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Original
ArticleOriginal
Article
Prevalence of Hepatitis B Virus Infection in the Gezira State of
Central Sudan
H. M.Y. Mudawi, H. M. Smith*, S. A. Rahoud**, I. A. Fletcher*, O. K. Saeed**, S. S. Fedail
Department of Internal ABSTRACT
Medicine, University of
Khartoum, Khartoum, Aim: This is a cross-sectional study to determine the prevalence and risk factors for transmission of hepatitis
Sudan, *Institute of Liver B virus (HBV) infection in the Gezira state of central Sudan prior to the introduction of blood screening and
Studies, Kings College vaccination against HBV. Materials and Methods: The study was carried out on the population of Um Zukra
Hospital, London, United village in Gezira state of Central Sudan. The village was surveyed on five consecutive days in Dec 2000.
Kingdom, **Department Epidemiological characteristics were recorded and participants were interviewed for risk factors of viral hepatitis.
of Internal Medicine, Blood samples were then collected and tested for HBsAg and HBcAb. Results: A total of 404 subjects were
University of Gezira, screened with a mean age of 35 years; 54.9% were females, HBsAg and HBcAb were reactive in 6.9% and 47.5%
of the studied population, respectively. Exposure to HBV increased with increasing age. The only significant
risk factor for transmission of infection was a history of parenteral antischistosomal therapy. Conclusion: This
Dr. H. M. Y. Mudawi, study shows that prevalence of HBV infection is high in the studied population and it is hoped that introduction
P. O. Box 2245, Khartoum, of blood screening and vaccination against HBV would decrease the carrier pool in the next few years.
E-mail: hmudawi@hotmail. Key Words: Hepatitis B virus, risk factors, vaccination.
Received 11.12.2006, Accepted 13.02.2007
The Saudi Journal of Gastroenterology 2007 13(2):81-3
Hepatitis B virus (HBV) infection is a major health problem populated by approximately 1.5 million individuals and is
causing considerable morbidity and mortality from both an area highly endemic for schistosomiasis and malaria.[2]
acute infection and chronic sequelae including chronic The study area was selected due to the high prevalence of
hepatitis, cirrhosis and hepatocellular cancer. More than S. mansoni infection. Random stool samples were taken
2 billion people show evidence of past or current HBV from different villages in the Gezira state and examined for
infection and over 350 million people are chronic carriers S. mansoni eggs. The highest prevalence (70%) was found
worldwide. Three quarters of the world’s population lives in in Um Zukra village. According to a census performed in
areas with high levels of infection. Sudan is classified among 1999, the population of Um Zukra is approximately 4000
the countries with high HBV endemicity.[1] Screening of individuals.
blood and blood products for HBV was only introduced to
blood banks throughout the country in 2002, before which, The village is surrounded by a cultivated area and the canal
screening was only performed in a very few centers in the is at a distance of only 450 meters from the center of the
capital, Khartoum. Vaccination for HBV was included as village. There are two water pumps (wells) used for drinking
part of the extended program of immunization in 2005. water, the other water source for washing and bathing is the
Our study objectives were to determine the prevalence and canal. The village was surveyed on five consecutive days
risk factors for transmission of HBV infection prior to the in December 2000 when all the villagers appearing in the
introduction of blood screening and HBV vaccination in a study site were enrolled after individual informed consent
village in the Gezira state of central Sudan, an area endemic was obtained. Three physicians interviewed the participants
Gezira, Sudan
Address:
Address:
Sudan.
com
for schistosomiasis and malaria.
MATERIALS AND METHODS
Study area
This study was carried out in the population of Um Zukra
village in the Managil province, Gezira state of Central
Sudan. The village is about 350 km south of Khartoum, the
capital and 110 km west of Wad Medani town. The Gezira
and Managil irrigation system is spread over an area of about
two million acres cultivated with cotton and other crops,
and completed a questionnaire with basic demographic
data including age, gender and potential risk factors for the
transmission of HBV infection such as previous personal
history of jaundice, surgery, dental treatment, parenteral
antischistosomal therapy and blood transfusion. Patients
were also examined for the presence of tattoos / scarification.
The study was approved by the medical research board of
the University of Khartoum.
Serological analysis
10 ml blood samples were drawn from each subject; sera
81
The Saudi Journal of
Gastroenterology Volume 13, Number 2
Rabi’ al-Awwal 1428 H
April 2007
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.
Mudawi, et al.
Table 1: Demographic criteria of 404 subjects screened for all hepatitis B virus markers in Um Zukra village
Variable Number tested (%) HBV markers reactive (%) OR P value
Gender
Females 222 97 (43.7) 1.41 0.108
Males 182 95 (52.2)
History of S. mansoni infection No 37 22 (59.5) 0.59 0.176
Yes 367 170 (46.3)
Parenteral antischistosomal therapy* No 327 143 (43.7) 2.25 0.0025*
Yes 77 49 (63.6)
Surgery No 358 169 (47.2) 1.12 0.841
Yes 46 23 (50)
Blood transfusion No 383 181 (47.3) 1.23 0.816
.com).
were separated, aliquoted, labeled within 6 h of collection
and stored at -70ºC. The sera were analyzed at the Institute
of Liver Studies, Kings College Hospital in London where
all samples were tested for HBsAg and HBcAb using ELISA
tests (IMX HBsAg (V2) and AxSYM HBV core antigen
recombinant, Abbott).
Statistical analysis
test with Yates’ correction was used to compare
proportions. Odds ratios (OR) with 95% confidence intervals
(95% CI) were calculated either directly or by the Mantel-
Haenszel method for stratified OR.
A total of 404 subjects were included in the study, the mean
age being 35 years with an age range of 8-90 years. 54.9% of
the subjects were female, 51.2% had a history of jaundice,
30.7% had dental treatment, 18.8% received parenteral
antischistosomal therapy, 11.2% had a previous history of
surgery, 5.1% received a blood transfusion and 2.7% had
a tattoo / scarification on examination [Table 1]. HBsAg
was reactive in 6.9% of subjects; there was no statistically
significant difference regarding infection rate in different age
Yes 21 11 (52.4)
Dental treatment No 278 121 (43.5) 1.35
Yes 126 71 (56.3)
History of jaundice No 197 89 (45.2) 1.20
Yes 207 103 (49.8)
Tattoos / scarification No 393 185 (47.1) 1.97
Yes 11 7 (63.6)
*Significant P value
Age Number tested
0-10 8
11-20 91
21-30 95
31-40 72
41-50 57
51-60 50
> 60 31
P value 0.702
Table 3: Age groups of 404 subjects in Um Zukra village
screened for hepatitis B virus markers
Age Number tested All hepatitis B virus
markers reactive (%)
0-10 8
11-20 91
21-30 95
31-40 72
41-50 57
51-60 50
> 60 31
P value* 0.000*
*Significant P value
0.203
0.411
0.436
Table 2: Age groups of 404 subjects screened for HBsAg
in Um Zukra village
HBsAg reactive (%)
1 (12.5)
6 (6.5)
5 (5.1)
4 (5.5)
3 (5.3)
6 (12)
The χ23 (9.7)
RESULTS
1 (12.5)
26 (28.6)
41 (43.2)
34 (47.2)
36 (63.2)
34 (68)
20 (64.5)
groups [Table 2]. HBcAb was reactive in 47.5%. Exposure to
HBV infection was highest in those over the age of 50 years
(68%) and lowest in those under the age of 10 years (12.5%)
[Table 3]. The only significant risk factors for HBV exposure
were a previous history of parenteral antischistosomal therapy
and increasing age [Tables 1, 3].
DISCUSSION
The prevalence of HBV infection in this study is less than
82 The Saudi Journal of
Gastroenterology
Volume 13, Number 2
Rabi’ al-Awwal 1428 H
April 2007
that reported in previous studies from Sudan where HBsAg
and all HBV markers were reactive in 14% and 68% of cases
respectively.[3,4] The risk of acquiring chronic HBV infection
were not statistically significant among different age groups.
This is different from results from countries such as Saudi
Arabia[5] and countries in South East Asia where a large
percentage of chronic carriers were noted to be children
and which had resulted from perinatal transmission.[6]
Almost half the population screened had evidence of
This PDF is available for free download from
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HBV infection in the Gezira state of central Sudan
exposure to HBV in concordance with previous studies
from Sudan.[3,4] A significant risk factor for infection in this
study as well as in a previous study conducted in Sudan[3]
was prior exposure to parenteral antischistosomal therapy;
a practice abandoned in 1980 after introduction of oral
antischistosomal therapy. Introduction of HBV vaccination
in children and screening of blood and blood products
should reduce the rate of HBV infection in this country.
Mass vaccination programs for HBV in infants and school
children in Saudi Arabia have resulted in significant rates
of drop in overall HBsAg seroprevalence from 6.7% to 0.7%
REFERENCES
1. Expanded program on immunization, hepatitis B vaccine, making
global progress. EPI update, WHO: October 1996.
2. el Gaddal AA. The Blue Nile Health Project: A comprehensive approach
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schemes of the Sudan. J Trop Med Hyg 1985;88:47-56.
3. McCarthy MC, Burnas JP, Constantine NT, el Hag AA, el Tayeb ME, el
Dabi MA, et al. Hepatits B and HIV in Sudan: A serosurvey for hepatits
B and HIV antibodies among sexually active heterosexuals. Am J Trop
Med Hyg 1989;41:726-31.
4. Hyams KC, al Arabi MA, al Tagani AA, Messiter JF, al Gaali AA, George
and of HBcAb seroprevalence from 4.2% to 0.46% over a JF. Epidemiology of hepatitis B in the Gezira region of Sudan. Am J
period of eight years.[7] Trop Med Hyg 1989;40:200-6.
5. al-Faleh FZ, Ayoola EA, Arif M, Ramia S, al-Rashed R, al-Jeffry M, et
al. Seroepidemiology of hepatitis B virus infection in Saudi Arabian
CONCLUSION children: A baseline survey for mass vaccination against hepatitis B. J
Infect 1992;24:197-206.
It can be concluded that prevalence of HBV infection is 6. Stevens CE, Beasley RP, Tsui J, Lee WC. Vertical transmission of hepatitis
high in the studied population. Hopefully, introduction B antigen in Taiwan. N Engl J Med 1975;292:771-4.
of blood screening and vaccination of infants against 7. Al-Faleh FZ, Al-Jeffri M, Ramia S, Al-Rashed R, Arif M, Rezeig M, et al.
Seroepidemiology of hepatitis B virus infection in Saudi children 8 years
HBV should reduce the HBV infection carrier pool and after a mass hepatitis B vaccination programme. J Infect 1999;38:167-
eventually prevent infection in both children and adults 70.
over the next few years. A repetition of a similar survey
after 10 years should be made in order to measure such a
reduction and monitor the effectiveness of the screening Source of Support: National center for gastrointestinal and liver disease,
and vaccination program. Khartoum, Sudan. Conflict of Interest: None declared.
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The Saudi Journal of
Gastroenterology Volume 13, Number 2
Rabi’ al-Awwal 1428 H
April 2007