SEROEPIDEMIOLOGY AND RISK FACTORS OF HEPATITIS B VIRUS

IN JIBLAH TOWN, YEMEN

Sadiq Kaid Al-Mohaniimage 

Dean of faculty of medical laboratories, Jiblah University for Medical and Health Science, Yemen.

ABSTRACT 

Aims and objective: Viral Hepatitis is a major global health problem affecting millions of people worldwide. The endemicity of hepatitis B virus infection believed high in Yemen. Data for prevalence of hepatitis B virus in Jiblah town in Yemen are rare and inadequate. Therefore, this study aimed to assess the seroprevalence of Hepatitis B virus and associated risk factors aming the general population of Jiblah town, Yemen. 

Methods: A total of 100 participated included in this study. Serum samples were collected and assayed for HBsAg using the ELISA quantitative technique. A structured questionnaire was used to collect behavioral and sociodemographic data. 

Results: the results revealed that, the seroprevalence of hepatitis B virus was 3.33%. There was a statistically significant difference between hepatitis B virus infection and monthly income. 

Conclusion: The finding of this study indicated that the magnitude of hepatitis B virus infection among the general population was intermediate level. Modifiable risk factor, monthly income was identified. 

Keywords: Hepatitis B virus, Jiblah, Seroepidemiology, Yemen.

INTRODUCTION

 

The rate of HBV infection varies from high - (>8% infection rate) to intermediate - (2–8%) and low-endemicity (<2%) areas6. Iran, Bahrain and Kuwait are areas of low endemicity. Iraq, Cyprus and the United Arab Emirates have intermediate endemicity; and Palestine, Yemen, Egypt, Oman, Jordan, and Saudi Arabia have high endemicity8. Previous data showed that HBV is hyper endemic in Yemen9. Yemen consequently falls into the intermediate to high endemicity category10. Previous epidemiological studies were done in different regions in Yemen, showed that the prevalence rates of HBsAg are (4.75%) in Aden, (10.5%) in Sana’a, (26.3%) in Socotra, (5.6%) and in Haja11.

Jiblah is a town located in south-western Yemen,  approximately eight kilometers south-west of governorate of Ibb. Due to purported universal culture value of Jiblah and its surroundings, Jiblah is added to the UNESCO World Heritage Tentative List12. There have been no previous studies to describe risk factors for HBV in Jiblah, therefore, the aim of the present study is to determine the current seroprevalence of HBV and risk factors involved in the presence of the HBV infection in the general population of Jiblah Town, Yemen.

An inflammation of the liver is called hepatitis that is caused by infectious viruses and non-infectious agents leading to a range of health problems and burden for the healthcare system. Hepatitis represents the seventh leading cause of worldwide mortality1. Five viruses, Hepatitis A virus (HAV), Hepatitis B virus (HBV), Hepatitis C virus (HCV), Hepatitis D virus (HDV), and Hepatitis E virus (HEV) cause viral hepatitis2. During 2019, the World Health Organization (WHO) estimates that 296 million people worldwide are living with HBV and 1.5 million people were newly infected with HBV. WHO estimates that 1.1 million deaths occurred in 2019 due to HBV infection3. In 2016, the WHO Global Health Sector Strategy called for Hepatitis elimination by 2030 through scaled-up prevention, testing, and treatment4. Elimination of hepatitis as a public health threat was defined as a 90% reduction in incidence and a 65% reduction in mortality, compared with the 2015 baseline5. According to time and availability of health facilities, HBV infection varies significantly from one part of the world to another6. The WHO estimates that 3.3% of the general population living in the Eastern Mediterranean region (EMR) are infected with HBV7.

 

MATERIALS AND METHODS

 

This study was a community-based cross–sectional study conducted in Jibla Town, Yemen. A total of 120 subjects who lived in study area were selected by random sampling with a 100% response rate. Five ml of venous blood was drawn under aseptic conditions, then sera were screened for Hepatitis B surface antigen (HBsAg) using commercial kits (One step HBsAg Test, Intec, China). Positive samples were confirmed by enzyme immunoassay (EIA) for Hepatitis B surface antigen with commercially kits (Fortress Diagnostic Ltd. UK). To obtain relevant information, pre-tested standard questionnaire was prepared to collect participants’ socio-demographic variables, HBV vacci-nation status, and knowledge of infectious agents and risk factors of HBV infection.

Statistical analysis

Analysis of collected data was done by using SPSS Version 20. The percentage of variables was quantified. Statistical comparison between categorical variables was performed using Chi-squared pair test and p <0.05 was considered to indicate significance.  

 

RESULTS

 

In this study, overall seroprevalence of HBV infection among study population was 3.33% as shown in Figure 1. The age of the participants ranged from 6 to 70 years with a mean of 39.1 years. HBV prevalence was higher with elder age groups, but this was statistically insignificant (p value 0.999). Of the total, 87 (72.5%) were males and 33 (27.5%) females. Although there was no association between HBV infection and gender, the percentage of HBV infection among males were 4 (4.6%) which is higher than in females. Married participants were 92 (76.67%), while unmarried were 28 (23.33%) and HBV infection was higher among married people 4 (4.35%), but this was statistically insignificant (p value 0.999).

Regarding the educational status of the respondents, about 94 (78.33%) were educated and the rest 26 (21.67%) of them had no education. The present study showed the highest seroprevalence of HBV infection among non-educated subjects 2 (7.69%) and the lowest educated subjects 2 (2.3%). The difference found was statistically insignificant (p value 0.634).  Most participants 55 (45.83%) had monthly income less than YR 30,000 (approximately US$ 54.5) and only 4 (3.33%) of participants had more than YR 80,000 (approximately US$ 145.5). The difference found was statistically significant (p value 0.000) (Table 1).

DISCUSSION

 

Globally, the prevalence of HBV infection in the general population is 3.5% and 3.3% in Eastern Mediterranean countries13. As result of introducing the universal immunization program in Yemen against HBV for infants and high risk groups in early 200014; recent studies conducted in Yemen reported the lowest prevalence of HBV infection in which ranges from 0.7-2% among general population15. This study presented that, the prevalence rate of HBsAg was 3.33%. Since 2014, war in Yemen as a result of political conflict which led to worst humanitarian crisis in the world. This war led to destruction of health system in Yemen16. The result of the present study was lower than results of the studies conducted in Sana'a 4%17 and 7.1%18.The extent to which the health system to cover different regions of the country with HBV vaccine, differences in the geographical distribution of the infection and level of awareness of population  could be the reasons of the different results of studies that have been conducted in Yemen. The present results indicate that, there is no association between HBV infection and the age of target population (p value 0.999). This is similar to a previous studies in Yemen and Iran8,15. In this study, seroprevalence was high in males 4 (4.6%), but there is no significant difference (p value 0.666). Some studies conducted in Yemen, Ethiopia and Egypt revealed similar results15,19,20, whereas other studies carried out in Mongolia and Yemen showed that males revealed a significant higher level of HBV than females22,23.In the present study, it was found that marital status was insignificantly associated with HBV infection (p value 0.999) which is similar to studies conducted in Yemen5,17,24, and study conducted in Ethiopia25. Other studies showed that marital status was a significant predictor for HBV infection. Married participants compared to participants who are unmarried were more likely to have HBV infection23. The present study also showed insignificant association between educational level and HBsAg seroprevalence (p value 0.624) despite the reports demonstrated that there is a relationship between higher education levels and good health. Regarding the educational status of the respondents, about 94 (78.33%) were educated and the rest 26 (21.67%) of them had no education. The present study showed the highest seroprevalence of HBV infection among non-educated subjects 2 (7.69%) and the lowest educated subjects 2 (2.3%). The difference found was statistically insignificant (p value 0.634).  Most participants 55 (45.83%) had monthly income less than YR 30,000 (approximately US$ 54.5) and only 4 (3.33%) of participants had more than YR 80,000 (approximately US$ 145.5). The difference found was statistically significant (p value 0.000) (Table 1).

 

DISCUSSION

 

Globally, the prevalence of HBV infection in the general population is 3.5% and 3.3% in Eastern Mediterranean countries13. As result of introducing the universal immunization program in Yemen against HBV for infants and high risk groups in early 200014; recent studies conducted in Yemen reported the lowest prevalence of HBV infection in which ranges from 0.7-2% among general population15. This study presented that, the prevalence rate of HBsAg was 3.33%. Since 2014, war in Yemen as a result of political conflict which led to worst humanitarian crisis in the world. This war led to destruction of health system in Yemen16. The result of the present study was lower than results of the studies conducted in Sana'a 4%17 and 7.1%18.The extent to which the health system to cover different regions of the country with HBV vaccine, differences in the geographical distribution of the infection and level of awareness of population  could be the reasons of the different results of studies that have been conducted in Yemen. The present results indicate that, there is no association between HBV infection and the age of target population (p value 0.999). This is similar to a previous studies in Yemen and Iran8,15. In this study, seroprevalence was high in males 4 (4.6%), but there is no significant difference (p value 0.666). Some studies conducted in Yemen, Ethiopia and Egypt revealed similar results15,19,20, whereas other studies carried out in Mongolia and Yemen showed that males revealed a significant higher level of HBV than females22,23.In the present study, it was found that marital status was insignificantly associated with HBV infection (p value 0.999) which is similar to studies conducted in Yemen5,17,24, and study conducted in Ethiopia25. Other studies showed that marital status was a significant predictor for HBV infection. Married participants compared to participants who are unmarried were more likely to have HBV infection23.The present study also showed insignificant association between educational level and HBsAg seroprevalence (p value 0.624) despite the reports demonstrated that there is a relationship between higher education levels and good health. The result of this study is similar to studies conducted in Ethiopia25 and Yemen15,26,27; in addition to the recent study that conducted in 2022, among general population in Egypt21. This study likewise revealed high prevalence of HBV infection among people who had low monthly income (p value 0.000). Yemen is one of the least developed countries in the world in which about 27% of people live under the food poverty line, and 42% are under the national income poverty line28.

Monthly income of the individual plays an important role in determining the level of health status. As well known, poverty is a key factor in the spread of common diseases.

Limitation of the study

This study had some limitations; including sample size may be small in related to population size. This may be due to political crises and war in Yemen which led to unavailability recent data about population size in the study area.  Because of high financial cost of the tests, only positive results were confirmed by HBsAg ELISA technique. 

 

CONCLUSION

 

The findings of this study indicated that the magnitude of HBV infection among the general population was intermediate level. The prevalence of hepatitis B in Yemen is still high compared to many other countries. There are some geographic areas in the country that may be at high risk. Control strategies should take these differences into account. Modifiable risk factor, monthly income was identified. A current war in Yemen led to instability of country and made obtaining the most reliable epidemiological data on HBV infection among the general population in Yemen very challenging.

 

AUTHOR'S CONTRIBUTION 

 

Author read and agreed to the final version for submission to this journal, and agree to be accountable for all aspects of the work.

 

ACKNOWLEDGEMENTS 

 

We thank Dr. Abdullah Almatari, the President of Jiblah University of Medical and Health Sciences, for cooperation in this study. Our thanks to Mr Nabeel M. Al-Qassem for his cooperation in this study. Also we thank Ahlam Alsaber for helping in laboratory field work in Jiblah university hospital.

 

CONFLICT OF INTEREST 

 

The authors declare that they have no conflict of interest.

 

REFERENCES

 

  1. Lim JK, Nguyen MH, Kim WR, Gish R, Perumalswami P, Jacobson IM. Prevalence of Chronic Hepatitis B Virus Infection in the United States. Am J Gastroenterol 2020 Sep; 115(9):1429-1438. http://dx.doi.org/10.14309/ajg.0000000000000651
  2. Jefferies M, Rauff B, Rashid H, Lam T, Rafiq S. Update on global epidemiology of viral hepatitis and preventive strategies. World J Clin Cases 2018 Nov 6; 6(13):589-599.http://dx.doi.org/10.12998/wjcc.v6.i13.589
  3. World Health Organization. Global progress report on HIV, viral hepatitis and sexually transmitted infections, 2021. https://www.who.int/publications/i/item/9789240027077
  4. Jumabayeva A, Nersesov A, Kulzhanov M, et al. Prevalence of viral Hepatitis B, C, and D in Kazakhstan. Sci World J 2022 Apr 22:9102565.http://dx.doi.org/10.1155/2022/9102565
  1. World Health Organization. (‎2016)‎. Global health sector strategy on viral hepatitis 2016-2021. Towards ending viral hepatitis. World Health Organization. https://apps.who.int
  2. Beykaso G, Mulu A, Giday M, et al. Burden and transmission risks of viral hepatitis in Southern Ethiopia: Evidence needed for prevention and control measures. Risk Manag Healthc Policy 2021 Dec 1; 14:4843-4852.http://dx.doi.org/10.2147/RMHP.S336776
  1. Alali AA, Abo-Shehada MN. Prevalence of Hepatitis B virus infection in the Gulf Cooperation Council: A systematic review and meta-analysis. BMC Infect Dis 2022; 22:819.https://doi.org/10.1186/s12879-022-07806-4
  2. Nojoomi F, Ghasemian A, Fallahi S, Abdollahzadeh S. High prevalence and risk factors of hepatitis B, C and E infections among Middle Eastern countries. Immunopathol Persa 2018;4(2):e18. http://dx.doi.org/10.15171/ipp.2018.18
  3. Al-Masoodi BAH, Reem A, Bahaj SS, et al. Prevalence of occult hepatitis B virus infection among patients receiving haemodialysis in Sana'a city. IJID Reg 2022 Sep 20; 5:141-145. http://dx.doi.org/10.1016/j.ijregi.2022.09.004
  4. Alzubiery TKA, Alhazari T, Alcantara JC, Majed SA, Bazaid AS, Aldarhami A. Updated seroprevalence of Hepatitis B surface antigen and anti-hepatitis core antibody among blood donors in Yemen. Infect Drug Resist 2022 May 31; 15:2787-2796. http://dx.doi.org/10.2147/IDR.S357819
  5. Al-Zubiery T, Alharazi T, Alsumairy H, Al-Zubiery A. Sero-Prevalence of HBs Ag, HCV and HIV among blood donors in three blood bank centers in Sana'a city: Yemen. J Biotech Biomed Sci 2017; 1(1):46-52.https://doi.org/10.14302/issn.2576-6694.jbbs-17-1853
  1. Jibla and its surroundings, UNESCO World Heritage Centre, retrieved 2009-04-20.
  2. Al-Nwany NT, Ahmad N, Mohammed Nawi A, Hassan MR, Hod R, Baharom M. Seroprevalence of Hepatitis B virus infection and its associated factors among blood donors in Yemen. Malays J Med Sci 2021 Oct; 28(5):54-63.http://dx.doi.org/10.21315/mjms2021.28.5.5
  1. Al-Shamahy HA, Hanash SH, Rabbad IA, Al-Madhaji NM, Naser SM. Hepatitis B vaccine coverage and the immune response in children under ten years old in Sana'a, Yemen. Sultan Qaboos Univ Med J 2011 Feb;11(1):77-82. Epub 2011 Feb 12. PMID: 21509212.
  2. Al-Shamahy HA, Ajrah MA,  Al-Madhaji AG, et al. Prevalence and potential risk factors of hepatitis B virus in a sample of children in two selected areas in Yemen. Universal J Pharm Res 2019; 4(3); 1-6.https://doi.org/10.22270/ujpr.v4i3.269
  1. Amran OAA, Al-Shamahy HA, Al Hadad AM, and Jaadan BM. Explosion of hepatitis B and C viruses among hemodialysis patients as a result of hemodialysis crisis in Yemen. Universal J Pharm Res 2019; 4(5): 1-6.https://doi.org/:10.22270/ujpr.v4i5.311
  1. Al-Nabehi BAH, Al-Shamahy HA, Saeed WSE, et al. Sero-molecular epidemiology and risk factors of viral hepatitis in urban Yemen. Int J Virol 2015; 11: 133-138. http://dx.doi.org/10.3923/ijv.2015.133.138
  1. Al Makdad ASM,  Al-Haifi AY,  Al-Mutaa NAM, and  Al-Shamahy HA. Immunological status of Hepatitis B virus infection among freshmen university students in Yemen. Universal J Pharm Res 2023; 8 (1):1-8.https://doi.org/10.22270/ujpr.v8i1.900
  1. Hollande C, Parlati L, Pol S. Micro-elimination of Hepatitis C virus. Liver Int 2020 Feb; 40 Suppl 1:67-71.http://dx.doi.org/10.1111/liv.14363
  1. Negash M, Ayalew M, Geremew D, et al. Seroprevalence and associated risk factors for HIV, Hepatitis B and C among blood donors in south Gondar District blood Bank, Northwest Ethiopia. BMC Infect Dis 2019; 19:430.https://doi.org/10.1186/s12879-019-4051-y
  1. Raslan E, AbdAllah M, Soliman S. The prevalence and determinants of hepatitis B among Egyptian adults: A further analysis of a country-representative survey. Egypt Liver J 2022; 12:46. https://doi.org/10.1186/s43066-022-00207-x
  2. Dambadarjaa D, Radnaa O, Khuyag SO, et al. Hepatitis B, C, and D virus infection among population aged 10-64 Years in Mongolia: Baseline survey data of a nationwide cancer cohort study. Vaccines (Basel) 2022 Nov 14; 10(11):1928.http://dx.doi.org/10.3390/vaccines10111928
  1. Al-Marrani WHM, Al-Shamahy HA. Prevalence of HBV and HCV; and their associated risk factors among public health center cleaners at selected Public Health Centers in Sana'a city-Yemen. Universal J Pharm Res 2018; 3(5): 58-62. https://doi.org/10.22270/ujpr.v3i5.204
  2. Al-Waleedi AA, Khader YS. Prevalence of hepatitis B and C infections and associated factors among blood donors in Aden city, Yemen. East Mediterr Health J 2012 Jun; 18(6):624-9. http://dx.doi.org/10.26719/2012.18.6.624
  3. Assefa A, Shiferaw D, Bishaw Z, Kiros T. Seroprevalence of Hepatitis B Virus (HBV) and Hepatitis C Virus (HCV) among blood donors from Bahir Dar, Ethiopia. Adv Pub Health 2022, Article ID 5073171.https://doi.org/10.1155/2022/5073171
  1. Bawazir AA, Parry CM, Hart CA, Sallam TA, Beeching N, Cuevas LE. Seroepidemiology and risk factors of hepatitis B virus in Aden, Yemen. J Infect Public Health 2011 Mar;4(1):48-54. http://dx.doi.org/10.1016/j.jiph.2010.11.003
  2. Murad EA, Babiker SM, Gasim GI, et al. Epidemiology of hepatitis B and hepatitis C virus infections in pregnant women in Sana’a, Yemen. BMC Preg Childbirth 2013; 13:127. https://doi.org/10.1186/1471-2393-13-127
  3. World Health Organization. Regional Office for the Eastern Mediterranean. (‎2010)‎. Country cooperation strategy for WHO and Republic of Yemen: 2008–2013. World Health Organization. Regional Office for the Eastern Mediterranean.https://apps.who.int/iris/handle/10665/113235