Seroprevalence and Associated Factors of Hepatitis B and Hepatitis C Viral Infections Among Prisoners in Tigrai, Northern Ethiopia

Introduction

The hepatitis B and hepatitis C viruses are important health and socioeconomic problems across the world causing considerable numbers of diseases and deaths, especially in Africa and Asia.¹ It is predicted that 2 billion and 170 million people have been infected by HBV and HCV, respectively, in the world. About 15–40% of patients with chronic hepatitis B virus can progress to liver cirrhosis, liver failure, and primary hepatocellular carcinoma (HCC).^2,3 According to the most recent estimates of the Global Burden of Disease study, viral hepatitis is responsible for approximately 1.5 million deaths each year, which is comparable to annual deaths from HIV/AIDS, malaria, and tuberculosis (1.3, 0.9, and 1.3 million, respectively).⁴

In general, 80% (about 71.1 million people) of hepatitis C-infected individuals develop chronic HCV, of which 10–15% will develop liver cirrhosis.⁵ About 25% of global liver cancer cases are due to HCV infection.⁶ Chronic hepatitis B among prisoners showed varied prevalence rates globally; data reported from prison settings of the United States (US), Denmark, Belgium, Ireland, and Greece were 3.7%, 4.4%, 6.5%, 9%, and 5.8%, respectively.^7,8 The majority of persons with chronic hepatitis B and hepatitis C are unaware of their infection and do not benefit from clinical care, treatment, or interventions. Thus, because of a lack of follow-up and approach to treatment, one-third of persons with chronic viral hepatitis will die because of liver disease, including cirrhosis, liver cancer, and liver failure.⁹

The main transmission routes of hepatitis B virus are horizontal (blood or sexual contact) and vertical (mother to child). The routes of horizontal transmission are blood and blood derivatives, infected blood transfusion products, needle stick or blood splatter from a person infected with hepatitis B virus or an undiagnosed person, open injuries and scratches, bloody surgery, intravenous drug use, tattoos and piercings, hemodialysis, and sharing of razors and toothbrushes.¹⁰ Using sharp materials¹¹ and having a history of multiple heterosexual partners¹² are risk factors for the transmission of HBV, as reported from prison setting studies in Northern Ethiopia. Furthermore, long stays in prisons, which provide a fertile ground for infection transmission, might increase the risk of transmission of pathogenic organisms, including blood-borne viral infections such as hepatitis B and hepatitis C viruses.^13,14 Limited health facilities, lack of health services, and absence of sanitary facilities in the prison settings also predispose prisoners to new infections.¹⁵ The rates of hepatitis B and hepatitis C infections among prisoners in all countries are reported to be higher than in the general population.¹⁶

The epidemiology of hepatitis B can be described in terms of the prevalence of hepatitis B surface antigen (HBsAg) in a population, broadly classified into high (>8% HBsAg prevalence), intermediate (2–7%), and low prevalence (<2%). High-HBV prevalence is common in much of the Asia Pacific and sub-Saharan African regions.¹⁷ In our regional state, Tigrai, information about hepatitis B and hepatitis C viruses in prison settings has not been addressed, however; the rates of HBV among blood donors and pregnant mothers have been reported to be 3.79%¹⁸ and 5.5%,¹⁹ respectively. The rate of HCV among blood donors was also reported as 1.3%¹⁸ from Tigrai . Hence, we found that assessing the prevalence of HBV and HCV in the prison settings is important to design further interventions for prevention and control of HBV and HCV in the Tigrai regional state of Ethiopia. Therefore, we aimed to describe the seroprevalence and associated factors among prisoners in Tigrai, Northern Ethiopia.

Methods

Study Area, Study Design, and Study Period

The study settings were the prison facilities of the Tigrai regional state, which is in the northern part of Ethiopia. We took a letter of support from Mekelle University College of Health Sciences to the office of Tigrai prison administration. Based on the letter of support, we gathered the required information and selected three prison settings; Wukro town from the Eastern zone, Mekelle city from Mekelle zone, and Michew town from the Southern zone of Tigrai using the lottery method. Mekelle, a city of Tigrai, is positioned 784 km north of Addis Ababa, the capital city of Ethiopia, and has a total of 1,800 prisoners, whereas Wukro is located 67 km northeast of Mekelle with a total of 600 prisoners. Michew, the third selected town, is the administrative town of the southern zone of Tigrai and is located 120 km to the south of Mekelle city with a total of 720 prisoners. A cross-sectional study was conducted from February 2020 to May 2020 in prison settings of Tigrai regional state of Ethiopia. Male and female individuals aged 18 and above who stayed for more than 6 months in these prison settings were included. We used a single population proportion to calculate a total of 315 study participants using a previous prevalence of 10.4%¹² at a 5% margin of error and 95% level of confidence.

Sample Collection and Laboratory Analysis

Face-to-face interviews were performed to collect demographic characteristics and risk factors from study participants prospectively. These are age, sex, marital status, educational level, income status, tattooing, number of sexual partners, sharing contaminated materials, blood transfusion history, dental extraction, alcohol consumption, number of prisoners per room, and duration of imprisonment. Five milliliters of blood was aseptically obtained from each study participant using a plain tube. Plasma was separated by centrifuging blood at 1,000 revolutions per minute (rpm) for 1 minute, labeled with a participant code number, and a cold box was used to transport to Tigrai Blood Bank and −20°C was used to store the specimens upon delay. Detection of hepatitis C and hepatitis B viruses were performed using Anti-HCV antibody (Volkan Kozmetik Sanayi Ve Ticaret ltd. STI, Turkey) and Hepatitis B surface Ag (Zhejiang orient Gene Biotech Co., Ltd., China) based on standard operational procedures (SOPs), respectively. All rapid test positive results were confirmed using ELISA technique (Beijing Wantai Biological Pharmacy Enterprise Co. Ltd).

Data Management

Data was entered and analyzed using Statistical Package for Social Sciences (SPSS) version 20. Descriptive statistics, crude and adjusted odds ratio were conducted by univarate and multivariate regression model. P<0.05 was considered statistically significant.

Quality Control

Positive and negative controls (HBsAg and Anti HCV) were performed in parallel to the test of interest as quality control.

Ethical Considerations

Ethical clearance was obtained from the Ethical Review Committee (ERC) of the College of Health Science, Mekelle University and the ERC number is 1499/2020. Based on the letter of support that we took from Mekelle University, the Tigrai prison administration office allowed us to proceed to the selected prison settings and we collected written informed consent from each study participant before data and blood sample collection. The confidentiality of patients’ information was safeguarded throughout the process.

Results

Demographic Characteristics of Participants

A total of 315 prisoners participated and more than 90% of them were males. The age of participants ranged between 18 and 72 years, with a mean of age of 30 (±10.5) and the majority (38%) of the prisoners were 18–25 years old. The income of more than 40% of the prisoners was low (<500 Ethiopian birr/month) and about 85% of the prisoners did not know what HBV and HCV were. About 39% of the prisoners who participated in the study had been in prison for more than 3 years (Table 1).

Table 1 Seroprevalence of HBV and HCV in Prison Settings of Tigrai, Northern Ethiopia (n=315)

Sero-Prevalence of HBV and HCV

The overall seroprevalences of HBV and HCV were 25 (7.9%) and 1 (0.3%), respectively. Mixed infections were not identified in our study. All of the HBV and HCV were recovered from male participants. The lowest prevalence of HBV was observed in 43–72 year olds (2; 0.6%), while the highest was in the 18–25 year olds (13; 4.1%). The prevalence of HBV among unmarried was 14 (4.4%) and those with a low income (<500 Ethiopian birr/month) was 14 (4.1%) and 15 (4.8%), respectively.

The positivity rates of HBV among prisoners who had lived with 100 individuals in a single room, stayed longer than 3 years of imprisonment, had more than one sexual partner, and had an exchange of sharp materials with another person were 15 (4.8%), 17 (5.4%). 13 (4.1%), and 15 (4.8%), respectively (Table 1).

Associated Factors of HBV

This study assessed variables such as knowledge about HBV, number of prisoners per cell, length of stay in prison, alcohol consumption, tattoos, and sharing of sharp materials whether variables have associations with HBV infection or not. Only previous alcohol consumption (AOR=3.4, 95% CI=1.17–7.74) and number of prisoners per cell (AOR=5.6, 95% CI=1.14–13.6) showed an association with HBV infection (Table 2).

Table 2 Factors Associated with the Hepatitis B Viral Infection in Prison Settings of Tigrai, Northern Ethiopia (n=315)

Discussion

The sub-Saharan Africa region is categorized as high HBV prevalence, in which the rate of HBV is greater than 8%.¹⁷ Horizontal transmission is one of the two important transmission routes of HBV and the prison setting is one example where hepatitis viruses transmission can take place.¹⁰ The prevalence of HBV and HCV in prisoners of all countries is significantly higher than those in the general population¹⁶ and prisoners contribute to the increased transmission and spread of HBV and HCV infections to the general population.²⁰ In the study area, there was no data about the prevalence of HBV and HCV. Thus, we aimed to describe the seroprevalence of HBV, HCV, and associated factors among prisoners in Tigrai, Ethiopia.

The overall prevalence of HBV infection in the study area was 25 (7.9%). This was in line with reports from prison settings of the north east (6.5%)²¹ and community setting (7.2%)²² of Ethiopia, Afghanistan (6.5%),²³ and Libya (6.9%).²⁴ However, it was lower than reports from other studies in Ethiopia (10.4%)¹¹ and abroad in Ghana (17.4%),²⁵ Malawi (17.5%),²⁶ Egypt (9.8%),²⁷ and Croatia (11.3%).²⁸ The reason why their results were high might be associated with injectable drug use (IDU) and homosexual practices,^25,28 even if there was a report from Ethiopia that no homosexuality was identified from the interviewed participants.¹² Our result of HBV in this study was higher than the results of studies conducted in other countries including Stockholm (1.9%),²⁹ Switzerland (5.9%),³⁰ Turkey (4.7%),³¹ Lebanon (2.4%),³² Iran (2.5%),³³ Kyrgyzstan (6.2%),³⁴ and Nigeria (5.9%).³⁵ The reasons might be due to differences in study design, health system facilities in prisons, and prisoners’ level of awareness on HBV.^31,32

The prevalence of HBV among blood donors, pregnant women, and HIV-positive individuals in Ethiopia were (3.8%,³⁶ 3.79%¹⁸), (3.7%,³⁷ 5.5%¹⁹) and (5.9%),³⁸ respectively, which was lower than our result. The factors that were practiced in the prison settings of the study area like sharing of sharp materials might aggravate the transmission of HBV. However, a higher rate of HBV seroprevalence (10.9%) had been reported among street dwellers from Gondar-Ethiopia.³⁹ The difference shows that street dwellers, like prison inmates, are among the high-risk populations for bloodborne infections, including HBV infections.⁴⁰

The rate of HCV was only 1 (0.32%), which was much lower than previous reports in Ethiopia (2.6%,¹² 1.9%,²² 1.3%¹⁸), Ghana (19.2%),²⁵ Egypt (15.8%),²⁷ Iran (9.5%),³³ and Nigeria (13.7%)³⁵ but almost similar with a study done in Turkey (0.5%).³¹

The age group of 18–25 years was identified by World Health Organizations and the United Nations as key vulnerable subgroup prisoner populations for HIV and viral hepatitis.^41–43 Risk behaviors of HBV and HCV were observed more prevalently among young and male prisoners.^44,45 This might be realized by sexually active groups and illegalization of substance use globally.⁴⁶

In our study, 10.7% of study participants who had tattoos were positive for HBV infection. This was supported by previous studies conducted in Brazil (14%)⁴⁷ and Ghana (12%),²⁵ while 10.3% of HBV-positive individuals had shared risk materials.^11,12 Prisoners who stayed longer than 3 years in prison were 3-times more likely to be infected by HBV infection than those who reported a period of imprisonment less than 1-year, but not statistically significant, which is supported by a previous study conducted in Egypt.²⁷

A multivariate analyses result showed that individuals living in prison rooms consisting of more than 100 prisoners were 4-times (AOR=3.95, 95% CI=1.14–13.6, p=0.028) more infected with HBV than as compared with their counterparts living in prison rooms with less than 50 individuals. The cells might to be overcrowded and individuals in these cells might be in cloth contact with each other. Prisoners who had an alcohol consumption history were 3-fold (AOR=3.1 95% CI=1.17–7.74, p=0.022) more infected with HBV as compared with those without an alcohol consumption history. This was comparable with a previous study conducted in Nigeria.^27,35

The association between HCV infection and different factors were not done because of the low (1; 0.31%) prevalence rate. However, HCV infection in association with tobacco, alcohol consumption, period of imprisonment, and intravenous drug use were reported in the previous studies.^30,48

Conclusions

The prevalence of HBV among prisoners in the selected prisons of Tigrai was nearly high or borderline with a very low prevalence of HCV. The most HBV positive prisoners were the young adults, large number of prisoners per cell, and those who had a previous history of alcohol consumption. The overall outcome of the present study recommends that there should be prison-focused intervention activities such as conducting regular health education, more enhanced prevention, and control activities with more emphasis on the mode of transmission. There should be an HBV screening policy introduced, especially when prisoners enter the prison facility.