Hepatitis B virus and sexual behavior in Rakai, Uganda

Prevalence and risk factors of metabolic dysfunction-associated steatotic liver disease in south Central Uganda: A cross-sectional survey

BACKGROUND

Despite numerous risk factors and serious consequences, little is known about metabolic dysfunction-associated steatotic liver disease (MASLD) at population level in Africa.

AIM

The aim of the study was to estimate the prevalence and risk factors of MASLD in people living with and without HIV in Uganda.

METHODS

We collected data from 37 communities in South Central Uganda between May 2016 and May 2018. We estimated MASLD prevalence using the fatty liver index and advanced liver fibrosis using the dynamic aspartate-to-alanine aminotransferase ratio. We collected additional data on sociodemographics, HIV and cardiovascular disease (CVD) risk factors. We used multivariable logistic regression to determine the association between HIV, CVD risk factors and MASLD.

RESULTS

We included 759 people with HIV and 704 HIV-negative participants aged 35-49. MASLD prevalence was 14% in women and 8% in men; advanced liver fibrosis prevalence was estimated to be <1%. MASLD prevalence was more common in women (15% vs. 13%) and men (9% vs. 6%) with HIV. Being female (odds ratio [OR] = 2.1; 95% confidence interval [CI] = 1.4-3.3) was associated with a higher odds of MASLD after adjustment for confounders; HIV infection was borderline associated with MASLD (OR = 1.4; 95% CI: 1.0-2.0).

CONCLUSIONS

In a relatively young cohort in Uganda, 14% of women and 8% of men had MASLD. There was an indication of an association between HIV and MASLD in multivariable analysis. These data are the first to describe the population-level burden of MASLD in sub-Saharan Africa using data from a population-based cohort.

Hepatitis B status and associated factors among participants screened for simulated HIV vaccine efficacy trials in Kenya and Uganda

INTRODUCTION

Hepatitis B (HBV) prevalence remains high in Sub Saharan Africa and among some key populations such as those with continued exposure through sexual contact. We assessed the HBV status among potential participants who were screened for simulated HIV vaccine efficacy trials in Kenya and Uganda.

METHODS

We conducted a cross sectional analysis of data collected from individuals who were screened in Kenya (Nairobi) and Uganda (Entebbe and Kampala). The studies followed hypothetical procedures of an HIV vaccine efficacy trial and aimed to enroll HIV negative key and vulnerable populations at elevated risk of HIV acquisition. HBV status was the main outcome categorized using Hepatitis B surface antigen (HBsAg) and total Hepatitis B core antibody (HBcAb). Baseline characteristics potentially associated with never being infected were analyzed using logistic regression.

RESULTS

We screened 1,366 participants with mean age (SD) 28.7 (7.3) years. Overall, 46.6% were from Entebbe, 50.7% had secondary or higher level of education, 76.4% had informal high-risk jobs and 56.3% were male. Kampala had only female participants contributing 60.6% of females screened. Of the screened participants, 94.7% and 3.4% were negative and positive for HBsAg respectively. The prevalence on HBV infection was 3.9% among males and 2.8% among females while prevalence by site was: Entebbe (4.9%); Kampala (4.1%) and Nairobi (0.3%). The highest HBV prevalence was found among participants aged 25-29-years (5.2%), those with primary level education (4.5%), and those in informal low risk jobs (6.5%). Considering 1265 participants with complete data on HBsAg and HBcAb-Total, HBV status was never infected (67.9%), past infection (28.5%), chronic infection (3.2%) and acute infection (0.5%). Of 859 who were never infected, 685 (79.7%) were tested for anti-HBs titers of whom 60 (8.8%) had titers >10IU/L (immune due to vaccination). The odds of never being HBV infected were lower among older individuals 25-29 years (AOR 0.51; 95%CI 0.36-0.71) and ≥30 years (AOR 0.35; 95% CI 0.25-0.49). The odds were higher among participants with informal high-risk jobs from Kampala (AOR 2.21; 95% CI 1.41-3.47) and Nairobi (AOR 2.61; 95% CI 1.72-4.00) compared to those from Entebbe.

CONCLUSION

HBV prevalence and immunity due to vaccination were low among HIV negative individuals who are eligible for HIV vaccine trials and prevalence varies by age, education level and main occupation. Younger individuals and those recruited from existing cohorts/ clinics have a higher likelihood of having no prior HBV infection. HIV prevention intervention trials are a platform to identify individuals that need HBV vaccination.

Hepatitis B virus infection and factors associated with its acquisition among adults in a Lake Victoria HIV hyperendemic fishing community in Kyotera district, Uganda: a cross-sectional observation

OBJECTIVE

To investigate hepatitis B virus (HBV) prevalence and factors associated with viral acquisition in a HIV-hyperendemic fishing community, we tested sera for anti-hepatitis B core (HBc) and hepatitis B surface antigen (HBsAg).

DESIGN

Observational cross-sectional study.

SETTING

Large fishing village on Lake Victoria, one of the HIV-hyperendemic Rakai Community Cohort Study (RCCS) sites (HIV prevalence ~40%).

PARTICIPANTS

Sample of 460 RCCS participants aged 15-49 years from survey conducted from 5 December 2016 to 13 February 2017. These proportionately included HIV-negative, HIV-positive antiretroviral therapy (ART)-naïve and HIV positive on ART participants.

RESULTS

Of the 460 participants, 49.6% (95% CI 45.0% to 54.1%) had evidence of prior HBV infection and 3.7% (95% CI 2.3% to 5.9%) were either acutely or chronically infected. HBV risk increased with age, number of lifetime sex partners and HIV seropositivity. HBV risk decreased with HIV ART use among HIV-positive participants. Prevalence of prior HBV infection was 17.1% in participants aged 15-19 years, 43.2%, 55.3% and 70.1% in participants aged 20-39, 30-39 and 40-49 years, respectively (p<0.001). Additionally, the prevalence of prior HBV infection was 23.8% in participants with 0-1 lifetime sex partners, 43.2% and 54.8% in participants with 2-3 lifetime sex partners and 4+ lifetime sex partners, respectively (p<0.001).

CONCLUSIONS

Findings from this fishing community suggest the need to provide HBV vaccination to adults at risk of sexual transmission who have not been previously immunised.

Hepatitis B prevalence and incidence in the fishing communities of Lake Victoria, Uganda: a retrospective cohort study

Introduction

Hepatitis B is a serious potentially fatal hepatocellular disease caused by the hepatitis B virus. In the fishing communities of Lake Victoria Uganda, the hepatitis B virus infection burden is largely unknown. This study assessed the prevalence and incidence of hepatitis B in these communities.

Methods

This was a retrospective cohort study that tested serum samples collected from 13 to 49-year-old study participants that were residing in two Ugandan Lake Victoria fishing communities of Kasenyi (a mainland) and Jaana (an island). The samples were collected between 2013 and 2015 during the conduct of an HIV epidemiological cohort study in these communities. A total of 467 twelve-month follow-up and 50 baseline visit samples of participants lost to follow-up were tested for hepatitis B serological markers to determine prevalence. To determine hepatitis B virus incidence, samples that were hepatitis B positive at the follow-up visit had their baseline samples tested to identify hepatitis B negative samples whose corresponding follow-up samples were thus incident cases.

Results

The baseline mean age of the 517 study participants was 31.1 (SD ± 8.4) years, 278 (53.8%) of whom were females. A total of 36 (7%) study participants had hepatitis B virus infection, 22 (61.1%) of whom were male. Jaana had a higher hepatitis B virus prevalence compared to Kasenyi (10.2% vs 4.0%). In total, 210 (40.6%) study participants had evidence of prior hepatitis B virus infection while 48.6% had never been infected or vaccinated against this disease. A total of 20 (3.9%) participants had results suggestive of prior hepatitis B vaccination. Hepatitis B incidence was 10.5 cases/100PY (95% CI: 7.09–15.53). Being above 25 years of age and staying in Jaana were significant risk factors for hepatitis B virus acquisition (AOR 1.6, 95% CI: 1.1–2.2; p < 0.01 and 1.4, 95% CI: 1.1–1.8; p < 0.01 respectively).

Conclusion

Hepatitis B virus incidence in Lake Victoria fishing communities of Uganda is very high, particularly in the islands. Interventions to lower hepatitis B virus transmission in these communities are urgently needed.

Cancer Risk Studies and Priority Areas for Cancer Risk Appraisal in Uganda

Background

Research into aetiologies and prevention of the commonest cancers and implementation of primary and secondary prevention can reduce cancer risk and improve quality of life. Moreover, monitoring the prevalence of cancer risk factors in a specific population helps guide cancer prevention and early detection efforts and national cancer control programming.

Objective

This article aims to provide the scope and findings of cancer risk studies conducted in Uganda to guide researchers, health-care professionals, and policymakers.

Methods

Between November 2019 to January 2020, we searched peer-reviewed published articles in Pubmed, EMBASE and Cochrane Library (Cochrane central register of controlled trials-CENTRAL). We followed the recommendation of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses - the PRISMA. The primary focus was to identify cancer risk and prevention studies conducted in Uganda and published in peer-reviewed journals from January 2000 and January 2020. We used key Boolean search terms with their associated database strings.

Results

We identified 416 articles, screened 269 non-duplicate articles and obtained 77 full-text articles for review. Out of the 77 studies, we identified one (1%) randomized trial, two (2.5%) retrospective cohort studies and 14 (18%) case-control studies, 46 (60%) cross-sectional studies, five (6.4%) ecological studies, three panel studies (4%) and six (8%) qualitative studies. Cervical cancer was the most studied type of cancer in Uganda (23.4%, n = 18 studies), followed by lymphomas - both Hodgkin and Non-Hodgkin sub-types (20.7%), n = 16 studies) and breast cancer (15.6%, n = 12 studies). In lymphoma studies, Burkitt lymphoma was the most studied type of lymphoma (76%, n = 13 studies). The studies concentrated on specific cancer risk awareness, risk perceptions, attitudes, uptake of screening, uptake of human papillomavirus vaccination, the prevalence of some of the known cancer risk factors and obstacles to accessing screening services.

Conclusion

The unmet need for comprehensive cancer risk and prevention studies is enormous in Uganda. Future studies need to comprehensively investigate the known and putative cancer risk factors and prioritize the application of the higher-hierarchy evidence-generating epidemiological studies to guide planning of the national cancer control program.

A Serological Survey of Selected Papua New Guinea Blood Donors for Hepatitis B and Related Co-Infections

Hepatitis B virus (HBV) infection is a serious problem and earlier studies in Papua New Guinea have reported a high prevalence of hepatitis B virus infection. These studies were undertaken using insensitive tests and before an expanded immunization program. The current HBV status is therefore uncertain. A retrospective study to investigate the HBV status was carried out using blood donor data at Nonga General Hospital, East New Britain Province, Papua New Guinea, from January 2003 to December 2018. Additional data for Human Immunodeficiency Virus, syphilis and hepatitis C virus were also collected. Data were analysed using NCSS statistical software. The mean hepatitis B antigen (HBsAg) sero-prevalence was 21% for the period of study and showed a downward trend over the period of the study, which may reflect the effect of the extended immunization program. HBsAg prevalence in male donors (23%) was significantly higher than females (16%). Donors living in Pomio district had a significantly lower proportion of sero-positive HBsAg donors (7%) than Gazelle (22%), Kokopo (22%) and Rabaul (20%), which was attributed to this district's geographical isolation. Ethnically, Pomios donors (8%) had significantly lower HBsAg prevalence than the Taulils, (29%), Bainings (21%) and Tolais (21%). Fifteen to nineteen year olds (23%) were the predominant age group affected, and vertical or perinatal transmission was probably the primary transmission route. Our findings call for greater awareness on the part of public policy makers and should be considered when planning future public health campaigns.

Prevalence and burden of HBV co-infection among people living with HIV: A global systematic review and meta-analysis

Globally, in 2017 35 million people were living with HIV (PLHIV) and 257 million had chronic HBV infection (HBsAg positive). The extent of HIV-HBsAg co-infection is unknown. We undertook a systematic review to estimate the global burden of HBsAg co-infection in PLHIV. We searched MEDLINE, Embase and other databases for published studies (2002-2018) measuring prevalence of HBsAg among PLHIV. The review was registered with PROSPERO (#CRD42019123388). Populations were categorized by HIV-exposure category. The global burden of co-infection was estimated by applying regional co-infection prevalence estimates to UNAIDS estimates of PLHIV. We conducted a meta-analysis to estimate the odds of HBsAg among PLHIV compared to HIV-negative individuals. We identified 506 estimates (475 studies) of HIV-HBsAg co-infection prevalence from 80/195 (41.0%) countries. Globally, the prevalence of HIV-HBsAg co-infection is 7.6% (IQR 5.6%-12.1%) in PLHIV, or 2.7 million HIV-HBsAg co-infections (IQR 2.0-4.2). The greatest burden (69% of cases; 1.9 million) is in sub-Saharan Africa. Globally, there was little difference in prevalence of HIV-HBsAg co-infection by population group (approximately 6%-7%), but it was slightly higher among people who inject drugs (11.8% IQR 6.0%-16.9%). Odds of HBsAg infection were 1.4 times higher among PLHIV compared to HIV-negative individuals. There is therefore, a high global burden of HIV-HBsAg co-infection, especially in sub-Saharan Africa. Key prevention strategies include infant HBV vaccination, including a timely birth-dose. Findings also highlight the importance of targeting PLHIV, especially high-risk groups for testing, catch-up HBV vaccination and other preventative interventions. The global scale-up of antiretroviral therapy (ART) for PLHIV using a tenofovir-based ART regimen provides an opportunity to simultaneously treat those with HBV co-infection, and in pregnant women to also reduce mother-to-child transmission of HBV alongside HIV.

Eligibility for hepatitis B antiviral therapy among adults in the general population in Zambia

INTRODUCTION

We evaluated antiviral therapy (AVT) eligibility in a population-based sample of adults with chronic hepatitis B virus (HBV) infection in Zambia.

MATERIALS AND METHODS

Using a household survey, adults (18+ years) were tested for hepatitis B surface antigen (HBsAg). Sociodemographic correlates of HBsAg-positivity were identified with multivariable regression. HBsAg-positive individuals were referred to a central hospital for physical examination, elastography, and phlebotomy for HBV DNA, hepatitis B e antigen, serum transaminases, platelet count, and HIV-1/2 antibody. We determined the proportion of HBV monoinfected adults eligible for antiviral therapy (AVT) based on European Association for the Study of the Liver (EASL) 2017 guidelines. We also evaluated the performance of two alternative criteria developed for use in sub-Saharan Africa, the World Health Organization (WHO) and Treat-B guidelines.

RESULTS

Across 12 urban and 4 rural communities, 4,961 adults (62.9% female) were tested and 182 (3.7%) were HBsAg-positive, 80% of whom attended hospital follow-up. HBsAg-positivity was higher among men (adjusted odds ratio [AOR], 1.37; 95% confidence interval [CI], 0.99-1.87) and with decreasing income (AOR, 0.89 per household asset; 95% CI, 0.81-0.98). Trends toward higher HBsAg-positivity were also seen at ages 30-39 years (AOR, 2.11; 95% CI, 0.96-4.63) and among pregnant women (AOR, 1.74; 95% CI, 0.93-3.25). Among HBV monoinfected individuals (i.e., HIV-negative) evaluated for AVT, median age was 31 years, 24.6% were HBeAg-positive, and 27.9% had HBV DNA >2,000 IU/ml. AVT-eligibility was 17.0% by EASL, 10.2% by WHO, and 31.1% by Treat-B. Men had increased odds of eligibility. WHO (area under the receiver operating curve [AUROC], 0.68) and Treat-B criteria (AUROC, 0.76) had modest accuracy. Fourteen percent of HBsAg-positive individuals were HIV coinfection, and most coinfected individuals were taking tenofovir-containing antiretroviral therapy (ART).

CONCLUSION

Approximately 1 in 6 HBV monoinfected adults in the general population in Zambia may be AVT-eligible. Men should be a major focus of hepatitis B diagnosis and treatment. Further development and evaluation of HBV treatment criteria for resource-limited settings is needed. In settings with overlapping HIV and HBV epidemics, scale-up of ART has contributed towards hepatitis B elimination.

Seroprevalence of hepatitis B virus: Findings from a population-based household survey in KwaZulu-Natal, South Africa

Background:

Hepatitis B virus (HBV) infection is a major cause of morbidity and mortality; however, little is known about the prevalence and distribution of HBV in some populations and regions.

Methods:

A total of 9791 participants, 15–49 years old, were enrolled in a household survey in KwaZulu-Natal, South Africa. Peripheral blood samples were tested for markers of HBV (hepatitis B surface antigen (HBsAg), hepatitis B e antigen (HBeAg), antibody to HBeAg (anti-HBe)) and analysed, accounting for multilevel sampling and weighted to represent the population.

Results:

Overall HBsAg prevalence was 4.0% (95% confidence interval (CI) 3.4–4.5%): 4.8% (95% CI 3.8–5.8%) in men and 3.2% (95% CI 2.5–3.9%) in women (p = 0.01). Among HBsAg-positive participants, 35.2% (95% CI 29.2–41.2%) were HBeAg-positive and 66.3% (95% CI 60.1–72.4%) were anti-HBe-positive. HBsAg prevalence was 6.4% (95% CI 5.3–7.5%) among HIV-positive participants compared to 2.6% (95% CI 1.9–3.2%) among HIV-negative participants (p < 0.01), and was higher among HIV-positive men (8.7%, 95% CI 6.3–11.2%) than among HIV-positive women (5.0%, 95% CI 3.8–6.2%) (p < 0.01).

Conclusions:

HBV infection among HIV-positive men remains an important public health problem in communities in KwaZulu-Natal, South Africa. The prevalence of HBsAg and HBeAg highlight the importance of surveillance and an important missed opportunity for the scale-up of programmes to achieve the goal of controlling HBV for public health benefit.

Serological profile of HBV infection among apparently healthy hospital attendees

Hepatitis B virus (HBV) infection has been rated 10th among the killer diseases. Occult HBV infection goes undetected with the widely used HBsAg screening in most hospital thereby encouraging progression into complications such as liver cirrhosis and hepatocellular carcinoma. This work therefore aimed at evaluating HBV serological profiles among the population of apparently healthy hospital attendees and their proportion of susceptibility to HBV infection. 239 participants were recruited for this study. Their blood samples were screened for the HBV markers - HBsAg, anti-HBs, HBeAg, anti-HBe, and anti-HBc. In conclusion, this work depicted various serological patterns of HBV infection among apparently healthy hospital attendees suggesting there are occult HBV infection and immune escape mutant in our population. It also showed that a huge number of the study population were susceptible to HBV infection.

Human immunodeficiency virus infection predictors and genetic diversity of hepatitis B virus and hepatitis C virus co-infections among drug users in three major Kenyan cities

Background

Drug users act as reservoirs and transmission channels for hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV) infections to the general population worldwide. Periodic epidemiological studies to monitor the prevalence and genetic diversity of these infections to inform on interventions are limited.

Objective of the study

The objective of this study was to determine the predictors of HIV infection and genetic diversity of HBV and HCV among drug users in Kenya.

Materials and methods

A cross-sectional study on previous drug use history among drug users was conducted in three Kenyan cities using a respondent-driven sampling method between January 2011 and September 2012. Blood samples were collected and analysed for the presence of HBV, HCV and HIV serological markers and to determine the genotypes of HBV and HCV.

Results

The overall prevalence of HBV, HCV and HIV among drug users was 4.3%, 6.5% and 11.1%, respectively, with evidence of HBV/HIV, HCV/HIV and HBV/HCV/HIV co-infections. The HBV circulating genotypes were A1 (69%) and D6 (19%), whereas HCV genotypes were 1a (72%) and 4a (22%). Injection drug use was a significant predictor of HIV/HCV infections. Younger age (30 years; aOR (adjusted odds ratio) = 0.50, 95% CI (confidence interval): 0.33–0.76; p < 0.001) and early sexual debut (aOR = 0.54, 95% CI: 0.40–0.82; p < 0.05) were negatively associated with detection of any of the three infections. Injecting drug use was positively associated with HCV infection (aOR = 5.37, 95% CI: 2.61–11.06; p < 0.001).

Conclusion

This high level of genetic diversity exhibited by HBV and HCV isolates requires urgent implementation of harm reduction strategies and continuous monitoring for effective management of the patients.

Patterns of serologic markers of hepatitis B virus infection and the risk of transmission among pregnant women in southwestern Nigeria

Hepatitis B virus (HBV) infection is a major health concern in developing countries that has a high morbidity and mortality rate. Vertical transmission of HBV from mother to child has been identified as a major factor leading to chronicity with attendant liver conditions, especially in poor socioeconomic settings. This study aims to evaluate the prevalence of serological HBV markers among pregnant women in Ibadan southwestern Nigeria and to determine the implications for perinatal HBV transmission. This study revealed the presence of varied HBV serological patterns of infection or immunity among pregnant women in Ibadan, Nigeria, and thus the risk of mother to child transmission.

Hepatitis B incidence and prevention with antiretroviral therapy among HIV-positive individuals in Uganda

OBJECTIVE

Antiretroviral therapy (ART) may interfere with replication of hepatitis B virus (HBV), raising the hypothesis that HBV infection might be prevented by ART. We investigated the incidence and risk factors associated with HBV among HIV-infected adults in Rakai, Uganda.

METHODS

We screened stored sera from 944 HIV-infected adults enrolled in the Rakai Community Cohort Study between September 2003 and March 2015 for evidence of HBV exposure. Serum from participants who tested anti-hepatitis B core-negative (497) at baseline were tested over 3-7 consecutive survey rounds for incident HBV. Poisson incidence methods were used to estimate incidence of HBV with 95% confidence intervals (CIs), whereas Cox proportional regression methods were used to estimate hazard ratios (HRs).

RESULTS

Thirty-nine HBV infections occurred over 3342 person-years, incidence 1.17/100 person-years. HBV incidence was significantly lower with ART use: 0.49/100 person-years with ART and 2.3/100 person-years without ART [adjusted HR (aHR) 0.25, 95% CI 0.1-0.5, P < 0.001], and with lamivudine (3TC) use: 0.58/100 person-years) with 3TC and 2.25/100 person-years without 3TC (aHR 0.32, 95% CI 0.1-0.7, P =  < 0.007). No new HBV infections occurred among those on tenofovir-based ART. HBV incidence also decreased with HIV RNA suppression: 0.6/100 person-years with 400 copies/ml or less and 4.0/100 person-years with more than 400 copies/ml (aHR, 6.4, 95% CI 2.2-19.0, P < 0.001); and with age: 15-29 years versus 40-50 years (aHR 3.2, 95% CI 1.2-9.0); 30-39 years versus 40-50 years (aHR 2.1, 95% CI 0.9-5.3).

CONCLUSION

HBV continues to be acquired in adulthood among HIV-positive Ugandans and HBV incidence is dramatically reduced with HBV-active ART. In addition to widespread vaccination, initiation of ART may prevent HBV acquisition among HIV-positive adults in sub-Saharan Africa.

High prevalence of occult hepatitis B infection in an African urban population

Occult hepatitis B infection (OBI), the presence of low hepatitis B virus (HBV) deoxyribonucleic acid (DNA) levels in patients without detectable hepatitis B surface antigen (HBsAg), has significant implications for understanding the natural history of hepatitis B infection. We determined the prevalence of OBI in African patients using a sensitive polymerase chain reaction (PCR) assay and describe here the characteristics of OBI in an urban African hospital population. Routine serological testing as well as molecular studies were performed on sera from 314 patients who were part of a previous study from an urban hospital emergency room in Kampala, Uganda, detecting HBV DNA using a nested PCR with amplification of two regions of the HBV genome. HBV viral loads (VL) were determined by real-time PCR (rtPCR) and sequencing performed to determine HBV genotype and S gene mutations. Among 314 subjects tested, 50 (16%) had chronic HBV infection, 94 (30%) had detectable HBV DNA despite testing HBsAg negative (OBI), and 170 (54%) were not infected. VLs of OBI subjects were relatively low although 19 (20%) had VL exceeding 10(4)  IU ml(-) . Subjects with chronic HBV infection had a higher median VL compared to OBI patients (P < 0.001). All chronic HBV sequenced (10) and 83/89 OBI sequences were genotype A, the remaining six being genotype D. S-gene mutations were present in some but not all OBI patients (48%). OBI is more prevalent among African patients than previously thought. This may have implications for clinical management and transfusion-related HBV transmission.

High prevalence of hepatitis B virus infection among pregnant women attending antenatal care: a cross-sectional study in two hospitals in northern Uganda

OBJECTIVE

To determine the prevalence of the hepatitis B viral (HBV) infection and hepatitis B e antigen (HBeAg) positivity among pregnant women attending antenatal clinics in two referral hospitals in northern Uganda.

DESIGN

Cross-sectional observational study.

SETTING

Two tertiary hospitals in a postconflict region in a low-income country.

PARTICIPANTS

Randomly selected 402 pregnant women attending routine antenatal care in two referral hospitals. Five women withdrew consent for personal reasons. Data were analysed for 397 participants.

PRIMARY OUTCOME

Hepatitis B surface antigen (HBsAg) positivity.

RESULTS

Of 397 pregnant women aged 13-43 years, 96.2% were married or cohabiting. 47 (11.8%) tested positive for HBsAg; of these, 7 (14.9%) were HBeAg positive. The highest HBsAg positivity rate was seen in women aged 20 years or less (20%) compared with those aged above 20 years (8.7%), aOR=2.54 (95% CI 1.31 to 4.90). However, there was no statistically significant difference between women with positive HBsAg and those with negative tests results with respect to median values of liver enzymes, haemoglobin level, absolute neutrophil counts and white cell counts. HIV positivity, scarification and number of sexual partners were not predictive of HBV positivity.

CONCLUSIONS

One in eight pregnant women attending antenatal care in the two study hospitals has evidence of hepatitis B infection. A significant number of these mothers are HBeAg positive and may be at increased risk of transmitting hepatitis B infection to their unborn babies. We suggest that all pregnant women attending antenatal care be tested for HBV infection; exposed babies need to receive HBV vaccines at birth.

Prevention of materno-foetal transmission of hepatitis B in sub-Saharan Africa: the evidence, current practice and future challenges

Hepatitis B (HBV) infection is highly endemic in sub-Saharan Africa (SSA), where more than 8% of the population remain chronic HBV carriers. SSA has one of the highest HBV-related liver cancer rates in the world (CA Cancer J Clin, 55, 2005, 74) and HBV-related liver cancer is the most common cause of premature death in West Africa (Lancet Oncol, 9, 2008, 683; Hepatology, 39, 2004, 211). As such, HBV represents a significant global threat to health in the African continent. Most SSA countries have elected to vaccinate all children against HBV through the WHO-sponsored Expanded Program of Immunization and the current recommendation from WHO-AFRO is for birth-dose HBV vaccination to prevent maternal/child transmission (MFT) and early horizontal transmission of HBV. However, in Africa, HBV vaccine coverage remains low and HBV birth-dose vaccination has not been implemented. HBV transmission from mother to child in the early perinatal period therefore remains a significant contributor to the burden of HBV-related disease in SSA. This review explores the evidence for materno-foetal transmission of HBV in SSA, outlining current practice for HBV MFT prevention and identifying the significant challenges to implementation of HBV prevention in SSA.

High burden of hepatitis B infection in Northern Uganda: results of a population-based survey

Background

Worldwide 2 billion people are exposed to hepatitis B infection, 350 million have chronic infection, 65 million in sub-Saharan Africa. Uganda is highly endemic with 10% national prevalence of hepatitis B infection, rates varying across the country from 4% in the southwest and 25% in the Northeast. Childhood vaccination was rolled out in 2002, the effect of which on the burden of hepatitis B has not been examined. We determined the prevalence and risk factors for hepatitis B infection in the Northern Uganda Municipality of Gulu.

Methods

We carried out a cross-sectional, population-based survey. The study population included those found at home at the time of recruitment. Data on demographics, wealth index, cultural and behavioral factors, vaccination and health education on hepatitis B were collected. Hepatitis B infection (Hepatitis B surface antigen positive) and lifetime exposure (anti-hepatitis B core antibody positive) were measured. Analysis was done in 2 age groups, 1–14 years, 14 years and more. Associations between predictors and HBV infection were assessed.

Results

Information on 790 respondents were analyzed. Overall, 139/790 (17.6%) had hepatitis B infection and 572/790 (72.4%) lifetime exposure. In the younger age group 16/73 (21.9%) had hepatitis B infection and 35/73 (48%) lifetime exposure. Increasing wealth was protective for infection (OR 0.46 per quartile, 95% CI=0.26-0.82, p=0.009), while older age was protective for lifetime exposure (OR 2.70 per age group, 95% CI 1.03-7.07, p=0.043). In the older age group, overall hepatitis B infection was seen in 123/717 (17.2%) and lifetime exposure in 537/717 (74.9%). The female sex (OR 0.63, 95% CI=0.42-0.98, p=0.032) and increasing age (OR 0.76 per age group, 95% CI=0.64-0.91, p=0.003) were factors associated with infection. For lifetime exposure, increasing number of lifetime sexual partners was a risk factor (OR 1.19 per partner category, 95% CI=1.04-1.38, p=0.012).

Conclusions

We found a high prevalence of hepatitis B infection and lifetime exposures to hepatitis B in this northern Uganda Municipality. Targeted vaccination of susceptible adults and improving existing childhood vaccinations and provision of treatment for those with infection will play roles in reducing the high prevalence rates seen in the population.