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Full Project – Prevalence of hepatitis B infection among pregnant women

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CHAPTER ONE

Background to the Study

Hepatitis B virus (HBV), a DNA virus of the family hepadnaviridae is the causative agent of hepatitis B infection(Pungpapong, Kim, & Poterucha, 2007).It is 50 – 100 times more infectious than HIV and 10 times more infectious than hepatitis C virus (HCV) with many carriers not realizing they are infected with the virus, thus referred to as a “silent killer” (Samuel, Muller, & Alexander, 2004).The minimum infectious dose is so low that such practices like sharing a tooth brush or a razor blade can transmit infection (Chang, 2007). HBV also shares similar routes oftransmission with HIV(Willey, Sherwood, & Woolverton, 2011).

The virus hasbeen detected in peripheral mononuclear cells, tissues of pancreases, spleen, kidney and skin, and fluids like saliva,semen, sweat, breast milk, tears, urine and vaginal secretion (Chen, Liu, Fan, Gao, Chen, Wong, Wu & Wen, 2009). Hepatitis B virus has infected more than one-third of the global population. It has been estimated that 360 million chronic carriers are living around the world with a high risk for developing cirrhosis, hepatic carcinoma and hepatic failure(Liu & Hou, 2006).Prevalence of HBV carriers in low prevalence regions (The USA, Canada, Eastern Europe, Australia and New Zealand) is 0.1% – 2%. It is 3% – 5% in moderate prevalence regions (Mediterranean countries, Japan, Central Asia, Middle East and South America) and 10%- 20% in high prevalence areas (South East Asia, China and Sub Saharan countries) (Porolajal & Majdzadeh, 2009).

Hepatitis B can be transmitted vertically from mother to fetus or neonate during pregnancy, labor or breast feeding or horizontally via intimate contact blood transfusion, nosocomial transmission, transplantation and tattooing.Saraswathi, & Aljabri, (2012)revealed that vertical transmission is responsible for 35%- 40% of the HBV incident cases worldwide Most ofthe infected persons have acquired the infection duringperinatal or early childhood. Risk of chronicity dependson the age of acquisition and route of transmission and ishighest among neonates who acquire infection vertically(Borgia, Carleo, Gaeta, & Gentile, 2012).

Acute HBV infection in the early pregnancy is associated with 10% risk of perinatal transmission, but infection close to or during labor may infect more than 60% of neonates(Sookoian, 2006).Neonatal HBV infection is often asymptomaticin early life but is associated with increased riskof liver disease in later life. In vertically HBV infected children,risk of developing liver cancer is 200 times morethan that of general population (Jonas, 2009). Estimating the prevalence of HBV infection amongpregnant women is very important information in controlof vertical transmission of the disease. There are variablereports on prevalence HBV infection in pregnant womenin Nigeria (Agbonlahor, Nwobu, Igwe C, Agba, Okpala, Ikaroha, & Ezegbudo 2004).

The clinical course of hepatitis B virus infection is complex and is influenced by several factors classified into viral factors and host factors. The viral factors include level of hepatitis B virus replication (viral load), hepatitis B virus genotype, and mutations in viral genome. The host factors include age of acquisition of infection, immune status, concurrent infection with other hepatotropic viruses, and alcohol intake (Aggarwal & Ranyan, 2004). Overall, chronic hepatitis progresses to end stageliver disease in 15 to 40 percent of patients(Liaw, Tai, Chu, & Chen, 1998). For a successful infection, Hepatitis B virus requires an infectious source, a susceptible host, and an established route of transmission (Kao & Chen, 2002). The predominant routes of transmission in various locations vary according to the endemicity of HBV infection. The virus is 100 times more infectious than humanimmune-deficiency virus (HIV) and unlike HIV, it can live outside the body in dried blood for longer than a week (Ott, 1999; Kirchner & Lin, 2004). The most efficient way to control hepatitis B is to prevent individuals from contracting

it rather than treat the infections. Two main approaches lead to achieving this goal: interrupting the virus at the various routes of transmission and immunizing susceptible host. Although immunization is more effective, public health measures should include both approaches.

Prevention strategies must include Hepatitis B vaccination of high risk groups and all new born infants, screening of blood and blood products before transfusion, using universal precautions in healthcare settings like avoid sharing needle among injecting drug users and promote safe sexual practices (Chen, 2005).

In the early 1980s, vaccination against hepatitis B became available, first with plasma derived vaccines and then with recombinant DNA vaccines. All these vaccines are safe and have a protective efficacy of approximately 95%. Despite this success, the duration of protection afforded by hepatitis B vaccination is unknown (Chen, 2005).Detecting persistent antibody is the easiest but not necessarily the most accurate way to measure persistent protection (West& Calandra 1996: Chen, 2005).

The implications of hepatitis B in pregnancy cannot be over emphasized. Hepatitis B virus can be transmitted from mother to child in utero. The sequelae of infection in children can be phenomenal(Owusu-boateng & Adu-Sarkodie, 2002). The exact mechanism of prenatal transmission is not clear. It is unusual for infants to be infected in utero, cord blood is usually negative for hepatitis B markers; however occasional intrauterine infection does occur (Ko & Tseng, 1994). This study aims to estimate the total prevalence ofHepatitis BVirus infection among pregnant women (A study of Federal Medical Centre, Owo).

1.2 Statement of the Problem

Viral hepatitis during pregnancy is associated with high risk of maternal complications and has become a leading cause of foetal death. Hepatitis is one of the major and common infectious diseases of the liver worldwide is caused by a small enveloped DNA virus, the Hepatitis B Virus (HBV). Nigeria is classified among the group of countries endemic for HBV infection. Currently, about 18 million Nigerians are infected. Many of these people may not be aware of the infection and hence fail to seek appropriate medical attention therefore progressing to chronic liver diseases, cirrhosis and hepatocellular carcinoma. Similarly, when pregnant women are involved they constitute a serious health risk not only to their unborn child but also the society at large.

In Sub-Saharan Africa HBV, infection usually is acquired through maternal-fetal transmission or in early childhood leading to a high prevalence of chronic infection (Aggarwal, 2004). A proportion of people infected with Hepatitis B Virus (5%-10%) among adults progress to chronicity, defined as persistence of infection for more than six months (Aggarwal & Ranjan, 2004).

The rate of chronicity is much higher among neonates born to hepatitis B infected mothers and children because they have an immature immune system. Ninety percent of infants infected prenatally progress to chronic infection. Progression to chronic HBV infection occurs in 25 to 30 percent of persons infected before five years of age, and in 3 to 5 percent of those infected later in childhood or as adults (Lok & McMakon, 2001).

Once the infection becomes chronic, HBV or part of the viral genome usually persists a lifetime in the liver of the carrier. The carriers are not only reservoirs of the virus but also victims of chronic liver diseases themselves (Kao, 2002; Chen, 2003). Moreover, the higher prevalence of chronic infection due to maternal-fetal transmission also translates into higher rates of cirrhosis and cancer in these areas. Treatments are not curative because they rarely produce permanent remission of the disease (Lin &Kirchner, 2004). In other to be able to control this disease effectively, there is a need to know the prevalence among pregnant women. The need to generate such data is the problem of the study.

1.3 Purpose of the Study

The main purpose of the study is to determine the prevalence of hepatitis Bvirus infection among pregnant women. (A case study of Federal Medical Centre, Owo, Ondo State). Specifically, the study aims to:

Examine the prevalence of Hepatitis B Virus infection among pregnant women
To determine the demographic and risk factors associated with Hepatitis B Virus infection among pregnant women

1.4 Research Questions

The study is designed to answer the following questions;

What is the prevalence of Hepatitis B Virus among pregnant women attending ante-natal care in Federal Medical Centre Owo, Ondo State.
What is the influence of the following variables on prevalence of Hepatitis B Virus: Age, Parity, Level of Education and family type.

1.5 Research Hypotheses

To guide this study, the following hypotheses were formulated:

H₁ i. There is no significant influence between age and prevalence of Hepatitis B Virus

There is no significant influence between parity and prevalence of Hepatitis B Virus

iii. There is no significant influence between level of education and prevalence of Hepatitis B Virus

There is no significant influence between family type and prevalence of Hepatitis B Virus

1.6 Significance of the Study

The following are the significance of the study:

The result from this study will educate the general public especially the pregnant women on the prevalence and prognosis of Hepatitis B Virus infection among pregnant women.
The research will be a contribution to the body of literature in the area on the prevalence of hepatitis B virus infection among pregnant women constituting the empirical literature for future research in the subject area.
Knowledge of the immune status of pregnant women if known will help the clinical management of the woman and reduce vertical transmission risks.
This will also help in advising and taking precautionary measures to protect the mothers and their unborn children, and provide information required for prevention or management of Hepatitis B Virus. Testing for Hepatitis B Virus infection in pregnancy is important in view of the morbidity and mortality of the host (pregnant women), its effect on the process of parturition, and the risk of vertical transmission from mother-to-child.

1.7 Scope of the Study

This study is designed to identify the prevalence of hepatitis B virus infection among pregnant women attending antenatal care in Federal Medical Centre Owo, Ondo State. The study will be restricted to Federal Medical Centre Owo, Ondo State.

1.8 Limitation of the Study

The study had some limitations; it was hospital based and included a selected population of women with exposure to no condom sexual intercourse and therefore at high risk of sexually transmitted infections including HBV. In addition, it would be very difficult to demonstrate evidence for chronicity of hepatitis B infections because tests for hepatitis B core antibodies and HBV DNA could not be performed because of logistical reasons.

Furthermore, the exclusion of private patients could also affect the generalization of findings. This is however minimized by the fact that non-paying patients are a mixture of mothers from low as well as high socioeconomic status. However, the findings of this study have adequately shed light into the problem of hepatitis B infection among pregnant women attending antenatal care in Federal Medical Centre Owo, Ondo State.

1.9 Definition of Operational Terms

Hepatitis B:Hepatitis B is a potentiallyseriousform of liverinflammationdue to infection by thehepatitis B virus(HBV).

Pregnant Women:having a child or other offspring developing in the body; with child or young, as a woman or female mammal.

Prevalence:the quality or state of being prevalent, the degree to which something is prevalent; especially: the percentage of a population that is affected with a particular disease at a given time.

Virus:an infective agent that typically consists of a nucleic acid molecule in a protein coat, is too small to be seen by light microscopy, and is able to multiply only within the living cells of a host.

Infection:the process of infecting or the state of being infected.

Disease:a disorder of structure or function in a human, animal, or plant, especially one that produces specific symptoms or that affects a specific location and is not simply a direct result of physical injury.

Antenatal: this is a medical care given to pregnant woman before their babies are born.

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