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Seroprevalence of Hepatitis B and C Virus Infection Among Barbers in Isfahan Province, Iran

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Avicenna J Clin Microb Infec. 2015 August; 2(3): e27147. DOI: 10.17795/ajcmi27147
Published online 2015 August 1. Research Article
Seroprevalence of Hepatitis B and C Virus Infection Among Barbers in
Isfahan Province, Iran
Parisa Shoaei 1; Behrooz Ataei 2,*; Amir Mohammad Ataie 3; Zary Nokhodian 4; Payman Adibi 5
1Nosocomial Infection Research Center, Isfahan University of Medical Sciences, Isfahan, IR Iran
2Infectious Diseases and Tropical Medicine Research Center, Isfahan University of Medical Sciences, Isfahan, IR Iran
3School of Medicine, Isfahan University of Medical Sciences, Isfahan, IR Iran
4Acquired Immunodeficiency Research Center, Isfahan University of Medical Sciences, Isfahan, IR Iran
5Department of Gastroenterology, Integrative Functional Gastroenterology Research Center, Isfahan University of Medical Sciences, Isfahan, IR Iran
*Corresponding author: Behrooz Ataei, Infectious Diseases and Tropical Medicine Research Center, Isfahan University of Medical Sciences, Isfahan, IR Iran. Tel: +98-3113359359,
E-mail: ataei@med.mui.ac.ir
Received: January 19, 2015; Revised: July 2, 2015; Accepted: July 4, 2015
Background: Hepatitis B virus (HBV) and hepatitis C virus (HCV) infections are among the most occupational hazards in the world,
including Iran. Barbers have continued to expose to different infectious diseases. They may often be exposed accidentally to the blood and
body fluids of their customers, through needle pricks, scissor cuts, tattooing and other beauty treatments.
Objectives: The aim of the present study was to determine the seroprevalence of HBV, and HCV infections and to investigate the correlation
between the HBs-Ab titer and some of the risk factors in the barbers of Isfahan city, Iran.
Patients and Methods: This cross-sectional seroepidemiological study was performed on 479 male and female barbers during July to
September 2012 in Isfahan Province, Iran. Data were collected using a self-reporting questionnaire including demographic characteristics
and main risk factors for HCV and HBV infections. A 5-mL venous blood sample was obtained from each subject. The levels of antigen and
antibodies (HBs Ag, HBc Ab, HBs Ab, and HCV Ab) were measured by the enzyme-linked immunosorbant assay (ELISA). Data were analyzed
using descriptive statistics by SPSS software, version 16.
Results: The mean age of the individuals was 39.6 ± 11.4 years. Two hundred and thirty-three cases (48.6%) were men and 246 (51.4%) were
women. All the subjects were negative for HCV Ab. The seropositivity of HBV was 6.6%. No significant correlation was found between risk
factors and being HBV-seropositive. Among our participants, it was found that most barbers had been exposed to razors or scissor cuts.
Conclusions: Our findings indicate that both HCV and HBV infections may not constitute occupational hazards for barbers; however, it is
essential to promote awareness of these risks among barbers and effective HBV vaccination should be performed among them.
Keywords: Occupational Diseases; Hepatitis B; Hepatitis C; Risk Factors
Copyright © 2015, Hamadan University of Medical Sciences. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non-
Commercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial
usages, provided the original work is properly cited.
1. Background
Hepatitis B virus (HBV) and Hepatitis C Virus (HCV) in-
fections have emerged as a serious global public health
problem (1, 2). These viruses lead to severe liver disease
like as hepatocellular carcinoma, cirrhosis, and end stage
liver disease. According to the world health organization
(WHO), 2 billion people have been infected with HBV of
which more than 350 million have chronic infections and
170 million people have been infected with HCV world-
wide (3). It is estimated that nearly 2.6% of Iranian popu-
lation are HBV carriers and 67.8% of chronic hepatitis pa-
tients are positive for at least one of the serologic markers
of HBV although in Isfahan province HBV prevalence is 1.3%
that is lower than the other parts of Iran (4, 5). Alavian et
al. studied the general population of Iran and estimated
a low HCV infection prevalence rate (0.16%) in Iran (6). Bar-
bers may be exposed unexpectedly to the blood and body
fluids of their clients and can be infected. Important fac-
tors contributing to HBV and HCV spread among barbers
include razor sharing of customers, tattooing, piercing,
pedicure, manicure and other beauty treatments. In de-
veloping countries, HBV and HCV infections have been
implicated as an occupational hazard of the barbers (7).
Previous studies have indicated that in developed coun-
tries, certain beauty treatments play an important role in
the speared of HBV and HCV infection among barbers and
their clients (8). Hepatitis B virus can survive on the instru-
ment, tabletops and workbenches for at least seven days;
therefore, it is important for the barbers to know their
HBV status by being screened for the HBV surface antigen
and antibody and to be vaccinated against HBV if found to
be unprotected (4, 9). Safe and protective vaccine against
HBV is available throughout world including Iran. Many
barbers have a low awareness about viral hepatitis and the
risk of transmission of infectious agents by reuse of razors
and scissors on multiple clients; therefore, many barbers
remain at high risk of acquiring infections (6, 10). Both
Shoaei P et al.
13
Avicenna J Clin Microb Infec. 2015;2(3):e27147
HBV and HCV infections have been determined in many
groups; however, there is no published data on the serop-
revalence rate of them among barbers in Isfahan. The aim
of this study was to determine the prevalence of HBV and
HCV infection and associated factors among barbers in Is-
fahan province, Iran.
2. Objectives
The aim of the present study was to determine the sero-
prevalence of HBV, and HCV infections and to investigate
the correlation between the HBs-Ab titer and some of the
risk factors among the barbers in Isfahan province, Iran.
3. Patients and Methods
3.1. Design and Subjects
This cross-sectional sero-epidemiological study was
conducted on male and female barbers who worked in
the barber shops and beauty salons in Isfahan province,
Iran, from July to September 2012.
Four hundred and seventy-nine licensed barbers that
officially registered in Isfahan barbers syndicate were se-
lected using systematic random sampling. The research
protocol was approved by the ethics committee of Isfa-
han university of medical sciences in Iran and the neces-
sary professional coordination was performed with the
Isfahan barber syndicate. A written informed consent
was obtained from the participants. Demographic char-
acteristics of the participants including age, gender, edu-
cational status, previous blood transfusion, intravenous
drug use, hepatitis history, surgery, duration of profes-
sion as a barber, tattooing, barbers’ instruments, dental
procedures, duration of health care training courses
and other beauty treatments were gathered using a self-
reporting questionnaire. The participants were informed
that their personal information was kept privately and
then they took part in the study voluntarily and filled out
the consent form.
3.2. Laboratory Procedures
Five mL of venous blood was obtained from each par-
ticipant. The blood sera obtained from the barbers were
stored at -20 C until they were analyzed to determine the
makers of both hepatitis B and C virus infections. Hepati-
tis B virus infection markers consisted of surface antigen
(HBs Ag), core antibody (total HBc Ab) and surface Ab (HBs
Ab). Each marker was evaluated by a commercial enzyme-
linked immunosorbant assay (ELISA test system, DIA-PRO
Kit, Diagnostic Bio probes S.R.J Italy) according to the
manufacture recommendations. Antibodies to HCV were
tested using a third-generation ELISA (DIA-PRO kit).
3.3. Statistical Analysis
Statistical analysis was performed using SPSS software
(version 15.0, 2007, SPSS Inc, Chicago, Illinois, USA). De-
scriptive statistics of demographic variables and other
characteristics of the subjects were computed. Mean and
standard deviation (SD) were calculated for quantitative
variables and proportions for categorical variables. Uni-
variate analysis was used to assess relation between be-
ing HBV-positive and related risk factors.
4. Results
4.1. Demographic Profile of Respondents
From a total of 479 barbers included in the study, 233
cases (48.6%) were male and 246 (51.4%) were female.
The age range of barbers was 28 - 51 years with the mean
age (mean ± SD) of 36.9 ± 11.4 years. Duration of working
ranges from 1 - 28 years with the mean duration of work-
ing was 14.6 ± 13.4 years. Approximately, half of the bar-
bers (49.8%) had diploma and college education and only
2.7% were illiterate and about two thirds of the subjects
(85.9%) were married (Table 1).
Table 1. Characteristics of the Barbers Participated in This Study
Characteristics Values a
Sex
Male 233 (48.6)
Female 246 (51.4)
Age, y 36.9 ± 11.4
Education
Illiterate 13 (2.7)
Read and write 52 (10.9)
Preliminary 78 (16.3)
Secondary 97 (20.3)
Diploma and above 239 (49.8)
Marital Status
Single 52 (10.4)
Married 404 (85.9)
Widow 15 (2.4)
Divorced 9 (1.3)
Health Care Training b
Yes 244 (59.6)
No 186 (40.4)
Duration of health care
training courses, y
2.8 ± 7
Tattooing 87 (18.3)
Cupping 79 (16.7)
Surgery 240 (51.2)
Ear piercing 171 (36.2)
Blood transfusion 31 (6.5)
Dental work 450 (95.1)
Intravenous drug use 1 (0.2)
Sharp instruments 330 (69.2)
a Data are presented as mean ± SD or No. (%).
b Missing data.
Shoaei P et al.
Avicenna J Clin Microb Infec. 2015;2(3):e2714714
4.2. Definition
HBV seropositivity was defined as a positive HBs-Ag or
anti-HBs or HBc Ab test, indicating past or current infec-
tion with HBV in unvaccinated population. Samples with
anti-HBs antibody titer of > 10 mIU/mL were taken as pro-
tected and samples with antibody titers < 10 IU/mL were
considered as nonprotected (3).
Safe practice and science of standard barbering toward
HBV and HCV include washing hands before each client,
cleaning instruments with disinfectant between clients,
using new blade on a new client, changing disinfectant
frequently, using disinfects for skin cuts and disposing of
used blades in the garbage (8, 11).
4.3. Serologic Tests
From a total of 479 barbers, 22 cases (6.6%) were sero-
positive for HBV and all of them were negative for HCV.
Active HBV as recognized by a positive HBs-Ag was pres-
ent in 4 cases (0.8%). Three cases (0.6%) were HBs-Ag posi-
tive, anti-HBc positive, indicating chronic HBV infection.
Both anti-HBs and anti-HBc antibodies were detected
in 3 (0.6%) of vaccinated barbers. Six people (1.3%) were
positive for anti-HBc antibodies and their HBV DNA was
negative that indicated they were healthy people with a
history of previous HBV infection. Among unvaccinated
barbers, 6 cases (3.3%) were HBs Ab positive. Overall, 457
cases (95.4%) of the study participants had never been ex-
posed to HBV infection. At the time of sampling, 296 cases
(61.8%) had completed the program of vaccination earlier
and 183 (38.2%) had not. Distribution of HBV infection
markers are shown in Table 2. No significant association
was found between tattooing, cupping, surgery, blood
transfusion, dental work, ear piercing, intravenous drug
using and a history of using sharp instruments (P > 0.05).
4.4. Coverage of Hepatitis B Vaccine Among Bar-
bers
The result of the study showed that out of 479 barbers,
202 cases (42.6%) were immunized (anti-HBs Ab > 10 mIU/
mL) and 277 (57.8%) were nonimmunized against HBV in-
fection (HBs Ab < 10 mIU/ml). The majority of the barbers
had participated in health care training courses related
to their job and the mean duration of these courses was
2.8 ± 7 years.
Table 2. Distribution of Hepatitis B Virus Infection Markers in
Study Population
Positivity Values a
HBs Ag and anti-HBc 3 (0.6)
Anti-HBs and anti-HBc 3 (0.6)
Only anti-HBc 6 (1.3)b
Only anti HBs (unvaccinated) 6 (3.3)
Only HBs Ag 4 (0.8)
HBV seropositivity 22 (6.7)
a Data are presented as No. (%).
b All of them were negative for HBV DNA.
5. Discussion
In this study, we determined the seroprevalence of hepa-
titis B virus and hepatitis C virus infection and several risk
factors associated with this occupation among barbers.
The prevalence of HBV and HCV is known to differ across
countries and may also differ based on the individual char-
acteristics and conditional factors (7, 8). Hepatitis B virus
and HCV infections are common causes of occupational
blood-borne diseases that can be transmitted between
barbers and their clients and frequently lead to a chronic
asymptomatic carrier condition for a long time before the
development of severe end-stage liver diseases. Therefore,
barbers with HBV or HCV infection may be unaware of their
diseases or carrier condition and infect other persons such
as their customers or families (12). Our results determined
that none of the barbers over the study period showed the
presence of antibodies to HCV. Based on the low HCV sero-
postivity rate (0.16%) in general population, our results can
be expected (5). In other similar studies that performed
among traditional barbers in developing countries it was
found that HCV was 0.4% in Turkey, 12.3% in Egypt and 5%
in Morocco (2, 13, 14). Sharp instruments have been identi-
fied as a key risk factor for transmission of HCV. Skin tattoo-
ing is mentioned as an independent risk factor for being
HCV-positive in our country; however, there was nobody
infected with HCV in our study (5). Health care training
courses, education teaching about risk of occupational
contacts with body fluids and low infection prevalence in
community might be the reasons for a lack of detectable
antibodies to HCV among the barbers (5, 13, 14).
In a seropidemiological study that performed in Isfahan
province, Iran, 1.3% of the general population was HBs Ag
carriers and there was a total of 17.6% HBV seropositive
cases (15). In other similar seroepidemilogical studies
conducted among barbers in Sivas region of Turkey and
Huanshi of China, Candan et al. and She et al. reported that
HBV and HCV seropositivity was elevated in traditional
barbers compared to the general population (7, 16). Our
study showed that 0.8% of our subjects were HBs Ag car-
riers and there was a total of 6.6% HBV seropostivity. The
rate of HBs Ag among our subjects was lower than that re-
ported among barbers in Italy (1.8%), Izmil of Turkey (2.2%),
and Egypt (4.2%) and in Moroco (2%) (2, 13, 14, 17). The most
important cause of the reduction of HBs Ag seropositivity
is related to the effective Expended Program on Immuni-
zation (EPI) and vaccination of high risk groups in Iran (4,
15). In our study nearly 40% of the participants were not
vaccinated against HBV and they might be at the risk of
HBV infection; therefore, a standard vaccination course
is recommended in unprotected barbers. Certain beauty
treatments play an important role in transmission of HBV
and HCV infection. The results of the study that performed
in Rome, showed that there was a significant association
between shaving and tattooing and the prevalence of HBV
and HCV infections among barbers (17).
The results of various studies have been shown that
HBV and HCV can be transmitted through razor shaving,
Shoaei P et al.
15
Avicenna J Clin Microb Infec. 2015;2(3):e27147
sharing and other instrument among barbers and their
clients (6, 7). Most of our subjects (69.2%) had a history
of sharp instruments, such as razors and scissors that
repeatedly were used for different customers without
intervening sterilization; however, we did not find a sig-
nificant relation between hepatitis B or C infection and
history of sharp instruments (P > 0.05).
Here we found that nearly 50% of the all barbers were
educated; therefore, most of them might be aware of the
route of transmission of HBV and HCV infections. Formal
education of barber shop personnel in health care train-
ing courses and vaccination against HBV could reduce
the rate of infection among them.
Although HBV and HCV infection might constitute oc-
cupational hazards for the barbers in our study, HBV se-
ropositivity did not exhibit a significant association (P
> 0.05) with risk factors such as time in job, tattooing,
blood transfusion and other related factors (Table 1).
According to the prevalence of HBV and HCV infection
among barbers in Isfahan province, it can be concluded
that both HCV and HBV infections may not constitute occu-
pational hazards for barbers; however, it is essential to pro-
mote awareness of these risks among barbers and effective
HBV vaccination programs should be exposed among them.
Furthermore, efforts should be continued for HBV and
HCV screening, immunization programs and formal
education to promote knowledge among barbers about
health hazards in barbering profession. Also, similar
studies are needed to be conducted in barber shops of
other cities in our country.
Acknowledgements
This article is extracted from a research (grant number
185072) that performed in infectious disease research
center, Isfahan university of medical sciences, Isfahan,
Iran. The authors would like to express their gratitude to
the vice chancellor of Isfahan University of medical sci-
ences for its financial support.
Authors’ Contributions
Design of the study: Behrooz Ataei. Preparation of the
samples: Zary Nokhodian. Writing the draft, and analyz-
ing the data: Parisa Shoaei. Editing the manuscript: Pay-
man Adibi. All of the authors read the final manuscript.
The idea of the subject: Behrooz Ataei, Amir Mohammad
Ataie: writing the manuscript.
Funding/Support
This article is a result of research number 185072 that
performed in infectious disease research center, Isfahan
University of Medical Sciences, Isfahan, Iran. The authors
would like to express their gratitude to the vice chancel-
lor of Esfahan University of medical sciences for their fi-
nancial support.
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Background: In Pakistan, most patients with Hepatitis B and C have history of facial and armpit shaving from barbers. Objective: Evaluate the awareness and risk factors associated with barbers in transmission of Hepatitis B and C. Subjects and methods: A cross sectional survey was conducted in Rawalpindi and Islamabad, the twin capital cities of Pakistan between January and July 2009. Five hundred and eight barbershops were surveyed. Results: Out of 508 barber shops, 99.8% and 98.2% were washing their razor with water and water plus antiseptic solution, respectively, while 99.8% were using new blades. Only 39.6% knew that hepatitis B virus (HBV) and hepatitis C virus (HCV) were viral diseases, 26.6% knew that it can lead to cancer, 90.7% thought that hepatitis could be transferred by blade sharing, 47.8% knew that a vaccine for HBV was available, and 43.0% had education beyond the primary level. None of the barbers used a new or washed apron/towel on every customer. Conclusion: In Pakistan, a small number of barbers are shaving clients with an old style razor with a permanent blade. There is moderate awareness about the various modes of transmission of hepatitis among the barbers, and most of them don’t know about vaccination. A predominant number of them are considering interferon treatment as a vaccine for hepatitis B and C.
Article
There is strong evidence that razors, barber's scissors, nail files and body piercing instruments are risk factors for transmission of hepatitis B and C. to investigate the knowledge, attitudes and practices regarding hepatitis B and C virus among barbers in Sana'a city. KAP study was conducted from July-September 2011. Two hundred and thirty four barbershops were surveyed. Out of 234 barber shops, 73.1% heard about viral hepatitis B and C. The awareness of modes of transmission of hepatitis and the different sources/risk factors were moderate, ranging from 51.6% who knew that hepatitis can be transmitted through sexual transmitted to 82.1% who knew that hepatitis can be transmitted through blood transfusion. 54.9% of barbers did not agree that it was essential to have periodic tests for HBV and HCV; however, 67.5%would themselves like to be tested for these infections. 32% washed their hands before attending each client, 59% cleaned instruments with disinfectant between clients, 96.1% washed razors with tap water before use on a new client, 92.6% also washed their razors with an antiseptic solution after every use, 87% used a new blade on new clients and 55% used disinfectants for skin cuts. In Yemen, a large number of barbers are shaving clients with an old style razor with a permanent blade. There is moderate awareness about the various modes of transmission of hepatitis among the barbers.