Hepatitis B virus infection and associated factors among pregnant women attending antenatal clinics in West Hararghe public hospitals, Oromia region, Ethiopia

Introduction Globally, approximately 350-400 million persons are chronically infected with hepatitis B virus (HBV), over 65 million of whom are in Africa. One in four people with chronic hepatitis B develop serious health problems. Mother-to-child transmission (MTCT) is responsible for more than half of chronic infections. If infected at birth, a child has a 90% chance of becoming a chronic carrier. We evaluated hepatitis B virus prevalence and risk factors for infection among pregnant women attending antenatal clinics in West Hararghe public hospitals, Oromia region, Ethiopia. Methods We conducted a cross-sectional study among 363 pregnant women at routine antenatal clinic visits in West Hararghe public hospitals from April-May, 2017. We used systematic random sampling method to enroll participants. We used a structured questionnaire to collect information on risk factors, and collected blood samples to test for hepatitis B Virus surface antigen (HBsAg) by enzyme-linked immunosorbent assay (ELISA). Data were entered using EpiData Version.3.1 and exported to SPSS Version 23.0 for descriptive analyses and binary logistic regression Results The overall seroprevalence of HBsAg among participants was 6.1% (95% CI 3.9-8.5). History of abortion (aOR=4.3, 95% CI 1.3-15.0), traditional tonsillectomy (tonsillectomy conducted by an untrained practitioner) (aOR=4.4, 95% CI 1.1-17.8), admission to a health facility (aOR=4.4, 95% CI 1.2-16.9), multiple sexual partners (aOR=6.3, 95% CI 1.7-23.4) and familial liver disease (aOR=8.2, 95% CI 2.1-32.8) were associated with hepatitis B virus infection among pregnant women. Conclusion The prevalence of hepatitis B virus in study area indicates a high-intermediate level epidemic. Multiple types of healthcare, as well classic risk factors such as multiple sex partners and a family history of liver disease increased the odds of infection. Hygiene promotion and infection prevention methods in healthcare settings are recommended to avoid nosocomial infections. To reduce MTCT, we recommended screening all pregnant women for hepatitis B virus as part of routine antenatal care and supportive treatment and making available methods of preventing infection at birth, including prophylaxis and birth dose vaccine.


Introduction
Hepatitis B is a potentially life-threatening liver infection caused by the hepatitis B virus (HBV) [1]. Chronically infected persons have an increased lifetime risk for cirrhosis and hepatocellular carcinoma (HCC). Worldwide, about 2 billion persons have been infected with HBV; an estimated 350-400 million are chronically infected, of whom at least 65 million are in Africa. More than 800,000 people die every year due to complications of HBV infection [1][2][3]. Mother-to-child transmission (MTCT) accounts for more than half of chronic HBV infection worldwide, despite an existing immunoprophylaxis regimen [4]. Children born to hepatitis B surface antigen-positive (HBsAg+) and hepatitis B envelope antigen-positive (HBeAg+) mothers have a 70-90% chance of prenatal acquisition of HBV infection and 85-90% of them will become chronic carriers of the disease. Beyond this, viral hepatitis during pregnancy is associated with a high risk of maternal complications and maternal mortality. As a result, the World Health Organization recommends screening pregnant women for infection, providing monovalent HBV vaccination and hepatitis B immune globulin (HBIg) to neonates within 24 hours of birth and decreasing viral replication with antiretroviral therapy for pregnant women [1,5]. Previous studies in Ethiopia have indicated an HBV prevalence among pregnant women of 3.8% to 7.8% [6,7].

Socio-demographic characteristics of the study participants:
a total of 363 pregnant women were included in the study. The HBV prevalence identified in this study is similar to that found in previous studies in Ethiopia, including in Debre Tabor Hospital, North West Ethiopia (5.3%) [11], Bahir Dar City, North Ethiopia (6.6%) [12] and Hawasa University Referral Hospital, Southern Ethiopia (7.8%) [7]. When compared with other African countries, results are also similar to the prevalence in Sudan (5.6%) [13] and Cameroon (7.7%) [14], but lower than other study conducted in Nigeria 11% [15], Mali (8.0%) [16], and Uganda (11.8%) [17]. Given the wide range of risk factors for HBV infection, these variations could be due to differences in cultural practices, sexual behaviors, sampling method and/or laboratory test methods employed to detect HBsAg.
Multiple risk factors in our study were associated with receipt of health care, both traditional (delivered by an untrained practitioner at home) and formal (delivered by a trained practitioner at a health facility).
Procedures including removal of the uvula and/or tonsils are frequently practiced in parts of Ethiopia, including West Hararghe zone, outside the context of a formal healthcare facility [18]; approximately 1/3 of Ethiopians undergo traditional tonsillectomies during childhood [19]. A single surgical kit may be used on more than one child during these procedures which may increase the risk of HBV infection [20]. As abortion is only legal in cases of rape, incest, or to save the life of the mother in Ethiopia, induced abortions may also be performed in informal circumstances, increasing infection risk [21].
Poor hygiene, contaminated instruments and lack of personal protective equipment can put women at risk of multiple infections [22] during these procedures. Abortion is also frequently associated with unwanted and unsafe sexual intercourse, which may itself increase the risk of HBV infection [23]. Previous studies conducted among pregnant women in Ethiopia showed that abortion [22], but not traditional tonsillectomies [7,24], were associated with HBV infection. • An evidence to expand HBV screening of all pregnant women in ANC clinics and to start birth dose HBV vaccine.

Competing interests
The authors declare no competing interests.

Authors' contributions
Belay Mamuye conceived and designed the study, coordinated specimen and data collection, performed data analysis, drafted the paper and prepared the manuscript. All authors contributed to the writing of the paper and approved the final paper.

Acknowledgments
We would like to express our sincere gratitude to Chiro Blood Bank  Tables   Table 1: socio-demographic characteristics of pregnant women