Detection of Hepatitis C and Hepatitis B Virus Infection Among Prison Inmates and Psychiatric Patients in Kaduna Metropolis, Nigeria
Chapter One
Aim of the Study
This study aimed at determining the prevalence of HCV and HBV infections among prison inmates and psychiatric patients in Kaduna Metropolis, Nigeria.
Specific Objectives
The specific objectives of this research were to:
- Screen for HCV antibodies and HBsAg among prison inmates and psychiatric patientsin Kaduna
- Detect HCV RNA using reverse transcription polymerase chain reaction (RT- PCR).
- Determine the risk factors that predispose individuals to HCV and HBV
CHAPTER TWO
LITERATURE REVIEW
History of Hepatitis C Virus
The discovery of Hepatitis C virus in 1989 was a major breakthrough. Before that point, it was clear that a major cause of acute hepatitis after a blood transfusion was neither related to Hepatitis A nor to Hepatitis B, hence the early names for this disease, non-A, non-B hepatitis (Rogo et al., 2010). This was only possible following the development of serological diagnostic tests for hepatitis A and B in 1965 and 1973 respectively (Eze et al., 2010). Hepatitis C virus, a relatively new virus discovered about 25 years ago has become a major cause of chronic liver disease worldwide and the main reason for liver transplantation in the western world (Godwin et. al., 2013). Its evolution is believed to be mediated by several processes such as genetic drift caused by lack of proof-reading activity in the viral RNA-dependent RNA-polymerase during replication, immune pressure and recombination (Suwanna et al., 2010). Hepatitis C virus formerly designated Non-A-Non- B hepatitis is a linear, single stranded RNA virus belonging to the Flaviviridae with at least six genotypes identified (Eze et al., 2010). The agent was named Hepatitis C virus by Choo and his co-workers in 1989 (Ejiofor et al., 2010). Before 1992, when widespread screening of blood supply began in the United States, Hepatitis C was also commonly spread through blood transfusion and organ transplants (CDC, 2013).
Hepatitis C Virus
The virus is a small (55-65nm in size), enveloped, positive sense, single stranded RNA virus of approximately 9.6kb (Ji-Hoon et al., 2013) from the family Flaviviridae, genus, Hepacivirus, and Hepatitis C virus type species (Simmonds et al., 2005; Eze et al., 2010). Its complete genome organization resembles that of the Pestiviruses and Flaviviruses and encodes untranslated conserved regions (5′UTR and 3′UTR) (Suwanna et al., 2010). The viral proteins are translated as a polyprotein of about 3010 amino acids that is processed co-and post-translationally by cellular and viral proteases into structural and non structural proteins (Ji-Hoon et al., 2013).
The open reading frame of the virus encodes the structural proteins, core (C), envelope (E1, E2), and the nonstructural proteins (p7, NS2, NS3, NS4a, NS4b, NS5a and NS5b) (Rogo et al., 2010; Hoshida et al., 2014). The viral genome is extremely heterogeneous (Casanova et al., 2014) and is enclosed in a protein coat which is wrapped in a lipid envelope derived from the host cell (Ejiofor et al., 2010). Based on genetic differences between HCV isolates, the genotype has been recently updated to seven main genotypes that differ by more than 30% in their nucleotide sequence (Casanova et al., 2014). The subtypes are further broken down into quasispecies based on their genetic diversity (Kato, 2000; Rogo, 2010) and high error rate on the part of the virus RNA dependent RNA polymerase.
Hepatitis C virus genotyping is an important tool for the diagnosis and follow-up of infected patients (Campiotto et al., 2005). The structure and replication of HCV are incompletely understood due to low viral titers found in sera and livers of individuals infected and lack of an efficient cell culture system or small animal model permission for HCV infection (Kawo et al., 2012). The virus principally replicates in the hepatocytes even though other sites (haematopoietic cells such as B lymphocytes and stem cells) of replication have been reported (Greenwood et al., 2012) Hepatitis C infection is a contagious liver disease that results from infection with the hepatitis C virus.
Modes of Transmission
Hepatitis C virus is spread parenterally (Ejiofor et al., 2010) or when blood from an infected person enters the body of someone who is not infected (CDC, 2010; CDC, 2011; CDC, 2013). This infection was spread through blood transfusion and organ transplant before the advent of blood screening in 1992, but today the virus is spread through sharing of needles to inject drugs (Nelson et al., 2011; Afolabi et al., 2012), tattooing, body piercing or scaring with unsterilized equipment (Vescio et al., 2008; Imperial, 2010; CDC, 2010). Centers for Disease Control and Prevention (2010) has however posited that there is little evidence that HCV can spread by getting tattooed in licensed commercial facilities. The most efficient mode of the viral transmission is through large or repeated direct percutaneous exposure to blood such as transfusion or transplantation from infectious donors or injecting drugs use (Rogo et al., 2010). Unfortunately, the screening of blood donors for HCV is not yet routinely performed by some blood banks in developing countries and most new cases in developed countries are related to intravenous drug use (Daw, 2014).
CHAPTER THREE
MATERIALS AND METHODS
Study Area
This study was carried out in Kaduna State, Nigeria. Kaduna State (Figure 3.1) is located in the north west of Nigeria with the capital city as Kaduna which had its name derived from a Hausa word, ‗Kada‘, meaning Crocodile. The State has a land mass of 44,567 square kilometers and on it lies between latitude 10o 20′ N and longitude 7o 45′ E. The estimated population is 6,113,503 as of 2006 census. The state was created on 27th May, 1967 and has 23 Local Government Areas (LGAs) divided into three geo-political zones and senatorial districts namely: Northern zone, Central Zone and Southern Zone (Franklin, 2014).
The State has one Neuro-Psychiatric Hospital and 14 prisons namely; Kaduna convict prison, Open Prison Camp Barnawa, Zaria prison, Kafanchan prison, Birnin Gwari prison, Prison Farm Centre Kujama, Gwantu Satelite Prison, Kwoi Satelite Prison, Manchok Satelite Prison, Kachia Satelite Prison, Saminaka Satelite Prison, Soba Satelite Prison, Ikara Satelite Prison, and Makarfi Satelite Prison. The Kaduna Convict Prison and the Federal Neuro-Psychiatric Hospital were used for this study. One prison out of the many was used for this study due to some restrictions by the prisons management in Kaduna State as a result of the high insurgency in the country as at the time of sample collection.
Study Design
The Study was a cross-sectional survey where the subjects were selected using random sampling method.
Study Population
The study population comprised of male and female inmates of Kaduna Convict Prison and out patients attending the Federal Neuro-Psychiatric Hospital, Kaduna State.
CHAPTER FOUR
RESULTS
Out of 276 subjects tested for both HCV and HBV infections, 28 were positive for anti- HCV IgM giving a sero prevalence of 10.14% while 24 were positive for anti-HCV IgG giving an IgG sero prevalence of 8.7%. Seventeen subjects tested positive for HBsAg giving a sero prevalence of 6.15%. One person out of the 276 subjects had a co-infection giving a sero prevalence of 0.36%. (Figure: 1).
CHAPTER FIVE
DISCUSSION
With the paucity of published information on the epidemiology of HCV and HBV infections among inmates and psychiatric patients in Nigeria, this study has shown that the infections are prevalent among these populations. Anti-HCV IgM was detected with a prevalence of 10.14%, anti-HCV IgG 8.7% and HBsAg 6.15%. The presence of these viruses among these subjects indicates that they can be infectious to others. These findings cannot be over emphasized because subjects are at risk of developing hepatocellular carcinoma if preventive measures are not taken. The anti-HCV IgM and IgG seroprevalence in this research were higher than the 4.8% found among inmates in France (Semaille et al., 2013) and 4.2% among mentally ill persons in Nigeria (Omoaregba et al., 2013). In contrast, the HCV seroprevalence in this study is lower than the 12.3% reported among inmates in Nasarawa State, Nigeria (Adoga, et al., 2009) and the 19.4% recorded in Iran (Ataei et al., 2015). The anti HCV prevalence rates of this study corroborates the 5.8- 12.3% range for HCV prevalence rate in Nigeria as reported by Ojide et al. (2015).
CHAPTER SIX
SUMMARY, CONCLUSION AND RECOMMENDATION
SUMMARY
Hepatitis C virus is a positive sense single stranded RNA virus of the family Flaviviridae and Genus Hepacivirus (Kapoor et al., 2011). It is the causative agent of human hepatitis C infection and most commonly transmitted through exposure to infected blood. Hepatitis B is a DNA virus of the family Hepadnaviridae, Genus Orthohepadnavirus and species Hepatitis B virus (Pungpapong et al., 2007). Hepatitis C and hepatitis B virus co-infection is very common because of the shared modes of transmission and subjects with high risk of parenteral infections tend to have this (Chi and Shou, 2008). It is estimated that about 200 million people in the world are infected with HCV and over 350 million with HBV leading to more than one million deaths annually (Akinsegun et al., 2012). The Department of Health and Human Services, CDC (2011) posited that hepatitis C is the most common type of hepatitis found in jails and prisons. People with mental illness are likely to be over represented in high-risk categories for infection with pathogens with similar routes of transmission such as HBV and HCV (Stanley et al., 2001).
This study has provided data on the prevalence of HCV and HBV among prison inmates and psychiatric patients in Kaduna Metropolis. The data generated in this research will serve as baseline information for the prevention and control of these viruses and for future studies. This study aimed at determining the prevalence of HCV and HBV and to evaluate HCV viremia among prison inmates and psychiatric patients in Kaduna Metropolis. The specific objectives of this research were to screen for HCV antibodies and HBsAg, to detect HCV RNA using RT-PCR, and to determine the possible risk factors that predispose individuals to HCV and HBV infections.
A total of 276 subjects were tested for both HCV and HBV infections. Antibodies to HCV were detected using ELISA and the Rapid test method was used to detect HBsAg. Hepatitis C virus genome of ELISA positive samples was amplified using RT-PCR. Data on demographic and risk factors were obtained via a self-designed questionnaire. Twenty- eight subjects were positive for anti-HCV IgM giving a seroprevalence of 10.14% while 24 subjects were positive for anti-HCV IgG giving an IgG seroprevalence of 8.7%. Seventeen persons tested positive for HBsAg giving a seroprevalence of 6.15%. One subject out of the 276 subjects had a co-infection of both viruses giving a seroprevalence of 0.36%.
There was no statistically significant association between the occurrence of HCV IgM and HCV IgG and study population. For IgM antibodies, prison inmates had a prevalence of 10.45% (16/153) while psychiatric patients 9.75% (12/123). A HCV-IgG prevalence of 8.5% (13/153) was obtained among prison inmates while the psychiatric patients had 8.9% (11/123). With regard to HBV infection the inmates had a higher prevalence (9.2%: 14/153) than the psychiatric patients (2.4%: 3/123)
Even though there was no significant association between the observed seroprevalence of HCV IgG among subjects by gender, the females were two times more likely to be infected with HCV than males. However, HCV IgG was similarly distributed (8.4% for males and 9.4% for females) by gender. None of the 85 female subjects who enrolled in this study was infected with HBV while 17 of the 191 male subjects were infected with HBV.
For anti-HCV IgM, subjects within age group 48 years and above had the highest prevalence of 28.9% (13/45) while no subject within the age group 23-27 years had the infection. For anti-HCV IgG, subjects within age group 48 years and above had the highest prevalence of 31.1% (14/45) while no subject within age groups 38-42 and 43-47 years had anti HCV IgG antibodies. For HBsAg, participants within age group 28-32 years had the highest prevalence of 11.7% (7/60) and subjects found within age group 48 years and above had the lowest prevalence of 2.2% (1/45).
Amplification of the HCV RT-PCR products was observed on the gel with band size of 244bp confirming the presence of HCV-RNA in the serum of patients with positive anti- HCV IgM test. There was no statistically significant association between the viral infections and all demographic factors studied except age where the highest HCV and HBsAg prevalence were obtained among subjects aged ≥ 48 years and 28-32 years respectively. Having tattoo/scarification and alcohol intake were statistically associated with HCV while clothes sharing was associated with HBsAg among the inmates. For the psychiatric patients, having tattoo/scarification, history of transfusion, alcohol intake, sexual experience and shaving equipment sharing were found to be statistically associated with HCV while clothes‘ sharing was associated with HBsAg.
CONCLUSION
This study has shown prevalence of 6.15% for HBsAg, 10.14% for anti-HCV IgM and 8.7% for anti-HCV IgG among prisons inmates and psychiatric patients in Kaduna metropolis between the months of February and March, 2015. A co-infection rate of 0.36% was obtained. This confirms the circulation of these viruses in these populations. A high prevalence of 9.2% for HBsAg, 10.5% for IgM and 8.9% for IgG prevalence was obtained among the prison inmates while HCV IgM prevalence of 9.8%, 8.9% IgG and HBsAg 2.4% was found among psychiatric patients in this study.
This study detected HCV-RNA in ten (10) serum samples. More women had HCV infection (14.1%) than men while no female subject was infected with HBV. Subjects within age group 28-32 years had the highest HBsAg prevalence (11.7%) while those ≥ 48 years recorded the highest HCV infection.
Marital status was significantly associated with HCV infection among other demographic factors. Tattoo/Scarification and alcohol intake were statistically associated with HCV while clothes sharing was associated with HBsAg among the inmates. For the psychiatric patients, tattoo/scarification, history of transfusion, alcohol intake, sexual experience and equipment sharing were found to be statistically associated with HCV while clothes sharing was associated with HBsAg.
RECOMMENDATIONS
In view of the above findings it is recommended that:
1 Inmates should be screened for these infections at the point of incarceration in order to ascertain their status and routine tests should be considered for the psychiatric patients during their follow-up clinics to detect new health problems.
- General public health and prevention programmes should be intensified to create awareness of these viruses especially in correctional facilities and psychiatric hospitals since the prevalence of these viruses is higher in these populations than the general
- Government should encourage and support HCV vaccine development research and make HBV vaccine available and affordable to
- Effective implementation of surveillance to prevent the smuggling of drugs and drug equipment could minimize HCV and HBV infection risk in these facilities and the community
- Further should be carried out to proffer reasons as to why the prevalence of HCV is higher among females and HBV among
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