ORIGINAL

Niger J Paed 2015; 42 (3):199 –203

Uleanya ND

Obidike EO

Prevalence and risk factors of

hepatitis B virus transmission

among children in Enugu, Nigeria

DOI:http://dx.doi.org/10.4314/njp.v42i3.5

Accepted: 26th March 2015

Abstract: Background: Hepatitis

B Virus (HBV) infection has

reached pandemic proportions all

over the world with areas of high-

est prevalence being the sub-

Saharan Africa and Southeast

Asia. Most deaths related to HBV

are due to complications from

chronic infection. Acquisition of

infection at a younger age is the

most important predictor of

chronicity. Eradication of HBV is

an important but difficult tasks

facing public health. HB immuni-

zation is the single most important

factor in hepatitis B control and

was commenced in 2004 in

of Nigeria Teaching Hospital,

Ituku. Hepatitis B surface antigen

(HBsAg) was determined using

Determine Test Kits and a struc-

tured interviewer administered

questionnaire administered.

Results: Six were positive for

HBsAg, giving a prevalence rate

of 4.3%. HBsAg was least preva-

lent among children 1-5 years

(2%). None of the children ≤ 5

years who received HB vaccina-

tion was positive for HBsAg

though one child > 5 years who

received the vaccine was positive.

Sharing of toothbrushes among

siblings was found to be a signifi-

cantly associated risk factor. Only

6.4% of mothers knew their hepa-

titis B status.

(

)

Uleanya ND

Department of Pediatrics,

Enugu State University Teaching

Hospital, Enugu. Nigeria.

P. O. Box 9225,

Enugu. Nigeria.

Email: nulesa2001@yahoo.com

Obidike EO

Department of Pediatrics,

University of Nigeria Teaching

Hospital, Ituku-Ozalla, Enugu. Nigeria.

Nigeria.

Objectives: To determine the

prevalence of Hepatitis B surface

antigen (HBsAg) among children

in the era of HB immunization,

the risk factors of transmission

and knowledge of mothers about

their HB status.

Methods: A cross sectional study

carried out on one hundred and

forty children aged 18 months to

Conclusion: There is a gradual fall

in the prevalence of HBsAg in our

environment due to HB immuniza-

tion. Sharing of toothbrushes may

be a potent means of transmission

of HBV infection.

Keywords: HBV, Prevalence,

Children, Transmission, HB

immunization

1

5 years at the children outpatient

clinic (CHOP) of the University

Introduction

lation and as many as 12.5 million will eventually die

due to complications from hepatitis B – chronic hepati-

8

,9

Hepatitis B Virus (HBV) is a ubiquitous partially double

stranded DNA virus with areas of highest prevalence

being the sub-Saharan Africa, South-East Asia, the

Amazon basin, Alaska, Northern Canada, Eastern

Europe, Greenland, parts of the Middle East, China, and

tis, cirrhosis and hepatocellular carcinoma (HCC) .

Annual mortality directly related to hepatitis B liver

disease and cancer worldwide has been between 600,000

1

-1 million .

1

parts of Pacific Islands . The infectious virus consists of

Younger age at acquisition of infection continues to be

the most important predictor of chronic carriage and

those who develop chronic hepatitis B h_,₆ave a 15 - 40 %

an outer envelope – HBsAg, the first seromarker and

one of the most useful markers of active or chronic

hepatitis B infection, and an inner core made up of

Hepatitis B core Antigen (HBcAg), found in acute or

chronic infections and the e-antigen (HBeAg₂)_,,₃_,₄w_,₅ hich

4

risk of developing the complications this chronicity

being due to their immature immune system. More than

95% of adults spontaneously recover from an acute

HBV infection as defined by clearance of the HBsAg

from the blood, an ef_,f₁e₀ct that reflects the host’s degree

serves as a marker of active viral replication

. An

estimated 2 billion people have been infected with HBV,

with 350-400 million of them remaining chronic carriers

4

of immune response . Transmission occurs when in-

6,7

worldwide . It has also been estimated that 25 - 30% of

fected blood or body fluid from an infected₁_,₁p₁erson en-

ters the body of another who is not immune .Africans

who are carriers of HBV are infected in early childhood,

8,9

the chronic carriers will die of the sequelae . In Africa,

the number of HBV carriers is estimated to be about 50

million representing about 10-20% of the general popu-

8,9

predominantly by horizontal transmission . Vertical

2

00

transmission contributes 5-15% - (occurring more in

piratory tract infections, malaria etc. from July to De-

cember 2010. Inclusion criteria were ages 18 months to

15 years and those whose parent (s) gave informed con-

sent while all children less than 18 months or above 15

years of age as well as those whose parents refused to

consent despite due education on the need for the study

were excluded.

those with high viral load and actively replicating virus)

8

.

However, for unknown reasons, probably genetic,

HBeAg positivity rates are much lower in African

8,9

women of childbearing age .

The eradication of HBV is one of the most important but

difficult tasks facing public health in Nigeria. This

maybe due to ignorance, about the infectivity (including

mechanisms of transmission) and the dire consequences

of HBV infection in children. This most probably, being

because the infections are asymptomatic and the

Ethical clearance was obtained from the University of

Nigeria Teaching Hospital Health Research and Ethics

committee. Informed consent – both verbal and written,

were obtained from the child and/or the parent (s). They

were duly educated on the need for, and benefits of the

study, the specimen to be collected and how it was to be

collected. A structured interviewer administered ques-

tionnaire was designed for the study. Information sought

included biodata, occupational and educational status of

both parents – for the determination of socioeconomic

class, risk factors for HBV infection including previous

history of blood transfusion, history of scarification,

tattooing, ear piercing, circumcision, use of contami-

nated needles and syringes for injection (either used or

reused needle or syringe was considered as contami-

nated), intravenous drug use, histories of sex (where

necessary), bites by other children, and sharing of tooth

brush. Others were child immunization status and

knowledge of maternal immunization status. The immu-

nization cards of all those who received the vaccine

were demanded and verified.

sequalae are long. It may also be from the poor immuni-

zation coverage in Nigeria. As at 2010, the national im-

12

3

munization coverage was 69% using DPT coverage .

There are three major methods of controlling HBV in-

fection. The first is immunization, which is the single

most important factor in hepatitis B control, has the po-

tential of eradicating hepatitis B and studies have con-

firmed protection following vaccination in b₇o_,₈t_,₁h₃ industri-

alized and non-industrialized communities

. It’s in-

corporation into National immunization programme is

designed to reduce the risk of early childhood acquisi-

tion of HBV thereby reducing the number of chronic

carriers in endemic populations and has the advantage of

accessing infants through pre-existing vaccine delivery

systems and vaccinating ind₄i_,v₁₅iduals prior to their engag-

1

ing in high risk behaviours . Next is the use of antivi-

ral drugs such as lamivudine, tenofovir, ribavirin etc.

Then the immunostimulatory therapy with α-interferon

7

and pegylated α-interferon . Other adjuncts include con-

Assay for HBsAg was done using Abbott Determine

HBsAg test kits - an enzyme immunoassay (specificity

of 99.85% and a sensitivity of 94.64%). The test was

then read after a waiting interval of 15 minutes to 24

hours (as specified by the manufacturer).

The data were analyzed using SPSS version 19. Meas-

ures of central tendency – the mean were used to sum-

marize quantitative variables where applicable. Fre-

quency tables were constructed as appropriate. Chi

square analysis for non-continuous variables with p

value at the level of < 0.05 as significant was also done.

Odds ratios for the risk factors were calculated. Socio-

economic class w₁a₉s determined using the method pro-

posed by Oyedeji.

tinued screening of pregnant mothers for HBsAg to pre-

vent vertical transmission, post exposure prophylaxis

using hyperimmune globin within 24 hours or at most 7

1

4

days following exposure , and massive and sustained

public health education on the various avoidable modes

of transmission of HBV and available preventive meas-

ures.

The universal HB immunization was commenced in

Nigeria in 2004 as other major modalities are almost

nonexistent. Hence mass vaccination in a large scale

ought to become imperative as this will decrease the

reservoir of chronic carriers. HB immunization coverage

12

in Nigeria in 2010 was 66% . Some previous studies

between 1983-2005 have reported prevalence rates of

6

zation was nonexistent . This study was therefore

.5-7.6% in Enugu and₁₆th_,₁e₇_,₁e₈nvirons when HB immuni-

Results

undertaken to determine the prevalence of HBsAg

among children in this era of HB immunization, the

remote risk factors of HBV transmission in our environ-

ment and knowledge of mothers about their HB status.

The age and sex distribution of the study population is

as shown in Table 1. The mean age of the children was

7.27 ± 3.6 years. There were 74 males and 66 females

with a male to female ratio of 1.1: 1. The majority of the

children 62 [44.3%] were in the age range of 6-10 years.

The least represented age range was 11-15 years – 28

(20%).Their socioeconomic class is also as shown in

Table 1. Most of the subjects were in the lower class.

Among the 140 children, 6 were positive for HBsAg,

giving a prevalence rate of 4.3%. Of the 6 HBsAg posi-

tive children, 5 belonged to the lower socioeconomic

class while one belonged to the middle class. Three of

the males and 3 of the females were positive for HBsAg

Methods

The study was carried out at the Children Outpatient

clinic of the University of Nigeria Teaching Hospital, a

tertiary medical institution in Enugu. It was cross sec-

tional, recruiting consecutively 140 children who at-

tended the clinic with minor illnesses such as upper res-

2

01

giving a prevalence rate of 4.1% and 4.5% respectively.

The observed differences in the prevalence rates be-

tween males and females were not of statistical signifi-

cance. The least prevalence was also observed among

children 1-5 years (2%) while the highest prevalence of

dren of the positive mothers were positive for HBsAg.

Table 3: Showing the distribution of HBsAg among

immunized children

Age

(Years)

Number of

immunized

children

HBsAg

Positive

N (%)

Status

Negative

N (%)

HBsAg was observed among those aged 6-10 years

2

(

6.5%) [C2 = 1.4 –X =1.4, p = 0.5]. Table 2.

≤

5

45

36

0 (0.0)

1 (2.8)

45 (100.0)

35 (97.2)

Table 1: Socio-demographic characteristics of the study

subjects

≥

5

Age Range

Number (%)

Table 4: Risk factors of HBV and their relative risk of

1

6

1

-5

-10

1-15

50 (35.7)

62 (44.3)

28 (20.0)

positivity among the subjects

2

Risk

Total

HBsAg

positive

N (%)

χ

p

OR

factor

sample

Gender

Male

Female

Social class

Upper class

Middle class

Lower class

74 (52.9)

66 (47.1)

Blood transfusion

Present

Absent

Scarification mark

Present

Absent

17

123

1 (5.9)

5 (4.1)

0.12

1.86

0.55

0.20

1.5

3.2

31 (22.1)

43 (30.7)

66 (47.1)

20

120

2 (10.0)

4 (3.3)

Tattooing

Present

Absent

*

The lowest age in this study was 18 months

1

139

0 (0.0)

6 (4.3)

-

Table 2: Showing age prevalence of HBsAg

Circumcision

Present

Absent

Intravenous drug use

Absent 140

Contaminated syringe/needle

Age range

Years)

HBsAg

Positive

N (%)

Status

Negative

N (%)

75

65

3 (4.0)

3 (4.6)

0.04

1.00

0.9

(

1

-5

1 (2.0)

4 (6.5)

1 (3.6)

49 (98.0)

58 (93.5)

27 (96.4)

6 (4.3)

-

6

1

-10

1-15

Present

Absent

Ear piercing

Present

Absent

Sharing of toothbrush

Present

Absent

Bitten by playmates

Present

Absent

Unprotected sex

15

125

0 (0.0)

6 (4.8)

Among the 50 children who were 5 years or less, 45

(

90%) received HB immunization while the remaining 5

10%) could not recall whether or not they received the

63

77

3 (4.8)

3 (3.9)

0.06

5.22

2.04

-

1.00

0.04

0.21

-

1.2

6.1

0.3

-

vaccine. Thirty six (40%) children out of the 90 who

were more than 5 years old received the immunization,

37

103

4 (10.8)

2 (1.9)

2

5 (27.8%) said they did not receive the immunization,

9 (32.2%) could not recall receiving the immunization.

55

85

4 (7.3)

2 (2.4)

None of the children ≤ 5 years who had received HB

immunization was positive for HBsAg. However, one

(

2.8%) child > 5 years who claimed (immunization not

Absent

140

6 (4.3)

verified as subject has no card) to have received HB

immunization was HBsAg positive. Table 3.

Among the children studied, whether HBsAg positive or

negative, none was involved with intravenous drug

abuse or unprotected sex. However, all had received

intramuscular injections for one reason or the other as is

depicted in Table 4.

Discussion

This study has demonstrated an HBsAg prevalence rate

of 4.3%. This is lower than the 6.6% recorded in this

16

Fifteen (10.7%), used contaminated needle/syringe. Sev-

enteen (12.1%) had a past history of blood transfusion,

center five years earlier . It therefore demonstrates the

gradual fall in HBsAg prevalence among children in our

environment as a result of HB immunization. It is a₇lso

2

0 (14.3%) had scarification marks, 1(0.7%) had a tat-

1

too, 75 (53.6%) were circumcised, 63 (45%) had ear

lower than the 7.6% reported by Chukwuka et al in

2

piercing, 37 (26.4%) shared toothbrushes at one time or

Nnewi and 10.7% recorded by Jibrin, et al in Sokoto at

2

the other with other siblings (C

2

= 5.22 -X =5.22, p =

the same time as this study. Earlier studies have also

documented higher prevalence of HBV in No₀rthern Ni-

0

.04) and 55 (39.3%) had been bitten by other children

2

at one time or the other. However, the odds ratio of the

risk of transmission of HBV through these risk factors is

as shown in table 4.

geria than Enugu – 9.4% by Ashir, et al, 44.7% by

21

Bukbuk et al . This reduction in HBsAg rates call for

strengthening of routine immunization and sustained

efforts in all parts of Nigeria, to reduce significantly the

hyperendemicity of HBV.

The highest prevalence of HBsAg positivity was found

in those children aged 6-10 years. This high prevalence

Among the mothers of these children, only nine (6.4%)

knew their hepatitis B status. Of these seven were nega-

tive for HBsAg while 2 were positive. None of the chil-

2

02

of HBsAg positivit₆y_,₁₈in this age group agrees with other

titis B among the mothers. That only 6.4% knew their

HB status is worrying and reflects the poor general

knowledge and attitude towards hepatitis B. The impli-

cation is the hyperendemicity of this deadly disease in

Nigeria. This calls for massive public health enlighten-

ment campaign just like in HIV/AIDS to curb this dis-

ease. In developing countries like Nigeria, intravenous

drug use is not yet common among children. However,

exposure to repeated injections sometimes with contami-

nated therapeutic injection equipment, probably due to

ignorance, parental preferences, or lack of awareness of

infection control practices and resources for sterilization,

1

studies in Enugu. This may be because at this age

most children are very active and exploring their world.

2

Howeve₂r, it differs with the observations by Jibrin and

2

Alikor who found highest prevalence rate among chil-

dren 11-15 years. The difference in age group of preva-

lence may be because of increase in other high risk be-

haviors including unprotected sexual habits among chil-

dren of this age group, Port Harcourt being a seaport and

23

more cosmopolitan. Komas, et al had noted higher

prevalence of HBV markers among adolescents and

young adults in Bangui, who did not use condom and

also those having more than one sexual partner. It may

also be as a result of the inability of these children to

lose the surface antigen due to impaired immunity.

24

are very common. The zero prevalence in this study

among the risk factors of tattooing and contaminated

needle/syringe may have been as a result of the small

sample size involved. Also although not statistically

significant as risk factors, but as has been documented

previously blood transfusion and scarification marks

have odd ratios of 1₂.5₄ and 3.2 respectively, making them

In this study, zero prevalence was observed in the age

group 18 months -3 years, which may imply that vertical

transmission of HBV has remained low in Nigerian

women. This prevalence rate in this age group may fur-

ther highlight the effectiveness of HB vaccine in an en-

25

potent risk factors. Al-Fawaz had adduced that even

rd

an HBsAg free blood obtained by the very sensitive 3

16

demic area like ours. Considering that Emechebe docu-

mented a prevalence rate of 5.6% among children 2-5

years in this centre 5 years earlier, this study’s 2%

among same age range may be due to vaccine efficacy.

An increasing prevalence of HBsAg with age was also

observed in th₂_,i₁s₆_,₂s₂tudy. Other studies have also noted a

generation screening techniques can not completely

safeguard against HBV. This is true of occult hepatitis B

in which there is presence of HBV DNA in the liver in

the absence or undetectable serum HBsAg and measur-

26

able or immeasurable serum HBV DNA. Also, it had

been noted that history of blood transfusion was a suffi-

cient risk factor for chronic hepatitis B infection, a ma-

jor etiolog₂₇ic factor for primary hepatocellular carcinoma

in Africa.

similar trend.

This pattern still shows the predomi-

nance of horizontal transmission of HBV infection in

our environment. A slightly higher prevalence of

HBsAg was observed among the females. Though the

prevalence rates observed in this study are₁₆lower, it is at

variance with the finding in Enugu earlier, in Port Har-

Sharing of toothbrush among siblings/household mem-

bers was found to be statistically significant while bite

by playmates was not. The alkaline nature of the saliva

may have been contributory in hindering transmission

through bite. However, an intraoral trauma during

brushing could be the source of transmission. Also the

chance of transmitting the virus through this route is

likely to be substantial given the fact that such sharing is

likely to occur over prolonged₂₄periods. This finding is

similar to that by Nwokediuko.

22

21

court and in Borno who observed a higher prevalence

among males.

The social class of the parents in this study was not sig-

nificantly associated with HBsAg positivity. This may

be because of equal exposure to the risk factors of HBV

among children of different social classes. However, in

this study it was observed that the higher the social

class, the lower the number of children positive to

HBsAg. This could be because people in the lower so-

cioeconomic class are more likely to indulge in activities

that may promote infection with HBV such as alterna-

tive medicine, share sharp objects and toothbr₃ushes.

Conclusion

2

This is similar to the findings of Komas, and

There is a gradual fall in the prevalence of hepatitis B

surface antigen in our environment possibly due to HB

immunization. The vaccine may also not be 100% pro-

tective. Sharing of toothbrush was found to be a signifi-

cantly associated mode of transmission of HBV infec-

tion. There is a very poor knowledge of HBV among our

people.

16

Emechebe.

In 2004, the universal HB immunization was com-

menced in Nigeria though it was incorporated into the

National Programme of Immunization (NPI) in 1995.

The total sum of vaccinated children in this study who

were sure of their immunization was 81. Only one was

positive for surface antigen. If actually this subject re-

ceived complete doses of the vaccine, it may point to the

fact that it is not 100% effective in preventing HBV in-

fection. This prevalence of 1.2₁%₃ is comparable to that

observed by Odusanya, et al. Not minding this find-

ing, with such a level of vaccine efficacy it is likely to

impact positively and prevent or reduce the transmission

of hepatitis B infection in the community.

Author’s contribution

UND: Conceived the study, developed the research

question, and designed the questionnaire, literature re-

view, data collection, directed data analysis, manuscript

writing and general coordination.

OEO: Co-designed the questionnaire, directed data

analysis and manuscript writing

Conflict Interest: None

This study also revealed a very poor knowledge of hepa-

Funding: None

2

03

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