Factors for viral infection in blood donors of South Kivu in the Democratic Republic of Congo

Introduction Assessing the knowledge, attitudes, practices and behaviors among blood donors in South Kivu and identify risk factors for viral markers. Methods A descriptive and analytical cross-sectional study involved 595 blood donors in the city of Bukavu (Head city of the province of South Kivu) in the eastern Democratic Republic of Congo. Results Our sample consisted of 70.3% men with a median age of 23 and 77% of young people fewer than 30 years. The score of knowledge and attitude of blood donor's volunteer on blood safety were assessed at 23.5% and 79.1%. A statistically significant difference was observed between the loyal and new blood donors volunteer (25.1% vs 64.6% p < 0.001); between blood donors volunteer of low and high education level (p = 0.04). Motivation to donate blood in 95.9% of cases respect ethical rules of donation. The prevalence of viral markers in blood donors is as follows: 4.8% hepatitis B, 3.9% hepatitis C, 1.6% HIV. For HIV, the low level of education and replacement blood donors are most at risk, the antigen of hepatitis B is observed in blood donors over 30 years, blood donors living couple. Conclusion General knowledge on blood safety is very low in the first link in the chain transfusion (blood donors). A good education of this population conducted by the transfusion service reinforced building (training and support) is needed.


Introduction
In sub-Saharan Africa there is a high incidence of several diseases and pathological conditions that complicate directly or indirectly by anemia [1][2][3][4]. Democratic Republic of Congo (DRC.) is not immune to these diseases malaria, hemoglobinopathies , obstetric haemorrhage and nutritional deficiencies. To correct the often severe anemia, in most cases, a blood transfusion is indicated [3,4]. Unfortunately at the same time, African countries and the Democratic Republic of Congo. in particular, are facing highly endemic communicable diseases by blood and inadequate organization of blood transfusion services, increasing the risk of contamination of recipients through blood products [3,5]. Thus the prevalence of viral and parasitic markers is generally high. It varies between 0.6 % and 16 % for the human immunodeficiency virus (HIV), 5 to 25% for the surface antigen of hepatitis B ( HBsAg) and 0.5% to 3% for hepatitis C [3] . In Democratic Republic of Congo, prevalence differs depending on location, in Kinshasa between 2001 and 2004 HIV in blood donors ranged from 5.94 % to 6.1% and HBsAg between 3.63 and 9.2% [6], syphilis was 1.05% and the hepatitis C virus (HCV) was 4.3% between 2002 and 2004 [7] and in North-Eastern country in 2007 HIV was 4.7%, syphilis 3.7 % and 5.4 % HBsAg [8]. Transfusion infection risk can be significantly reduced by some measures involving the accountability of donor blood candidate [9]. Among these measures the self-exclusion of the donor candidate blood before his risky behavior and clinical selection before donation [4, [10][11][12][13] by health workers. This selection is a step in the general clinical examination done before the donation. It aims to search medical cons -indications to donate blood [10,14]. Results of these strategies are remarkable in industrialized countries [4]. The reasons given by Nedié this success would be a high level of education and knowledge of people in these countries [4]. In the Democratic Republic of Congo as Africa, the level of education of the population is not as high, an information to the public is essential. The present study aims to make an inventory by assessing of knowledge, attitudes and

Study population and material
The sample size was calculated by the software OpenEpi by introducing a 50 % factor (knowledge) results in a population, a confidence level of 95% and a precision of 5%. On this basis minimum 384 subjects were included. We recruited 595 blood donors including 408 at the provincial hospital, 70 and 117 at Katana and Panzi. The inclusion of blood donors in each hospital structure was made randomly and has been to recruit the (volunteer, paid and family) donor between 18 and 65 years of age with an odd number in the order of arrival. The interviewers were nurses or laboratory technicians attached to the blood bank of the health institution and trained in blood safety by BPTC. In these health centers, pre-donation interview with using a questionnaire was carried out before each donation to detect cons -indications to Page number not for citation purposes 3 donate blood. This interview was conducted either by a doctor or by a nurse responsible for transfusion in the institution trained for this purpose. For blood donors included in the study, an additional questionnaire was proposed. The questionnaire contained closedended questions and was pre-tested. The questions focused on the general characteristics of blood donor motivation to donate blood, sexual behavior, knowledge about research communicable diseases (HIV window, concept of risk), the consequences of blood transfusion and personal history. Before administering the questionnaire an explanation has been provided by the nurse and an informed consent was signed. For the donors included in this study and that who were allowed to donate blood after the predonation interview, the blood sample was obtained at the time of collection of the blood bag. For donors included in the study but temporarily or permanently prohibited donation, the blood sample was taken after obtaining their verbal consent. This sample was used to determine HIV, HCV, HBV prevalence's using the same methods as those made for any biological qualification of blood donation at the blood bank. We used Determine HIV1 -2TM Determine HBsAg and HCV Determine tests.

Variables
We selected as variables for analysis: age ( 18-30 years, 31-40 years, 41 years and older) , sex, marital status, without , primary, secondary level of education (and higher ) but we dichotomized ( low and high) in the statistical analysis . Low for primary school and those who did not attend school at all, high for those who attended secondary and tertiary levels of education. Blood donors were divided into volunteers, family and paid; the last two categories were grouped into the category of replacement donors. The sexual behavior of the donor, knowledge of the consequences of transfusion, the different attitudes of blood donor and different knowledge of blood donor were taken into account. "Motivation to donate blood " variable was divided into two parts: the motivation to donate blood for transfusion safety (I gave blood to save lives, because the media talk about, as peers, because I was transfused and no explanation) and motivation to donate blood not for blood safety (I gave blood for the detection of diseases, to be paid because a parent is hospitalized and because of the pressures of the environment). In the overall assessment of the knowledge of volunteer blood donor on blood transfusion we used a score considering the 9 categories of knowledge and we found a very good knowledge among blood donors who had a score of 7 correct answers and a good knowledge for those who were 5-6 and a lack of knowledge for a score less than 5. For general evaluation of positive attitudes towards blood safety we have achieved a score taking into account the correct answers expected from all sections of the attitude variable except for the responses to the question "during the interview is what that donors do they give truthful answers? The attitude was measured using a score: a score of ≥4 was considered a very good attitude, a score of 3 meant that the blood donor had a good attitude and a score of ≤ 2 reflected a bad attitude in volunteer blood donors. In the analysis, the "knowledge" and "attitude" variables were dichotomized to avoid small sample size.

Statistical analysis
After data collection, entry thereof is organized using the software EPI Info Version 3.5.1. Analyzes were made by the same software and also by STATA version10. The descriptive analysis was performed through calculations proportions for discrete or categorical variables, the median, minimum and maximum for age.
The test Pearson chi-square or Fisher exact (when necessary) was used to compare proportions; the significance level used was 0.05.
Analyzes of knowledge and attitude were made only among volunteer blood donors trained in transfusion safety, while analyze for the seroprevalence of virus were made on the whole sample. In fact we are currently doing an assessment of the knowledge and attitude on volunteer blood donors who have received training. The association between independent and dependent variables (prevalence of HIV, HCV and HBsAg) was judged by the odds ratio (OR) with a 95% confidence interval (95% CI).

Demographics of blood donors in South Kivu
Sociodemographic characteristics of the study population, as shown in Table 1 below, are as follows: 593 subjects, 70.3% were men; the median of age of blood donors is 23 years with a minimum of 18 and a maximum of 64 years. More than three quarters of the blood donors were under 30 years, 71% were single, 60% had secondary education and 5% are illiterate, 88.9% are volunteer donors which 78.7% loyal.

Knowledge and attitudes of volunteer blood donors
Motivation to donate blood in 95.9% of cases in accordance with the rules of ethics of blood donation, among them 93.5% said they gave their blood to save lives. Outside of volunteering among 513 blood donors volunteer, we observed that four blood donors came for screening, a person gave blood hoping for a cash consideration and 16 persons (3.1%) have given a parent who was hospitalized.
Related to sexual behavior, almost all blood donors volunteer (96.5%) attended at most one sexual partner in the last 6 months.  ( Table 3).
Specifically this knowledge is poor in topics such as research on blood donation hepatitis, syphilis and malaria with percents respectively 38.0%, 34.4 % and 36.1%. Good attitude on blood safety is different depending on the characteristics except for sex as we see in Table 3.

Viral risk factors among volunteer blood donors
The result of the prevalence of viral markers in blood donors shows that the prevalence of hepatitis B was 4.8%. Antibodies against the hepatitis C were found in 3.9% of cases and HIV was found in 1.6% of blood donors. As shown in Table 4 , we did not observe significant differences in seroprevalence of HIV and hepatitis C by knowledge and attitude of blood donors volunteer but the proportion of HBsAg was statistically higher in voluntary donors who had a good knowledge compared to those who did not have( 7.1% is that it is a satisfaction or routine in the group of former donors or other identifying factor that explains this? In this case, the thinking should be conducted to determine the responsibility of blood donors volunteer [9] and the trainers. Given the differences between the score of the attitudes and knowledge; theoretically we would like both scores go together, we believe that our volunteer blood donors apply to adopt best learned attitudes that are consistent with safe blood without a control of the basics of communicable diseases by blood. One possible reason that could explain this is that these attitudes are common to the prevention of other diseases transmitted by blood or sex. But our study cannot provide information on this point; this will be covered in a qualitative study that should be conducted in voluntary donors to understand the difference between knowledge score and attitude. Evaluations of training provided should be made to identify ways of improving the quality of training and knowledge of blood donors. These assessments should be systematic because these formations blood donors are carried out by health workers trapped in the logic paradigm Pasteur [17] characterized by a very hierarchical health system where priority is given to the technical aspects , a planning top to bottom, and maximalist normative , leaving little room for care providers and the opinion of the population ( blood donors) .
Add to this disease perdiemite or financial snacks distributed during training, awareness and blood collection. This disease is observed in health workers or the heads of associations and even among blood donors at the expense of the quality of work [17].
Africa is characterized by attitudes of solidarity and the primary motivation to donate blood for a family member [4]. This is contrary to the results found in this study but is consistent with the data from 4 African countries described by Tagny et al [15]. In our environment there is a dynamic grouping of blood donors associations that began before the existence of the organization of blood transfusion services by the health authorities. These members of civil society associations are non-profit and organize promotional activities in favor of voluntary blood donation. These actions maintain the voluntary blood donation in the big cities but this reality is not the same in rural areas where health family donation is predominant because of cultural beliefs and lack of information [15]. However there is a problem when 4 out of 5 volunteers face exposure to risk donors, arrange to donate blood in order to be screened. This situation can be attributed to strong awareness campaigns in the community, in the media and in schools conducted given the complexity of human and discouragement of African doctor before some paradigms [17] and to the socio -economic situation dilapidated . The other problem is that this interview is not always done by qualified personnel and on time, it is often done by nurses in an environment of mobile blood collection without adequate and favorable conditions.  26]. In our sample, the number in the group of low level of study is low which might not be able to detect the difference in the two groups. In this study singles are at lower risk than those living with a partner, this is may be so by chance. The profile of a blood donor at a lower risk of infection varies depending on the studies and it will be difficult to find a perfect profile [27]. Attention should be paid on the whole of transfusion chain to reduce risk of infection by implementing quality assurance measures appropriate to the context.

Conclusion
Reduction of transfusion risk starts with thorough control of the first element in the transfusion chain that is to say, the blood donor. This study has shown that knowledge on blood safety and blood borne diseases among blood donors is very low; the prevalence of viral markers increases and the family donation becomes more important. Capacity building at all levels is imperative. It will be for