Infections due to Hepatitis B, C, and HIV viruses are serious health problems worldwide and are emerging concerns in developing and developed nations. In particular, viral hepatitis B and C are both contagious diseases that can be vertically transmitted that have a high rate.17 These infections are the most common cause of hepatic dysfunction during pregnancy, with alarming complications and also affecting the newborn that leads the neonates into chronic virus carriage to live cirrhosis and hepatocellular carcinoma.18,19
Hepatitis B prevalence varies worldwide, either in developed or developing nations, where the prevalence of developing nations is estimated to be about 8% while in developed countries estimated to be 2%, which is low when compared to developing nations where the HBV is endemic with sex, age, and socioeconomic status are important risk factors for infection. The prevalence rates of HBV in the countries are categorized into three parts, which are a high endemic area (> 8%), an intermediate endemic area (2–8%), and a low endemic area (< 2%).20–22 In Somalia, it included the high endemic area for positivity of HBV infection. Vertical transmission of hepatitis B virus infection is one of the main transmission routes in developing countries when compared to developed countries, where most case of hepatitis B infection occurs in adults, but in developing countries occurs mostly in infants and children with 90% of the cases occurring at the time of birth.23,24
Hepatitis B is the most common hepatitis virus infection during pregnancy.25 Evidence shows that the prevalence of the hepatitis B virus among pregnant in worldwide is 3%,26 or 2.5%- 1.5%,27 and in Africa, the rate of prevalence among pregnant women of estimated ranges is between 3.67%-16.5%.28 Prior systematic review and meta-analysis study in Somalia among pregnant women with hepatitis B virus infection found an overall prevalence of 20.8%.8
In our study, the prevalence rate was found 2.8% among pregnant women with hepatitis B virus infection and this study appears to be medium endemicity according to WHO guidelines for global hepatitis B virus infection epidemiologically. Somalia is categorized as a high-endemicity area.3 The prevalence of this study compares very well with that reported medium endemicity from geographic regions 2.9 in Rwanda, 2.4 in Magacaskor,29 3.2 in Eritrea,30 3.5% in Ethiopia,31 3.9% in Tanzania,32 4% in Egypt,33 and Pakistan 4.6%.34
The prevalence in this study is also higher than the prevalence rates of 1% in Qatar, 1.5% in Libya and United Arab Emeritus,29 1.53% in Afghanistan,35 and 1.9% in Algeria and Saudia Arabia.29 Although our prevalence rate is lower than other studies 14.1% in Nigeria,36 8% in Sudan,37 9.4% in Kenya,38 and 11% in South Sudan.39 The differences in rates were explained by the difference in demographics, cultural practices, and behavior of the study population for risk of hepatitis B virus infection, methods used to detect HBV infection either using Rapid hepatitis B test, ELISA or DNA detection studies, algorithms and methods of laboratory testing and lastly study settings, such as post-conflict areas.
Hepatitis C prevalence also varies from country to country and even in the same country, from region to region. WHO revealed that the prevalence of HCV is classified as having low endemic rates of < 1.5%, moderate 1.5%-3.5%, and high grade > 3.5%.40 The estimated prevalence of hepatitis C virus among pregnant women was 1% and 8% globally.49 Although, a recent article shows that HCV in Somalia is estimated to be 1.41%,41 which was lower than the previous study's 4.8%.8 The vertical transmission of the viral hepatitis C virus infection is less than transmitted to offspring when comparable to HBV infection and it is estimated that 7–8% of HCV seropositive women can transmit it to their neonates during pregnancy.42
To our knowledge, this is the first comprehensive study regarding hepatitis C virus infection among pregnant women in Somalia. Researchers and health educationists in the country give more attention to HBV and HIV infection than viral hepatitis C infection. Our study showed that the prevalence of Hepatitis C virus infection was 0.4% among pregnant women. This finding is similar to studies conducted that estimated 0.36% in Libya, 0.6% in Sudan, 0.7% in Saudi Arabia,29 and 0.6% in Ethiopia.43 However, our finding is much lower prevalence rates than studies of hepatitis C virus infection conducted in Rwanda at 2.6%50 Uganda at 2.5%, Algeria at 3.21%, Iraq at 4.9%, Tanzania at 6.6%, and Yamen at 8.5%.29 And even much lower than the prevalence rate reported in the last study conducted in general, which was estimated to be 1.14%.41 No co-infection of hepatitis B and C were detected in this study.
The HIV prevalence rate among pregnant women was 0.2% in this study, and according to a recent survey done in 2018, the average prenatal HIV prevalence rate across the country was 0.1%. However, the geopolitical areas of Somali states differed, with 0.15% in Somaliland, 0.17% in Punland, and 0.04% in the rest of the country's federal member states16. And Similar Study that conducted in Mogadishu showed that the rate of HIV in preganant women was 0.2%51 while another recent study conducted in Oman, which was 0.1%,44 but our rate is lower than in East African countires of HIV prevalence among pregnant women that was 5.75% in Ethiopia, 5.6% in Tanzania,45 6.9% in Kenya,46 and 5.5% in Uganda,47 and 2.25% in South Sudan.48 The above differences may be a result of variations in sexual habits and behavior, awareness of HIV infection and testing, sociocultural practices such as religion, and access to healthcare.
This is the first major document in Somalia providing the prevalence of viral hepatitis B, C, and HIV among pregnant women attended to Department of Obstetrics and Gynaecology of the largest tertiary care hospital in the country. We believe that our findings contribute in several ways to our understanding of hepatitis and HIV infections among pregnant women in Somalia and provide a basis for future studies. Furthermore, the present findings might help policymakers and healthcare providers formulate several courses of action for prevention, prophylaxis, and treatment of HBV, HCV, and HIV infections, avoiding unfavorable maternofetal outcomes and reducing costs to the healthcare system.