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Hepatitis B and C status among health care workers in the five main hospitals in eastern Libya
Journal of Infection and Public Health (2014) 7, 534—541
Hepatitis B and C status among health care workers in the five main hospitals in eastern Libya Abdel-Nasser Elzouki a,∗,1, Salwa M. Elgamay b, Abdeulaziz Zorgani c, Omer Elahmer d a
Department of Medicine, Hamad General Hospital, Hamad Medical Corporation, Weill Cornell Medical College, Qatar b Faculty of Medical Technology, Derna, Libya c Department of Microbiology and Immunology, Faculty of Medicine, Tripoli University, Tripoli, Libya d National Center for Diseases Control, Tripoli, Libya Received 1 April 2014 ; received in revised form 19 June 2014; accepted 11 July 2014
KEYWORDS Health care workers; Hepatitis B; Hepatitis C; Hepatitis B vaccine; Libya
Summary The aim of the present study was to determine the frequency of hepatitis B and C transmission to health care workers (HCWs) in five major hospitals in eastern Libya and to analyze how the risk of these infections are affected by the type of occupation, hospital work place and working period. From July 2008 to June 2009, 601 HCWs (mean age: 32.90 ± 8.85 years) were tested for HBV and HCV markers using ELISA techniques. Polymerase chain reaction (PCR) was performed on all positive samples of HBsAg and Anti-HCV antibody to determine the level of HBV-DNA and HCV-RNA viremia, respectively. The overall frequency of HBsAg positivity was 1.8%. Anti-HBc, HBeAg and Anti-HBe antibodies were found in 8.5%, 0.7% and 8.0% of samples, respectively. The HBV-DNA level was positive in 55% of all HBsAg-positive samples. Approximately half of the HCWs (51.4%) were Anti-HBs antibody positive. The overall positivity rate of Anti-HCV antibodies was 2.0%, and HCV-RNA was positive in 33.3% of these samples. Overall, 52% of HCWs reported receiving full vaccination doses (three doses) against HBV infection. Among them, anti-HBs positivity was approximately 98.0%. 3.9% of those who never received any HBV vaccination dose were HBsAg positive, compared to 1.3% HBsAg positive in those HCWs who had received one or two doses of hepatitis B vaccine (p = 0.01 for all comparisons).
∗ Corresponding author at: Department of Medicine, Hamad General Hospital, Hamad Medical Corporation, P.O. Box 3050, Doha, Qatar. Tel.: +974 44392489; mobile: +974 66022836. E-mail address: nelzouki [email protected] (A.-N. Elzouki). 1 During the study period, this author was affiliated with the Department of Medicine, Aljomhoria Hospital, Al Arab Medical University, Benghazi, Libya.
http://dx.doi.org/10.1016/j.jiph.2014.07.006 1876-0341/© 2014 King Saud Bin Abdulaziz University for Health Sciences. Published by Elsevier Ltd. All rights reserved.
Hepatitis B and C in health care workers in Libya
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Nurses and nurse-aides had the highest rates of both HBsAg and Anti-HCV among the studied HCWs (HBsAg: 2.1% and 3.2%; Anti-HCV: 3.2% and 4.9%, respectively). It is noteworthy that doctors also had a relatively high prevalence rate of Anti-HCV (2.2%). Obstetric wards, isolation room, dialysis units and dentist work places had higher frequencies of HBV. HCV was found to be higher in the medical and surgical wards (the prevalence varied between 3% and 5.6%). There was no significant difference between HBsAg status and the work period of HCWs. In conclusion, universal precautions should be applied for the care of all patients by all HCWs. Further, HBV vaccines should be more readily available for Libyan HCWs by reinforcing current vaccination programs. © 2014 King Saud Bin Abdulaziz University for Health Sciences. Published by Elsevier Ltd. All rights reserved.
Introduction Hepatitis B virus (HBV) and hepatitis C virus (HCV) are among the main causes of liver-associated diseases, including liver cirrhosis and hepatocellular carcinoma [1,2]. Both viruses are major global public health problems warranting high priority efforts for prevention, control and treatment. Approximately two billion individuals worldwide have been infected by HBV, and between 350 and 400 million individuals have chronic HBV infection [3], while an estimated 200 million people (i.e., 3.3% of the world’s population) are chronically infected by HCV worldwide [4]. A majority of countries in the Middle East show an intermediate or high endemicity of HBV infection, which clearly poses a serious public health problem in the region [5]. The prevalence of HBV and HCV in Libya has been recently reported in a large general population-based study to be 2.2% for HBsAg and 1.8% for Anti-HCV antibodies [6]. The modes of transmission of these two bloodborne viruses in developing countries include perinatal transmission or household contact, while sexual contact, shared needles in intravenous drug abusers and contaminated blood or organ transplants are responsible for their transmission in developed countries [7]. However, screening tests as well as vaccination for HBV have dramatically reduced the risk of transmission worldwide [8]. Occupational exposure to HBV and HCV is a wellrecognized risk for health care workers (HCWs). The assessment of the risk of transmission to HCWs requires information derived from various sources including the place of HCW hospital work, the working period, the type of occupation, and the rate of exposure to patient blood and blood products [9]. The rates of transmission of HBV and HCV to HCWs are also influenced by the prevalence of HBV and HCV infection in the general population.
In developing countries, the prevalence of HBV and HCV among HCWs is high, while the vaccination status among HCWs and its relationship with occupational factors are not well documented [10,11]. Because the information regarding transmission of blood-borne viruses in HCWs is very limited in Libya we decided to determine the frequency of HBV and HCV transmission to HCWs in the five major hospitals in eastern Libya. A further aim of this study was to analyze how the risk of these infections are affected by the type of occupation, the place of work in the hospital and the working period as well as the vaccination status among this high risk group.
Materials and methods Study population The present study was conducted from July 2008 to June 2009 on 601 HCWs from five major hospitals in the three main cities in eastern Libya. There were 116, 120, 100, 152 and 113 HCWs from various professional categories who were randomly selected to represent the 1007, 455, 556, 405 and 680 HCWs in the Aljomhoria Hospital and Children’s Hospital (Benghazi), Althawra Hospital (Albaida), Alwahda Hospital (Derna), and Albutnan Medical Center (Tubruk), respectively. HCWs were defined as workers at risk of needle sticks or other sharps injuries in the hospitals. This definition included physicians, dentists, nurses, midwives, laboratory technicians, nursing aids, medical assistants, and cleaners. They were randomly selected from different places of work in these hospitals to include operation theaters, labor rooms, dental clinics, laboratories, endoscopy units, nephrology units, coronary care units (CCUs), intensive care units (ICUs), surgical and medical wards, and out-patient departments, as well as
536 hospital cleaners and workers in pharmacies and administration departments.
Data collection Demographic and epidemiological data were collected through direct personal interviews with each HCW carried out by one of the authors (S.A.). These data include sex, age, professional activities and practices, type of work, place and duration of work in the hospital as well as any history of hepatitis B vaccination. The data were anonymous and linked to the blood sample tube only by a code.
A.-N. Elzouki et al.
Statistical analysis The data were analyzed in SPSS statistical software version 19.0. Descriptive statistics in the form of the mean and standard deviations and the frequency with percentages were calculated for interval and categorical variables, respectively. The Chi-square test was used to identify differences between categorical variables and Student’s t-test was used for interval variables as appropriate. The results were considered statistically significant when the p-value (two-tailed) was less than 0.05.
Sample collection and laboratory analysis: A blood sample (5—10 ml) was extracted from each HCW and transported immediately to the local laboratory, in the same hospital in which the HCW was working, where it was centrifuged and the sera were stored at −20 ◦ C until transported to the Reference Laboratory for Disease Control at the National Centre for Disease Control of Libya in Tripoli city. Samples were tested for HCV markers using the enzyme linked immunosorbent assay (ELISA) technique (EIAgen HCV Ab [v.4] Adaltis, Italy) according to the manufacturer’s instructions. HBV markers (i.e., HBeAg, anti-HBe, anti-HBs, and total anti-HBc) were detected using the Enzyme Linked Fluorescent Assay (ELFA) (mini Vidas analyzer-BioMerieux, France). Both the HBsAg and Anti-HCV antibody results were considered positive (reactive) or negative (non-reactive) according to the interpretation parameters provided by the manufacturers. A positive control and a negative control were integrated in each run to validate the assay. Polymerase chain reaction (PCR) was also performed for all HBsAg and anti-HCV reactive samples to determine the levels of HBV-DNA and HCV-RNA viremia, respectively. Both HBV and HCV markers, as well as PCR assays, were performed at the Reference Laboratory for Disease Control at the National Centre for Disease Control of Libya, Tripoli.
Ethical considerations Ethical approval was obtained from the research ethical committee of Al-Arab Medical University, Benghazi, Libya. The study was conducted in accordance with the Helsinki Declaration [12] and under the supervision of the National Center for Disease Control of Libya. All participants provided written informed consent before the collection of data and blood samples.
Results The cohort was comprised of 601 HCWs from five major hospitals in eastern Libya: two hospitals (Aljomhuria Hospital and Children Hospital) in Benghazi (around one million inhabitants); Albeida (Althawra Hospital); Derna (Alwahda Hospital); and Tubruk (Albutnan Medical Center). There was a predominance of females (437, 72.3%), the majority of participants (560, 93.2%) were Libyan, and 41 individuals (6.8%) were non-Libyan. The mean age of the cohort was 32.90 ± 8.85 years (range = 17—60 years). More than three quarters (78.6%) of the studied HCWs were younger than 40 years of age. The overall frequency of HBsAg positivity was 1.8% (11 HCWs). However, Anti-HBc, HBeAg and Anti-HBe antibodies were found in 8.5%, 0.7% and 8.0% of participants, respectively. The HBV-DNA level was positive in 55% (6/11) of HBsAg-positive HCWs. Only half of the studied HCWs (51.4%) were immune to HBV infection as manifested by the detection of Anti-HBs antibodies. The overall positivity of Anti-HCV antibodies was 2.0% (12 HCWs), and the HCV-RNA level was positive in four (33.3%) of these samples. The distribution of hepatitis B and C markers, as well as the positivity of their viremia, is shown for the HCWs in each hospital in Table 1. Only half of the HCWs (312, 52%) received full vaccination doses (three doses) against HBV infection. Among them, the efficiency of the vaccine as manifested by anti-HBs positivity was approximately 98.0%. Table 2 shows the distribution of HBsAg according to hepatitis B vaccine status. Of the HCWs who had not received any vaccine, 3.9% (6/156) were HBsAg positive compared to only 1.3% (4/312) in HCWs who had received one or two doses of hepatitis B vaccine (p = 0.01 for all comparisons). As shown in Table 3, nurses and nurse-aides had the highest prevalence rates of both HBsAg and Anti-HCV antibody among the studied HCWs (HBsAg:
1 (0.9) 1 (0.8) 0 (0.0) 0 (0.0) 2 (1.8) 5 (4.3) 1 (0.8) 0 (0.0) 3 (2.0) 3 (2.7) 1 (0.8) 1 (0.8) 0 (0.0) 0 (0.0) 3 (2.7)
9 (7.8) 9 (7.5) 7 (7.0) 12 (7.9) 14 (12.4)
1 (0.9) 2 (1.7) 1 (1.0) 0 (0.0) 110 (97.3)
9 (6.7) 8 (6.7) 6 (6.0) 14 (9.2) 11 (9.7)
61 (52.5) 57 (47.5) 45 (45.0) 90 (59.2) 56 (49.6)
3 (2.6) 0 (0.0) 0 (0.0) 0 (0.0) 3 (2.7)
HCV-RNA +ve N (%) Anti-HCV +ve N (%) HBV-DNA +ve N (%) Anti-HBs +ve N (%) Anti-HBe +ve N (%) HBeAg +ve N (%) Anti-HBc +ve N (%) HBsAg +ve N (%)
537 Table 2 HBsAg positivity according to the hepatitis B vaccine received by health care workers (HCWs).
Aljomhoria Hospital (Benghazi) (n = 116) Children Hospital (Benghazi) (n = 120) Althawra Hospital (Albaida) (n = 100) Alwahda Hospital (Derna) (n = 152) Albutnan Medical Center (Tubruk) (n = 113)
Table 1
Distribution of Hepatitis B and C markers and their viremia among health care workers in the five hospitals of eastern Libya.
Hepatitis B and C in health care workers in Libya
Vaccine dose received by HCWs One dose (n = 50)* Two doses (n = 79) Three and four doses (n = 312)* Vaccine not received (n = 156)* Total (n = 601) *
HBsAg +veN (%) 1 (2.0) 0 (0) 4 (1.3) 6 (3.9) 11 (1.8)
p < 0.05 for all comparisons.
2.1% and 3.2%, and Anti-HCV antibody: 3.2% and 4.9%, for nurses and nurse-aides, respectively). It is noteworthy that doctors also had a relatively high prevalence rate of Anti-HCV antibody (2.2%). More than half of HCWs were Anti-HBs antibody positive. Most of this positivity is due to vaccine exposure rather than past hepatitis B infections. The distribution of HBV markers according to the work places of the HCWs was also studied. HCWs working on gynecology and obstetric wards, surgical wards, medical wards and dialysis units had a higher frequency of infection with either HBV and/or HCV (the prevalence rate varied between 3% and 5.6%) compared to other work site categories such as the ICU, CCU, operating rooms, dental clinics, laboratories, emergency rooms, OPD and isolation wards (data not shown). Table 4 shows the distribution of hepatitis B and C markers according to the duration of time participants spent as HCWs. There was no significant difference between HBsAg status and the work period of HCWs (1.8% for >5 years of work versus 1.9% for HCWs with a period of work duration less than 5 years, p = 0.4 p > 0.05). However, there was a trend toward increased Anti-HCV antibody positivity among those HCWs who have been working for more than 5 years, although this finding did not reach the level of statistical significance (2.5% for >5 years of work versus 1.4% for less than 5 years of work, p = 0.08).
Discussion According to the World Health Organization (WHO) the proportion of HCWs in the general population varies substantially from region to region (0.2—2.5%), as does the average number of occupational injuries per HCWs (for example, 0.2—4.7% sharp injuries per worker per year) [13]. The annual proportion of HCWs exposed to HBV each year was 5.9% for HBV, corresponding to approximately 66,000 HBV infections in HCWs worldwide. In developing countries, 40—65% of HBV infections
538
Table 3
Distribution hepatitis B and C markers according to the type of occupation of the health care workers.
Occupation
HBsAg +ve N (%)
HBcAb +ve N (%)
HBeAg +ve N (%)
Anti-HBe +ve N (%)
1 (0.7) 1 (0.9) 4 (2.1) 2 (3.3) 1 (1.4) 1 (7.7) 1 (4.0)
10 (29.4) 4 (3.6) 19 (10.1) 8 (13.1) 8 (11.4) 1 (7.7) 1 (4.0)
2 (1.5) 0 (0.0) 2 (1.1) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
7 (5.2) 7 (6.4) 20 (10.6) 7 (11.5) 5 (7.1) 1 (7.7) 1 (4.0)
84 (62.7) 70 (63.6) 98 (52.1) 22 (36.1) 28 (40.0) 8 (61.5) 3 (12.0)
0 (0.0) 1 (0.9) 3 (1.6) 1 (1.6) 0 (0.0) 1 (7.7) 0 (0.0)
3 (2.2) 0 (0.0) 6 (3.2) 3 (4.9) 0 (0.0) 0 (0.0) 0 (0.0)
1 (0.7) 0 (0.0) 1 (0.5) 2 (3.3) 0 (0.0) 0 (0.0) 0 (0.0)
11 (1.8)
51 (8.5)
4 (0.7)
48 (8.0)
309 (51.4)
6 (1.0)
12 (2.0)
4 (0.7)
Doctors (n = 134) Lab technicians (n = 110) Nurses (n = 188) Nurse-aides (n = 61) Hospital cleaners (n = 70) Anesthesia technicians (n = 13) Others (n = 25) Total (n = 601)
Table 4
HBV-DNA +ve N (%)
Anti-HCV +ve N (%)
HCV-RNA +ve N (%)
Distribution of hepatitis B and C markers according to the duration of the work period of health care workers.
Work period
HBsAg +ve N (%)
HBeAg +ve N (%)
Anti-HBe +ve N (%)
Anti-HBs +ve N (%)
HBV-DNA +ve N (%)
Total (n = 601)
5 (1.8) 6 (1.9)
14 (1.75) 37 (11.5)
3 (1.1) 1 (0.3)
13 (4.6) 35 (10.9)
123 (43.9) 186 (57.9)
3 (1.0) 3 (0.9)
4 (1.4) 8 (2.5)
1 (0.4) 3 (0.9)
11 (1.8)
51 (8.5)
4 (0.7)
48 (8.0)
309 (51.4)
6 (1.0)
12 (2.0)
4 (0.7)
No significant difference.
Anti-HCV +ve N (%)
HCV-RNA +ve N (%)
A.-N. Elzouki et al.
HBcAb +ve N (%)
0—5 years (n = 280)* >5 years (n = 321)*
*
Anti-Hbs +ve N (%)
Hepatitis B and C in health care workers in Libya in HCWs are attributable to percutaneous occupational exposure. By contrast, in developed countries, the exposure rate was less than 10%, largely due to high rates of immunization and the availability of post-exposure prophylaxis [14]. The strengths of the present study include the fact that it involved multiple centers, which allowed us to identify the seroprevalence of HBV and HCV, the working period, and the different occupational risks of acquiring infection in HCWs in five different sites in eastern Libya. The lower prevalence of HBsAg (1.8%) was similar to data from a national population-based sero-epidemiological survey that found that the overall prevalence of HBV was 2.2% [6]. Two previous local studies carried out in Libya have found that 31% and 14.8% of HCWs in Tripoli and Benghazi, respectively, were infected [15,16], and the low prevalence among HCWs in the present study might be explained by their awareness of the routes of HBV transmission, the implementation of infection control measures and a free vaccination program. Numerous sero-prevalence studies have documented the risks of HCWs of contracting hepatitis B. Rates in our cohort exceeded those reported in Brazil (0.8%), Egypt (1.5%) and Morocco (1%) [17—19]. Moreover, HCWs are reported to have a lower (1%) prevalence of HBsAg compared to Moroccan blood donors (1% versus 2%) (17) [17—19]. In contrast, we observed lower prevalence rates than those found in Syria (6%), Cameroon (23.6%), Nigeria (13%), Pakistan (2.18%) and Uganda (8.1%) [20—24]. Anti-HBc, HBeAg and Anti-HBe antibodies were found in 8.5%, 0.7% and 8.0%, respectively. Similar positive anti-HBc serological results were found in Brazil by Luiz et al., 9.4% [19]. Only half of the studied HCWs (51.4%) were immune to HBV infection as manifested by the detection of AntiHBs antibodies. These results show that half of the studied HCWs could have contracted HBV after a needle stick injury involving an HBV carrier’s blood. Recently, Ziglam et al. [25] have demonstrated that only 21.8% (591/2704 of HCWs) had anti-HBs antibody concentrations (less than 10 U/ml) in a tertiary care hospital in Tripoli, Libya. This survey shows that one in fifty (N = 12) of the HCWs employed in high-risk environments had Anti-HCV antibodies (2.0%), and HCV-RNA as measured by PCR was positive in four (33.3%) of these HCWs. Various studies detected substantially different results: in Cameroon (16%), Egypt (16.6%, with HCV-RNA detected in 72.1% of the samples), and Syria (3%), while in Poland, 1.7%, with HCV-RNA detected in 3 out of these 16 (19%) sera samples [18,20,22,26]. It has been suggested that the reported risk of HCV infection following occupational exposure is low, with seroconversion rates
539 between 0% and 5%, with <1% as the most commonly reported rate [27,28]. Recently, a study performed in Italy focusing on the HCV knowledge and attitudes and exploring the evidence-based practices for the prevention of HCV has recommended that behavior changes should be aimed at abandoning outdated practices and adopting and maintaining evidence-based practices [29]. Our results described a higher rate of HCV antibody positivity than a large scale multi-staged study covering more than 65,000 individuals of all age groups from the whole of Libya, in which the prevalence of Anti-HCV antibodies was 1.3% [6]. This might be explained by the risks of occupational blood exposure such as needle stick injuries. Nurses and nurse-aides have had the highest prevalence rates of both HBsAg and Anti-HCV among the studied HCWs (HBsAg: 2.1% and 3.2% and Anti-HCV antibody: 3.2% and 4.9%, for nurses and nurse-aides, respectively). It is noteworthy that doctors also had a relatively high prevalence rate of Anti-HCV antibodies (2.2%); it has been demonstrated that doctors/surgeons have the highest risk of HBV infection from their patients [30—32]. More than half of HCWs were Anti-HBs antibody positive, and most of this positivity is due to vaccine exposure rather than past hepatitis B infection. The variations among the different cadres of HCWs might be a reflection of the different levels of exposure and the hazardous work environments that the different categories of HCWs operate in. This finding is in line with other studies [15,21]. Assessing HBV vaccination coverage in the health care setting is needed to evaluate the proportion of workers susceptible to HBV infection [33]. In Libya, while hepatitis B vaccination was added to the expanded program on immunization (EPI) in 1993, it is not mandatory for HCWs. Therefore, it is the employee’s responsibility to continue the vaccination schedule. A threshold of sero-positivity of 10 U/ml was chosen, as recommended by the United States Advisory Committee on Immunization Practices and the WHO [34]. We have shown that only half of the HCWs (52%) complete the full vaccination regimen (three doses) against HBV infection. Among them, the efficiency of the vaccine as manifested by anti-HBc positivity was approximately 98.0%. Among HCWs that did not receive any vaccine, 3.9% were HBsAg positive compared to only 1.3% in those HCWs who had received incomplete hepatitis B vaccination (p < 0.05 for all comparisons). A previous study conducted in Tripoli, Libya found that 78.2% of the HCWs were vaccinated [25]. The HBV vaccination
540 rates among HCWs in the Middle East and other countries with low socioeconomic status have been reported to be unsatisfactory [35]. According to the WHO estimates, vaccination rates vary from 18% in Africa to 77% in Australia and New Zealand [14]. In the United States, 75% of the HCWs at risk had received three or more doses of vaccine [36]. The distribution of HCV and HBV markers according to the categories of HCWs was also studied. ICU, CCU, isolation rooms or operating rooms were the work places found to be associated with HBV infection. Meanwhile, the surgical wards, medical wards and dialysis units were the work places with a higher frequency of HCV-infected HCWs. A high prevalence rate of both HBV and HCV were detected among gynecologists and obstetricians, and the prevalence of HBV was found to be extremely high (80%) among this population [24]. Ziraba et al. [21] concluded that laboratory technicians are more likely to be exposed to HBV, but in this study the frequency of HBV exposure was markedly low among laboratory technicians (0.8%). The current study investigated the distribution of hepatitis B and C markers according to the work duration of the HCWs. There was no significant difference between HBsAg status and the work period of HCWs (1.8% for >5 years of work versus 1.9% for less than 5 years of work, p > 0.05). However, there was a trend of increased Anti-HCV antibody positivity among those HCWs who have been working for periods of more than 5 years. Similar results of higher Anti-HCV antibody positivity were found among older HCWs [18]. Another study found that the age and employment duration strongly correlated with HBV prevalence [23]. Recently, a study carried out in Poland found that HBV occurred most frequently during the periods of 15—19, 20—24 and 25—29 years of employment (50% of cases), and it was lower for women than for men by 1.71 years (18.2 years versus 19.9 years) [37]. The limitations of our study are the size of our population sample due to limited funding and the cost of biological testing. Therefore, we had low numbers of HCWs in some settings (particularly in ICU and dialysis units). In addition, we did not determine the category of vaccinated and unvaccinated individuals. In conclusion, knowing the status of HBV and HCV infections among HCWs, the need for preventive measures (standard precautions) and enforcing vaccination against HBV are recognized as fundamental factors to protect this high risk group against these diseases. Moreover, the study explored that HBV vaccines should be more readily available for Libyan HCWs by reinforcing current vaccination programs.
A.-N. Elzouki et al.
Funding No funding sources.
Competing interests None declared.
Ethical approval Not required.
Acknowledgment The authors would like to thank the laboratory staff of the Center of Disease Control of Libya for technical support.
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541 [25] Ziglam H, El-Hattab M, Shingheera N, Zorgani A, Elahmer O. Hepatitis B vaccination status among healthcare workers in a tertiary care hospital in Tripoli, Libya. J Infect Public Health 2013;6:246—51. [26] Slusarczyk J, Małkowski P, Bobilewicz D, Juszczyk G. Crosssectional, anonymous screening for asymptomatic HCV infection, immunity to HBV, and occult HBV infection among health care workers in Warsaw, Poland. Przegl Epidemiol 2012;66:445—51. [27] Hofmann F, Michaelis M, Rieger MA, Hasselhorn HM, Berthold H. Occupational medicine significance of hepatitis C in health care employees. Gesundheitswesen 1997;59:452—60 [in German]. [28] Baldo V, Floreani A, Dal Vecchio L, Cristofoletti M, Carletti M, Majori S, et al. Occupational risk of blood-borne viruses in healthcare workers: a 5-year surveillance program. Infect Control Hosp Epidemiol 2002;23:325—7. [29] Bianco A, Bova F, Nobile CGA, Pileggi C, Pavia M. Healthcare workers and prevention of hepatitis C virus transmission: exploring knowledge, attitudes and evidence-based practices in hemodialysis units in Italy. BMC Infect Dis 2013;13:76. [30] Naz S, Ahmad M, Asghar H. Prevalence of hepatitis ‘B’ among hospital personnel in combined military hospital (CMH) Muzaffarabad. Int J Agric Biol 2002;4(2):227—30. [31] Belo AC. Prevalence of hepatitis B virus markers in surgeons in Lagos, Nigeria. East Afr Med J 2000;77(5):283—5. [32] Al-Sohaibani MO, Al-Sheikh EH, Al-Ballal SJ, Mirghani MA, Ramia S. Occupational risk of hepatitis B and C infections in Saudi medical staff. J Hosp Infect 1995;31:143—7. [33] Singhal V, Bora D, Singh S. Hepatitis B in health care workers: Indian scenario. J Lab Phys 2009;1:41—8. [34] West DJ, Calandra GB. Vaccine induced immunologic memory for hepatitis B surface antigen: implications for policy on booster vaccination. Vaccine 1996;14(11):1019—27. [35] Sadoh WE, Fawole AO, Sadoh AE, Oladimeji AO, Sotiloye OS. Practice of universal precautions among healthcare workers. J Natl Med Assoc 2006;98:722—6. [36] Simard EP, Miller JT, George PA, Wasley A, Alter MJ, Bell BP, et al. Hepatitis B vaccination coverage levels among healthcare workers in the United States, 2002—2003. Infect Control Hosp Epidemiol 2007;28:783—90. [37] Parszuto J, Jaremin B, Zagozdzon P, Bardo´ n A, Obuchowska A. Age and duration of employment of health care workers with occupational viral hepatitis B and C. Med Pr 2013;64:19—28.
Available online at www.sciencedirect.com
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Hepatitis B and C status among health care workers in the five main hospitals in eastern Libya Abdel-Nasser Elzouki a,∗,1, Salwa M. Elgamay b, Abdeulaziz Zorgani c, Omer Elahmer d a
Department of Medicine, Hamad General Hospital, Hamad Medical Corporation, Weill Cornell Medical College, Qatar b Faculty of Medical Technology, Derna, Libya c Department of Microbiology and Immunology, Faculty of Medicine, Tripoli University, Tripoli, Libya d National Center for Diseases Control, Tripoli, Libya Received 1 April 2014 ; received in revised form 19 June 2014; accepted 11 July 2014
KEYWORDS Health care workers; Hepatitis B; Hepatitis C; Hepatitis B vaccine; Libya
Summary The aim of the present study was to determine the frequency of hepatitis B and C transmission to health care workers (HCWs) in five major hospitals in eastern Libya and to analyze how the risk of these infections are affected by the type of occupation, hospital work place and working period. From July 2008 to June 2009, 601 HCWs (mean age: 32.90 ± 8.85 years) were tested for HBV and HCV markers using ELISA techniques. Polymerase chain reaction (PCR) was performed on all positive samples of HBsAg and Anti-HCV antibody to determine the level of HBV-DNA and HCV-RNA viremia, respectively. The overall frequency of HBsAg positivity was 1.8%. Anti-HBc, HBeAg and Anti-HBe antibodies were found in 8.5%, 0.7% and 8.0% of samples, respectively. The HBV-DNA level was positive in 55% of all HBsAg-positive samples. Approximately half of the HCWs (51.4%) were Anti-HBs antibody positive. The overall positivity rate of Anti-HCV antibodies was 2.0%, and HCV-RNA was positive in 33.3% of these samples. Overall, 52% of HCWs reported receiving full vaccination doses (three doses) against HBV infection. Among them, anti-HBs positivity was approximately 98.0%. 3.9% of those who never received any HBV vaccination dose were HBsAg positive, compared to 1.3% HBsAg positive in those HCWs who had received one or two doses of hepatitis B vaccine (p = 0.01 for all comparisons).
∗ Corresponding author at: Department of Medicine, Hamad General Hospital, Hamad Medical Corporation, P.O. Box 3050, Doha, Qatar. Tel.: +974 44392489; mobile: +974 66022836. E-mail address: nelzouki [email protected] (A.-N. Elzouki). 1 During the study period, this author was affiliated with the Department of Medicine, Aljomhoria Hospital, Al Arab Medical University, Benghazi, Libya.
http://dx.doi.org/10.1016/j.jiph.2014.07.006 1876-0341/© 2014 King Saud Bin Abdulaziz University for Health Sciences. Published by Elsevier Ltd. All rights reserved.
Hepatitis B and C in health care workers in Libya
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Nurses and nurse-aides had the highest rates of both HBsAg and Anti-HCV among the studied HCWs (HBsAg: 2.1% and 3.2%; Anti-HCV: 3.2% and 4.9%, respectively). It is noteworthy that doctors also had a relatively high prevalence rate of Anti-HCV (2.2%). Obstetric wards, isolation room, dialysis units and dentist work places had higher frequencies of HBV. HCV was found to be higher in the medical and surgical wards (the prevalence varied between 3% and 5.6%). There was no significant difference between HBsAg status and the work period of HCWs. In conclusion, universal precautions should be applied for the care of all patients by all HCWs. Further, HBV vaccines should be more readily available for Libyan HCWs by reinforcing current vaccination programs. © 2014 King Saud Bin Abdulaziz University for Health Sciences. Published by Elsevier Ltd. All rights reserved.
Introduction Hepatitis B virus (HBV) and hepatitis C virus (HCV) are among the main causes of liver-associated diseases, including liver cirrhosis and hepatocellular carcinoma [1,2]. Both viruses are major global public health problems warranting high priority efforts for prevention, control and treatment. Approximately two billion individuals worldwide have been infected by HBV, and between 350 and 400 million individuals have chronic HBV infection [3], while an estimated 200 million people (i.e., 3.3% of the world’s population) are chronically infected by HCV worldwide [4]. A majority of countries in the Middle East show an intermediate or high endemicity of HBV infection, which clearly poses a serious public health problem in the region [5]. The prevalence of HBV and HCV in Libya has been recently reported in a large general population-based study to be 2.2% for HBsAg and 1.8% for Anti-HCV antibodies [6]. The modes of transmission of these two bloodborne viruses in developing countries include perinatal transmission or household contact, while sexual contact, shared needles in intravenous drug abusers and contaminated blood or organ transplants are responsible for their transmission in developed countries [7]. However, screening tests as well as vaccination for HBV have dramatically reduced the risk of transmission worldwide [8]. Occupational exposure to HBV and HCV is a wellrecognized risk for health care workers (HCWs). The assessment of the risk of transmission to HCWs requires information derived from various sources including the place of HCW hospital work, the working period, the type of occupation, and the rate of exposure to patient blood and blood products [9]. The rates of transmission of HBV and HCV to HCWs are also influenced by the prevalence of HBV and HCV infection in the general population.
In developing countries, the prevalence of HBV and HCV among HCWs is high, while the vaccination status among HCWs and its relationship with occupational factors are not well documented [10,11]. Because the information regarding transmission of blood-borne viruses in HCWs is very limited in Libya we decided to determine the frequency of HBV and HCV transmission to HCWs in the five major hospitals in eastern Libya. A further aim of this study was to analyze how the risk of these infections are affected by the type of occupation, the place of work in the hospital and the working period as well as the vaccination status among this high risk group.
Materials and methods Study population The present study was conducted from July 2008 to June 2009 on 601 HCWs from five major hospitals in the three main cities in eastern Libya. There were 116, 120, 100, 152 and 113 HCWs from various professional categories who were randomly selected to represent the 1007, 455, 556, 405 and 680 HCWs in the Aljomhoria Hospital and Children’s Hospital (Benghazi), Althawra Hospital (Albaida), Alwahda Hospital (Derna), and Albutnan Medical Center (Tubruk), respectively. HCWs were defined as workers at risk of needle sticks or other sharps injuries in the hospitals. This definition included physicians, dentists, nurses, midwives, laboratory technicians, nursing aids, medical assistants, and cleaners. They were randomly selected from different places of work in these hospitals to include operation theaters, labor rooms, dental clinics, laboratories, endoscopy units, nephrology units, coronary care units (CCUs), intensive care units (ICUs), surgical and medical wards, and out-patient departments, as well as
536 hospital cleaners and workers in pharmacies and administration departments.
Data collection Demographic and epidemiological data were collected through direct personal interviews with each HCW carried out by one of the authors (S.A.). These data include sex, age, professional activities and practices, type of work, place and duration of work in the hospital as well as any history of hepatitis B vaccination. The data were anonymous and linked to the blood sample tube only by a code.
A.-N. Elzouki et al.
Statistical analysis The data were analyzed in SPSS statistical software version 19.0. Descriptive statistics in the form of the mean and standard deviations and the frequency with percentages were calculated for interval and categorical variables, respectively. The Chi-square test was used to identify differences between categorical variables and Student’s t-test was used for interval variables as appropriate. The results were considered statistically significant when the p-value (two-tailed) was less than 0.05.
Sample collection and laboratory analysis: A blood sample (5—10 ml) was extracted from each HCW and transported immediately to the local laboratory, in the same hospital in which the HCW was working, where it was centrifuged and the sera were stored at −20 ◦ C until transported to the Reference Laboratory for Disease Control at the National Centre for Disease Control of Libya in Tripoli city. Samples were tested for HCV markers using the enzyme linked immunosorbent assay (ELISA) technique (EIAgen HCV Ab [v.4] Adaltis, Italy) according to the manufacturer’s instructions. HBV markers (i.e., HBeAg, anti-HBe, anti-HBs, and total anti-HBc) were detected using the Enzyme Linked Fluorescent Assay (ELFA) (mini Vidas analyzer-BioMerieux, France). Both the HBsAg and Anti-HCV antibody results were considered positive (reactive) or negative (non-reactive) according to the interpretation parameters provided by the manufacturers. A positive control and a negative control were integrated in each run to validate the assay. Polymerase chain reaction (PCR) was also performed for all HBsAg and anti-HCV reactive samples to determine the levels of HBV-DNA and HCV-RNA viremia, respectively. Both HBV and HCV markers, as well as PCR assays, were performed at the Reference Laboratory for Disease Control at the National Centre for Disease Control of Libya, Tripoli.
Ethical considerations Ethical approval was obtained from the research ethical committee of Al-Arab Medical University, Benghazi, Libya. The study was conducted in accordance with the Helsinki Declaration [12] and under the supervision of the National Center for Disease Control of Libya. All participants provided written informed consent before the collection of data and blood samples.
Results The cohort was comprised of 601 HCWs from five major hospitals in eastern Libya: two hospitals (Aljomhuria Hospital and Children Hospital) in Benghazi (around one million inhabitants); Albeida (Althawra Hospital); Derna (Alwahda Hospital); and Tubruk (Albutnan Medical Center). There was a predominance of females (437, 72.3%), the majority of participants (560, 93.2%) were Libyan, and 41 individuals (6.8%) were non-Libyan. The mean age of the cohort was 32.90 ± 8.85 years (range = 17—60 years). More than three quarters (78.6%) of the studied HCWs were younger than 40 years of age. The overall frequency of HBsAg positivity was 1.8% (11 HCWs). However, Anti-HBc, HBeAg and Anti-HBe antibodies were found in 8.5%, 0.7% and 8.0% of participants, respectively. The HBV-DNA level was positive in 55% (6/11) of HBsAg-positive HCWs. Only half of the studied HCWs (51.4%) were immune to HBV infection as manifested by the detection of Anti-HBs antibodies. The overall positivity of Anti-HCV antibodies was 2.0% (12 HCWs), and the HCV-RNA level was positive in four (33.3%) of these samples. The distribution of hepatitis B and C markers, as well as the positivity of their viremia, is shown for the HCWs in each hospital in Table 1. Only half of the HCWs (312, 52%) received full vaccination doses (three doses) against HBV infection. Among them, the efficiency of the vaccine as manifested by anti-HBs positivity was approximately 98.0%. Table 2 shows the distribution of HBsAg according to hepatitis B vaccine status. Of the HCWs who had not received any vaccine, 3.9% (6/156) were HBsAg positive compared to only 1.3% (4/312) in HCWs who had received one or two doses of hepatitis B vaccine (p = 0.01 for all comparisons). As shown in Table 3, nurses and nurse-aides had the highest prevalence rates of both HBsAg and Anti-HCV antibody among the studied HCWs (HBsAg:
1 (0.9) 1 (0.8) 0 (0.0) 0 (0.0) 2 (1.8) 5 (4.3) 1 (0.8) 0 (0.0) 3 (2.0) 3 (2.7) 1 (0.8) 1 (0.8) 0 (0.0) 0 (0.0) 3 (2.7)
9 (7.8) 9 (7.5) 7 (7.0) 12 (7.9) 14 (12.4)
1 (0.9) 2 (1.7) 1 (1.0) 0 (0.0) 110 (97.3)
9 (6.7) 8 (6.7) 6 (6.0) 14 (9.2) 11 (9.7)
61 (52.5) 57 (47.5) 45 (45.0) 90 (59.2) 56 (49.6)
3 (2.6) 0 (0.0) 0 (0.0) 0 (0.0) 3 (2.7)
HCV-RNA +ve N (%) Anti-HCV +ve N (%) HBV-DNA +ve N (%) Anti-HBs +ve N (%) Anti-HBe +ve N (%) HBeAg +ve N (%) Anti-HBc +ve N (%) HBsAg +ve N (%)
537 Table 2 HBsAg positivity according to the hepatitis B vaccine received by health care workers (HCWs).
Aljomhoria Hospital (Benghazi) (n = 116) Children Hospital (Benghazi) (n = 120) Althawra Hospital (Albaida) (n = 100) Alwahda Hospital (Derna) (n = 152) Albutnan Medical Center (Tubruk) (n = 113)
Table 1
Distribution of Hepatitis B and C markers and their viremia among health care workers in the five hospitals of eastern Libya.
Hepatitis B and C in health care workers in Libya
Vaccine dose received by HCWs One dose (n = 50)* Two doses (n = 79) Three and four doses (n = 312)* Vaccine not received (n = 156)* Total (n = 601) *
HBsAg +veN (%) 1 (2.0) 0 (0) 4 (1.3) 6 (3.9) 11 (1.8)
p < 0.05 for all comparisons.
2.1% and 3.2%, and Anti-HCV antibody: 3.2% and 4.9%, for nurses and nurse-aides, respectively). It is noteworthy that doctors also had a relatively high prevalence rate of Anti-HCV antibody (2.2%). More than half of HCWs were Anti-HBs antibody positive. Most of this positivity is due to vaccine exposure rather than past hepatitis B infections. The distribution of HBV markers according to the work places of the HCWs was also studied. HCWs working on gynecology and obstetric wards, surgical wards, medical wards and dialysis units had a higher frequency of infection with either HBV and/or HCV (the prevalence rate varied between 3% and 5.6%) compared to other work site categories such as the ICU, CCU, operating rooms, dental clinics, laboratories, emergency rooms, OPD and isolation wards (data not shown). Table 4 shows the distribution of hepatitis B and C markers according to the duration of time participants spent as HCWs. There was no significant difference between HBsAg status and the work period of HCWs (1.8% for >5 years of work versus 1.9% for HCWs with a period of work duration less than 5 years, p = 0.4 p > 0.05). However, there was a trend toward increased Anti-HCV antibody positivity among those HCWs who have been working for more than 5 years, although this finding did not reach the level of statistical significance (2.5% for >5 years of work versus 1.4% for less than 5 years of work, p = 0.08).
Discussion According to the World Health Organization (WHO) the proportion of HCWs in the general population varies substantially from region to region (0.2—2.5%), as does the average number of occupational injuries per HCWs (for example, 0.2—4.7% sharp injuries per worker per year) [13]. The annual proportion of HCWs exposed to HBV each year was 5.9% for HBV, corresponding to approximately 66,000 HBV infections in HCWs worldwide. In developing countries, 40—65% of HBV infections
538
Table 3
Distribution hepatitis B and C markers according to the type of occupation of the health care workers.
Occupation
HBsAg +ve N (%)
HBcAb +ve N (%)
HBeAg +ve N (%)
Anti-HBe +ve N (%)
1 (0.7) 1 (0.9) 4 (2.1) 2 (3.3) 1 (1.4) 1 (7.7) 1 (4.0)
10 (29.4) 4 (3.6) 19 (10.1) 8 (13.1) 8 (11.4) 1 (7.7) 1 (4.0)
2 (1.5) 0 (0.0) 2 (1.1) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
7 (5.2) 7 (6.4) 20 (10.6) 7 (11.5) 5 (7.1) 1 (7.7) 1 (4.0)
84 (62.7) 70 (63.6) 98 (52.1) 22 (36.1) 28 (40.0) 8 (61.5) 3 (12.0)
0 (0.0) 1 (0.9) 3 (1.6) 1 (1.6) 0 (0.0) 1 (7.7) 0 (0.0)
3 (2.2) 0 (0.0) 6 (3.2) 3 (4.9) 0 (0.0) 0 (0.0) 0 (0.0)
1 (0.7) 0 (0.0) 1 (0.5) 2 (3.3) 0 (0.0) 0 (0.0) 0 (0.0)
11 (1.8)
51 (8.5)
4 (0.7)
48 (8.0)
309 (51.4)
6 (1.0)
12 (2.0)
4 (0.7)
Doctors (n = 134) Lab technicians (n = 110) Nurses (n = 188) Nurse-aides (n = 61) Hospital cleaners (n = 70) Anesthesia technicians (n = 13) Others (n = 25) Total (n = 601)
Table 4
HBV-DNA +ve N (%)
Anti-HCV +ve N (%)
HCV-RNA +ve N (%)
Distribution of hepatitis B and C markers according to the duration of the work period of health care workers.
Work period
HBsAg +ve N (%)
HBeAg +ve N (%)
Anti-HBe +ve N (%)
Anti-HBs +ve N (%)
HBV-DNA +ve N (%)
Total (n = 601)
5 (1.8) 6 (1.9)
14 (1.75) 37 (11.5)
3 (1.1) 1 (0.3)
13 (4.6) 35 (10.9)
123 (43.9) 186 (57.9)
3 (1.0) 3 (0.9)
4 (1.4) 8 (2.5)
1 (0.4) 3 (0.9)
11 (1.8)
51 (8.5)
4 (0.7)
48 (8.0)
309 (51.4)
6 (1.0)
12 (2.0)
4 (0.7)
No significant difference.
Anti-HCV +ve N (%)
HCV-RNA +ve N (%)
A.-N. Elzouki et al.
HBcAb +ve N (%)
0—5 years (n = 280)* >5 years (n = 321)*
*
Anti-Hbs +ve N (%)
Hepatitis B and C in health care workers in Libya in HCWs are attributable to percutaneous occupational exposure. By contrast, in developed countries, the exposure rate was less than 10%, largely due to high rates of immunization and the availability of post-exposure prophylaxis [14]. The strengths of the present study include the fact that it involved multiple centers, which allowed us to identify the seroprevalence of HBV and HCV, the working period, and the different occupational risks of acquiring infection in HCWs in five different sites in eastern Libya. The lower prevalence of HBsAg (1.8%) was similar to data from a national population-based sero-epidemiological survey that found that the overall prevalence of HBV was 2.2% [6]. Two previous local studies carried out in Libya have found that 31% and 14.8% of HCWs in Tripoli and Benghazi, respectively, were infected [15,16], and the low prevalence among HCWs in the present study might be explained by their awareness of the routes of HBV transmission, the implementation of infection control measures and a free vaccination program. Numerous sero-prevalence studies have documented the risks of HCWs of contracting hepatitis B. Rates in our cohort exceeded those reported in Brazil (0.8%), Egypt (1.5%) and Morocco (1%) [17—19]. Moreover, HCWs are reported to have a lower (1%) prevalence of HBsAg compared to Moroccan blood donors (1% versus 2%) (17) [17—19]. In contrast, we observed lower prevalence rates than those found in Syria (6%), Cameroon (23.6%), Nigeria (13%), Pakistan (2.18%) and Uganda (8.1%) [20—24]. Anti-HBc, HBeAg and Anti-HBe antibodies were found in 8.5%, 0.7% and 8.0%, respectively. Similar positive anti-HBc serological results were found in Brazil by Luiz et al., 9.4% [19]. Only half of the studied HCWs (51.4%) were immune to HBV infection as manifested by the detection of AntiHBs antibodies. These results show that half of the studied HCWs could have contracted HBV after a needle stick injury involving an HBV carrier’s blood. Recently, Ziglam et al. [25] have demonstrated that only 21.8% (591/2704 of HCWs) had anti-HBs antibody concentrations (less than 10 U/ml) in a tertiary care hospital in Tripoli, Libya. This survey shows that one in fifty (N = 12) of the HCWs employed in high-risk environments had Anti-HCV antibodies (2.0%), and HCV-RNA as measured by PCR was positive in four (33.3%) of these HCWs. Various studies detected substantially different results: in Cameroon (16%), Egypt (16.6%, with HCV-RNA detected in 72.1% of the samples), and Syria (3%), while in Poland, 1.7%, with HCV-RNA detected in 3 out of these 16 (19%) sera samples [18,20,22,26]. It has been suggested that the reported risk of HCV infection following occupational exposure is low, with seroconversion rates
539 between 0% and 5%, with <1% as the most commonly reported rate [27,28]. Recently, a study performed in Italy focusing on the HCV knowledge and attitudes and exploring the evidence-based practices for the prevention of HCV has recommended that behavior changes should be aimed at abandoning outdated practices and adopting and maintaining evidence-based practices [29]. Our results described a higher rate of HCV antibody positivity than a large scale multi-staged study covering more than 65,000 individuals of all age groups from the whole of Libya, in which the prevalence of Anti-HCV antibodies was 1.3% [6]. This might be explained by the risks of occupational blood exposure such as needle stick injuries. Nurses and nurse-aides have had the highest prevalence rates of both HBsAg and Anti-HCV among the studied HCWs (HBsAg: 2.1% and 3.2% and Anti-HCV antibody: 3.2% and 4.9%, for nurses and nurse-aides, respectively). It is noteworthy that doctors also had a relatively high prevalence rate of Anti-HCV antibodies (2.2%); it has been demonstrated that doctors/surgeons have the highest risk of HBV infection from their patients [30—32]. More than half of HCWs were Anti-HBs antibody positive, and most of this positivity is due to vaccine exposure rather than past hepatitis B infection. The variations among the different cadres of HCWs might be a reflection of the different levels of exposure and the hazardous work environments that the different categories of HCWs operate in. This finding is in line with other studies [15,21]. Assessing HBV vaccination coverage in the health care setting is needed to evaluate the proportion of workers susceptible to HBV infection [33]. In Libya, while hepatitis B vaccination was added to the expanded program on immunization (EPI) in 1993, it is not mandatory for HCWs. Therefore, it is the employee’s responsibility to continue the vaccination schedule. A threshold of sero-positivity of 10 U/ml was chosen, as recommended by the United States Advisory Committee on Immunization Practices and the WHO [34]. We have shown that only half of the HCWs (52%) complete the full vaccination regimen (three doses) against HBV infection. Among them, the efficiency of the vaccine as manifested by anti-HBc positivity was approximately 98.0%. Among HCWs that did not receive any vaccine, 3.9% were HBsAg positive compared to only 1.3% in those HCWs who had received incomplete hepatitis B vaccination (p < 0.05 for all comparisons). A previous study conducted in Tripoli, Libya found that 78.2% of the HCWs were vaccinated [25]. The HBV vaccination
540 rates among HCWs in the Middle East and other countries with low socioeconomic status have been reported to be unsatisfactory [35]. According to the WHO estimates, vaccination rates vary from 18% in Africa to 77% in Australia and New Zealand [14]. In the United States, 75% of the HCWs at risk had received three or more doses of vaccine [36]. The distribution of HCV and HBV markers according to the categories of HCWs was also studied. ICU, CCU, isolation rooms or operating rooms were the work places found to be associated with HBV infection. Meanwhile, the surgical wards, medical wards and dialysis units were the work places with a higher frequency of HCV-infected HCWs. A high prevalence rate of both HBV and HCV were detected among gynecologists and obstetricians, and the prevalence of HBV was found to be extremely high (80%) among this population [24]. Ziraba et al. [21] concluded that laboratory technicians are more likely to be exposed to HBV, but in this study the frequency of HBV exposure was markedly low among laboratory technicians (0.8%). The current study investigated the distribution of hepatitis B and C markers according to the work duration of the HCWs. There was no significant difference between HBsAg status and the work period of HCWs (1.8% for >5 years of work versus 1.9% for less than 5 years of work, p > 0.05). However, there was a trend of increased Anti-HCV antibody positivity among those HCWs who have been working for periods of more than 5 years. Similar results of higher Anti-HCV antibody positivity were found among older HCWs [18]. Another study found that the age and employment duration strongly correlated with HBV prevalence [23]. Recently, a study carried out in Poland found that HBV occurred most frequently during the periods of 15—19, 20—24 and 25—29 years of employment (50% of cases), and it was lower for women than for men by 1.71 years (18.2 years versus 19.9 years) [37]. The limitations of our study are the size of our population sample due to limited funding and the cost of biological testing. Therefore, we had low numbers of HCWs in some settings (particularly in ICU and dialysis units). In addition, we did not determine the category of vaccinated and unvaccinated individuals. In conclusion, knowing the status of HBV and HCV infections among HCWs, the need for preventive measures (standard precautions) and enforcing vaccination against HBV are recognized as fundamental factors to protect this high risk group against these diseases. Moreover, the study explored that HBV vaccines should be more readily available for Libyan HCWs by reinforcing current vaccination programs.
A.-N. Elzouki et al.
Funding No funding sources.
Competing interests None declared.
Ethical approval Not required.
Acknowledgment The authors would like to thank the laboratory staff of the Center of Disease Control of Libya for technical support.
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