five hepatitis viruses (hepatitis A, B, C, D and E), with a particular focus on hepatitis B and C, owing to the relative public health burden they represent. Also describes the contribution of the health sector to combating viral hepatitis, towards its elimination as a public health threat. It promotes synergies between viral hepatitis and other health issues, and aligns the hepatitis response with other global health and development strategies, plans and targets. It positions the response to viral hepatitis within the context of universal health coverage – an overarching health target of the 2030 Agenda for Sustainable Development. The strategy outlines a way ahead, and provides:

A vision of a world where viral hepatitis transmission is halted and everyone living with viral hepatitis has access to safe, affordable and effective care and treatment; A goal of eliminating viral hepatitis as a major public health threat by 2030; Targets that seek to reduce the incidence of chronic hepatitis infection from the current 6–10 million cases of chronic infection to 0.9 million infections by 2030, and to reduce the annual deaths from chronic hepatitis from 1.4 million to less than 0.5 million by 2030.

Achieving these targets will require a radical change in the hepatitis response, and will mean that hepatitis is elevated to a higher priority in public health responses. The strategy must exploit new opportunities, including: increasing public awareness; advances in hepatitis medicines, diagnostics and other technologies; and strengthening commitment to achieve health equity.The strategy defines a set of priority actions for countries to undertake, and counterbalances this with a set of priority actions for WHO to undertake, in support of countries. 

Despite the high burden of HBV in Nigeria, there is no efficient surveillance system for monitoring and understanding the epidemiology of the infection (National AIDS/STIs Control Programme, Federal Ministry of Health. National Strategic Plan for the Control of Viral Hepatitis in Nigeria (2016–2020) Abuja; 2016). Program data are deficient as pregnant women are not routinely screened for HBV (Akindigh T. M., Joseph A. O., Robert C. O., et al., 2019) and population-based serosurveys are not regularly conducted (Olakunde B. O., Adeyinka D. A., Ndukwe C. D.,et al., 2021). Accurate estimates of the burden of HBV in Nigeria, especially among pregnant women, are needed for rational planning of health services and would allow public-health policymakers to assign sufficient priority and resources to its management and prevention. 

In the absence of surveillance data, information from multiple studies has been used to generate prevalence estimates.

In 2014, a meta-analysis of studies published between 2000 and 2013 in Nigeria estimated the HBV prevalence in pregnant women as 14.1% (95% confidence interval [CI] = 9.6, 18.6%) from 14 studies. (Musa B. M., Bussell S., Borodo M. M., et al., 2015). However, the review focused on women attending antenatal care in health facilities. Furthermore, the review did not consider the prevalence of HBV by sociodemographic characteristics, the risk factors associated with HBV, and the prevalence of HBeAg among HBV-infected pregnant women. Similar limitations were present in the 2018 national household survey among a population of 435 pregnant women in Nigeria. (Federal Ministry of Health. Nigeria HIV/AIDS Indicator and Impact Survey (NAIIS) 2018: Final report. Abuja; 2019).

Consequently, most health facilities especially in rural communities in Nigeria often do not screen pregnant women and many fails to give significant attention to HBsAg during antenatal clinic.However, with adequate resources and strong political commitment, this disease can be eliminated by 2030.

It is on this premise, that a study to determine the significance of HBV among pregnant women, perceptions on the spread and assessment on access to services towards eliminating vertical transmission of hepatitis B virus among pregnant women attending clinic in the rural community is considered a necessity. This in a view to achieving the WHO targets that seek to reduce the incidence of chronic hepatitis infection from the current 6–10 million cases of chronic infection to 0.9 million infections by 2030, and to reduce the annual deaths from chronic hepatitis from 1.4 million to less than 0.5 million by 2030.

1.3 Research Questions

Are there practices associated with the spread of hepatitis B virus among pregnant women attending clinic in Agede PHC, Kishi Oyo State?

Is there significance of hepatitis B virus among pregnant women attending clinic in Agede PHC, Kishi Oyo State?

What are the perceptions of pregnant women towards HBsAg screening during antenatal clinic in Agede PHC, Kishi Oyo State? 

Is there availability of Hepatitis B Vaccine Birth-Dose (HB-BD) in Agede PHC, Kishi Oyo State?

1.4 Objectives of the study

1.4.1 General objective 

The aim of this study is to determine the prevalence of hepatitis B virus among pregnant women attending antenatal clinic in Agede PHC, Kishi Oyo State.

1.4.2 Specific objectives.

To identifypractices associated with the spread of hepatitis B virus among pregnant women attending clinic in Agede PHC, Kishi Oyo State;

Todetermine thesignificance of hepatitis B virus among pregnant women attending clinic in Agede PHC, Kishi Oyo State;

To classify available healthcare services for pregnant women attending clinic in Agede PHC, Kishi Oyo State;

Toevaluateperceptions of pregnant women towards HBsAg screening during antenatal clinic in Agede PHC, Kishi Oyo State and

Toassess theavailability of hepatitis B vaccine birth dose (HB-BD) in Agede PHC, Kishi Oyo State.

1.5 Significance of study

The epidemic of viral hepatitis B and C affects 325 million people globally and is 10 times larger than the global HIV epidemic. Every day, more than 3600 people die of viral hepatitis-related liver disease, liver failure and liver cancer.Dying from viral hepatitis in Africa has become a greater threat than dying from HIV/AIDS, malaria or tuberculosis. Yet, a new analysis shows that the disease remains neglected in many parts of the continent.

This study will determine the significance of hepatitis B virus and identify common practices among pregnant womenthat are associated risk factors to the spread of hepatitis B virus as well assess services available to eliminate the endemicity and provide solution via recommendations on how best vertical transmission of hepatitis B virus can be reduced through effective antenatal services in the rural communities.

1.6 Scope of the study

This is a cross-sectional study in rural community on the prevalence of hepatitis B virus among pregnant women attending clinic. It is carried out at the antenatal clinic of Primary Health Center Agede,Kishi Oyo state.

However, the focus is limited to hepatitis B virus infection among pregnant women attending antenatal clinic in this study area.

1.7 Definition of terms

Acute Hepatitis

Acute hepatitis is a term used to describe a wide variety of conditions characterized by acute inflammation of the hepatic parenchyma or injury to hepatocytes resulting in elevated liver function indices.

Antenatal

The period of pregnancy in woman usually between conception and establishment of labour.

Antenatal Clinic (ANC)

A designated place with focused attention on care of pregnancy, delivery and safe motherhood for pregnant women during pregnancy.

Antibodies

Antibodies are proteins that protect body when an unwanted substance enters. It is produced by the body immune system; antibodies bind to these unwanted substances in order to eliminate them from the system.

Antigenicity

Antigenicity is the ability to be specifically recognized by the antibodies generated as a result of the immune response to the given substance.

Blood borne Viruses

Viral organisms that can be transmitted through exposure (of broken skin, mucous membranes or blood) to infected blood and body fluids. There are three (3) main blood borne viruses (BBVs) known as; Hepatitis B, Hepatitis C and HIV.

Chronic Hepatitis

Long-term infection with the hepatitis virus is known as chronic hepatitis, Chronic hepatitis is usually a "silent" infection for many years, until the virus damages the liver enough to cause the signs and symptoms of liver disease. Hepatitis B virus disease takes six (6) months and above to become chronic.

Hepatitis B antibodies

Anti-HBs (or HBsAb) means a specific “immune” system that protects body against the hepatitis B virus and makes person not to be infected spread hepatitis B to others.

Hepatitis B antigen (HBeAg)

Is a small polypeptide that exists in a free form in the serum of individuals during the early phase of hepatitis B infection, soon after HB surface antigen (HBsAg) becomes detectable. Serum levels of both HBeAg and HBsAg rise rapidly during the period of viral replication.

Hepatitis B core antigen (HBcAg)

The hepatitis B virus associated with a 27 nm viral nucleocapsid particle present in the nuclei of infected hepatocytes and with the inner, core component of the Dane particle. These two HBV antigens have been shown to be antigenically distinct by immune electron microscopy.

Hepatitis B immunoglobulin (HB IG)

Is a human immunoglobulin that is used to prevent the development of hepatitis B and is used for the treatment of acute exposure to HBsAg.

Hepatitis B serology

The measurement of several hepatitis B virus (HBV)-specific antigens and antibodies.

Hepatitis B surface antibody (anti-HBs)

The presence of anti-HBs is generally interpreted as indicating recovery and immunity from hepatitis B virus infection. Anti-HBs also develops in a person who has been successfully vaccinated against hepatitis B.

Hepatitis B surface antigen (HBsAg)

The first protein (marker) of the hepatitis B virus, detectable in serum in acute hepatitis B infection.

Hepatitis B Virus (HBV)

Is a Viral pathogenic micro-organism that causes infection known as Hepatitis B virus disease that affects the liver.

Hepatitis B Virus Disease

An infectious disease caused by HBV which affects the liver, causing acute or chronic infection in the body.

Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is a primary tumor or liver cancer which occurs when a tumor grows on the liver. and constitutes more than 90% of the primary tumor of the liver.

Immunogenicity

The term immunogenicity refers to the ability of a substance to induce cellular and humoral immune response.

Pregnancy

The (physiological) product of fertilization that occurs in female reproductive system which produces one or more offspring.

Prevalence

The total number of individuals with a disease or health condition in a population at a specific period of time, usually expressed as a percentage of the population.

Rural Community

A place with fewer people, having their homes and businesses located far away from one another.

Serology 

The scientific study of serum and other body fluids, the term often usually refers to the diagnostic identification of antibodies in the serum.

Seropositive

Having a positive result in a test of blood serum, e.g., for the presence of hepatitis B virus.

Vertical transmission

Passage of a disease-causing agent (pathogen) from mother to child across the placenta, in the breast milk, or through direct contact during or after birth.

Woman

A female human being in her reproductive age