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ORIGINAL ARTICLE
Year : 2021  |  Volume : 24  |  Issue : 8  |  Page : 1164-1169

Trends and Burden of Hepatitis B Viral Infection in Children and Adults in a Tertiary Health Facility in North East Nigeria Over a Fifteen-year Period


1 Department of Paediatrics, College of Medical Sciences, Gombe State University, Gombe, Nigeria
2 Department of Paediatrics, Federal Teaching Hospital, Gombe, Nigeria
3 Infectious Diseases Training and Research group, Gombe, Nigeria
4 Department of Community Medicine, College of Medical Sciences, Gombe State University, Gombe, Nigeria
5 Department of Internal Medicine, Federal Teaching Hospital, Gombe, Nigeria
6 Department of Medical Microbiology, Federal Teaching Hospital, Gombe, Nigeria

Date of Submission07-Jul-2020
Date of Acceptance17-Feb-2021
Date of Web Publication14-Aug-2021

Correspondence Address:
Dr W E Isaac
Department of Paediatrics, College of Medical Sciences, Gombe State University
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_425_20

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   Abstract 


Background: Hepatitis B infection is endemic in Nigeria where greater than six percent of the general population are chronic carriers. Transmission predominantly occurs in infants and children when compared with adults. Viral hepatitis deaths are mostly due to chronic liver disease. Routine immunization against hepatitis B virus infection in Nigeria is still low. Aims: We planned to describe the burden and trend of hepatitis B viral infection at Federal Teaching Hospital, Gombe. Methodology: This study was a retrospective cross-sectional descriptive study. The results of all hepatitis B surface antigen (HBsAg) tests using rapid chromatographic immunoassay performed at the Federal Teaching Hospital, Gombe (FTHG), Nigeria from January 2000 to December 2014 were retrieved and analyzed. Results: Between 2000 and 2014, 23,611 individuals ranging from 2 months to 98 years of age were tested for HBsAg. A total of 13,136 (55.6%) were males and 10,475 (44.4%) were females. Among individuals tested for hepatitis B surface antigen, 18.9% (4,456) were positive. A total of 70.6% (3,147) were males and 29.4% (11,239) were females. Male sex was significantly associated with HBsAg positivity (P < 0.001). The mean HBsAg prevalence over the 15-year periods among males and females were 22% and 12%, respectively (P < 0.001). The mean yearly HBV prevalence was 17.5%, 17.2%, 19.6%, 15.5%, and 4.4% among age-groups 0–18 years, 19–25 years, 26–45 years, 56–65 years, and >65 years, respectively (P = 0.132). The proportion of HBsAg-positive individuals was highest in the year 2012 (28.7%) and lowest in 2014 (1.8%). Conclusion: There was an increasing trend in HBV testing and diagnosis in children and adults in our facility over the last 15 years. Health facility capacity for HBV treatment and care requires strengthening

Keywords: Burden, hepatitis B, Nigeria, trend


How to cite this article:
Isaac W E, Jalo I, Ajani A, Oyeniyi C O, Abubakar J D, Aremu J T, Danlami M H. Trends and Burden of Hepatitis B Viral Infection in Children and Adults in a Tertiary Health Facility in North East Nigeria Over a Fifteen-year Period. Niger J Clin Pract 2021;24:1164-9

How to cite this URL:
Isaac W E, Jalo I, Ajani A, Oyeniyi C O, Abubakar J D, Aremu J T, Danlami M H. Trends and Burden of Hepatitis B Viral Infection in Children and Adults in a Tertiary Health Facility in North East Nigeria Over a Fifteen-year Period. Niger J Clin Pract [serial online] 2021 [cited 2022 Jan 19];24:1164-9. Available from: https://www.njcponline.com/text.asp?2021/24/8/1164/323856




   Introduction Top


Viral hepatitis is a major public health threat and a leading cause of death worldwide causing an estimated 1.34 million deaths per year (nearly 4,000 per day), rivaling mortality caused by other major infectious diseases, including HIV/AIDS, malaria, and tuberculosis.[1] Sub-Saharan Africa bears disproportionately the burden of hepatitis B viral infection with a prevalence of 6.1%–8.8%, about 80 million chronically infected individuals, and an estimated 87,890 deaths mainly through hepatocellular carcinoma and/or liver cirrhosis. Eighty percent of liver cancer in Africa is caused by HBV.[1],[2],[3] However, HBV infection has heterogeneous outcomes: acute viral hepatitis, spontaneous clearance, or chronicity, with its common fatal sequelae of hepatic cirrhosis and hepatocellular carcinoma.[1]

HIV coinfection, adds considerably to the clinical burden in sub-Saharan Africa with 2.6 million HIV–HBV coinfected individuals, increases the potential risk of perinatal HBV transmission, and is associated with a more aggressive disease course of chronic hepatitis B.[4],[5]

Nigeria ranks first among the top ten countries with the greatest burden of viral hepatitis in sub-Saharan Africa and the country accounts for 8.3% of the global burden of chronic HBV.[6],[7] With a national prevalence of 8.1% and 20 million infected, HBV presents an enormous health challenge for the country.[7]

Immunization is the most effective measure to prevent the transmission of HBV.[1] The widespread use of the hepatitis B vaccine in infants has considerably reduced the incidence of new chronic HBV infections.[1]

In Nigeria, hepatitis B vaccination was started in 2004, and currently, four doses are administered at birth, 6 weeks, 10 weeks, and at 14 weeks.[8] The most recent estimate of hepatitis B vaccination coverage at birth with valid evidence is 35% and about 60% for the 3rd dose of hepatitis B vaccine in the country (Hep3) Nigeria.[9]

The screening, evaluation, and treatment of HBV-related liver disease and its complications are severely limited in developing country settings such as Nigeria, with significant morbidity and mortality among the young and reproductive segments of the society.[10] While trend studies in hepatitis B surface antigen are very limited, they assist in health care needs assessments, service provision planning, and policy development and implementation.

The objective of this study was to describe the burden and trend of hepatitis B viral infection using hepatitis B surface antigen marker in the Federal Teaching Hospital Gombe from its inception in 2000 to 2014.


   Methodology Top


Design

This was a retrospective cross-sectional study.

Study area

Gombe is the administrative capital of Gombe state and is one of the six states that comprise the North East Geopolitical zone in the country. The North-East geopolitical remains the zone with the highest levels of poverty and the worst maternal and child health indices in Nigeria.[11]

Study setting

This study was conducted in Federal Teaching Hospital Gombe, a 500-bed hospital serving Gombe state and neighboring states. The FTHG started providing services in the year 2000.

Study population

All children and adults who presented to the out-patient departments, and those that were admitted irrespective of their HIV and/or hepatitis C virus status were subjected to hepatitis B surface antigen testing from 2000 to 2014.

Laboratory methods

All children and adults were tested using the hospital standard for hepatitis B surface antigen test strip. The test strip used was ACON HBsAg (ACON Laboratories, Incorporated San Diego, California, USA) a rapid one-step test for the qualitative detection of hepatitis B surface antigen in serum or plasma. The HBsAg test strip has a relative sensitivity, greater than 99.8%, and a specificity of 99.7%.[12]

Laboratory registers/Data collection

The records of hepatitis B surface antigen results of children and adults in Federal Teaching Hospital, Gombe between 2000 and 2014 were retrieved. Variables analyzed included age, sex, year, month, and results of hepatitis B surface and envelope antigen tests.

Data analysis

All records were imputed into EPInfor Version 3.2 and analyzed.

Ethical clearance

Clearance for this study was obtained from the Research and Ethical committee of the Federal Teaching Hospital, Gombe. Ethical clearance was obtained from the hospital research and ethics committee with reference number: NHREC/25/10/2013


   Results Top


Between 2000 and 2014, 23,611 children and adults ranging from 2 months to 98 years of age were tested for HBsAg; of those tested, 55.6% (13,136) were males and 42.6% (10,475) were females. A total of 4,456 (18.9%) were seropositive for HBsAg. Seventy percent (3147) of those expressing HBsAg were males (χ2 = 345.7, P < 0.05) with a male to female ratio of 1:2.4.

Testing for HBsAg

[Table 1] showed an increasing trend in testing for HBV infection reaching a peak of 17 times the baseline in 2009 and thereafter declined to eight times the baseline in 2014. There was a sharp decline in testing in 2006 and 2007. HBsAg expression increased numerically with a greater screening of children and adults [Table 1], and an overall trend was statistically significant. The proportion of HBsAg carriers showed a rather steady rise within the review period and some variations with a peak of 28.7% in 2012 and a trough of 1.8% in 2014 [Figure 1].
Figure 1: HBsAg Percentage positivity in adults and children in Federal Teaching Hospital Gombe, 2000–2014

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Table 1: Yearly trend of HBsAg screening tests and carriage in adults and children in Teaching Hospital Gombe Nigeria 2000-2014

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[Table 2] showed more females than males were tested between 2000 and 2004 and thereafter more males received an HBV test. A trend of increasing testing for HBsAg and rising levels of HBsAg seropositivity in both males and females was demonstrated during the period 2000–2014 [Figure 2] Both year on year and cumulative sex distribution was statistically significant [Table 2]. Cumulatively, more males than females tested for HBsAg and were twice as likely to be seropositive for the antigen. In all age groups, there was a general trend towards increasing screening for HBV in the period of study, with peak testing in the age group 26–45 and the age group >65 years the lowest. Over the review period, the proportion of HBsAg-positive children and adults varied widely within both the same age group and various age groups [Table 3].
Figure 2: Percentage positivity and sex distribution of HBsAg carriers in adults and children in Federal Teaching Hospital Gombe. Nigeria, 2000–2014

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Table 2: Yearly trend of HBsAg screening tests and sex of HBsAg carriers in adults and children in Teaching Hospital Gombe

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Table 3: Yearly trend of HBsAg screening tests and age group of HBsAg carriage in adults and children in Teaching Hospital Gombe Nigeria 2000-2014

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   Discussion Top


To the best of our knowledge, this report on hepatitis B surface antigen trend is the largest from a health facility in Nigeria and the sub-region and indeed underscores the serious public health threat hepatitis B viral infection poses to the country and Sub Saharan Africa in general.[1] In recognition of its public health importance, target 3.3 of the 2030 Agenda for Sustainable Development calls for specific action to combat viral hepatitis.[13]

Knowledge of viral hepatitis remains low among Nigerians despite being a leading infectious cause of death each year.[8] As a consequence, most of the estimated 20 million Nigerians living with viral hepatitis B are undiagnosed, increasing the likelihood of future transmission to others and placing them at greater risk for severe, even fatal health complications, such as liver cirrhosis and hepatocellular carcinoma.[8]

In our study, facility testing for HBsAg in all ages and both males and females increased steadily and significantly over time. While our study did not explore factors responsible for this trend, it could be related to individual, institutional, and/or community-level factors.[14] HBV testing is a gateway to prevention and treatment cascade.[1],[15],[16] In 2015, access to HBV testing was limited as only 9% were diagnosed globally and less than 5% in Africa.[1]

Three-dose hepatitis B vaccine with a birth dose remains the most cost-effective intervention to prevent this infection.[1] However, in Nigeria, hepatitis B vaccination coverage at birth was very low at 35% and 60% for 3rd dose of hepatitis B vaccine.[9] In Gombe state, where our study center is located, hepatitis B birth dose vaccine coverage was 29.9% in 2016/2017.[11] In 2015, the coverage for hepatitis B- birth dose in the African region was only 10%, compared to the global estimate of 39%.[17] In our study, the sharp drop in testing and diagnosis in 2006, 2007, and 2014 were all related to an incessant boycott of services (strike) by health care workers. This can have a significant impact on health service provision.[18]

Furthermore, in our study, more children and adults were increasingly diagnosed in absolute terms with hepatitis B virus infection during the period from 2000 to 2014. Diagnosis of hepatitis B with linkage to treatment, care, and support is a vital component of the hepatitis B care cascade.[1],[8],[15],[16] One of the barriers to the implementation of screening and treatment for hepatitis B is the cost associated.[10] Early detection and treatment of HBV infection reduce hepatocellular carcinoma (HCC) incidence and mortality.[19]

While an accurate estimate of the proportion of Nigerians diagnosed with HBV is unknown, the greatest challenge in achieving elimination targets is scaling up testing[20] to all those 20 million projected to be carriers of the infection.[8]

The year-on-year percentage prevalence of HBV infection varied, but the trajectory is an increasing one in our health facility. Hospital reports of HBV trend in Nigeria[21] and India,[22] even though limited by duration and sample size when compared to our study showed equally high HBV prevalence reflecting hyperendemicity of HBV in these settings.[1]

HBV trend in Ghana,[23] over 5-year period among blood donors and in Turkey[24] among all age groups, showed low infection related to high vaccine coverage in children compared to Nigeria and India.

Year on year, more males than females were infected with HBV during the study period. Indeed, males were twice as likely to be HBsAg carriers as females. Reports on HBV trends in Nigeria,[21] India,[22], and Turkey[24] showed a greater burden of HBV in males than females. In contrast, more females than males were infected with HBV over a 5-year period in Ghana.[23] The sex difference in hepatitis B prevalence may be due to a difference in viral exposure with men being more exposed as a result of an inherently more active lifestyle or behavior[22] including, male circumcision, tribal marks, uvulectomy, and sharing of sharp objects.[25] Factors predisposing females to sexually-transmitted infections are related to biologic, physiologic, and their socioeconomic circumstance.[26]

In all age groups, there was considerable variation in the percentage of children and adults with HBV infection. However, the HBsAg carriage trend was highest in the age group 26–45 years throughout the 15-year study period. In recent years, more people older than 65 years harbored HBV infection than in earlier years. The high burden of hepatitis B in young and middle-aged adults in our study may be associated with the perinatal transmission,[1] lack of HBV immunization[1],[8],[9], or early childhood and adolescent transmission.[1] Sero-conversion of HBsAg is slow, and in West Africa Shimakawa et al.[27] reported an HBsAg clearance of 1.0%/year with half clearing by 57-year-old. Younger age and high HBV DNA levels at baseline were associated with delayed HBsAg seroconversion.[28]


   Conclusion Top


Our study has demonstrated an increasing trend in HBV testing and diagnosis in children and adults in our facility over the last 15 years. This finding will no doubt assist in health care needs assessments, service provision planning, and institutional policy development and implementation for viral hepatitis prevention, treatment, and care.

Study Limitations

As a retrospective cross-sectional study, we were unable to report Anti-Hbs or Anti-Hbc status which could have defined nonexposure and therefore requiring HBV vaccine preventive intervention. As this was a one-point screening test, we could not determine if all the cases detected were those with chronic infection (HBsAg for >6 months). We could not report liver function and hepatitis B viral load tests as these results were not available.

Recommendations

Provider initiated testing and counseling for all children and adults should be offered and linked to treatment, care, and support.

Routine immunization including HBV vaccination should be made mandatory through legislation in Nigeria and indeed in Sub-Saharan Africa.

Institutional capacity for HBV multicenter research, treatment, and care in the country will be highly beneficial.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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Ladep NG, Lesi OA, Mark P, Lemoine M, Onyekwere C, Afihene M, et al. Problem of hepatocellular carcinoma in West Africa. World J Hepatol 2014;6:783-92.  Back to cited text no. 2
    
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Yang JD, Mohamed EA, Aziz AO, Shousha HI, Hashem MB, Nabeel MM, et al. Characteristics, management, and outcomes of patients with hepatocellular carcinoma in Africa: A multicountry observational study from the Africa Liver Cancer Consortium. Lancet Gastroenterol Hepatol 2017;2:103-11.  Back to cited text no. 3
    
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Kourtis AP, Bulterys M, Hu DJ, Jamieson DJ. HIV–HBV coinfection-A global challenge. N Engl J Med 2012;366: 1749 52.  Back to cited text no. 4
    
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Matthews PC, Geretti AM, Goulder PJ, Klenerman P. Epidemiology and impact of HIV coinfection with hepatitis B and hepatitis C viruses in Sub-Saharan Africa. J Clin Virol 2014;61:20-33.  Back to cited text no. 5
    
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MacLachlan JH, Locarnini SC, Benjamin C. Estimating the global prevalence of hepatitis B. Lancet 2015;386:1515-7.  Back to cited text no. 6
    
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Federal Ministry of Health. National Agency for the Control of AIDS. Nigeria HIV/AIDS Indicator and Impact Survey (NAIIS) report. National Survey 2019. https://www.naiis.ng/resource/ factsheet/ [Last accessed on 2020 May 27].  Back to cited text no. 7
    
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Federal Ministry of Health. National Guidelines for the Prevention, Care and Treatment of Viral Hepatitis B & C in Nigeria. National AIDS/STIS Control Program, Federal Ministry of Health. 2016. https://www.who.int/hiv/pub/guidelines/nigeria_ art.pdf [Last accessed on 2020 May 03].  Back to cited text no. 8
    
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Howell J, Ladep NG, Lemoine M, Nayagam S, Toure PS, Diop MM et al. Prevention of Liver Fibrosis and Cancer in Africa: The PROLIFICA project--a collaborative study of hepatitis B-related liver disease in West Africa. S Afr Med J. 2015;105:185-6. doi:10.7196/samj.8880.  Back to cited text no. 10
    
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National Bureau of Statistics (NBS) and United Nations Children's Fund (UNICEF). 2017. Multiple Indicator Cluster Survey 2016 17, Survey Findings Report. Abuja, Nigeria: National Bureau of Statistics and United Nations Children's Fund. https://www.unicef.org/nigeria/sites/unicef.org.nigeria/ files/2018-09/Nigeria-MICS-2016-17.pdf. [Last accessed on 2020 May 06].  Back to cited text no. 11
    
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www.aconlabs.com.HbsAg EIA Test kit Package Insert/HBeAg Test Kit. [Last accessed on 2020 Feb 29].  Back to cited text no. 12
    
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The Sustainable Development Goals Report 2018, UN, New York; 2018. Available from: https://doi. org/10.18356/7d014b41 en. https://unstats.un.org/sdgs/files/report/2018/TheSustainableDevelopmentGoalsReport2018-EN.pdf. [Last accessed on 2020 May 20].  Back to cited text no. 13
    
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World Hepatitis Alliance. Overcoming the Barriers to Diagnosis of Viral Hepatitis: The Role of Civil Society and the Affected Community in finding the missing millions White Paper. Available from: www.worldhepatitisalliance.org. [Last accessed 2020 Mar 29].  Back to cited text no. 14
    
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Lemoine M, Shimakawa Y, Njie R, Taal M, Ndow G, Chemin I, et al. Acceptability and feasibility of a screen-and-treat programme for hepatitis B virus infection in The Gambia: The Prevention of Liver Fibrosis and Cancer in Africa (PROLIFICA) study. Lancet Glob Health 2016;4:e559-67.  Back to cited text no. 15
    
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Shankar H, Blanas D, Bichoupan K, Ndiaye D, Carmody E, Martel-Laferriere V, et al. A novel collaborative community-based hepatitis B screening and linkage to care program for African immigrants. Clin Infect Dis 2016;62(Suppl 4):S289-97.  Back to cited text no. 16
    
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25.
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27.
Shimakawa Y, Lemoine M, Njai HF, Bottomley C, Ndow G, Goldin RD, et al. Natural history of chronic HBV infection in West Africa: A longitudinal population-based study from The Gambia. Gut 2016;65:2007-16.  Back to cited text no. 27
    
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Shimakawa Y, Yan H-J, Tsuchiya N, Bottomley C, Hall AJ. Association of early age at establishment of chronic hepatitis B infection with persistent viral replication, liver cirrhosis and hepatocellular carcinoma: A systematic review. PLoS One 2013;8:e69430.  Back to cited text no. 28
    


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  [Table 1], [Table 2], [Table 3]



 

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