Hepatitis B infection among health workers in Uganda: Evidence of the need for health worker protection☆
Introduction
Hepatitis B infection remains a public health problem globally, causing 700,000 deaths annually [1], [2] and a major occupational hazard for health care personnel [3], [4], [5], [6], [7], [8], [9], [10]. Where hepatitis B infection is highly endemic and frequently occurs in early childhood, it is often asymptomatic and leads to the chronic carrier state in 50–90% of children [2]. Adults infected with hepatitis B virus usually recover, but 5–10% develop a chronic carrier state, resulting in chronic hepatitis, liver cirrhosis and hepatocellular carcinoma [2], [11] with fulminant and usually fatal acute hepatitis in 1% on first infection [2], [6], [11]. Most infections still occur in highly endemic countries of Asia and sub-Saharan Africa [1], including Uganda [12], [13], where more than 8% of the population are chronic carriers of the virus. In Uganda, it was recently shown that 52% of the adult population have serological evidence of previous hepatitis B exposure and 10% are chronic carriers [14].
Health care personnel have an increased risk of hepatitis B infection compared to the general population [7], [8], and transmission from health workers to patients has been documented [9], [15], [16]. Occupational exposure to hepatitis B can result from percutaneous injury (needle stick or other sharps injury), mucocutaneous contact (splash of blood or other body fluids into the eyes, nose or mouth) or blood contact with non-intact skin [4], [6], [15]. Vaccination against hepatitis B induces immunity in 95% of healthy recipients [1], and protection of health workers through immunisation, use of protective equipment and post-exposure management is critical [7], [9], [15]. Nationally appropriate policy decisions on vaccination of health workers in Uganda should be based on information on hepatitis B exposure in this group.
A survey was conducted to assess the exposure of health workers in Uganda to hepatitis B, measles and rubella infections. The objectives with respect to hepatitis B were to determine the prevalence of hepatitis B serological markers among health workers; to document the risk factors associated with positive hepatitis B serology; and to determine health worker willingness to take up vaccination against hepatitis B. Findings for measles and rubella exposure are reported elsewhere [17].
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Study design, subjects and data collection
A cross-sectional serological and questionnaire survey was conducted among health personnel in 48 of 56 districts in Uganda, excluding 8 insecure districts (Gulu, Kitgum, Pader, Kotido, Moroto, Nakapiripirit, Soroti and Katakwi).
A sample size of 289 health workers was determined with participants stratified into three risk categories, to allow comparison of outcomes for these groups, with a 95% level of confidence, statistical power of 80% and precision of 5% [18]. Sample size was determined
Results
Of the predetermined sample size of 289 health workers initially selected from 98 health units, 270 (93.4%) agreed to participate in the survey and 19 were replaced, giving a refusal rate of 6.6%. In some instances additional workers were also enrolled at their request but not separately identified, raising the sample size to 311 workers for whom results are presented.
Of the 311 health workers, 57% were women (Table 2). Age ranged from 20 to 62 years, with a mean of 36.9 years and median of
Discussion
Our study confirms the high prevalence of hepatitis B infection among health personnel in Uganda, with more than 60% having evidence of current or previous infection and 9% harboring active infection at the time of the study. Prevalence of hepatitis B exposure rose with age and duration of service, and a history of blood transfusion more than tripled the risk. These findings are consistent with the first national hepatitis B serosurvey in Uganda carried out subsequently, which showed that over
Acknowledgements
The authors are greatly indebted to the late Mr. Apollo Muwonge, laboratory technologist, and other staff of the Uganda Virus Research Institute EPI laboratory, who carried out the serological assays for this study. We thank Mr. Nasan Natseri and Mr. Peter Kintu for assistance with data management and analysis. We finally thank the team of Research Assistants from the Ministry of Health for their dedication through the data collection. This study was funded by the Centers for Disease Control,
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The findings and conclusions in this study are those of the authors and do not necessarily represent the views of the funding agencies or the organizations to which the authors belong.