CHAPTHER ONE

INTRODUCTION

1.1 BACKGROUND

Viral hepatitis prevails all over the world and is a key global public health issue. It is the

inflammation of the liver resulting in hepatic diseases such as liver cirrhosis,

hepatocellular carcinoma (HCC) and acute liver failure. Hepatitis is characterized by the

existence of inflammatory cells in the tissue of the liver principally caused by viral

infections. There are five hepatotrophic viruses Hepatitis A, B, C, D and E that are

recognized to cause hepatitis and of these, Hepatitis B virus and Hepatitis C virus are

amongst the most regular viral infections in human beings (Eke et al., 2011; El-Serag,

2012). Hepatitis B virus (HBV) and hepatitis C virus (HCV) are the most common viral

causes of hepatic diseases universally (Xing et al., 2003). HBV causes hepatitis of

altering severity and remains in 95% of children and 10% of adult patients (Muhammad et

al., 2007). HBV and HCV both share a common mode of transmission through parenteral,

sexual and perinatal means. However, HBV is 50 to 100 times more transmissible than

HIV (Geberemiche al et al., 2013; Yami et al., 2011). It is projected that over 2 billion

people globally have been infected with HBV (Trepo et al., 2014). Of these, over 240

million have chronic infection and stand the chance of developing hepatic diseases which

may result in death (WHO, 2015a). The issue of HBV infection is topmost in the

developing world, especially in sub-Saharan Africa and Asia. World Health Organization

(WHO) projected that the prevalence of HBV infection in Africa ranges between 5-10%

(WHO, 2015a). WHO also estimated that about 130 - 150 million people globally have

chronic infection with hepatitis C infection (WHO, 2015b).

Hepatitis B and C infections initially begin from acute infection and progress to chronic

1
infection. A study conducted by Mboto et al., (2005) on HCC in Gambia reported a

prevalence of 38.5% and 7.7% in patients with HBV and HCV infections respectively.

Similarly, a study carried out by Chinombe et al., (2009) in Zimbabwe, observed a

prevalence of 48.3% and 20% in patients with HBV and HCV infections respectively. In

this same study, Chinombe et al., (2009) reported a prevalence of 8% in HBV/HCV co-

infection. Furthermore, a study conducted in Ethiopia by Taye et al., (2014) determined a

prevalence of 22.3% and 3.6% in HBV and HCV infections respectively in chronic

hepatitis patients. In this same study, Taye et al., (2014) determined a prevalence of 4.8%

for HBV/HCV co-infection. It is projected that over 2 billion people globally have been

infected with HBV (Trepo et al., 2014). Of these, over 240 million are chronically

infected and stand the chance of developing hepatic diseases which may result in death

(WHO, 2015a). The issue of HBV infection is topmost in the developing world, especially

in sub-Saharan Africa and Asia. World Health Organization (WHO) projected that the

prevalence of HBV infection in Africa ranges between 5-10% (WHO, 2015a). WHO also

estimated that about 130 - 150 million people globally are chronically infected with

hepatitis C infection (WHO, 2015b). Hepatitis B and C infections initially begin from

acute infection and progress to chronic infection. In Cameroon, studies carried out

revealed that the prevalence of hepatitis B surface antigen and in rural general populations

was greater than 8% (Kfutwah et al, 2012).

In Cameroon, HBV and HCV are the most common causes of viral hepatitis infections

(Fouelifack et al, 2012). Acute viral infection is characterized by nausea, malaise,

abdominal pain and jaundice. In most cases the infection is asymptomatic, while the

persistence of viremia after a period of six months leads to chronic hepatitis. The latter

remains silent and is the main risk factor for end-stage liver diseases (Euler et al, 2003).

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In the North West Region of Cameroon, it was determined that the prevalence of hepatitis

B in the general population was at 12.6% and male patients were more likely to have

positive results than female patients (Zoufaly et al., 2011)..

Treatment regimen following a positive diagnosis of the infection involves the use of

interferon alpha 2b, P EG-interferon alpha 2a, lamivudine, adefovir, entecavir, telbivudine

and tenofovir (Tran, 2009).

Treatment regimen is the use of pegylated interferon (I FN) alpha and ribavirin (Fried et

al., 2002; Hadziyannis et al., 2004). Early detection of HCV infection ensures early

administration of antiviral treatment which is the most effective than beginning at a later

stage (Alter et al., 1990). Moreover, early identification together with counselling and

life style modification reduces the transmission of the infection to other people.

Therefore, the present study sought to determine the trends with regards to the hepatitis B

and C viral infections among inhabitants of Kumba and its environs presenting with

hepatic disease.

1.2 Statement of the problem

Chronic HBV and HCV infections are the principal sources of hepatic diseases such as

HCC, which is one of the most widespread cancers in developing nations and the third

cause of cancer associated mortality worldwide (Jemal et al., 2012). In Africa, about 100

million individuals are projected to be infected with HBV and/or HCV, whereas resource-

rich countries report 23 million HBV and/or HCV-infected subjects (Blachier et al.,

2013). Approximately 60% of the world’s population lives in areas where HBV and HCV

infections are highly endemic, particularly Asia and Africa. (Gower et al 2014).

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Despite the high global burden of chronic hepatitis B and C infections, and the advances

and opportunities for treatment, most people infected with these viruses remain unaware

of their status and therefore frequently present with advanced disease which may be quite

difficult to treat.

In low-income settings, it is estimated that less than 5% are aware of their status. Early

identification of persons with chronic HBV and/or HCV infection would enable infected

persons to receive the necessary care and treatment to prevent or delay the onset of liver

disease and, in addition, prevent transmission by the vaccination of non-immune

household contacts and sex partners with HBV vaccine. While working in the kumba

community, out of the 122persons screened for HBV and 35 for HCV, 20 and 4 were

positive respectively. Many proved how ignorant they were concerning Hepatitis. Some

believe it is just an invention by the scientific world, others believe that it’s a curse from

the gods or witch craft. Even those that are aware of their status, they still do not take their

status seriously. With this discoveries in mind, the researcher decided to carry out this

research in kumba and it’s environs.

1.3 Justification and relevance of study

Hepatic diseases are serious conditions with increased morbidity and mortality rates

globally. Thus, WHO is calling for enhancement in interventions for the inhibition,

maintenance, and control of viral hepatitis which may result in hepatic diseases worldwide

(WHO-Secretariat, 2010). Viral hepatitis is endemic in sub-Saharan Africa including

Cameroon. There is limited literature on patients with Hepatitis B and C viral infections

presenting with hepatic diseases in Cameroon and Africa. It was therefore necessary to

undertake this study to increase awareness of these viruses which would inform better

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 alternatives for diagnosis and management of viral hepatic diseases in Kumba.

In Cameroon however, few studies have been carried to determine the occurrence of

hepatitis B virus and hepatitis C virus infections individuals in the community.

Nevertheless, the few that have been carryout were mostly in the urban areas. Considering

the problems associated with infection of hepatitis B and C, coupled with the fact that not

many studies has been carried out in places like Kumba communities, it is worth studying

the prevalence of Hepatitis B and C infection in inhabitants of Kumba. This study provides

additional information on the risk of transmission and the infection status of individuals in

Kumba. It also report reliable occurrence of this infectious disease among the inhabitants

and offer an opportunity for transmission prevention of the disease by educating and

screening those that took part in the study.

This study was carried out on people living in Kumba and its environs. And it has help to

investigate the percentage of the population living with hepatitis B and C and the risk

factors that predisposes them to Hepatitis B and C

1.4. Research Questions

1.4.1

General question

What is the prevalence of HBV and HCV among the inhabitances of kumba, as well as

their knowledge on HBV and HCV, and the number of known cases who are undergoing

treatment?

1.4.2. Specific question

1. What is the prevalence and co-infection of hepatitis B and C and among inhabitants of

Kumba its environs?

2. What are the participants’ knowledge on hepatitis B and C?

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3. What is the status awareness of some participants and are they on treatment?

1.5. Objectives of the study

1.5.1 General Objective

The general objective of the study was to determine the prevalence of HBV and HCV

among the inhabitants of kumba as well as their knowledge on HBV/HCV, and the number

of known cases who are undergoing treatment.

1.5.2 Specific objective

1. To determine the Prevalence and co-infection of Hepatitis B and HCV among

inhabitants of Kumba and its environs.

2. To assess the knowledge of participants on hepatitis B and C.

3. To determine the number of participants who are aware of their status and are on

treatment.

1.6. Scope of studies

This study was carried out in Kumba center and it’s environs (Ediki, Kake, Mabonge,

Mabanda) from 20th June to July 25th 2020.

Kumba is the headquarters of Meme Division in the South West region of Cameroon. It is

a road junction town which had an estimated population of about 400,000 inhabitants in

2015. It is known as the center for business as well as cocoa farming and palm oil

production in the Southwest region.

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The study was to evaluate the prevalence of Hepatitis B and C among people in Kumba

and its environs by testing for the HBsAg surface antigen and HCV. The study was

carried out 20th June 25th July 2020.

1.7. Operational definition of terms

Acute: Infections that develop over a short period of time

Chronic: Infection which develop over a long lasting period of time

Asymptomatic: Being positive for a disease but not showing any visible signs and

Symptoms

Fulminant: More severe form of a disease

Prevalence: The percentage of the population affected by a particular

condition in a given time.

Cirrhosis: Degeneration and inflammation of organ due to presence of a

Disease

Necrosis: Cell Death due to disease condition

Lesions: Infection site where a disease s more concentrated

Vireamia: Presence of virus in blood

HBsAg: The hepatitis B surface antigen is a laboratory marker that indicates current

HBV infection

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 CHAPTER TWO

LITERATURE REVIEW

2.1 Hepatitis B

2.1.1 Historical background

Around 400 BC (Hippocrates), viral hepatitis, primarily labeled as “epidermal jaundice”,

was described. Interest in the disease increased when Rudolf Virchow termed a patient

with sign and symptoms of epidermal jaundice having the lower end of the common bile

duct blocked with a plug of mucus in 1865. The disease was termed “catarrhal-jaundice”

since it was alleged to be caused by phlegm obstructing the bile duct (Gruber and

Virchow, 1865). In the early 1 960s, the unearthing of Australian antigen by Baruch

Blumberg and Harvey Alter was made.

Blumberg was working on blood samples he collected throughout the world to study the

inherited diversity in human beings with a focus on discovering the origin behind

variability of disease susceptibility and outcomes. Alter was testing serum from patients

who had received multiple transfusion of blood and had developed febrile transfusion

reactions by means of agar gel double diffusion (Ouchterlony). Alter begun testing the

serum that Blumberg had collected (Gerlich, 2013) focusing on detecting novel serum

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lipoproteins since Blumberg had proven that lipoproteins were polymorphic amongst

people (reviewed by Blumberg and Alter, 1965; Alter, 2014).

In 1963, a crude detection of hepatitis B surface antigen (HBsAg) was made precisely

through an Ouctherlony reaction amid serum from Australian aborigine and hemophiliac

patient (reviewed by Blumberg and Alter, 1965). This was an unanticipated discovery

since this preliminary precipitate didn’t take up a lipid stain but rather a protein

counterstain efficiently noticed the precipitate (Alter, 2014). The detected protein was

termed the Australian antigen (AuAg). It was found mostly in patient diagnosed with

leukemia and children with Down’s syndrome (Blumberg et al., 1967). By this time

accruing proof proved an association between the existence of AuAg and viral hepatitis.

Separate studies by Prince, Murakami and Okochi confirmed AuAg to be specifically

found in patients with serum hepatitis (Okochi and Murakami, 1968; Prince, 1968).

David S Dane examined AuAg immune complexes against purified AuAg using EM in

1970. He observed bigger particles comparable in size to other viruses with an evidently

noticeable inner core. Upon biochemical studies on the “Dane” particle, an inner core

nucleocapsid (Hepatitis B virus core antigen) and an outer surface protein AuAg which

was later called hepatitis B virus surface antigen (HBsAg) was identified (Dane et al.,

1970). DNA genome of hepatitis B virus was also elucidated. The existence of

endogenous DNA established that the Dane particle contained complete hepatitis B virus

with its nucleic acid genome (Hirschman et al., 1971; Kaplan et al., 1973). Further

studies by Robinson et al. (1974) and Will et al. (1982) provided evidence that the Dane

particle contained infectious HBV.

2.1.2 Structure of HBV

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Hepatitis B virus (HBV) is a hepatotrophic circular genome o f partially double stranded

DNA virus belonging to the Hepadnaviridae family with a core antigen enclosed by a

shell enclosing hepatitis B surface antigen (HBsAg) (Seeger and Mason, 2000). The virus

have preference for liver cells and infects only humans and some other non-human

primates.

The intact Hepatitis B virus is called a Dane particle and looks like a sphere under the

electron microscope. It is a 42.0nm partly double stranded DNA virus that consist of a

7nm thick outer lipoprotein coat or envelope containing the surface antigen (HBsAg) and

a 27n nucleocapside core (HBcAg and HBeAg)(Robinson, 1995; Hollinger and Liang,

2001). It has a vigorous polymerase enzyme-linked to single molecule of double stranded

hepatitis B virus DNA. The hepatitis B viron consists of a surface and a core.

The core comprises the viral genome, a relaxed circular, partially duplex DNA of 3200

nucleotides, and a polymerase which is responsible for the synthesis of viral DNA in cells

which are affected. The genome can encode four (4) sets of proteins and their regulatory

components by shifting the frames over the same genetic matter. The four polypeptide

reading frames (genes) are the S (surface), the C (core), the P (polymerase) and the X

(transcriptional trans-activating). The S genes consist of three regions, the pre-S1, pre-S2

and encodes the surface proteins (HBsAg), which is the serological hallmark of HBV

infection (Chisari et al., 1989).

The C gene is categorized into two compartments, the pre core and the core, and codes for

two different proteins, the Core antigen (HBcAg) and the e antigen (HBeAg) which is a

cleavage product of the viral core structural polypeptide. The HBeAg is released during

vigorous infection and growth of virus, when the soluble components of the core is

released (Ganem and Schneider, 2001).

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2.1.3 The immune system and HBV

In an acute HBV infection, HBsAg is used as a general marker of infection and it is to

be detected in the bloodstream before the appearance of symptoms (about -8 weeks). 2

Subsequent to show are the virion markers including soluble antigen (HBeAg) and via

specific DNA polymerase. The presence of HBcAg is not detected due initial too

presence of anti-HBc (2 to 4weeks) after the surface antigen has showed. Antibodies to

HBcAg (anti-HBc) are suggestive of infection: IgM anti-HBc indicates an acute

orcurrent infection and vanishes within six (6) months usually, whereas IgG anti-HBc

indicates a chronic or pa infection and persist for life. Hepatitis B surface antigen

persevering for a duration beyond six (6) months is termed as chronic hepatitis B virus

infection (Kwon and Lee, 2011). The manifestation of HBeAg and hepatitis B virus DNA

shows active replication of the virus and therefore highly infective but the latter is more

accurate and used mainly for monitoring response to therapy. Anti HBe in the blood

indicate that the virus is n o t replicating anymore but the individual may still be HBsAg

positive when tested and it is normally detected about 4 months after infection.

Following initial exposure to HBV, the host innate immunity plays an important role in

which NK cell action may concur with ultimate viremia (Webster et al., 2000).

Subsequently, a multi-specific CD 8+ T cell mediated response focused in the direction of

hepatitis B virus core, envelope and polymerase epitopes is essential to establish immune

control of hepatitis B virus, leading to spontaneous recovery (Ferrari et al., 1990; Maini

et al., 2000; Rehermann, 2000).

Injury of the liver is immunologically mediated in chronic hepatitis B and thus, the

sternness and course of the disease does not correlate with the level of virus in the serum

11
or amount of antigen expressed in the liver. Antigen specific cytotoxic T cells are alleged

to play part in injury of the cell and account for viral clearance. However, HBV infected

cells are made up of aggregated an HbS antigen which combines with and block anti-HbS

antibodies, and hence limit the humoral response. Arthritis, as well as skin and kidney

damage is caused by immune complexes due to the deposition of antibody and HBsAg in

tissues which will activate the immune system. Development of chronic infection may be

due to deficiency of an energetic and specific C D8+ cytotoxic T cell and C D4+ helper T-

cell reaction whereas, the use of non-specific T-cells results in low level chronic

inflammation and damage of the liver (Maini et al., 2000; Webster et al., 2000).

Similarly, spontaneous sero-conversion from HBeAg to anti HBeAb is also

immunologically mediated (Ganem et al, 2004). Constant cellular stimulation and C D8+

T cell cyto-toxicity may happen within the liver of chronically infected patients and is

unsuccessful in attaining control of HBV ensuing in a tenacious state of infection,

hepatocyte injury, cirrhosis, advanced hepatic fibrosis and high hepatocellular carcinoma

risk (Rehermann, 2000).

Individuals who have immuno-suppressed states, such as AIDS, chronic illness and

malnutrition are more likely to be asymptomatic carriers because of their weak immune

system. Immunity against hepatitis B virus infection is through a response to HBcAg and

HBsAg.

HBsAg is detected in the blood from one to six months after infection but antibodies against

the HBsAg is detectable after eight months and thus a ‘window’ where neither HBsAg nor

anti-HBsAg can be detected. Due to the immune response, the disease resolves in most

patients.

In chronic infection, HBsAg and HBeAg, anti-HBeAg and anti-HBcAg (IgM) are present

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in the blood throughout the infection

2.1.4 Epidemiology of HBV infection

The hepatitis B virus is transmitted through exchange of body fluids between healthy

and infected individuals. The path of transmission is through either parenteral (infected

serum, blood products, blood transfusions) or non-parenteral (saliva, tears, sweat, urine,

semen, skin wounds) route. It is also transmitted during child birth, unprotected sex and

by sharing of needles (Ahmad et al., 2004).

Studies conducted worldwide has shown that, HBV is transmitted predominantly

perinatally in highly endemic areas with the age of being infected and chronicity risk

being contrariwise related (Ganem and Schneider, 2001; Tran, 2009). Prenatally acquired

chronic hepatitis B infection is related to cirrhosis, glomerulonephritis, hepatic carcinoma

and end stage renal disease (ESRD) in children (Levy and Gagnadoux, 1996; Wasmuth,

2009). The virus can also be transmitted horizontally to children in their first year of life

(less than 5 years of age) if the mothers are HBsAg positive and Hepatitis e antigen

positive (Elinav et al., 2006), however, the HBV is not transmitted through the placenta

but the infection occurs during child birth. Studies have shown that if the pregnant women

have acute hepatitis B in the second or third trimester of gravidity or within two (2)

months of giving birth there is a high perinatal infection risk. This mode of transmission

occurs mainly in the Sub-Saharan Africa and Asia. Babies who are infected with hepatitis

B virus prenatally has a 70-90% chance of developing chronic hepatitis B virus infection

and one(1) in four(4) adult who were infected at birth develop hepatitis B virus related

liver disease and mostly will die impulsively (Chang, 2000). The children become chronic

carriers of HBV and remain the key pool for continuous transmission of the disease.

Several of them grow into mothers and persistent carriers and thus repeating the cycle

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(Mast et al., 2005).

HBV infection is a major public health problem with a high incidence of mortality and

morbidity. The World Health Organization (WHO) has estimated the problem of hepatitis

B virus infection to be roughly two (2) billion with greater than 350 million people

infected chronically globally (Hollinger and Liang, 2001; WHO, 2001). The world is

categorised into three (3) zones where the occurrence of chronic hepatitis B virus

infection is high (~8.0%), Eastern Europe (Hollinger and Liang, 2001; Lavanchy,

2004). In such areas, around 80% of the inhabitants develop hepatitis B virus infection

before 40 years, and 8-20% of the inhabitants are carriers’ hepatitis B virus. Sub-Saharan

Africa have the higher endemicity where about fifty (50) million people are HBV chronic

carriers (Burnett et al., 2005). The low endemic areas includes North America, Western

and Northern Europe, some parts of South America and Australia where few (20%) of the

inhabitants is infected with hepatitis B virus (WHO, 2001; Shepard et al., 2005; Ezechi et

al., 2014). Nations in the Middle East have inter mediate to high endemicity of hepatitis B

infection.

The high rate of perinatal infection and high carrier rate is the main mode for sustaining the

higher rate of prevalence in certain nations. In high endemic areas, most infections occur in

early stages, particularly attained from the carrier mother at delivery. This result in the adult

population having a carrier rate of 1 0%-20% with the rest of the population being

immuned. In intermediate endemic areas, infection is common in childhood as a result of

horizontal transmission between children, particularly siblings and most infections occurs

within the first 5 years of life (Elsheikh et al., 2007; El-Magrahe et al., 2010). The carrier

rate in adult is 2%-10% with at least half or a quarter of the population being immuned. In

low endemic regions, childhood infection is occasional with a rate of carriers at 0. 1%-0.5%

14
and thus most of the infection occurs in adolescent and young adults and the common mode

of transmission being sexual followed by percutaneous transmission (Edmunds et al.,

1996).

In Africa, several transmission of hepatitis B virus happens before the five (5) years of age

and it is mainly through medical procedures, close contact within households, traditional

scarification and other unknown contrivances (Alter and Seeff, 2000). Africa has a lesser

vertical transmission rate than Asia moderately as of lower of hepatitis B e antigen

(HBeAg) prevalence in Africa, which is a foremost contributing factor of perinatal

transmission (RoinGeard et al., 1993).

2.1.5 Pathogenesis and Clinical presentation of HBV infection

HBV enters the bloodstream and targets the hepatocytes. The hepatocytes which are

infected are distended and the cytoplasm assumes a ground appearance which is glassy.

HBV is not cytopathic, and injury of the liver in HBV chronic infection is due to

immunological response. Although the virus has a long incubation period ( 4 5 - 1 8 0 days),

virus replication starts a few days after infection. The replicative process is through a

reverse transcription, where the virus uncoats after absorption and the single stranded region

of the genome is restored by DNA polymerase.

Hepatitis caused by virus can be acute; an unexpected sickness with a mild-to-severe

course followed by comprehensive resolve. On the other hand, if the cell-mediated

immune reaction is feeble, the infection does not resolve and chronic hepatitis arises

with an extended course of active disease or silent asymptomatic infection. The disease

has diverse clinical sign and symptoms reliant on the individual’s age infection,

immune status and the phase at which the infection is detected.

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In acute infection of HBV there is a variable period of incubation, liable to the type of

virus, amount of virus in the inoculum, the manner of transmission and host factors. It

normally ranges between forty-five (45) and one hundred and twenty (120) days with a

mean of 60-90 days (Robinson, 1995). The growth of the virus first results in systemic

symptoms much like the low grade joint, runny nose, pharyngitis fatigue flu, muscle/joint

aches and cough, (Ryder and Beckingham, 2001). One to two weeks later, the icteric phase

of the disease begins with the presence of urine which is dark followed by stools which are

pale and the colour of mucous membranes, skin conjunctivae, and sclera become yellowish.

The infected person might develop jaundice as the bilirubin level rises, which the liver

normally clears it. There is a high level of HBV DNA. As t h e r e is growth of the virus in

the cells of the liver, these hepatocytes die (necrosis). During cell death enzymes are

released by the hepatocytes. These are the liver function enzymes aspartate

aminotransferase (AST), alanine aminotransferase

(ALT), gamma-glutamyl transpeptidase (GGT), and alkaline phosphatase (ALP). Raised

levels of these liver enzymes in the blood will aid in the establishment of hepatitis

(McMahon et al., 1985; Hoofnagle et al., 2007; Chu and Lee, 2008)

In about 2-3 weeks into the sickness, the infected person is frequently jaundiced, h a s an

enlarged liver which is painful and raised blood concentration of liver function enzymes,

AST and ALT whiles ALP , GGT and serum bilirubin is slightly elevated. There is a

fluctuating level of HBV DNA and a pronounced hepatic necro-inflammation (Hadziyannis,

2006). About 4 - 12 weeks thereafter, the jaundice fades and the disease resolutions with the

growth of natural protective anti bodies in around 95.0% of adults (Hollinger et al, 2001,

Hollinger and Liang, 2001.

Although most adults recover completely from an acute hepatitis B infection, about %-10%

16
5 of the virus perseveres in the human body. The figure is greater in children, about 70%-

90% of newborns infected in their first few years in life and become chronic hepatitis B

virus carriers (Robinson, 1995). Chronic hepatitis B is persistent (~ a asymptomatic with

only an enlarged tender liver and mildly raised liver function enzyme levels whiles other

may show signs of anxiety, anorexia, malaise and easy fatigability.

. Chronic hepatitis B virus infection can results to chronic hepatitis which leads to

cirrhosis of the liver and finally HCC or liver failure. Some patients are asymptomatic

carrier (antegenaemia) where the carrier individual on no occasion develops antibodies

against HBsAg and keep the virus without injury of the liver. It is estimated that, there are

about 200 million hepatitis B virus carriers globally whereas others are chronic-persistent

patients with a low-grade symptoms of hepatitis. Other patients experience chronic

active /aggressive hepatitis where the infected individual has an acute infection state that

lingers without the normal resolution (last longer than 6 - 12 months). This leads to liver

cirrhosis, hepatocellular carcinoma and finally death. Others experience severe acute

hepatitis with speedy devastation of the liver which leads to sudden death (fulminant

hepatitis) (Hoofnagle et al., 2007; Lee et al., 2008).

Hepatitis B virus infection in pregnant women is comparable to the overall adult populace

and doesn’t upsurge death rate nor does it produce teratogenic effect. Women infected

with hepatitis B virus have an increased odds for complication during gravidity (Reddick

et al., 2011) and a high mother-to-child transmission causing foetal and neonatal hepatitis

which can lead to serious effects on the neonate, leading to impaired physical and mental

and physical health in future. Acute HBV infection in pregnancy leads to increased

occurrence of low birth weight and infants prematurity, whereas chronic maternal HBV

infection results in gestational diabetes mellitus, antepartum hemorrhage and preterm birth

17
(Jonas, 2009). Further studies have shown that up to 90.0% of infected newborns in their

first year of life and 30.0% - 50.0 % of infected children between one (1) to four (4) years

advanced to chronic infections and approximately 25.0% of adults who were infected

during child hood develop to chronic infection and die from hepatitis B virus –associated

cirrhosis and cancer of the liver (WHO, 2002).

Individuals who contract the disease at an older age, patients who misuse alcohol and

individuals co-infected with HBV and HCV progress to cirrhosis more rapidly and have

an accelerated liver disease progression and an increased risk of HCC (Chu and Lee,

2008; Jamma et al., 2010).

2.1.6 Laboratory diagnosis of HBV infection

2.1.6.1 Serological detection

Diagnosis of HBV is mainly by serological means. It is established by rally of specific

antigen and/or antibody in the sera. The diagnosis is founded principally on the

identification of hepatitis B virus antigens (HBsAg), hepatitis B e antigens (HBeAg), anti-

bodies counter to these antigens (HBsAb, HBcAb) and the manifestation of viral nucleic

acid (HBV DNA) in the liver, blood , and additional sites of the hepatocytes (Datta et al.,

2014). Based on the existence or nonexistence of a mixture of antigens and antibodies, acute

or chronic, recent or past infection can be diagnosed (Lok and McMahon, 2007).

The presence of serum HBsAg or detection of HBV DNA indicates an HBV infection. In

acute infection, both HBsAg and IgM anti bodies to HBcAg maybe positive; however

determination of hepatitis B virus DNA is the utmost dependable test if acute liver failure

(ALF) is existing. The titers of HBsAg, HBeAg and HBV DNA are raised in the period of

incubation but HBeAg and HBV DNA concentration start to reduce at the beginning of

18
disease and disappears at the time of peak clinical disease (Ganem and Schneider, 2001).

IgG antibodies to HBcAg develops after an acute infection. Those who clears the disease or

achieve spontaneous resolution develops antibodies against the HBsAg which is associated

with a long term immunity. The presence of anti HBsAb and anti HBcAb (IgG) shows

immunity and recovery in a previous infection whereas, antibodies to only HBsAg will be

produced in a successful vaccination. In chronic infection, HBsAg positivity will persist,

in the serum for more than six months. The presence of HBeAg is the marker for high

infectivity since there are large amount of HBsAg associated with infectious virus.

The diagno sis of hepatitis B virus infection is greatly dependable on the immune

identification of HBsAg (Blumberg, 1997), however, there is the issue of non-

identification because of low levels of antigen or diagnostic-escape mutations in the

epitopes. In this instances, molecular based assays are of great importance.

2.1.6.2 Molecular Based technologies

A molecular method for the detection of HBV infections includes thermal cycling-based

techniques for the amplification of HBV DNA. Nucleic acid based HBV DNA assays are

more accurate in the quantification of HBV DNA levels and allow for assessment of

replicative stage (Lok and McMahon, 2007). Assays for HBV DNA detection are

categorized into two groups: Direct identification assays that uses probes to hybridize

directly to the HBV DNA. They are simple but lacks sensitivity which can be increased

by using another method of signal amplification. The other method is indirect detection

and it involves invitro amplification step to raise the amount of the target sequence,

followed by identification of the amplified target. The techniques used includes

Polymerase chain reaction (PCR), isothermal amplification-based methods eg nucleic acid

sequence based-amplification (NASBA), transcription mediated amplification (TMA) etc.

19
these procedures are more sensitive an reliable for the quantification of serum HBV DNA.

The main problem with these techniques includes adulteration or false positive results

which can be circumvented by the proper usage controls in the assay and adhering to

specific precautions (Victor et al., 1993).

2.1.7 Treatment and Prevention of HBV infection

About 90%-95% of grown-ups with acute hepatitis B virus infection resolves naturally

and sero-convert to anti-HBs without antiviral therapy. However, there are anti-viral

agents for the treatment of acute, chronic and persistent hepatitis B virus infection.

The antiviral medications for treating and managing chronic HBV infections includes

PEG interferon alpha2a, interferon alpha 2b, three nucleoside analogues (lamivudine,

adefovir and entecavir), telbivudine and tenofovir ((Tran, 2009).

Lamivudine suppresses HBV DNA to undetectable levels whiles interferon alpha

suppresses hepatitis B virus DNA and HBeAg in about half of the managed individuals

and prevents cirrhosis (Dienstag, 1983; Niederauetal., 1996). The nucleoside or

nucleotide analogue inhibit viral nucleocapsid formation and blocks viral DNA

synthesis by premature cha termination (Perrillo, 2005; Wieland et al., 2005) and are

used for longer durations. Nevertheless, they inhibit with mitochondrial D NA replication

and hence results in potentia toxicity; effects which are poorly term in the growing fetus

PEG-IFN is contraindicated i pregnancy hence, adefovir, lamivudine, entacavir,

tenofovir and telbivudine are the dr choice in pregnancy (Bzowej, 2010). Telbivudine,

lamivudine or tenofovir might be used for the avoidance of perinatal and intra uterine

HBV transmission in the last trimester gravidness in HBsAg positive women with raised

concentration of viremia(Xu et al., 2009; Shi et al., 2010; Han et al., 2011).

20
Effective methods for preventing perinatal transmission includes
1. Screening pregnant women for HBV
2. Administering HBV vaccines to babies beginning at birth. The vaccine is
recombinant vaccine. The vaccine is given to infants at birth, 2, 4, and 15m o n t h s ; it is
also given as 3 injections to adolescents and high-risk adults (health care workers, IV drug
users, etc.) (WHO, 2001; Jonas, 2009; Tran, 2009).
Administration of hepatitis B immune globulin (HBIG) at birth to babies born to infected

mothers and administration of antivirals in late pregnancy to mothers with high [viral load

(Patton and Tran, 2014). It protects by passive immunization but it lasts only for 6 months

though the protection is immediate.

2.2 Hepatitis C virus

2.2.1 Historical background

In the 1970’S, several cases of post transfusion hepatitis were associated to either Hepattis

A virus or HBV infection and a novel infection entity named “non A, non B hepatitis

(NANBH) was for the first period designated (Feinstone et al., 1975). Blood-borne

NANBH is a major post transfusion hepatitis which regularly developed into liver cancer

diseases such as cirrhosis HCC. Several years were devoted to detect the etiological agent of

NANBH since the virus was unable to grow proficiently in cultured cells (Gupta et al.,

2014) and the agent was suggested to be a virus based on physiochemical properties

(Bradley et al., 1983; Bradley et al., 1985). A breakthrough was made when workers at

Chiron cloned cDNAs agreeing to portion of the virus genome isolated from chimpanzee

that have been infected with the blood of an infected individual with post transfusion

NANBH and which subsequently developed acute NANBH ( Choo et al, 1989). The virus

was identified as the causative agent of NANBH and named hepatitis C virus (Kuo et al.,

21
1989). The only reservoirs are human and chimpanzees.

2.2.2 Structure of Hepatitis C virus

The hepatitis C virus viron is made up of a single stranded positive RNA genome belonging

to the Flaviviridae family, genus Hepacivirus (Simmonds et al., 2005). It is confined in an

icosahedral capsid, enclosed by a lipid bilayer within which two diverse glycoproteins are

attached (Penin et al., 2004).

HCV has an internal ribosome entry site (IRES) and a stem loop structure involved in

positive strand priming during hepatitis C copying. A long, unique open reading frame

(ORF) that encodes the structural and non-structural proteins, and a short 3~ NCR

principally.

2.2.3 The immune system and HCV

During HCV infection, the virus replicates within the host with an ongoing genetic

mutation. The mutants are different from each other and thus when the immune system

eradicates one form the other mutants continue to cause ongoing disease. As a result,

humoral immune responses have little effect on viral clearance (Bartosch et al., 2003;

Netski et al., 2005). In the second and third trimester, there is an increase in HCV RNA

due to production of oestrogen which suppress the intrathymic T cell differentiation and

whiles activating the extrathymic pathways.

Cellular immune responses have a significant part in determining the result of acute HCV

infection. CD4 and CD8 cellular response mediated by a type 1 T helper cell (Th 1)

lymphocytic response is associated with cytokine profile leading to viral clearance

(Thimme et al., 2001; Bowen and Walker, 2005). Spontaneous virus clearance is higher

22
in symptomatic acute HCV infection (Meigs et al., 2001).

2.2.4 Epidemiology of HCV infection

Drug injection usage is the main route of transmitting hepatitis C virus accounting for

about 2 /3 of infections in the United States and Western Europe and about 80.0% in

Australia (Dore et al., 2003; Shepard et al., 2005). HCV infection is also transmitted [less

commonly by accidental injuries with needles or sharps (with an incidence of 1.8% after a

needle stick injury), unsafe medical or surgical procedures, and perinatally (from mother

to child at birth which results in an incidence of 6% of new born to infected mothers)

(Shalmani et al., 2014). Transfusions with infected blood products or transplant from

infected donors also transmit the infection (Dhingra, 2002). Transmission through sexual

intercourse with an infected person also occurs but the risk increases when one has

multiple sex partners. Male to female transmission is more efficient than male to male.

Parenteral transmission through tattooing or acupuncture with unsafe materials, body

piercing and promiscuous male homosexual activity is associated with hepatitis C virus

infection (van de Laar et al., 2010).

The World Health Organization (WHO) has estimated that about 150-300 million people

(3.0%) of the world populace have had hepatitis C virus infections(Schiff, 2002) and

about 50.0% of all the cases develops to be chronic carriers and are at liver cirrhosis and

liver cancer risk ( WHO, 2000). High prevalence of ~ 2.9% are recorded in African

and Asian.

2.2.5 Pathogenesis and clinical manifestation

Hepatitis C virus has a lengthy incubation period between the beginning of infection and

clinical expression of liver disease but the virus is detected 1-3 weeks after infection. The

23
virus enters the bloodstream and infects the hepatocytes (liver cells), undergoes

replication simultaneously but does not kill the host cells and thus set up a persistent

infection leading to chronic disease. It can present as an acute or a chronic hepatitis.

Studies have shown that acute HCV infections are usually asymptomatic in about 70%-

80% of patients and hence infrequently diagnosed (McCaughan et al., 1992). About 20-

30% of adults who develop acute hepatitis C infections develop clinical sign and

symptoms with the start ranging from 3-12 weeks after introduction of the virus after a

prodromal phase of 6-7 weeks (Alter and Seeff, 2000; Thimme et al., 2001). Symptoms

may include weakness, anorexia, malaise, fatigue, weight loss, joint pains, flu-like

symptoms and jaundice. At about 2-8 weeks of exposure, serum alanine aminotransferase

(ALT) concentration rise indicating cells of the liver are dying (necrosis). The rise

normally reaches levels more than 10 times the upper limit of normal values (Thimme et

al., 2001). Within 1-2 weeks after contact, HCV RNA can be identified in the serum. The

HCV RNA level increases quickly in the first few weeks and then mounts between

1000000 to 100000000 IU/ml, shortly before the peak of ALT levels and onset of

symptoms. Acute HCV infection can be severe, but fulminant liver failure is rare. In self-

limited acute hepatitis C, signs and symptoms can persist for numerous weeks and

diminish as ALT and HCV RNA levels wane (Farci et al., 1996).Antibody to HCV test

positive near the start of signs roughly 1-3 months after contact and up to 30.0% of

individuals will test negative for anti HCV at the start of their signs (Farci et al., 1991).

Chronic hepatitis C is noticeable by the perseverance of HCV RNA in the blood for at

least 6 months after the start of acute infection. HCV is self-limiting in about 1 5%-25%

of patients, whereas about 75%-85% of patients who are infected do not get rid of the

virus by six (6) months, leading to persistent liver infection and then chronic active

24
hepatitis develops.

During the chronic infection period, HCV can give rise to extra-hepatic manifestations

including lethargy, muscle and joint pain, dark urine, jaundice (yellowing colour of the

eyes and skin) (appears only after other symptoms have started to go away) and clay-

coloured bowel movement.

In pregnant women, chronic active hepatitis C infection is associated with preterm delivery

and intra uterine growth hindrance (Zanetti et al., 1999) and vertical transmission occurs in

about 3%-10% of gravidities complicated by HCV infection (Berkley et al., 2008).

2.2.6 Laboratory diagnosis of HCV infection

There are two main methods of diagnosing and managing HCV infections: serological

assay (indirect test) that detects specific antibodies to hepatitis C virus (anti HCV) and

molecular assay (direct test) that can identify, measure or describe the components of

HCV particles such as HCV RNA and core antigen. Both tests play an important part in

infection diagnosis, therapeutic decision making and assessment of virological response

to therapy.

2.2.6.1 Serological assay

This is an indirect test which detects anti-HCV and it is used both to screen for and

diagnosis HCV infections. Three generations of ELISA have been developed for the

serology detection of anti-HCV but the third generation assays are mainly used. The

detection is built on the usage of a third generation enzyme immuno-assays (EIAs),

detecting antibodies directed against various HCV epitopes. The specificity of third-

generation EIAs for anti HCV is higher than 99% but their sensitivity is more

25
problematic to assess, due to non-existence of gold standard method (Colin et al.,

2001). It is associated with a 30%-50% rate false positive if used in a lower occurrence

populace (CDC, 2003). However, all these assays had the disadvantage of giving a high

false positive results and lack of sensitivity to detect antibodies during the window

period. Moreover, they cannot distinguish between acute, past and chronic infections

(Colin et al., 2001).A fourth generation has been developed but literature backing up

the addition of these assays as fourth-generation on the basis of better sensitivity and

specificity is inadequate(Colin et al., 2001). Recombinant-immunoblot assay (RIBA)

was developed as auxiliary a test to confirm serological reactivity by ELISA but no

longer in use because of molecular (Dow test et al., 1996).

2.2.6.2 Molecular Assay

Molecular techniques are important in the diagnosis and monitoring of treatment for

HCV. It is among the principal pathogens to be recognized by purely molecular

techniques since it was difficult to cultivate the virus in cell culture (Gupta et al., 2014).

Nucleic acid test (NAT)is regarded the ‘gold standard’ for the detection of active HCV

replication and for diagnosis acute HCV infection, since RNA is noticeable as early as one

week after exposure and 4-6 weeks before sero-conversion (Glynn et al., 2005; Kamal

and Nasser, 2008). NATs used for the detection of HCV RNA are based on polymerase

chain reaction (PCR), branched DNA signal amplification and transcription mediated-

amplification. The molecular assays are direct test and includes qualitative assay (for

detection) and quantitative assay (for quantification) of HCV RNA.

The qualitative NAT are normally considered as confirmatory test for HCV diagnosis and

they use conventional RT-PCR or transcription-mediated amplification (TMA). It is used

26
to confirm lower concentration viremia in individuals with reactive anti HCV outcomes

and to screen blood donation for proof of HCV infections (Fontana et al., 2000; Scott and

Gretch, 2007). Qualitative tests are of limited importance now due to the availability of

more sensitive quantitative PCR methods.

Quantitative assays has replaced qualitative assays because of its good specificity (98-

99%) and sensitivity (9 9%) (Ghany et al., 2009). Due to the high sensitivity, this method

is used effectively for checking response to therapy during antiviral management of HCV

infected individuals. There is also an assay for HCV genotyping which is based on direct

sequencing, reverse-hybridization to genotype-specific oligonucleotide probes and

restriction fragment length polymorphism analysis (Pawlotsky, 2003). The HCV

genotyping is of clinical importance since infection by certain genotypes is related with

disparity results of treatment (Pawlotsky, 2003).

2.2.7 Treatment and Prevention of HCV infection

Studies have shown that about 50%-80% of people who develop acute hepatitis C remains

HCV infected and there is spontaneous resolution among infected infants and young

females than among individuals who are older when they develop acute hepatitis (Seeff and

Hoofnagle, 2002; Thomas and Seeff, 2005).

The present normal management for chronic hepatitis C is the mixture of pegylated

interferon (IFN) alpha and ribavirin for a period of 12 months before the development of

cirrhoisis.

Only patients with visible HCV RNA are well-thought-out for pegylated IFN alpha and

ribavirin mixture therapy. This choice was based on superiority of this combination

treatment over standard interferon alpha and ribavirin . The HCV genotype is assessed

27
before treatment, as it determines the sign, the treatment duration, the ribavirin dose and the

virological monitoring procedure (Fried et al., 2002; Hadziyannis, 2 0 0 6 ) .

To reduce the risk of infection, depends on measures including education, screening of bloo

products, condom provision, alcohol abstinence and programs to reduce vertical

transmission (Zeba et al., 2011). There is no vaccination for the prevention of HCV

infection. The infection can be prevented by avoiding contact with infected blood, avoid

sharing of razo blades, toothbrushes, shavers and needles (CDC, 1 998b; Wiley et al.,

1998).

2.3: Review according to specific objectives

2.3.1 Prevalence of HBV and HCV infections.

The World Health Organization (WHO) estimates that in 2015:

 257 million people worldwide had hepatitis B

 71 million people worldwide had hepatitis C

Both of these types of hepatitis can lead to lifelong infection. WHO estimated that during

the same year, 1.34 million people died from liver cancer, cirrhosis, and other conditions

caused by chronic viral hepatitis (World Health Organization, Global hepatitis report,

2017).

There have been several reports of over 8% chronic HBV infection with an increased risk

for progressive hepatic disease in sub-Saharan Africa (Howell et al., 2014).

Hepatocellular carcinoma is the commonest cancer among males and third most common

among females (Howell et al., 2014).

Ghana is part of the areas of the world with a high (>8%) prevalence of chronic HBV

infection (Howell et al., 2014). Schweitzer et al., (2015) for instance, after assessing the

28
global burden of hepatitis B in 2013, reported the prevalence of chronic hepatitis B virus

infection in Ghana at 12.92 % (Schweitzer et al., 2015).

In other parts of Africa, a prevalence of 38.5% and 7.7% were recorded in HCC patients

with HBV and HCV infection respectively in Gambia. In a similar study conducted by

Chinombe et al., (2009) in Zimbabwe, a prevalence of 48.3% and 20% was detected in

patients with HBV and HCV infections respectively. In this same study, Chinombe et

al., (2009) observed a prevalence of 8% in HBV/HCV co-infection. Furthermore, a study

conducted in Ethiopia by Taye et al., (2014) determined a prevalence of 22.3% and 3.6%

in HBV and HCV infections respectively in chronic hepatitis patients. In this same study,

Taye et al., (2014) determined a prevalence of 4.8% for HBV/HCV co-infection.

2.3.2. Review on the knowledge of HBV and HCV

Knowledge is formed through interaction with the surroundings where individuals

themselves construct their understanding of the world through. Its exchange is an integral

part of learning as well as helping the individual to shape his or her abilities by converting

theoretical and practical skills into new knowledge. Through communication and its

processes, Human knowledge is mostly acquired. Knowledge is the key to prevention and

education is the key to knowledge. However, knowledge about the deadly disease in

Ghana is low. A talk with people across Kumasi has given me the impression that majority

of Ghanaians have little or no knowledge or understanding of the importance of their liver

condition for good health. This lack of knowledge or awareness is not only limited to only

hepatitis B but also their overall wellbeing in terms of health. A lot of factors impede

efforts put up by established institutions like WHO and other world organizations to curb

the menace of hepatitis B globally. Among these notably is the lack of knowledge and

29
awareness among health care providers, social service professionals, adolescents,

members of the public and even policy makers (WHO, 2006).

Even though it is an established fact that there has been a safe and effective vaccine for

hepatitis B over the past 20years, universal vaccination is still lacking in many countries

(WHO, 2008). Lack of commitment to preventive medicine and vaccines is one of the

major impediments for this drawback. Most governments which are supposed to be the

major financiers of public health activities have seriously not considered hepatitis B

prevention as a topmost priority in health care and have opted for selective prevention

strategies due to the apparent lack of knowledge about hepatitis B (Akumiah & Sarfo.,

2015). Most interventions aimed at reducing HBV prevalence among high risks groups

have failed because of the inability to access these groups. There is also lack of perceived

risk among these high risk groups and over 30% of those with acute hepatitis B infection

do not have identifiable risk factors (Mangtani, 1995). Lack of knowledge on hepatitis B

virus infection makes the condition a serious health issue which needs greater attention.

Prompt early care could be sought if a patient has knowledge about the signs and

symptoms. Similarly, a person’s knowledge about the mode of transmission and methods

of prevention would have helped people to take measures to protect themselves and others

from contracting the disease.

Burnett et al. (2007) examined the knowledge on HBV and liver cancer among 256

Vietnamese Americans with low socioeconomic status. The results showed that the

participants had general knowledge of HBV, but only 22% knew that HBV/HCV could

spread through unprotected sex. Many did not know that liver cancer is preventable or that

it is curable. Only a third of the participants knew about the vaccine that protects against

HBV. An average knowledge was confirmed by Mohamed et al. (2012) where the

30
knowledge level about HBV/HCV infections were investigated among 433 Vietnamese

men in Australia. About half of the respondents knew that HBV could spread by

unprotected sex. Only 32% of them knew that sharing food and drink with an infected

person is not a risk factor for being infected with HBV. Knowledge about the progression

and character of the disease was higher. Approximately 60% knew that long-time

infection still can transmit the disease, be asymptomatic and that treatment is available.

Less than half of the respondents knew that it could turn into a lifelong disease. A study

was carried out in China (Chao et al., 2010) to investigate the knowledge about HBV

among 250 health professionals by handing out a questionnaire at the “China national

conference on the prevention and control of viral hepatitis”. The results showed that even

among highly educated health professionals the knowledge on the disease was deficient.

One-third of the respondents did not know that it is common for chronic HBV infection to

be asymptomatic or that it can lead to liver cancer, liver cirrhosis and premature death.

The authors believe that this increases the risk of health professionals overlooking the

significance of screening even those who are asymptomatic, and vaccinating those who

need it.

Mohamed et al. (2012) also found that factors associated with greater knowledge about

HBV are high educational level or employment in professional jobs. The study by Taylor

et al. (2005) investigated knowledge and awareness of hepatitis B among randomly

selected Vietnamese adults living in the United States. About 81% of the 715 adults that

participated in the study had heard of hepatitis and 67% had been tested for HBV. The

knowledge of the infection was generally good, with about three-quarters knowing the

different ways of transmission but only 69% knew about infection through unprotected

sex. Hwang, Huang and Yi (2010) investigated knowledge about HBV and predictors of

31
HBV vaccination among 251 Vietnamese American college students. More than half of

the participants were aware that HBV/HCV could be transmitted via unprotected sex and

contaminated blood; though most of the participants’ thought that HBV/HCV were

transmitted through food and water. Less than one third knew that Asian Americans have

higher risk of being infected with HBV than other people. About 87% had heard about

HBV/HCV before and they had significantly greater knowledge compared to those who

had not heard about the disease. The knowledge was also greater among those who had

been screened for, or vaccinated against HBV/HCV, or had family members diagnosed

with HBV/HCV or liver cancer. The study also indicated that women had greater

knowledge about HBV/HCV compared to men. About 43% of the participants reported

being vaccinated against HBV/HCV and they had greater knowledge than those who had

not been vaccinated. Older participants or participants who were sexually active and/or

knew someone with HBV/HCV were less likely to have been vaccinated.

Moreover, another study which uncovered the poor knowledge among the people of rural

area in Iraq having knowledge about HBV is comparatively poor, with important thing

which need to be completed in term of awareness e.g. public awareness and immunization

attention, mainly among people, which are essential to decrease problem of the disease

(Hepatitis B) through further research needs to be explored the reasons behind such poor

knowledge in a more in-depth manner.”(Samir, 2013).

Furthermore, there was another study which was completed in Ethiopia among medical

students highlighted that, poor knowledge toward hepatitis B, its prevention and its mode

of transmission make them vulnerable to enter into medical profession, because according

to this study ninety five percent student have still no knowledge regarding immunization

of Hepatitis-B (Mesfinet al.2013).

32
2.3 ABSTRACT FROM RELATED STUDIES

2.3.1 Abstract One

Sero-prevalence of hepatitis B and C viral infections in Ghanaian HIV positive

cohort: a consideration for their health care Faustina Pappoe1, Charles Kofi Oheneba

Hagan2, Dorcas Obiri-Yeboah1 and Paul Nsiah3 2016

Background: Antiretroviral therapy (ART) has significantly decreased HIV/AIDS-related

morbidity and mortality. However, globally, many people living with HIV die from non-

AIDS related illnesses including liver diseases which occur partly due to co-infection with

HBV and or HCV. The aim of this study was to determine the sero prevalence of HBV

and HCV among HIV infected individuals receiving care from three different hospitals in

the Central Region of Ghana.

Methods: This research was a case-case study. The population consisted of ART naive

persons (newly confirmed HIV cases) and those who had been on ART for more than 3

months (old cases). Each individual’s socio demographic characteristics and clinical data

including their HBV and HCV status were collected. Those who knew their HBV and

HCV status and those who did not know their status were tested for circulating HBsAg

and anti-HCV using rapid diagnostic test cassettes. Descriptive analysis was done, and the

data presented as median with interquartile range, frequency and percentage. Fisher’s

exact test and Pearson Chi-square (χ 2) test were used to determine associations between

categorical variables.

Results: Overall, 394 HIV individuals aged, 3 to 76 years old with a median age of 41

(IQR:34–49) participated in this study. Circulating HBsAg and anti-HCV were detected in

6.1% (24/394) and 0.5% (2/393) participants respectively with an overall seroprevalence

33
of 6.6% (26/394). None of the participants was positive for both HBV and HCV

infections. 92.1% (363/394) had no information on their HBV status while all the 394

participants did not know their HCV status during data collection. No significant

association of HBV infection rate was found in all the socio-demographic data of the

participants. But HBV infection rates were significantly higher in those at WHO clinical

stages 2 and 3 (P = 0.004). Conclusion: HBV and HCV were detected among the HIV-

infected participants. Majority of the participants had no information on their HBV status

and none of the participants had information on his or her HCV status. This study

recommends the need for policy makers to provide free HBV and HCV screening for all

HIV infected individuals for their effective management. Keywords: HIV, HBV, HCV,

Co-infection, Seroprevalence, Ghana

2.3.2 Abstract Two

Hepatitis B and C Viral Infection: Prevalence, Knowledge, Attitude, Practice, and

Occupational Exposure amongn Healthcare Workers of Jimma University Medical

Center,

Southwest Ethiopia Habtemu J. Hebo et al. 2019

Background. Blood-borne infections have been recognized as an occupational hazard for

nearly 50 years. Current treatment for hepatitis B virus (HBV) is very expensive for

individuals in developing countries and cannot clear infection after it progresses to the chronic

stage. Thus, early screenings of people who are at higher risk like healthcare workers and

vaccination and awareness creation on standard precautions (SP) to prevent transmission are

mandatory. This study determined sero-prevalence of HBV and hepatitis Cvirus (HCV)

34
among healthcare workers of Jimma University Medical Center (JUMC).

Methods. An institution based cross-sectional study was conducted from Nov 2015 to Jan

2016. The lottery method was used to select 240 healthcare workers. Data were collected by a

self-administered questionnaire. Five to ten milliliters of whole venous blood was collected

from each participant. The blood samples were analyzed (tested) for hepatitis B surface

antigen (HBsAg) and anti-HCV antibody using automated Enzyme-Linked Immunosorbent

Assay (ELISA). Data were entered into Epi Data 3.1 and analyzed by SPSS 23.

Results. The positivity of HBsAg was2.5% (6/240; 95% CI: 0.52-4.48%) and that of anti-

HCV antibody was 0.42% (1/240; 95% CI: 0.0-1.23%). Most participants had good

knowledge of HBV (73.9%), HCV (60.9%), and SP (82.2%) and positive attitude towards

SP (88.7%), but only 42.6% had a good practice of SP. More than half (60%) and nearly half

(43%) had a history of ever exposure and exposure in the last one year before the survey,

respectively. Females were at lower risk of both having ever exposure (95% CI: (0.241,

0.777)) and exposure in the last one year before the survey (95% CI: (0.297, 0.933))

compared to males.

Conclusion. The prevalence of HBV was intermediate according to the endemicity

classification by WHO. The practice of SP was poor in most participants and, thus,

occupational exposure was high. Therefore, regular screening and vaccination of health care

workers, regular provision of basic or refresher training and availing logistics, and regular

motivation of healthcare workers on the practice of standard precautions are recommended.

2.3.3 Abstract Three

35
The prevalence of HBsAg, knowledge and practice of hepatitis B prevention among

pregnant women in the Limbe and Muyuka Health Districts of the South West

region of Cameroon: a three-year retrospective study.

(Esum Mathias Eyong, Brenda Mbouamba Yankam, Esemu Seraphine, Che Henry Ngwa,

Ngwayu Claude Nkfusai, Cho Sebastine Anye, Gilbert Karngong Nfor, Samuel Nambile

Cumber)

Key words: Hepatitis B virus, prevalence, pregnant women, knowledge, practice

Received: 13/05/2018 - Accepted: 01/03/2019 - Published: 15/03/2019

Introduction: hepatitis B infection is caused by the hepatitis B virus (HBV). HBV is

transmitted through sexual intercourse, by exchange of saliva

During kissing and also to newborns of infected mothers. In the Global Burden of

Diseases 2010, 786,000 deaths were attributed to HBV. Studies in Cameroon, reported the

prevalence of HBV as high as 10.1% and 12% among blood donors in hospital blood

banks. This study therefore, aims at determining the prevalence of HBsAg, knowledge

and practices of pregnant women on HBV prevention and transmission in the Limbe

Health District (LHD) and Muyuka Health District (MHD).

Methods: ANC registers were exploited from the health centers for a period of three years

(2014-2016) in order to determine the prevalence of HBV infection. 270 women attending

ANC were selected by exhaustive sampling. Knowledge and

Practices of participants on HBV prevention and transmission were assessed using a

structured questionnaire.

Results: the prevalence of HBV in the LHD and MHD were 5.7% and 7.5% respectively.

Pregnant women in the LHD demonstrated good knowledge but adopted poor practices

36
 whereas in the MHD, pregnant women demonstrated poor knowledge and adopted poor

practices regarding the mode of transmission and prevention of HBV

Infection. There was a significant association between the prevalence of HBsAg and

marital status (p = 0.000) in the LHD and age (p = 0.022) in the MHD.

Conclusion: this study indicated a high prevalence of HBV among pregnant women in the

LHD and MHD, knowledge and practices were

Identified as potential risk factors.

CHAPTER THREE

3.0 Introduction

This chapter consist of; study area, study design, study population, sample size, sampling

technique, inclusion and exclusion criteria, data collection instrument, ethical

consideration, Laboratory analysis, Data analysis.

3.1. Study Design

A community based cross sectional study was carried out from 20 th June to 25th July 2020.

Consent was gotten from the churches, njangi houses, parents and every participant to be

screened for HBsAg and HCV alongside the issuing of questionnaires to assess the

knowledge and awareness of participants on HBsAg and HCV.

3.2. Study Area

37
This study was carried out in Kumba which is the headquarters of Meme Division in the

South West region of Cameroon. It is a road junction town which had an estimated

population of about 400,000 inhabitants in 2015. It is known as the center for business as

well as cocoa farming and palm oil production in the Southwest region. The inhabitants’

activities are business, civil servants, transport network, farming. Study was carried out in

the Kumba and its environs (Ekombe, Mabanda, Mbalangi) and results for the HBsAg and

HCV test were used. This location was chosen because it harbors many of the inhabitants

of Kumba.

3.1 Study Population

Participants were those willing to test for HBsAg and HCV in the Kumba center and its

environs. The study include everybody from 10years and above willing and able to

participate in the study.

3.4 Sample size

One hundred and sixty five (165) blood samples were collected during the sampling

period for the cross-sectional study. This number was generated based on the previous

prevalence rate of 9.5% reported by Ephraim et al, 2015 using the formula:

N= [Z² (P) (1-P)] / (Error) ²

Where N= Sample size,

Z= A constant of 1.96,

Error= 4.5% (0.045),

P= Previous prevalence rate

N= [1.96²(0.095) (1-0.095)]/ (0.045)²

38
 N= [3.8416(0.095) (0.905)]/0.0020

N= [3.8416(0.085975)]/0.0020

N=0.33028/0.0020

N=165.14

3.2 Sampling technique

A community based convenient probability sampling technique was used where samples

were collected from participants at their convenience for the screening of HBsAg and

anti- HCV from 20th June to 25st July 2020. A structured questioner to assess the

knowledge and awareness of status on Hepatitis B and C was issued to participants and

results for screening were recorded.

3.3 Inclusion Criteria Participants involved people who were present during the time of the

study and who gave their consent to be tested for the HBsAg. And the results were

recorded and included in the study

3.4 Exclusion Criteria

Those that were excluded were those who were not present during sample collection and

those who refuse to participate in the study. Also those with ages less than 10 were

excluded in the study.

3.5 Data collection Instruments

Data was collected using pens, Pencils, ruler and A4 papers. HBsAg and HCV test strip,

EDTA Tube, Tourniquet, Syringe and a well-structured questionnaire.

3.6 Ethical consideration

Data was collected after research authorization was obtained from Redemption Higher

Institute Biomedical and Management Sciences Molyko- Buea and Regional Delegation

of Public Health.

39
After discussion of the purpose and aim of the study, permission was obtained from the

individuals, after confirming that the data will remain confidential. Serial Numbers were

used instead of personal identifiers like names so that participants cannot be linked to the

data collected. All data collected has been safely stored.

3.7 Laboratory Analysis

The study comprise of HBsAg results of the Kumba center and its environs gotten during

a period of one month. Laboratory analysis was done by testing for the Hepatitis B and C

surface antigen.

Principle: HBsAg and HCV Rapid Test is a direct binding test for the visual detection of

hepatitis B surface antigen (HBsAg) in serum, plasma or whole blood. It is used as an aid

in the diagnosis of hepatitis B and C infection. The One Step HBsAg and HCV Whole

Blood Test is based on the principle of sandwich immunoassay for determination of

HBsAg and HCV in serum or whole blood. Monoclonal and polyclonal antibodies are

employed to identify HBsAg and HCV specifically. This test strip contains a membrane

strip, which is pre-coated with mouse monoclonal anti-HBs and HCs capture antibody

on test band region. The mouse monoclonal anti-HBs-colloid gold conjugate and sample

moves along the membrane chromatographically to the test region (T) and forms a visible

line as the antibody-antigen-antibody gold particle complex forms. Both the Test Line and

Control Line are not visible before applying any samples. The Control Line is used for

procedural control. Control line should always appear if the test procedure is performed

properly and the reagents of control line are working.

Procedure:

The EDTA tube were labeled with the participant’s serial number. After tieing the

tourniquet 2cm above the collection site, a 5ml syringe was used to draw 3ml of blood and

40
then dispensing the collected blood into the tube. The tube was left to stand for 30 minutes

and some were centrifuged when the centrifuge was available during which the sample

separated and Plasma obtained. A dropper was used to dispense plasma on the test strip of

HCV and the HBsAg was dipped into the test tube to the max line and allowed for a few

second for a capillary movement of the sample. The results were recorded as positive

when the test and control lines both appeared or negative when only the control line was

visible.

3.8 Data Analysis

Data was presented in tables, pie charts and bar charts using Microsoft Excel 2013.

Categorical values were expressed as numbers and finally converted into percentages.

Responses to the questionnaire were graded and recorded into different sectors of risk and

Computation of all these were used to obtain the prevalence rate

CHAPTER FOUR

RESULTS

4.0 Introduction.

This chapter includes presentation of results according to demographic data and according

to the three different specific objectives.

A total of 165 participants, aged 10years and above were recruited for this study with

94males and 71females. Questionnaires were designed to capture their demographic

characteristics and clinical information. Table 1 summarizes the demographic

characteristics of the participants. Forty-eight participants representing 29.1% were within

41
the age category 31-40years.

4.1 Data according to gender and age of participants

The study was a community base carried from 20th June to 25thJuly 2020. Table 1 and 2

summarize the demographic characteristics of study participants according to gender and

age group respectively. In this study, 165 participants were included which was according

to their wiliness to part take in this study.

Table 1: Characteristics of the study subjects according to gender (n = 165).

Gender Number Percentages
Female 71 43.03%
Male 94 56.9%
Total 165 100%
Out of the 165participants in this studies, 71(43.03%) were females and 94(56.9%) were

male.

Table 2: Characteristics of the study subjects according to age group (n = 165).

Age groups in Years Number Percentages

10-20 16 1.6%

21-30 30 18.2%

31-40 48 29.1%

41-50 39 23.6%

>51 44 26.7%

42
 Total 165 100%

From the demographic data according to age group it shows that participants of ages 31-

40 years were more in the study with 40 participants making a percentage of 29.1%

4.2: Prevalence of HBV, HCV and HBV/HCV co-infections

Out of 165 patients, 18 were positive for HBsAg, 4 were positive for anti-HCV and 2

were positive for HBV/HCV co-infection. Table 3 summarizes the prevalence of hepatic

diseases in HBV, HCV and HBV/HCV co-infection positive participants.

Table 3: Prevalence of HBV, HCV and HBV/HCV co-infections (n=165)

INFECTIONS Number of positive cases Percentages of positive

cases

HBV 18 10.9%

HCV 4 2.4%

HBV/HCV 2 1.2%

Table 4: Knowledge of participants on Hepatitis B and C infections

S/ Knowledge Yes (%) No (%) Do not

N know (%)
01 Have you ever heard 73 (42.2) 92 (55.8) 0 (0)
about HBV and/or
HCV?
02 Is HBV and/or HCV 12 (7.3) 83 (50.3) 70 (42.4)
air borne diseases?
03 Do people get HBV 33(20) 49 (26.7) 83 (50.3)
and/or HCV by eating

43
 with food prepared by
an infected person?
04 Can HBV and/or HCV 67(40.6) 53 (32.1) 45 (27.3)
be transmitted through
sexual relationship?
05 Have you ever been 36(21.8) 97 (58.9) 32 (19.4)
screen for HBV and/or
HCV?
06 Can HBV and/or HCV 17(10.3) 82 (49.7) 66 (40)
lead to cancer of the
liver?
07 Is there a difference 43(20.3) 98 (59.4) 24 (14.5)
between Hepatitis and
Hypertension?

4.3: Knowledge of participants on Hepatitis B and C infections

Out of the 165 participants recruited in this study, majority (55.8%) have never heard

about HBV and/or HCV while more than a half (50.3%) answered correctly that HBV

and/or HCV can be transmitted as an air born. Majority said HBV/HCV can be

transmitted through sexual relationships. Of all the participants, less than half (21.8%) had

at least be screen once. Many (49.7%) did not know that HBV/HCV can lead to liver

cancer. Also, (59.4%) did not know the differences between Hepatitis and Hypertension.

Table 5: Awareness of participants on their status of Hepatitis B and C infection

S/ Questions HBV HCV

N yes no Ye No
s
01 Were you aware of your status on HBV 7 11 0 4
and/or HCV?

44
02 Are you on treatment? If yes are you using 5 13 0 4

Traditional medicine 3
Modern medicine 2
03 Do you experience any signs and 8 10 2 2
symptoms?
04 If married, have you spouse(s) been 13 5 4 0
screened for these infections?
05 Do you have any stigma from those that 7 11 0 4
know about your infection?

4.4: Awareness of participants on their status of Hepatitis B and C infection

Table 5 summaries the awareness of participants on their status of HBV/HCV infections.

18 and 4 participants were positive for HBV and HCV respectively. Of the 18 participants

positive for HBV, 7 were aware of their status and out of these 7, 5 were on treatment

while 3 said there were taking traditional medicine, 2 said there were on modern

medicine. For those that were positive for HCV, none of them were aware of their status.

CHAPTER FIVE

DISCUSSIONS, CONCLUSION AND RECOMMENDATIONS

5.0 Introduction

HBV and HCV infections are serious public health problems which affect approximately

2 billion and 130 - 170 million people across the globe respectively (Trepo et al., 2014).

45
Data on the prevalence of hepatitis viruses among patients presenting with hepatic disease

in Cameroon is very limited. This cross-sectional study was aimed at determining the

HBV and HCV infections among the inhabitants of Kumba and it’s environs from 20 th

June to 25th July 2020.

5.1 Discussion of results according to objectives

5.1.1 Prevalence of HBV, HCV and HBV/HCV co-infection

In this study, the prevalence of chronic hepatitis in HBsAg positive participants was much

lower than that reported in Accra by Schweitzer et al., (2015) and in Ethiopia by Taye et

al., (2014). These differences in prevalence could be due to the life style like circumcision

with unsterile objects, multiple sex partners, of the study subjects and the local endemicity

of the study area.

The current study reported a lower prevalence of chronic hepatitis in anti-HCV positive

patients compared to that accounted for by Taye et al., (2014). These differences in

prevalence could be due to the geographical location and living conditions of study

subjects. The prevalence of HBV/HCV co-infection among participants in the current study

was in contrary with that conducted by Taye et al., (2014). The prevalence of HBV/HCV

co-infection in the study may suggest that the two viruses are endemic in Cameroon.

However, the high number of participants who had HBV infection were between the age

categories of 25-39 years and this could be due to an active sexual life (Hou et al., 2005).

Males recorded a high number of HBV infection than females. This may be due to the

possibility of continual infection due to behaviours such as IV drug use and high risk

sexual activities than females who may be briefly infected and develop anti-HBs

(Khosravani et al., 2012). These findings were similar to that of HCV infections with the

46
exception of gender.

5.1.2 Knowledge of participants on HBV and HCV

From the results obtained, it shows that many people do not have knowledge on hepatitis

B and C. This could be due to the fact that, there is hardly sensitization on HBV and HCV

infections. Some of the participants have never heard about hepatitis B and C. the few that

have heard about HBV and HCV on these infections did not actually know the mode of

transmission and the signs/symptoms. A hand full of participants mistook Hepatitis for

Hypertension.

5.1.3 Known cases of HBV/HCV and those on treatment.

Awareness of participants on their status of HBV/HCV infections was low because many

of the positive cases had no knowledge on the screening of these infections. Those that

were aware of their status and were on treatment were few, while some were on

traditional medicine others were on modern medicine. Those that were not aware of their

status but positive were advised to begin treatment immediately and that their spouses

should go in for the screening of these infections and if negative they should go in for the

HBV vaccine. Some of those aware of their status were not on treatment because they

believe these diseases cannot be cured or managed this is can be due to no sensitization on

the prevention and treatment of HBV and HCV.

5.3 CONCLUSION

Viral hepatitis is a major global public health issue. HBV and HCV infections are the

most common viral causes of hepatic diseases. The study describes the prevalence of

47
hepatitis B and C viral infections among inhabitants presenting with hepatic infection in

Kumba. Of the 165 patients recruited, 18 were HBsAg positive, 4were anti-HCV positive

and 2 were both HBV/HCV co-infected.

Most of the inhabitants of Kumba are still not aware of mode of transmission, signs and

symptoms of HBV/HCV.

The 18 and 4 positive participants’ for HBV and HCV respectively, 7 and none were

aware of their status for HBV and HCV respectively. Just 5 of the known cases were on

treatment.

5.4 RECOMMENDATIONS

Information about the prevention, transmission and awareness of viral hepatic diseases

should be strengthened by giving health education through the television, radio,

newspapers, internet and any means possible. Those affected should be encourage to go in

for treatment. Also, further studies should be conducted using a larger sample size. In

addition to this, more sensitive and specific diagnostic tools like ELISA and PCR should

be used in diagnoses of viral hepatitis.

5.5 LIMITATION

This study might underestimate the true prevalence of both HBV and HCV infections as

most of the participants refused to participate in the study suspecting that they were

already infected and did not want to know their status. The study might also have been

underpowered for detecting cases of HCV as the sample size calculated for HBV was

used because of resource scarcity. HBsAg positivity indicates either acute (active) or

chronic infections. HBsAg negativity also indicates either the true absence of infection

48
(susceptibility) or immunity due to vaccination or immunity due to resolved infection.

Rapid test strip used in the study is less sensitive and less specific than other diagnostic

tools such as ELISA and PCR.

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 APPENDICES

Appendix 1: Questionaires on the knowledge and awareness of HBV and HCV

Dear respondent,

I am Ngam Juscentha Mbang, a degree student of Redemption Higher Institute of

biomedical and management Sciences Molyko-Buea; this questionnaire is meant for

academic purposes, on the knowledge and awareness on Hepatitis B and C infections. This

questionnaire is entirely anonymous and confidential. Please answer as truthfully as possible.

DEMOGRAPHIC DATA: Tick the right option

1) Age : 10-20 21-30 31-40 41-50 ˃50

2) Gender : Male female

SECTION A: To assess the knowledge of participants on HBV and HCV infections

1) Have you heard about Hepatitis B and C infections?

Yes No

2) Is HBV/HCV air borne diseases?

Yes no don’t know

3) Do people get HBV and/or HCV by eating with food prepared by an infected

person?

Yes no don’t know

57
4) Do people get HBV and/or HCV from sexual relationship?

Yes no don’t know

5) Does HBV and/or HCV cause liver cancer?

Yes no don’t know

6) Have you ever been screen for HBV and/or HCV?

Yes no don’t know

7) Is there a difference between Hepatitis and Hypertension?

Yes no don’t know

Section B: Awareness of participants on their status of Hepatitis B and C infection

8) Were you aware of your status on HBV and/or HCV?

Yes no don’t know

9) Are you on treatment? If yes are you using: traditional or modern

medicine?

Yes no don’t know

10) Do you experience any signs and symptoms?

Yes no don’t know

11) If married, have you spouse(s) been screened for these infections?

Yes no don’t know

12) Do you have any stigma from those that know about your infection?

Yes no don’t know

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Appendix 2: Research authorization from the Regional Delegate of Public Health

Redemption Higher Institute of Biomedical

and Management Sciences Buea

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Appendix 3: Clearance to carry out a proposed research

NGAM JUSCENTHA MBANG

60