Abdelmounem Eltayeib Abdo
Consultant Gasteroenterologist Director of the National Centre of Gastroenterology Ibn-Sina Hospital General Secretary of PanarabDirector of WGO Khartoum Training Center, Khartoum, Sudan, E-mail: munem2002@hotmail.com
Hepatitis virus infections are the most common cause of liver disease worldwide. Sudan is classified among the countries with high hepatitis B virus seroprevalence Hepatitis B Virus (HBV) infection is a global public health problem. It is estimated that there are more than 350 million HBV carriers in the world, of whom one million die annually from HBV-related liver disease.1 The implementation of effective vaccination programs in many countries has resulted in a significant decrease in the incidence of acute hepatitis B. Nevertheless, hepatitis B remains an important cause of morbidity and mortality.
Sudan is classified among the countries with high HBV endemicity. Earlier studies carried out in the 80’s and 90’s estimated higher rates of HBsAg of 17.5% among asymptomatic blood donors.2 The screening of blood donations for HBV was introduced throughout the country in 2002, before which time screening was performed in only a few centers in Khartoum. Vaccination for HBV was included as part of the extended programme of immunization in 2005. The introduction of vaccination and the screening of blood and blood products reduced the rate of HBV infection and the carrier pool.3 In more recent studies, the HBV seropositivity varies between different regions of Sudan, but ranges between 5 and 7% in the general population.3,4,5,6 More than a decade passed since the introduction of blood screening in blood banks, and this study is to monitor how much this together with other measures including vaccination were effective in reducing the infection rates of HBV. No recent data is available about the prevalence of HBV in all Sudan states, in a given time. The available data are scattered data of some states that included small numbers of patients.
One of the major factors attributing to increased transmission of HBV is the lack of awareness about the prevalence, mode of transmission and preventive measures. The study is designed to test the knowledge of blood donors about HBV. The study population were usually young and middle aged males, representing the most productive age group. Infection of this age group with HBV, HCV or HIV, has a major impact on the population as a whole. Knowledge and awareness about the mode of transmission is important for the planning and preventive health education programme. Disease control by preventive strategy is more effective than a curative one.
200 males presenting to the national blood bank for blood donation are approached to participate in this study, after an informed verbal consent for acceptance, a structured questionnaire including age, marital status and level of education is filled. The questionnaire also tests the donor’s knowledge about risk factors and mode of transmission and the consequences of HBV infection. Donors were asked if they were vaccinated and whether they are interested to know the results of their viral screening.
Retrospective data regarding the prevalence of HBV in the years 2012, 2013 and 2014 was collected from monthly reports delivered to the central bank of blood services from the Sudan States major blood banks. The number of states included in the study was 15 states in 2012, 17 states in 2013 and 18 states in 2014. Methods for screening for HBsAg differ between states; some states use ICT for testing, others use ELISA, and some states use both methods. The data was analyzed with statistical package for social sciences (SPSS 11.5). The results were presented in tables, discussed and compared with local and international studies.
200 blood donors were included in this study, to test their knowledge regarding HBV out of which 30% were under the age of 25 years, 49% were between 25-35 years, 19% were between 36-45 years and 2% were above the age of 46 years. Sixty two percent of the donors were single and 38% were married. (Tables 1-3)
| Table 1: Prevalence of HBV among blood donors in fifteen states in 2012. | |||
| State | Total no. of donors
tested |
No of HBV +ve
Donors |
Percentage |
| Khartoum | 19450 | 710 | 3.65% |
| Al-Gezira | 109588 | 4851 | 4.4% |
| Sinar | 7873 | 159 | 2% |
| Kassala | 6099 | 225 | 3.67% |
| Red Sea | 4602 | 74 | 1.6% |
| A-Gadarif | 1850 | 56 | 3% |
| Blue Nile | 3125 | 68 | 2.17% |
| White Nile | 5162 | 301 | 5.83% |
| Nahr El Nile | 4956 | 8 | 0.1% |
| Northern state | 2461 | 5 | 0.1% |
| North kordofan | 5409 | 179 | 3.3% |
| South Kordofan | 4248 | 670 | 15.7% |
| North Darfor | 5331 | 230 | 4.3% |
| South Darfor | 4834 | 124 | 2.5% |
| West Darfor | 1984 | 127 | 6.4% |
| Total | 187072 | 7787 | 4.1% |
| Table 2: Prevalence of HBV among blood donors in seventeen states in 2013. | |||
| State | Total no. of donors
tested |
No of HBV +ve
Donors |
Percentage |
| Khartoum | 120850 | 5680 | 5.48% |
| Al-Gezira | 13583 | 746 | 4.7% |
| Sinar | 12784 | 407 | 3.1% |
| Kassala | 7780 | 447 | 5.74% |
| Red Sea | 4524 | 103 | 2.2% |
| A-Gadarif | 66655 | 3140 | 4.71% |
| Blue Nile | 3601 | 166 | 4.61% |
| White Nile | 3331 | 410 | 12.3% |
| Nahr El Nile | 2232 | 38 | 1.7% |
| Northern state | 263 | 0 | 0% |
| North kordofan | 4651 | 282 | 6% |
| South Kordofan | 1976 | 94 | 4.75% |
| North Darfor | 3157 | 249 | 7.88% |
| South Darfor | 8364 | 502 | 6% |
| West Darfor | 1741 | 118 | 6.77% |
| East Darfor | 1280 | 65 | 5% |
| Middle Darfor | 413 | 24 | 5.8% |
| Total | 257185 | 12471 | 4.8% |
| Table 3: Prevalence of HBV among blood donors in eighteen States in
2014 |
|||
| State | Total no. of donors
tested |
No of HBV +ve
Donors |
Percentage |
| Khartoum | 90905 | 2505 | 2.7% |
| Al-Gezira | 27990 | 1470 | 5.25% |
| Sinar | 20171 | 863 | 4.2% |
| Kassala | 10910 | 499 | 4.5% |
| Red Sea | 4214 | 187 | 4.4% |
| A-Gadarif | 12042 | 1063 | 8.8% |
| Blue Nile | 6178 | 254 | 4.1% |
| White Nile | 10970 | 894 | 8.17% |
| Nahr El Nile | 5557 | 53 | 0.9% |
| Northern state | 4118 | 22 | 0.5% |
| North kordofan | 14222 | 805 | 5.6% |
| South Kordofan | 6514 | 183 | 2.8% |
| North Darfor | 10417 | 420 | 4% |
| South Darfor | 2183 | 99 | 4.5% |
| West Darfor | 2019 | 92 | 4.5% |
| East Darfor | 2608 | 95 | 3.6% |
| Middle Darfor | 3438 | 208 | 6% |
| West kordofan | 27484 | 1401 | 5% |
| Total | 261940 | 11113 | 4.2% |
Regarding the educational level of the donors 1% were education, 29% had a high school education and 54.5% had university level or postgraduate education. 4% had an intermediate school education, 29% had a high school education and 54.5% had university level or postgraduate education.
Fortyone donors (20.5%) had been in contact with a HBV positive patient, either a relative, neighbour or a friend.
When asked about HBV modes of transmission, 23% knew that HBV can be transmitted through blood, 0.5% mentioned sexual transmission, 8.5% knew that it can be transmitted both sexually and through blood transmission. Only 3% had a good knowledge and mentioned the three major modes of transmission, and the majority (59%) did not know any of HBV modes of transmission. Of those 0.8% were illiterate, 16.9% had a primary school level, 3.4% had a intermediate school level, 29.7% had a high school level, and 49.2% had a university or postgraduate level of education.
When asked about the consequences of HBV infection,74 donors (37%) knew that HBV can cause liver cirrhosis, seven donors (3.5%) knew that HBV can cause liver cirrhosis, and it can be complicated with portal hypertension and Hepatocellular Carcinoma. But 119 donors (59.5%) were not aware of the consequences of HBV, of those 0.8% were illiterate, 16% had a primary school level, 3.4% had a intermediate school level, 33.6% had a high school level, and 46.2% of donors with a university level of education did not know any of HBV modes of transmission.Only seventeen donors (8.5%) were vaccinated against HBV, 183(91.5%) were not vaccinated, of them 10(5%) did not think vaccination was important and 173(86.5%) did not know about the vaccine. One hundred eightyseven (93.5) wanted to know the result of their screening, 13(6.5%) did not want to know, mainly because of the fear of positivity and the impact of a positive result in their lives, jobs and families.
The overall prevalence of HBV in Sudan in 2012 was 4%. The prevalence varies between the 15 states included in the surveillance, ranging between 0.1 in Nahr Alnile and the Northern state to 15.7% in South Kordofan. In 2013, 17 states were included in the survey and the overall prevalence of HBV was found to be 5%. The prevalence of HBV ranged between 0% the Northern state to 12.3% in White Nile state. In 2014 HBV prevalence was found to be 4.2%. The survey included eighteen states and HBV prevalence ranged between 0.5% in the Northern state and 0.9% in Nahr Alnile to 8.8% in Gadarif.
Despite the implementation of effective vaccination programs, hepatitis B remains an important cause of morbidity and mortality worldwide. Understanding the epidemiology of the disease is essential in developing programs to prevent and treat this global infection.1 The lack of knowledge about HBV modes of transmission, its consequences, and its preventive measures is a major cause of increasing prevalence of HBV. Other causes include the influx of immigrants from endemic areas and the improvement diagnosis and documentation of HBV infection.
All blood donors included in the study are males. Females do not usually donate blood in Sudan. Men of young or middle age are those who willingly donate blood.
Although 20% had a relative, neighbour or a friend diagnosed with HBV or HBV related disease, their knowledge of HBV was generally poor. When asked about HBV modes of transmission; 23% knew that HBV can be transmitted through blood, 8.5% knew that it can be transmitted both sexually and through blood transmission, but only 3% mentioned all three major modes of transmission, including vertical transmission. The majority (59%) did not know any of HBV modes of transmission; of those 49.2% had a university level of education or higher.
Only 3% knew that HBV can cause liver cirrhosis and can be complicated by portal hypertension and Hepatocellular Carcinoma. The majority (59.5%) of the study population of whom 46.2% were university graduates did not know any consequences of HBV infection. The lack of knowledge is observed in all groups irrespective of their education level. A study was carried out among non medical students of the University of Kassala, to assess their knowledge and awareness towards HIV and HBV infection. It revealed that the students had poor knowl-edge about HBV mode of transmission, symptoms and preventive measures, in comparison they had better knowledge about HIV infection.7 Most of those vaccinated (8.5%) were offered the vaccine by their employers (e.g. Central Sudan bank, Al Gaili petrol refinery). The study population included two doctors who were not vaccinated. The majority (93.5%) wanted to know the result of their viral screening.
In 2012, the Northern and Nahr Alnile states had the lowest prevalence of HBV (0.1%). In 2013 no cases were detected in the Northern Province, probably because of the small size of the population tested, i.e. only 263 donors. The incidence in Nahr Alnile, in the same year, was 1.7%. In 2014, HBV prevalence in the Northern state was 0.5%, and was 0.9% in Nahr Alnile. Our data showed a lower percent when compared to a previous study in 2007, conducted among blood donors in Shendi, Nahr Alnile, and was found to be 5.1%.8
The highest prevalence of HBV in 2012 was in South Kordofan, which was 15.7%. In 2013, the White Nile state had the highest percent of 12,3. And in 2014, Al-Gadarif showed the highest prevalence of 8.8%. No published data about the prevalence in these states were found.
The prevalence in Khartoum, in 2012-2014 was 3.6%, 4.7%, and 2.7%. A study conducted, in 2008-2011 on patients undergoing surgery at Alshab Hospital, one of the major hospitals in Khartoum, revealed a higher percentage of 4.9%.9 In a more recent study in 2012 conducted among 843 health care workers in public teaching hospitals in Khartoum showed that Anti-HB core was found to be 57%, HBsAg was 6%, HBeAg was 9%, and Anti-HBsAg was 37%.10
The HBV prevalence in Al-Gezira state (Central Sudan) in 2012-2014, was 4.4%, 5.49%, and 5.2% respectively. These percentages are lower than those observed in a study conducted in 2000, in Um Zukra village in Al-Gezira state, the percent of HBV was found to be 6.9%.3 An earlier study in 1992, revealed much higher percents, it studied the prevalence of hepatitis B surface antigen in blood donors and laboratory technical staff in Al-Gezira state, and was found to be 17.3%, and 12.1% respectively. 11 A study of the epidemiology of HBV in Al-Gezira State in 1989 reported a high HBsAg rate of 18.7% and anti-HBc of 63.9%.12
The prevalence of HBV in South Darfor (West Sudan) in 2012-2014 was 2.5%, 6% and 4.5% respectively. An earlier study in 2007 conducted in blood donors in Nyala (West Sudan) revealed a percent of 6.25%.5
The prevalence of HBV in Kassla (East Sudan) in 2012-2014 was 3.6%, 5.7% and 4.2 % respectively. A much higher percentage of 8.2% was found in a study conducted in 2011 on healthy visitors at Kassala Hospital.13 The prevalence in the Red Sea state in 2012-2014 was 1.6%, 2.2%, and 4.4% respectively. In a study in 1987, HBsAg was detected in 14% of sexually active heterosexuals in Port Sudan and Suakin, and 27% were positive for Anti-HBc.11
Poor knowledge about HBV risk factors, complication and preventive measures, was observed in all sectors, even in those with higher level of education. It is attributed to the absence of formal school based health education. Lack of knowledge is a major obstacle in controlling HBV transmission. With the exception of the Northern and Nahr Alnile States that sustained low levels of HBV infection throughout the years, there is a large variation in the prevalence of HBV among different states, together with differences in prevalence in the same state throughout the years. This is due to the influx of immigrants from the borders of Sudan, and the internal population movements between states. But generally the rates are lower than those previously reported,3,4,5,6 as the overall prevalence in Sudan in 2012-2014 was 4.1%, 5% and 4%, respectively.
Although there is a large variation in the prevalence of HBV among the states, together with differences of prevalence in the same state throughout the years, the rates are generally lower than those previously reported. The overall prevalence in Sudan in 2012-2014 was 4.1%, 5% and 4% respectively.
The highest prevalence of HBV in 2012-2014 was in South Kordofan, the White Nile, and Al-Gadarif respectively. From 2012-2014, the Northern and Nahr Alnile states had the lowest prevalence of HBV. More measures should be taken by health authorities, especially in the states with a high prevalence of HBV, including mass screening and vaccination programmes. Despite the availability of HBV vaccine, almost all the donors were not vaccinated, poor knowledge about HBV mode of transmission, symptoms and preventive measures was demonstrated in all sectors irrespective of their level of education. HBV transmission, and thus prevalence can be controlled by improving the population knowledge.
As a conclusion, more efforts are needed to increase awareness about HBV infection, and ways of preventing transmission. Knowledge can be delivered through media, poster and brochures targeting all sectors, but focusing mainly on the young population as they in turn can act as a source of knowledge to their families. Blood donors found to be seronegative for HBV,
The authors declare that they have no conflicts of interest.
We obtained a written consent from all the 200 blood donors included in the study, it includes information and agreement that the data will be published.
1. Hwang EW, Cheung R. Global epidemiology of Hepatitis B Virus (HBV) infection. N A J Med Sci. 2011; 4(1): 7-13. doi: 10.7150%2Fijms.2.50
2. Elshafie SS. The prevalence of hepatitis B surface antigen in the Gezira (Sudan). Afr J Med Sci. 1992; 21: 61-63. doi: 10.2147%2Fceg.s3887
3. Mudawi HMY, Smith HM, Rahoud SA, Fletcher IA, Saeed OK, Fedail SS. Prevalence of hepatitis B virus infection in the Gezira State of Central Sudan. Saudi J. Gastroenterol. 2007; 13: 81-83. doi: 10.4103/1319-3767.32182
4. Abou MA, Eltahir YM, Ali AS. Seroprevalence of hepatitis B virus and hepatitis C virus among blood donors in Nyala, South Dar Fur, Sudan. Virology J. 2009; 6: 146. doi: 10.1186/1743- 422X-6-146
5. Elsheikh RM, Daak AA, Elsheikh MA, Karsany MS, Adam I. Hepatitis B virus and hepatitis C virus in pregnant Sudanese women. Virol. J. 2007; 4: 104. doi: 10.1186/1743-422X-4-104
6. Omer EE, Van’t Veer P, Kadaru AM, Kampman E, el Khidir IM, Fedail SS, Kok FJ. The role of hepatitis B and hepatitis C viral infections in the incidence of hepatocellular carcinoma in Sudan. Trans. R. Soc. Trop. Med. Hyg. 2001; 95: 487-491. doi: 10.1016/s0035-9203(01)90013-6
7. Khalid FA, Eltayeb AA, Elbadawi NEE. Awareness and Knowledge of Hepatitis B and HIV/AIDS, Among the University of Kassala Students, Sudan. J AIDS Clin Res. 2013; 4: 194. doi: 10.4172/2155-6113.1000194
8. Nagi AM, Altyeb HA, Ahmed AM. Seroprevalence of Hepatitis B and C Viral Infections among blood donors in Shendi, River Nile State, Sudan. Res. J. Med. Med. Sci. 2007; 2: 122-126. doi: 10.1186%2F1743-422X-6-146
9. Osman EA I, Abdulrahman NA, Abbass O, et al. Prevalance of hepatitis B surface and hepatitis C virus antibodies among pre-surgery screened patients in Khartoum, Central sudan. GlobalJ of virology and immunology. 2013; 22-25. doi: 10.5897/JGMV12.003
10. Elmukashfi TA, Ali Ibrahim O, Elkhidir IM, Ali Bashir A, Ali Awad Elkarim M. Socio-Demographic Characteristics of Health Care Workers and Hepatitis B Virus (HBV) Infection in Public Teaching Hospitals in Khartoum State, Sudan. Global Journal of Health Science. 2012; 4(4). doi: 10.5539/gjhs.v4n4p37
11. McCarthy MC, Burans JP, Constantine NT, et al. Hepatitis B and HIV in Sudan: a serosurvey for hepatitis B and human immunodeficiency virus antibodies among sexually active heterosexuals. American Journal of Tropical Medicine and Hygiene. 1989; 41(6): 726-731. doi: 10.4269/ajtmh.1989.41.726
12. Hyams KC, Al-Arabi Mohamed A, Al-Tagani Ahmed A, et al. Epidemiology of hepatitis B in the Gezira region of Sudan. American Journal of Tropical Medicine and Hygiene. 1989; 40(2): 200-206. doi: 10.4269/ajtmh.1989.40.200
13. Abdallah TM, Mohamed MH, Ali AA. Seroprevalance and epidemiological factors of hepatitis B virus infection in Eastern Sudan. International j of medicine and medical sciences. 2011; 239-241. doi: 10.5897/IJMMS.9000213
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