medRxiv preprint doi: https://doi.org/10.1101/2023.01.06.23284271; this version posted January 7, 2023.

The copyright holder for this

preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in
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1 Hepatitis B virus infection status and associated factors among health care
2 workers in selected hospitals in Kisumu County, Kenya: a cross-sectional
3 study.

4 Authors Name:

5 Frankline Otieno Mboya 1, Ibrahim I. Daud 1, Raphael Ondondo 2, Daniel Onguru 1

6 Target journal: Plos Global Public Health.

7 Authors institutional address:

8 1 Jaramogi Oginga Odinga University of Science and Technology.

9 P.O. Box 210-40601, Bondo- Kenya.
10 P.O. Box Nairobi-Kenya.
11 2 Masinde Muliro University of Science and Technology, Kakamega Kenya

12 P.O. Box 190-50100, Kakamega- Kenya.

13
14 Corresponding author:
15 Frankline Otieno Mboya
16 Jaramogi Oginga Odinga University of Science and Technology.
17 Tel: +254720304739
18 Email: otifrankline@gmail.com
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37 NOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.

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 medRxiv preprint doi: https://doi.org/10.1101/2023.01.06.23284271; this version posted January 7, 2023. The copyright holder for this
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It is made available under a CC-BY 4.0 International license .

38
39 Abstract (293)
40 Background: Poorly managed medical waste produced at the health facilities are potential
41 source of infections including occupational exposure to Hepatitis B Virus (HBV). This study
42 evaluated the prevalence of HBV infection among healthcare workers (HCW) in Kisumu
43 County.

44 Methods: We determined the prevalence of HBV infections among 192 HCW from nine
45 purposively selected high volume public hospitals in Kisumu County. A structured
46 questionnaire was administered, and 4.0 ml of venous blood sample collected for Hepatitis B
47 surface antigen (HBsAg), hepatitis B surface antibody (anti-HBs) and total hepatitis B core
48 antibody (anti-HBc) testing using enzyme immunoassay (EIA).

49 Results: Of the 192 HCW sampled, 52.1% were males and 78.7% are married, the median
50 participants age was 34.4 years with interquartile range (IQR) of 11 years. Most participants
51 had between 1-5 years of service while 43.8% had ≥2 doses of HBV vaccine.
52 The respective prevalence of HBsAg, anti HBs and anti HBc was 18.8% (95% CI: 13.5-25.0%),
53 63.0% (95% CI: 55.8-69.9%) and 44.8% (95% CI: 37.6-52.1%). Higher proportion of HBV
54 positive was found in HCW who had worked for less than one year and who had not received
55 any dose of HBV vaccine at 37.5% and 35.9 % respectively.. Significant risk of HBV lifetime
56 exposure was noted among HCW with one vaccine dose, those with no known exposure and
57 highest in those with knowledge on HBV transmission (aOR, 7.97; 95% CI, 2.10-153.3, p-
58 value=0.008). HCW who had received ≥2 doses of HBV vaccine (aOR, 0.03; 95% CI, 0.01-
59 0.10, p-value= <0.0001) had significant HBV protection. Duration of service was not
60 associated with HBV among HCW.

61 Conclusion: Prevalence of HBV infection was high among HCW in Kisumu County . Ministry
62 of health Kenya should strengthen comprehensive infection prevention and control practices to
63 reduce lifetime exposure to HBV infection among HCW.

64 Key words: Hepatitis B virus infection, Health care workers, HBV Vaccine

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 medRxiv preprint doi: https://doi.org/10.1101/2023.01.06.23284271; this version posted January 7, 2023. The copyright holder for this
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It is made available under a CC-BY 4.0 International license .

65 Background:
66 Globally, it is estimated that 257 million people are living with chronic hepatitis B (CHB) viral

67 infection, HBV epidemic mostly affects WHO African and Western Pacific Regions (1).

68 Prevalence of HBV infection in Africa is averagely more than 10% while pooled HBV

69 prevalence in HCW was 6.81% (95% CI 5.67–7.95) classifying the region as one of high

70 endemic area (2-5). In 2007, the Prevalence of HBV infection in Kenya was estimated to be 2–

71 5%, while 31% of the Kenyan population was found to have been previously exposed to HBV

72 (6).

73 Global mortality due to viral hepatitis was about 1.4 million in 2016 (7, 8), of those deaths

74 approximately 47% were due to HBV infection (9). HBV is highly infectious and is mainly

75 transmitted through vertical transmission, percutaneous blood, sexual and body fluid

76 contacts(10). Health care services in hospitals is aimed at restoring health and saving lives (11),

77 these services also generate infectious medical waste that if poorly managed could be potential

78 source for hospital acquired infections (HAI) which include HBV (12). The risk of HAI

79 increases when basic infection prevention and control (IPC) practices in health care settings

80 are not well laid out and adhered to. There is limited data on occupational exposure to HBV

81 infection and its prevalence among HCW in Kenya. This study estimated the prevalence of

82 HBV infection and exposures among HCW in Kisumu County.

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 medRxiv preprint doi: https://doi.org/10.1101/2023.01.06.23284271; this version posted January 7, 2023. The copyright holder for this
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It is made available under a CC-BY 4.0 International license .

83 Methods

84 Study aim, design, and setting

85 We conducted descriptive cross-sectional study between May 2020 and April 2021 to estimate

86 HBV infection prevalence and risk factors among HCW in nine largest public hospitals in

87 Kisumu County. These hospitals provide primary and referral medical care services, trainings,

88 and have different structural establishments depending on the hospital level. The hospitals

89 generate varying nature and type of medical waste depending on their capacity and medical

90 services/procedure offered.

91 Study population and characteristic of the participants

92 A total of 192 HCW (nursing officers, medical officers, clinical officers, medical laboratory

93 technologists, medical waste handlers, HIV testing counsellors, and mortuary technicians)

94 were included in the study. Probability proportional to size (PPS) sampling was used to identify

95 number of participants in each selected health facility and service delivery points, simple

96 random sampling from duty roster was used to sample the participants.

97 Data collection and Laboratory Procedures

98 A structured questionnaires was administered to collect sociodemographic data after obtaining

99 informed consent. 4.0 ml of venous blood sample was collected in ethylene-diamine-tetra-

100 acetic acid (EDTA) (Becton, Dickinson and Company, Franklin Lakes, New Jersey, USA) for

101 evaluating HBV infection based on three biomarkers: hepatitis B surface antigen (HBsAg),

102 antibodies against hepatitis B surface antigen (anti-HBs), and antibodies against total hepatitis

103 B core antigen (anti-HBc). Current HBV infection was determined by testing for HBsAg using

104 Murex HBsAg version 3 kit; immunity to HBV infection was established by testing for anti-

105 HBs using ETI-AB-AUK-3 Diasorin anti-HBs EIA kit; and past exposure to HBV infection

106 was assessed by testing for anti-HBc using Murex anti-HBc (total) kit. All tests were done as

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 medRxiv preprint doi: https://doi.org/10.1101/2023.01.06.23284271; this version posted January 7, 2023. The copyright holder for this
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It is made available under a CC-BY 4.0 International license .

107 per the manufacturers’ kit instructions without modifications. HBV current infection was

108 defined as individual’s blood is serologically positive for HBsAg while HBV lifetime exposure

109 are individuals whose blood is serologically positive for either HBsAg (current infection) or

110 anti-HBc (may indicate a current or past resolved infection).

111 Data analysis

112 Data was analysed using SPSS version 16.0 (SPSS Inc., Chicago, IL, USA). Results were

113 summarized using descriptive statistics. Logistic regression models were used for bivariate and

114 presented as odd ratios (OR) with 95% confidence intervals (CI). Multivariable analyses were

115 performed for factors attaining p-values ≤0.2 in bivariate analysis to determine independent

116 factors associated with HBV infection (positive for HBsAg or anti-HBc) among HCWs and

117 presented as adjusted OR (aOR). A threshold p-value of less than 0.05 was considered

118 statistically significant. The models were adjusted for age and gender.

119 Ethical considerations

120 The study received ethical approval form JOOTRH ethics review board
121 IERC/JOOTRH/244/20 and National Commission for Science, Technology & Innovation
122 (NACOSTI) granted research permit to conduct the study (licence no: NACOSTI/P/20/6300).
123 Permissions to collect data from hospitals within Kisumu County was granted by Kisumu
124 County Director of Health. All HBV susceptible HCW were referred for HBV vaccination
125 through Kenya Expanded program for immunization (KEPI).

126 Results

127 Sociodemographic characteristic of HCW

128 Of the 192 HCW sampled, 52.1% were males and 78.7% are married, the median participants
129 age was 34.4 years with interquartile range (IQR) of 11 years. Most participants had between
130 1-5 years of service. Varied results were observed in HCW IPC training and capacity
131 building: while capacity building on personal protective equipment (PPE) usage was 73.4%,
132 trainings on waste management was 30.2% and infectious agents found on waste was 32.3%.

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 medRxiv preprint doi: https://doi.org/10.1101/2023.01.06.23284271; this version posted January 7, 2023. The copyright holder for this
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It is made available under a CC-BY 4.0 International license .

133 There was moderate knowledge on HBsAg transmission, prevention/control and waste
134 disposal at 56.8%, 53.7% and 30.2% respectively. HBV vaccine completion rate was low at
135 43.8% of HCW receiving ≥2 vaccine doses while 40.6% being susceptible to HBV infection.
136 Whereas 90.6% of health care workers agreed that PPEs are generally available within the
137 work settings, 77.6% felt that they were inadequate. There was low daily usage of PPEs:
138 Apron/dust coat 65.1%, gumboots (waste handlers) 13.5%, gloves 44.8% and mask wearing
139 while on duty 56.3%. There was good access to hand hygiene 96.4% and availability of waste
140 management bins (black, yellow, red) 95.8% with low waste segregation at 29.7% while 67.2
141 % of waste were incinerated at site or networked to facilities with incinerator. Higher
142 proportion (53.1%) of HCW had either contact or needle stick injury exposure (Table 1).
143
144 Table1: Socio-demographic characteristics and risk factors of the study population (N=
145 192)

Variables Frequency Percent (%)

Sex
Female 92 47.92
Male 100 52.08
Age (years)
20-29 65 33.85
30-39 83 43.23
40-49 23 11.98
≥50 21 10.94
Marital status
Single 37 19.27
Married 151 78.65
Widowed/Separated/Divorced 4 2.08
Years of service (years)
Less than 1 8 4.17
1-5 85 44
6-10 51 26.56
>10 48 25
Cadre
Doctors 8 4.17
Clinical Officer 29 15.1
Nursing officer 39 20.31
Laboratory technologist 55 28.65
Mortuary attendance 7 3.65
HIV testing counsellor 17 8.85
Medical waste handlers 37 19.27
HBV Vaccine uptake

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≥2 doses 84 43.8
1 dose 30 15.6
Not vaccinated 78 40.6
History of exposure
Needle Stick Injury 91 47.4
Contact Exposure 11 5.7
No Known Exposure 90 46.9
History of Blood transfusion
No 189 98.4
Yes 3 1.6
Knowledge on HBsAg Transmission
No 83 43.2
Yes 109 56.8
Knowledge on HBsAg Prevention and
control
No 89 46.4
Yes 103 53.7
Training on PPE full module
No 141 26.6
Yes 51 73.4
Training on infectious agent on waste full
module
No 130 67.7
Yes 62 32.3
Training on waste management full
module
No 134 69.8
Yes 58 30.2
Knowledge on waste disposal
No 90 46.9
Yes 102 53.1
Availability of PPEs
No 18 9.4
Yes 174 90.6
Adequacy of PPEs
No 149 77.6
Yes 43 22.4
Daily use of apron/Dust coat
No 67 34.9
Yes 125 65.1
Daily use of gumboots (Waste handlers
only)
No 32 86.5
Yes 5 13.5
Daily use of gloves

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 medRxiv preprint doi: https://doi.org/10.1101/2023.01.06.23284271; this version posted January 7, 2023. The copyright holder for this
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It is made available under a CC-BY 4.0 International license .

No 106 55.2
Yes 86 44.8
Daily use of mask when on duty
No 84 43.8
Yes 108 56.3
Access to hand hygiene
No 7 3.7
Yes 185 96.4
Availability of waste management
materials (All 3 waste bins)
No 8 4.2
Yes 184 95.8
Proper waste segregation
No 135 70.3
Yes 57 29.7
Waste disposal Method (Incineration)
No 63 32.8
Yes 129 67.2
146 Values are presented as numbers and (%).

147 Prevalence of HBV Biomarkers among HCW in Kisumu County, 2020 (N= 192)
148 In table 2 below, the respective prevalence of HBsAg, anti HBs and anti HBc was 18.8% (95%
149 CI: 13.5-25.0%), 63.0% (95% CI: 55.8-69.9%) and 44.8% (95% CI: 37.6-52.1%) respectively.
150 Highest prevalence of HBsAg was seen among, HCW who had worked for less than one year
151 37.5% (95% CI: 8.5-75.5), HBV unvaccinated HCW 35.9% (95% CI: 25.3-47.6), HCW who
152 has had blood transfusion 33.3% (95% CI: 0.84-90.6) and HIV testing counselors 29.4% (95%
153 CI: 10.3-56).
154 Anti HBc prevalence was highest among HCW with one dose of HBV vaccine 83.3% (95%
155 CI: 65.3-94.4), those with less than one year in service 75.0% (95% CI: 34.9-96.8), waste
156 handlers not using gumboots 68.8% (95% CI: 50.0-83.9) and HBV unvaccinated HCW 66.7%
157 (95% CI: 55.1-76.9).
158 There is moderate HBV immunity or recovery level among HCW, the carders with highest anti
159 HBs positivity were laboratory scientist 74.6% (95% CI: 61.0-85.3), clinical officers 65.5%
160 (95% CI:45.7-82.1) and Nursing officers 64.1% (95% CI: 47.2-78.8). HTS counselors had the
161 lowest immunity or recovery level at 35.3% (95% CI: 14.2-61.7).
162 Table 2: Prevalence of hepatitis B virus markers among HCW in Kisumu County, 2020
163 (N= 192)
Prevalence of HBsAg Prevalence of Anti-HBs Prevalence of Anti-
Characteristic Biomarker Biomarker HBc Biomarker

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N(%) % (95%CI) N(%) % (95%CI) N(%) % (95%CI)

18.8(13.5- 44.8(37.6-
Overall 36/192 121/192 63.0(55.8-69.9) 86/192
25.0) 52.1)
Carder
25.0(3.19- 37.5(8.5-
Doctors 2/8 5/8 62.5(24.5-91.5) 3/8
65.1) 75.5)
48.3(29.5-
Clinical Officer 6/29 20.7(8-39.7) 19/29 65.5(45.7-82.1) 14/29
67.5)
38.5(23.4-
Nursing officer 8/39 20.5(9.3-36.5) 25/39 64.1(47.2-78.8) 15/39
55.4)
32.7(20.7-
Laboratory technologist 7/55 12.7(5.3-24.5) 41/55 74.6(61.0-85.3) 18/55
46.7)
57.1(18.4-
Mortuary attendance 0/7 0.0(0-41.0) 4/7 57.1(18.4-90.1) 4/7
90.1)
47.1(23.0-
HTS counsellor 5/17 29.4(10.3-56) 6/17 35.3(14.2-61.7) 8/17
72.2)
64.9(47.5-
Waste handlers 8/37 21.6(9.8-38.2) 21/37 56.8(39.5-72.9) 24/37
79.8)
Sex
46.0(36.0-
Male 12/100 12(6.4-20.0) 69/100 69.0(59.0-77.9) 46/100 56.3)
26.1(17.5- 43.5(33.2-
56.5(45.8-66.8)
Female 24/92 36.3) 52/92 40/92 54.2)
Age(Years)
38.5(26.7-
20-29 10/65 15.4(7.6-26.5) 41/65 63.1(50.2-74.7) 25/65 51.4)
18.1(10.5- 42.2(31.4-
30-39 15/83 28.1) 56/83 67.5(56.3-77.4) 35/83 53.5)
26.1(10.2- 60.9(38.5-
40-49 6/23 48.4) 11/23 47.8(26.8-69.4) 14/23 80.3)
57.1(34.0-
≥50 5/21 23.8(8.2-47.2) 13/21 61.9(38.4-85.1) 12/21 78.2)
Marital status
40.5(24.8-
Single 7/37 18.9(8.0-35.2) 20/37 54.1(36.9-70.5) 15/37 57.9)
18.5(12.7- 45.7(37.6-
Married 28/151 25.7) 98/151 64.9(56.7-72.5) 69/151 54.0)
50.0(6.8-
Widowed/Separated/Divorced 1/4 25(0.6-80.6) 3/4 75.0(19.4-99.4) 2/4 93.2)
Years of service(Years)
75.0(34.9-
<1 3/8 37.5(8.5-75.5) 4/8 50.0(15.7-84.3) 6/8 96.8)
36.5(26.3-
1-5 13/85 15.3(8.4-24.7) 51/85 60.0(48.8-70.5) 31/85 47.6)
51.0(36.6-
6-10 10/51 19.6(9.8-33.1) 38/51 74.5(60.4-85.7) 26/51 65.3)
20.8(10.5- 47.9(33.3-
>10 10/48 35.0) 28/48 58.3(43.2-72.4) 23/48 62.8)
HBV Vaccine uptake

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83.3(65.3-
1 dose 4/30 13.3(3.8-30.7) 20/30 66.7(47.2-82.7) 25/30 94.4)
10.7(5.0-
≥2 doses 4/84 4.8(1.31-11.8) 77/84 91.7(83.6-96.6) 9/84 19.4)
35.9(25.3- 66.7(55.1-
Not vaccinated 28/78 47.6) 24/78 30.8(20.8-42.2) 52/78 76.9)
History of exposure
40.7(30.5-
Needle Stick Injury
8/91 8.8(3.9-16.6) 65/91 71.4(61.0-80.4) 37/91 51.5)
18.2(2.3-
Contact Exposure
0/11 0.0(0.0-28.5) 8/11 72.7(39.0-94.0) 2/11 51.8)
31.1 (21.8- 52.2(41.4-
No Known Exposure
28/90 41.7) 48/90 53.3(42.5-63.9) 47/90 62.9)
Blood transfusion
18.5(13.3- 45.0(37.8-
No
35/189 24.8) 119/189 63.0(55.7-69.9) 85/189 52.4)
33.3(0.84- 33.3(0.8-
Yes
1/3 90.6) 2/3 66.7(9.4-99.2) 1/3 90.6)
Knowledge on HBsAg
Transmission
21.7(13.4- 51.8(40.6-
No
18/83 32.1) 40/83 48.2(37.1-59.4) 43/83 62.9)
16.5(10.1- 39.5(30.2-
Yes
18/109 24.8) 81/109 74.3(65.1-82.2) 43/109 49.3)
Knowledge on HBsAg
Prevention and control
22.5(14.3- 51.7(40.8-
No
20/89 32.6) 45/89 50.6(39.8-61.3) 46/89 62.4)
38.8(29.4-
Yes
16/103 15.5(9.2-24.0) 76/103 73.8(64.2-82.0) 40/103 48.9)
Training on PPE full module
19.9(13.6- 46.1(37.7-
No
28/141 27.4) 81/141 57.5(48.9-65.7) 65/141 54.7)
41.2(27.6-
Yes
8/51 15.7(7.0-28.6) 40/51 78.4(64.7-88.7) 21/51 55.8)
Training on infectious agent on
waste full module
21.5(14.8- 49.2(40.4-
No
28/130 29.6) 75/130 57.7(48.7-66.3) 64/130 58.1)
35.5(23.7-
Yes
8/62 12.9(5.7-23.9) 46/62 74.2(61.5-84.5) 22/62 48.7)
Training on waste management
full module
19.4(13.1- 48.5(39.8-
No
26/134 27.1) 80/134 59.7(50.9-68.1) 65/134 57.3)
36.2(24.0-
Yes
10/58 17.2(8.6-29.4) 41/58 70.7(57.3-81.9) 21/58 49.9)
Knowledge on waste disposal
23.3(15.1- 52.2(41.4-
No
21/90 33.4) 49/90 54.4(43.6-65.0) 47/90 62.9)

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38.2(28.8-
Yes
15/102 14.7(8.5-23.1) 72/102 70.6(60.8-79.2) 39/102 48.4)
Availability of PPEs
38.9(17.3-
No 4/18 22.2(6.4-47.6) 8/18 44.4(21.5-69.2) 7/18 64.3)
18.4(12.9- 45.4(37.9-
Yes 32/174 25.0) 113/174 64.9(57.4-72.0) 79/174 53.1)
Adequacy of PPEs
20.8(14.6- 49.6(41.4-
No 31/149 28.2) 89/149 59.7(51.4-67.7) 74/149 58.0)
27.9(15.3-
Yes 5/43 11.6(3.9-25.1) 32/43 74.4(58.8-86.5) 12/43 43.7)
Daily use of apron/Dust coat
23.9(14.3- 55.2(42.6-
No 16/67 35.9) 38/67 56.7(44.0-68.8) 37/67 67.4)
16.0(10.1- 39.2(30.6-
Yes 20/125 23.6) 83/125 66.4(57.4-74.6) 49/125 48.3)
Daily use of gumboots (Waste
handlers only)
25.0(11.5- 68.8(50.0-
No 8/32 43.4) 17/32 53.1(34.7-70.9) 22/32 83.9)
8.3(5.3-
Yes 0/5 0.0(0.0-52.2) 4/5 80.0(28.4-99.5) 2/5 85.3)
Daily use of gloves
17.0(10.4- 52.8(42.9-
No 18/106 25.5) 74/106 69.8(60.1-78.4) 56/106 62.6)
20.9(12.9- 34.9(24.9-
Yes 18/86 31.2) 47/86 54.7(43.6-65.4) 30/86 45.9)
Daily use of mask when on duty
17.9(10.4- 47.6(36.6-
No 15/84 27.7) 55/84 65.5(54.3-75.5) 40/84 58.8)
19.4(12.5- 42.6(33.1-
Yes 21/108 28.2) 66/108 61.1(51.3-70.3) 46/108 52.5)
Access to hand hygiene
42.9(9.9-
No 2/7 28.6(3.7-71.0) 3/7 42.9(9.9-81.6) 3/7 81.6)
18.4(13.1- 44.9(37.6-
Yes 34/185 24.7) 118/185 63.8(56.4-70.7) 83/185 52.3)
Availability of waste management
materials (All 3 waste bins)
50.0(15.7-
No 2/8 25.0(3.2-65.1) 4/8 50.0(15.7-84.3) 4/8 84.3)
18.5(13.2- 44.6(37.3-
Yes 34/184 24.9) 117/184 63.6(56.2-70.5) 82/184 52.1)
Proper waste segregation
20.7(14.3- 48.9(40.2-
No 28/135 28.6) 79/135 58.5(49.7-66.9) 66/135 57.6)
35.1(22.9-
Yes 8/57 14.0(6.3-25.8) 42/57 73.7(60.3-84.5) 20/57 48.9)

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Waste disposal Method

(Incineration)
44.4(31.9-
No 10/63 15.9(7.9-27.3) 42/63 66.7(53.7-78.1) 28/63 57.5)
20.2(13.6- 45.0(36.2-
Yes 26/129 28.1) 79/129 61.2(52.3-69.7) 58/129 54.0)
164 Values are presented as number (%); CI, confidence interval; HBsAg, hepatitis B surface
165 antigen; Anti-HBc; hepatitis B core antibody; Anti-HCV, antibody hepatitis C virus.
166 HBV infection by Vaccine uptake.

167 The prevalence of HBV was highest among healthcare workers who had not received any dose
168 of HBV vaccine (at 35.9%), those who received one dose of HBV vaccination had a prevalence
169 of 13.3%, while those who received two or more doses of HBV vaccination had a prevalence
170 of 4.8% (Figure 1). Notably, none of the 69 HCWs who reported receiving all the three required
171 doses of HBV vaccination were detected with HBV infection.
172
173 Figure 1: HBV infection by Vaccination status

Current Infection HBV infection by vaccination status

90 40.0
80 35.9 35.0

HBV Prevalence (%)

Number of HCWs

70 30.0
60 25.0
50
20.0
40
30 13.3 15.0
20 10.0
10 4.8 5.0
0 0.0
none one ≥two
Axis Title

HBsAg Neg HBsAg Pos HBV Prev

174

175

176

177
178
179
180
181
182
183 Factors associated with Current HBV infection

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184
185 Table3 shows that female HCW were more likely to have current HBV infection compared to
186 their male counterparts (aOR, 3.22; 95% CI, 1.06-9.75, p-value< 0.05). Additionally, HCW
187 without a history of known exposure had increased odds of current HBV infection compared
188 to those with a previous needle stick injury (aOR, 5.37; 95% CI, 1.81-15.92, p-value< 0.001).
189 However, HCW who reported receiving ≥2 doses of HBV vaccination had reduced likelihood
190 of current HBV infection. (aOR, 0.05; 95% CI, 0.01-0.20, p-value <0.001) respectively. None
191 of the other sociodemographic characteristics were associated with current infection of HBV
192 among HCW.
193
194 Table 3: Factors associated with current HBV infection among HCW in Kisumu

195 County.

Table 3: Factors associated with current HBV infection among HCW in Kisumu County
HWC OR (95% p-
Characteristic N(%) p-value aOR(95% CI)
(%) CI) value
36
Overall
N(%) (18.8)
Cadre
Doctors 8(4.2) 2(25.0) 1
0.78(0.12
Clinical Officer 29(15.1) 6(20.7) 0.793
-4.90)
0.77(0.13
Nursing officer 39(20.3) 8(20.5) 0.778
-4.59)
0.44(0.07
Laboratory technologist 55(28.7) 7(12.7) 0.364
-2.61)
Mortuary attendance 7(3.7) 0(0.0) -
1.25(0.19
HTS counsellor 17(9.9) 5(29.4) 0.819
-8.44)
0.83(0.14
Waste handlers 37(19.3) 8(21.6) 0.835
-4.91)
Sex
Male 92(47.9) 12(12.0) 1 1
100(52.1 2.59(1.21 3.22(1.06-
Female ) 24(26.1) -5.54) 0.014 9.75) 0.039

Age(years)
20-29 65(33.9) 10(15.4) 1
1.21(0.51
30-39 83(43.2) 15(18.1) -2.91) 0.665
1.94(0.62
40-49 23(12.0) 6(26.1) -6.12) 0.258

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1.72(0.51
≥50 21(10.9) 5(23.8) -5.76) 0.38

Marital status
Single 37(19.3) 7(18.9) 1
151(78.7 0.98(0.39
Married ) 28(18.5) -2.45) 0.958
Widowed/Separated/Div 1.42(0.13
4(2.1)
orced 1(25.0) -15.87) 0.772
Years of service(years)
<1 8(4.2) 3(37.5) 1 1
0.30(0.06 0.56(0.08-
85(44.3)
1-5 13(15.3) -1.42) 0.128 3.98) 0.56
0.41(0.08 1.89(0.17-
51(26.6)
6-10 10(19.6) -1.99) 0.267 21.55) 0.607
0.44(0.09 1.61(0.1-
48(25.0)
>10 10(20.8) -2.15) 0.31 25.91) 0.738
HBV Vaccine uptake
Not vaccinated 78(40.6) 28(35.9) 1 1
0.31(0.06-
1 dose 30(15.6) 4(13.3) 0.27 0.028 1.54) 0.153
<0.000 0.05(0.01- <0.000
≥2 doses 84(43.8) 4(4.8) 0.09 1 0.20) 1
History of exposure
Needle Stick Injury 91(47.4) 8(8.8) 1 1
Contact Exposure 11(5.7) 0(0.0) 1(-) 1(-)
4.69(2.00 5.37(1.81- <0.00
No Known Exposure
90(46.9) 28(31.1) -10.98) <0.001 15.92) 1
Blood transfusion
189(98.4
No
) 35(18.5) 1
2.20(0.19
Yes
3(1.6) 1(33.3) -24.95) 0.525
Knowledge on HBsAg
Transmission
No 83(43.2) 18(21.7) 1
109(56.8 0.71(0.35
Yes
) 18(16.5) -1.48) 0.364
Knowledge on HBsAg
Prevention and control
No 89(46.4) 20(22.5) 1
103(53.7 0.63(0.31
Yes
) 16(15.5) -1.32) 0.222
Training on PPE full
module
141(26.6
No
) 28(19.9) 1

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0.75(0.32
Yes
51(73.4) 8(15.7) -1.78) 0.514
Training on infectious
agent on waste full
module
130(67.7
No
) 28(21.5) 1 1
0.54(0.23 1.53(0.31-
Yes
62(32.3) 8(12.9) -1.27) 0.156 7.57) 0.604
Training on waste
management full
module
134(69.8
No
) 26(19.4) 1
0.87(0.39
Yes
58(30.2) 10(17.2) -1.93) 0.725
Knowledge on waste
disposal
No 90(46.9) 21(23.3) 1 1
102(53.1 0.57(0.27 0.49(0.13-
Yes
) 15(14.7) -1.18) 0.129 1.86) 0.297
Availability of PPEs
No 18(9.4) 4(22.2) 1
174(90.6 0.79(0.24
Yes ) 32(18.4) -2.56) 0.692
Adequacy of PPEs
149(77.6
No ) 27(19.6) 1 1
0.50(0.18 0.47(0.13-
Yes 43(22.4) 5(11.6) -1.38) 0.181 1.72) 0.256
Daily use of apron/Dust
coat
No 67(34.9) 16(23.9) 1 1
125(65.1 0.61(0.29 0.57(0.20-
Yes ) 20(16.0) -1.27) 0.185 1.64) 0.297
Daily use of gumboots
(Waste handlers only)
No 32(86.5) 5(13.5) 1
Yes 5(13.5) 32(86.5) 1(-) `-
Daily use of gloves
106(55.2
No ) 18(17.0) 1
1.29(0.63
Yes 86(44.8) 18(20.9) -2.67 0.486
Daily use of mask when
on duty
No 84(43.8) 15(17.9) 1

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108(56.3 1.11(0.53
Yes ) 21(19.4) -2.31) 0.78
Access to hand hygiene
No 7(3.7) 2(28.6) 1
185(96.4 0.56(0.10
Yes ) 34(18.4) -3.02) 0.503
Availability of waste
management materials
(All 3 waste bins)
No 8(4.2) 2(25.0) 1
184(95.8 0.68(0.13
Yes ) 34(18.5) -3.52) 0.645
Proper waste
segregation
135(70.3
No ) 28(20.7) 1
0.62(0.27
Yes 57(29.7) 8(14.0) 0.28 -1.47)
Waste disposal Method
(Incineration)
No 63(32.8) 10(15.9) 1
129(67.2 1.34(0.60
Yes ) 26(20.2) -2.98) 0.476
196 Values are presented as number (%); OR, odds ratio; aOR, adjusted odds ratio; 95% CI,
197 confidence interval.
198

199

200

201

202

203

204

205

206

207

208

209

210

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211 Factors associated with lifetime exposure to HBV infection among HCW in Kisumu

212 County, 2020.

213 In logistic regression analysis Table 4, HCW who received a single dose of HBV vaccination
214 had increased likelihood of lifetime exposure to HBV infection compared to HCW without
215 history of vaccination (aOR, 6.25; 95% CI, 1.29-30.30, p-value<0.05). Conversely, HCW who
216 reported receiving ≥2 doses of HBV vaccination had reduced likelihood of lifetime exposure
217 to HBV infection compared to those without HBV vaccination (aOR, 0.03; 95% CI, 0.01-0.10,
218 p-value= <0.0001) HCW who reported having knowledge on HBsAg transmission had higher
219 odds of lifetime exposure to HBV infection compared to their counterparts without knowledge
220 on HBV transmission (aOR, 7.97; 95% CI, 2.10-153.39, p-value<0.01). None of the other
221 sociodemographic characteristics were significantly associated with current infection of HBV
222 in HCW (Table 4).
223
224 Table 4: Factors associated with lifetime exposure to HBV infection among Health care
225 workers in Kisumu County, 2020.
226
OR
HCW p- aOR p-
Characteristics N(%) (95%CI)
(%) value (95% CI) value
Sex
92(47.9 40(43.5
Female 1
) )
100(52. 46(46.0 1.11(0.63
Male 0.726
1) ) -1.96)
Age
65(33.9 25(38.5
20-29 1
) ) 1
83(43.2 35(42.2 1.17(0.60 1.18(0.37-
30-39 0.649 0.784
) ) -2.26) 3.77)
23(12.0 14(60.9 2.49(0.94 1.77(0.28-
40-49 0.067 0.547
) ) -6.60) 11.37)
10(55.6 2.00(0.70 3.41(0.33-
50-59 18(9.4) 0.198 0.301
) -5.75) 34.81)
3.2(0.28- 0.27(0.01-
>=60 3(1.6) 2(66.7) 0.352 0.452
37.15) 7.98)
Marital status
37(19.3 15(40.5
Single 1
) )
151(78. 69(45.7 1.23(0.59
Married 0.572
7) ) -2.56)
Widowed/Separated/Divo 1.47(0.19
4(2.1) 2(50.0) 0.716
rced -11.59)

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Year of service
Less than 1 year 8(4.2) 6(75.0) 1 1
85(44.3 31(36.5 0.19(0.04 0.13(0.01-
1-5 years 0.051 0.193
) ) -1.01) 2.79)
51(26.6 26(51.0 0.35(0.06 0.57(0.02-
6-10 years 0.22 0.741
) ) -1.88) 15.34)
48(25.0 23(47.9 0.31(0.06 0.31(0.01-
More than 10 years 0.172 0.509
) ) -1.67) 9.82)

Carder
Doctors 8(4.2) 3(37.5) 1 1
29(15.1 14(48.3 1.56(0.31 0.72(0.05-
Clinical Officer 0.59 0.811
) ) -7.75) 10.26)
39(20.3 15(38.5 1.04(0.22 0.49(0.04-
Nursing officer 0.959 0.589
) ) -5.01) 6.59)
55(28.7 18(32.7 0.81(0.17 0.47(0.05-
Laboratory technologist 0.789 0.527
) ) -3.78) 4.87)
2.22(0.28 0.39(0.02-
Mortuary attendance 7(3.7) 4(57.1) 0.45 0.578
-17.63) 8.56)
1.48(0.27 0.73(0.05-
HTS counsellor 17(9.9) 8(47.1) 0.654 0.811
-8.27) 9.71)
37(19.3 24(64.9 3.08(0.63 2.00(0.17-
Waste handlers 0.164 0.578
) ) -14.98) 22.84)
HBV Vaccine uptake
78(40.6 52(66.7
Not vaccinated ) ) 1 1
30(15.6 25(83.3 2.5(0.86- 6.25(1.29-
0.023
1 dose ) ) 7.28) 0.093 30.30)
84(43.8 0.06(0.03 <0.000 0.03(0.01- <0.000
≥2 doses ) 9(10.7) -0.14) 1 0.10) 1
History of exposure
91(47.4 37(40.7
Needle Stick Injury
) ) 1 1
0.32(0.07 0.10(0.01-
Contact Exposure 0.087
11(5.7) 2(18.2) -1.59) 0.165 1.40)
90(46.9 47(52.2 1.59(0.89 3.55(1.34-
No Known Exposure 0.011
) ) -2.87) 0.12 9.43)

Blood transfusion
189(98. 85(45.0
No
4) ) 1
0.61(0.05
Yes
3(1.6) 1(33.3) -6.86) 0.69
Knowledge on HBsAg
Transmission
83(43.2 43(51.8
No
) ) 1 1

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109(56. 43(39.5 0.61(0.34 17.97(2.10

Yes 0.008
8) ) -1.08) 0.089 -153.39)
Knowledge on HBsAg
Prevention and control
89(46.4 46(51.7
No
) ) 1 1
103(53. 40(38.8 0.59(0.33 0.34(0.06-
Yes 0.25
7) ) -1.05) 0.075 2.12)
Training on PPE full
module
141(26. 65(46.1
No
6) ) 1
51(73.4 21(41.2 0.82(0.43
Yes
) ) -1.57) 0.545
Training on infectious
agent on waste full
module
130(67. 64(49.2
No
7) ) 1 1
62(32.3 22(35.5 0.57(0.30 0.65(0.10-
Yes 0.652
) ) -1.06) 0.075 4.21)
Training on waste
management full
module
134(69. 65(48.5
No
8) ) 1 1
58(30.2 21(36.2 0.60(0.32 2.37(0.32-
Yes 0.395
) 1) -1.14) 0.117 17.28)
Knowledge on waste
disposal
90(46.9 47(52.2
No
) ) 1 1
102(53. 39(38.2 0.57(0.32 0.41(0.11-
Yes 0.17
1) ) -1.01 0.053 1.47)
Availability of PPEs
No 18(9.4) 7(38.9) 1
174(90. 79(45.4 1.31(0.48
Yes 6) ) -3.53) 0.598
Adequacy of PPEs
149(77. 74(49.7
No 6) ) 1 1
43(22.4 12(27.9 0.39(0.19 0.49(0.16-
0.228
Yes ) ) -0.82) 0.013 1.56)
Daily use of apron/Dust
coat
67(34.9 37(55.2
No ) ) 1 1

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125(65. 49(39.2 0.52(0.29 0.73(0.26-

0.549
Yes 1) ) -0.95) 0.034 2.03)
Daily use of gumboots
(Waste handlers only)
32(86.5 22(68.8
No ) ) 1
0.82(0.13
Yes 5(13.5) 2(8.3) -5.01) 0.827
Daily use of gloves
106(55. 56(52.8
No 2) ) 1 1
86(44.8 30(34.9 0.48(0.27 0.40(0.16-
0.052
Yes ) ) -0.86) 0.013 1.01)
Daily use of mask when
on duty
84(43.8 40(47.6
No ) ) 1
108(56. 46(42.6 0.82(0.56
Yes 3) ) -1.45) 0.487
Access to hand hygiene
No 7(3.7) 3(42.9) 1
185(96. 83(44.9 1.08(0.24
Yes 4) ) -4.98) 0.917
Availability of waste
management materials
(All 3 waste bins)
No 8(4.2) 4(50.0) 1
184(95. 82(44.6 0.80(0.20
Yes 8) ) -3.31) 0.763
Proper waste
segregation
135(70. 66(48.9
No 3) ) 1 1
57(29.7 20(35.1 0.57(0.30 0.94(0.28-
0.991
Yes ) ) -1.07) 0.081 3.19)
Waste disposal Method
(Incineration)
63(32.8 28(44.4
No ) ) 1
129(67. 58(45.0 1.02(0.56
Yes 2) ) -1.87) 0.946
227
228 Values are presented as number (%); OR odds ratio; aOR, adjusted odds ratio; CI, confidence
229 interval.
230

231

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232 Discussion

233 Indeed the burden of Hospital acquired infection like Hepatitis B infection is high in developing
234 sub-Saharan African countries like Kenya (13). Despite the availability of guidelines and
235 treatment options, occupational risks related to hepatitis virus exposure is still a major concern
236 for those who handle hospital waste like health care workers (14). This study documented high
237 prevalence and lifetime exposure to HBV infection in Kisumu county, Kenya at 18.8% and
238 44.8% respectively, the subpopulations with the highest HBV infection are: HCW who had
239 worked for less than 1 year at 37.5%,HBV unvaccinated HCW at 35.9%, HCW with previous
240 history of blood transfusion at 33.3% and HIV testing counselor at 29.4%. The HBV
241 prevalence among HCW in this study is higher compared to 2.7% prevalence in general
242 population(15). This prevalence is higher than what was found in other studies both in Kenya
243 and Africa : pooled prevalence in Africa 6.8%, Kenya 4.0 %, southern Ethiopia 1.3%, north
244 west Ethiopia 6.0 %, Tripoli Libya 2.3% and 6.3% in Addis Ababa, (2-5, 14, 16). A study in
245 Kisumu, Siaya and Homabay county found that the prevalence of HBV among adolescent was
246 3.4% while dual infection of HBV and HIV in Kisumu county hospital, one of our study site
247 was 47% among patient presenting with jaundice in the clinic (17, 18). The high prevalence in
248 this study could be attributed to increased HBV infection risk of exposure on HCW as
249 highlighted in this study where 53.7% of HCW has had either needle stick or contact exposure,
250 inadequate trainings, observed knowledge gaps, poor infection prevention infrastructure, low
251 Hepatitis B virus vaccine coverage and low-adherence universal infection prevention and
252 control measures (consistent use of PPE, proper waste segregation and disposal) as shown in
253 table 1. Low training coverage on waste management, infectious agent on waste and
254 inadequacy of PPE at 30.2%,32.2%, 22.4% respectively could be the cause to high needle stick
255 injury, contact exposure and poor adherence to standard precautions. The findings on
256 inadequate HCW capacity building, poor adherence on IPC standard and additional precautions
257 are in concurrence with other studies which pointed to poor waste management and lack of
258 training and capacity building to staff (16, 19, 20). Health care system administrators should
259 ensure adequate PPEs are available, accessible and properly used by HCW, IPC trainings
260 should be done to all health care workers with provision of annual refresher.
261 Hepatitis B surface antibody (anti-HBs) prevalence in this study was 63.0%, these were HCW
262 who have recovered from infection or immunised HBV. Anti HBS positivity was highest in
263 laboratory technologists 74.6%, clinical officers 65.5%, and Nursing officers 64.1%.
264 Laboratory technologists were the highest immunized carder, this may be attributed to the

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265 implementation of laboratory quality management system and international organization for
266 standardization ISO 15189 which required that all laboratory personnel must be vaccinated
267 against blood borne pathogens (21). The low HBV immunity rate and non-completion of
268 vaccine doses is comparable to prior studies done in the region showing low HBV vaccine
269 uptake and non-completion of vaccine dosses(2, 16). The benefit vaccination as HBV infection
270 prevention measure has been documented, this study also found HCW who are fully vaccinated
271 had no lifetime exposure while unvaccinated HCW had highest 61% lifeline exposure to HBV
272 infection (22).Findings in this study highlights the need to capacity build HCW on the benefits
273 of getting full vaccine dose and need to avail the vaccine for all health care workforce. .

274 significant risk of lifetime exposure to HBV infection was noted among HCW with one vaccine
275 dose, those with no known exposure and highest in those who had Knowledge on HBsAg
276 transmission while significant HBV protection was seen in HCW who had adequate PPE and
277 those using gloves and dust coat consistently. A study in Southern Ethiopia found HBV
278 lifetime exposure was higher in MWH older than 40 years(2) while population based Azar
279 cohort study found that all age groups were exposed to HBV. In in Eastern Ethiopia, there was
280 higher prevalence of HBV infection in trainees. (23, 24). There is need to have remedial
281 measures that is aimed at reducing this high lifetime exposure rates by capacity building HCW,
282 availing proper infrastructure for infection prevention and control, strengthening HBV
283 vaccination and proper surveillance for HAI in all healthcare settings. Policy should be revised
284 to enforce mandatory HAI pre-employment screening and vaccination for personnel working
285 in healthcare settings.
286 Limitations for this study were that this was done during COVID 19 outbreak period when
287 there was a lot of fucus on infection prevention to mitigate COVID 19 infections, in as much
288 as this may have influenced the findings on the compliance with standard precautions, it
289 strengthened the adherence to standard infection prevention measures. Also, during this
290 COVID 19 period the government issued recommendations that elderly populations and those
291 with comorbidities should work from home so we may have missed some eligible health care
292 workers at the facilities. The study was conducted in nine highest volume government
293 hospitals, these hospitals have the highest workload, produce the largest volume wastes, and
294 have highest number of health care workers. We did not focus on lower level , private and
295 faith-based health facilities where the situation could be worse or better. We only assessed
296 HBV exposures that are related to health care settings therefore the generalizability is limited
297 to health facilitiyrelated exposures. Health care workers are not done for thorough pre-

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perpetuity.
It is made available under a CC-BY 4.0 International license .

298 employment medical examination so it’s difficult to point if the infections observed in this
299 study occurred before or after employment.

300 Conclusion

301 The prevalence of HBV infections among HCW is about 6 and 5-fold higher than general
302 population and adolescent blood donners respectively, this high prevalence needs multi
303 stakeholder approach to address.There was suboptimal training on waste management,
304 infectious agent on waste and PPE coupled with PPE inadequacy that could lead to high needle
305 stick injury poor adherence to universal/standard precautions.

306 There is need to ensure that adequate PPEs is available for HCW usage, trainings done to health
307 care workers on infection prevention and control.

308 From the study there was low uptake of HBV vaccination with HCW immunised either due to
309 vaccination or infection at 36.7 %, data also showed that there is significant relationship
310 between immunization status and positivity for HBV, the high lifetime exposure may be due
311 to high exposure to infections and low vaccination rates for personnel working in healthcare
312 settings. Policy should be revised to make it mandatory for pre-employment HBV vaccination
313 for most at risk populations like HCW and MWH.

314 No significant association was observed between HBV exposure and factors such as a history
315 of exposure, blood transfusion, use of PPE, Knowledge on HBsAg (transmission,
316 pathogenicity, treatment, prevention & control), training on (PPE, infectious agent, waste
317 management). None of the sociodemographic characteristics plus other factors such as carder
318 and departments were significantly associated with HBV exposure status for health care
319 workers.. There is need for proper surveillance for HAI in all healthcare settings.

320 Recommendation

321 There should be continuous training of HCW on universal precaution of infection prevention
322 measures. There is need to increase HBV vaccine coverage and improve HBV surveillance
323 among HCW.

324

325

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 medRxiv preprint doi: https://doi.org/10.1101/2023.01.06.23284271; this version posted January 7, 2023. The copyright holder for this
preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in
perpetuity.
It is made available under a CC-BY 4.0 International license .

326

327 Acknowledgements

328 We acknowledge the county Government of Kisumu, each hospital’s medical superintendent

329 and management for allowing us to do this study. We are also grateful to Kennya medical

330 research institute, Center for Global HIV research, Human immunodeficiency Virus Research

331 Laboratory (KEMRI,CGHR, HIV-R Laboratory ) for performing the laboratory tests for the

332 study.

333 We sincerely thank the data collectors and laboratory Scientists of each hospital for their

334 assistance in data and sample collection.

335 We thank and appreciate the study subjects who volunteered to participate in this study.

336 Lastly, we wish to appreciate and thank of Jaramogi Oginga Odinga University of Science

337 And Technology for their mentor and support in designing and conducting the study.

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preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in
perpetuity.
It is made available under a CC-BY 4.0 International license .

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