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Seroprevalence of HIV, HBV, HCV and HTLV among Pregnant Women in Southwestern Nigeria a
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Oluyinka Oladele Opaleye , Magdalene C Igboama , Johnson Adeyemi Ojo & Gbolabo Odewale
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Department of Medical Microbiology and Parasitology, College of Health Sciences, Ladoke Akintola University of Technology, PMB 4400, Osogbo, Nigeria Accepted author version posted online: 16 Apr 2015.
Click for updates To cite this article: Oluyinka Oladele Opaleye, Magdalene C Igboama, Johnson Adeyemi Ojo & Gbolabo Odewale (2015): Seroprevalence of HIV, HBV, HCV and HTLV among Pregnant Women in Southwestern Nigeria, Journal of Immunoassay and Immunochemistry, DOI: 10.1080/15321819.2015.1040160 To link to this article: http://dx.doi.org/10.1080/15321819.2015.1040160
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Seroprevalence of HIV, HBV, HCV and HTLV among Pregnant Women in Southwestern Nigeria Oluyinka Oladele Opaleye1, Magdalene C Igboama1, Johnson Adeyemi Ojo1, Gbolabo Odewale1
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Corresponding author: Dr. O. O. Opaleye, Department of Medical Microbiology and Parasitology, College of Health Sciences, Ladoke Akintola University of Technology, PMB 4400, Osogbo, Nigeria. E-mail: [email protected]; Tel: +234 8160471660
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Email addresses of all authors, Oluyinka Oladele Opaleye - [email protected]; [email protected], Magdalene C Igboama - [email protected], Johnson Adeyemi Ojo - [email protected], Gbolabo Odewale - [email protected] Running title: Viral STIs in pregnant women in Nigeria Abstract
Sexually transmitted infections (STIs) are major public health challenge especially in developing
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countries. This study was designed to determine the prevalence of Hepatitis B virus (HBV), Hepatitis C Virus (HCV), Human immunodeficiency virus (HIV) and Human T-cell
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lymphotropic Virus type I (HTLV-I) among pregnant women attending antenatal clinic, in
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Ladoke Akintola University Teaching Hospital, Osogbo, and South-Western Nigeria. One hundred and eighty two randomly selected pregnant women were screened for HBsAg, antiHCV, anti-HIV and HTLV-1 IgM antibodies using commercially available ELISA kit. Of the182
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Department of Medical Microbiology and Parasitology, College of Health Sciences, Ladoke Akintola University of Technology, PMB 4400, Osogbo, Nigeria
blood samples of pregnant women screened whose age ranged from 15-49 years, 13 (7.1%), 5 (2.7%), 9 (4.9%) and 44 (24.2%) were positive for HBsAg, anti-HCV, anti-HIV and HTLV-1 IgM antibodies respectively. The co-infection rate of 0.5% was obtained for HBV/HCV, HBV/HIV, HIV/HTLV-1 and HCV/HTLV-1 while 1.1% and 0% was recorded for HBV/HTLV-
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1 and HCV/HIV co-infections respectively. Expected risk factors such as history of surgery, circumcision, tattooing and incision showed no significant association with any of the viral STIs (p>0.05). This study shows that there is the need for a comprehensive screening of all pregnant
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Keywords: HBV, HCV, HIV, HTLV-1, co-infection, Seroprevalence, Sexually transmitted
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INTRODUCTION
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infections
Sexually transmitted infections (STIs) constitute major public and reproductive health challenges worldwide especially in developing countries (1, 2). Pregnant women in Africa are the most hit
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by STIs (2, 3) and it has been estimated that the number of pregnant women with STIs is increasing by about 250 million a year in the developed countries (4) and double that number in
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the developing countries (5). Sexual intercourse accounts for more than 90 percent of infections
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in Sub-Saharan Africa. Although many people who know they are infected reduce their risk behaviors, studies in developed countries suggest that a substantial percentage nevertheless continue to engage in unprotected sex thereby transmitting the infection to their sex partners.
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these viral infections and its attending consequences.
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women for HBsAg, anti-HCV, anti-HIV and HTLV-1 to prevent mother to child transmission of
Infections with sexually transmitted pathogens other than HIV impose a huge burden of morbidity and mortality in all countries irrespective of income level. Both short and long term sequelae of untreated STIs cause profound bio-medical, social and economic impact on
individuals and communities. (6, 7). STIs, especially in pregnant women, have been associated
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with a number of adverse pregnancy outcomes including spontaneous abortion, stillbirth, preterm delivery, low birth-weight, postpartum sepsis, premature rupturing of membranes, cervical and other cancers, chronic hepatitis, congenital infection, neonatal pneumonia, neonatal blindness (2)
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and various sequelae in surviving neonates who could get the infection from their mothers either
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Viral STI is associated with a high incidence of low birth weight prematurity, gestational
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diabetes mellitus, preterm delivery, premature contractions, premature rupture of membranes spontaneous miscarriages, stillbirth, , placental separation, preterm delivery, preterm labor and
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low birth weight intra-partum and post-partum, fetal hepatitis and vertical transmission
(8,9
,10) which in turn is associated with fetal or neonatal hepatitis, chronic HBV infection, liver cirrhosis and hepatocellular carcinoma in young adulthood (11). About 25% of these HBV infected children may even die of HBV related chronic liver disease in adulthood (12).
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Meanwhile chronic active hepatitis C infection is associated with increased incidence of preterm
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delivery, intra-uterine growth retardation and vertical transmission (13). Approximately 20% of children vertically infected with HCV will develop active infection indicated by persistent
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viremia, elevated ALT, and hepatomegaly (14)]. On the other hand HIV infection in pregnancy leads to spontaneous abortion, premature delivery, intrauterine growth restrictions, low birth weight and vertical transmission (15). HIV infected children could suffer and die from AIDS
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before, during or after birth.
while HTLV-I which is mainly transmitted through breast milk could cause infective dermatitis (16), Adult T-cell leukemia/lymphoma (ATL) and HTLV-I-associated myelopathy/tropical spastic par paresis (HAM/TSP) in infected children. It may also cause death later in life.
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Co-infection of these viruses in sexually active individuals such as pregnant women is common because of shared routes of transmission (17) and this presents a significant challenge to health care providers as this group of people are at increased risk of developing complications and life
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threatening diseases (18). In those co-infected with either HBV or HCV, there is faster
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progression of HIV to AIDS-defining illness (19). Hepatitis B and Hepatitis C virus infections
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hepatotoxicity from antiretroviral treatment and decrease survival time (20). During pregnancy or delivery there is increased risk of both sexual and vertical transmission (VT) of HCV and
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lower birth weights in mothers co-infected with HIV than in women with mono-infection (21). The viral STIs differ in prevalence from state to state and among study groups in Nigeria. In South-Western Nigeria, varying prevalence rates have been reported for these viral STIs in pregnant women. In Ibadan, Nigeria, a prevalence rate of 16.7% was reported for HTLV-I
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infection 7years ago (22) while in Osogbo, Kolawole et al. (23) reported a prevalence of 16.5%
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for HBV and Ogunro et al. (24) reported a prevalence of 9.2% for HCV. In view of these, this present study is designed to determine the prevalence of HBV, HCV, HIV and HTLV-1 among
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pregnant women attending antenatal clinic of the Ladoke Akintola Teaching Hospital in Osogbo, South Western Nigeria.
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impair immune reconstitution, lower overall level of CD4 count, increase the risk of
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METHODS
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Study population
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A total number of 182 pregnant women attending the antenatal clinic of the Ladoke Akintola
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consent has been obtained. Pregnant women who were unwilling to participate in the study were excluded from the study. The bio-data and information on the history of possible risk factors of
Serological testing
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the screened subjects were obtained using structured questionnaire.
The sera of these women were screened for HBsAg, anti-HCV, anti-HIV and HTLV-1 IgM
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antibodies using commercially available ELISA kit (HTLV-1-IgM ELISA Kit WKEA Med. Supplies, China), Immunochromatographic strip for HBV, HCV (Micropoint Rapid Diagnostic,
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Italy) and HIV (Alere Determine HIV 1/2 Matzuhidal, Japan) following the manufacturers
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instruction. Ethical approval was obtained from the ethical committee of the Ladoke Akintola Unversity Teaching Hospital.
Data analysis
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University Teaching Hospital Osogbo were recruited into this study after a verbal informed
The prevalence for HBV, HCV, HIV and HTLV-1 was calculated by using pregnant women with
positive samples as numerator and the total numbers of pregnant women enrolled in this study were the denominator. The generated data were presented in descriptive statistics. The data
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generated were further subjected to chi-square and univerate statistical test for comparison of proportions to determine any significant relationship between infection rate and demographical characteristics of the subjects. Statistical Package for Social Sciences (SPSS) version 16.0 was
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used for chi-square and univerate statistical test.
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Of the 182 pregnant women screened whose age ranged from 15-49 years,13 (7.1%), 5 (2.7%), 9 (4.9%) and 44 (24.2%) were positive for HBV, HCV, HIV and HTLV-I respectively (Table 1).
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Co-infection rate of 0.5% was obtained for HBV/HCV, HBV/HIV, HIV/HTLV-I and HCV/HTLV-I while 1.1% and 0% was recorded for HBV/HTLV-I and HCV/HIV co-infections respectively (Table 2).
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A good number of the women (38.5%) were in the age group 25-29yrs and the highest prevalence of HBV, HCV and HTLV-I infections occurred among pregnant women within this
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age group while the highest prevalence of HIV infection occurred in pregnant women within the
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age group 25-34yrs. (Table 3).
Majority of the pregnant women screened 140 (76.9%) attained tertiary level of education while 23.1% had below tertiary level of education. The women with tertiary level of education
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RESULTS
however had the highest prevalence for HBV, HCV, HIV and HTLV-1 of 6.6%,2.7%, 4.9% and 20.3% respectively. A significant association was observed between occupation and HBV infection (p0.05) and the prevalence of the four viral infections was higher among
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the largest population of the study group.
Marital status was shown to be significantly associated with HBV infection (P < 0.05) as 11/174
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(6.3%) of the married pregnant women and 2/8 (25.0%) of the unmarried pregnant women were positive with a higher prevalence being observed among the unmarried pregnant women. This could be related to indiscrete sexual life patterns of the unmarried women. Marital status however, did not affect the prevalence (P>0.05) of HCV, HIV and HTLV-1 infections (Table 4).
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A significant association was observed between occupation and HBV infection (P < 0.05) (Table 4) as 6/20 (30%) of the health care workers and 7/162 (4.3%) of the non-health care workers
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were positive. This finding correlates with that obtained from a study in Nnewi, Nigeria (Eke et
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al., 2011) where occupation was significantly associated with HBV infection. This association could be attributed to the fact that health care workers are more predisposed to acquiring infections. However, occupation seemed not to be a risk factor to the acquisition of the other
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subjects of the Yoruba ethnic group, which could be due to the fact that the Yorubas constituted
viral infections in this study (P>0.05). Expected risk factors including sexually transmitted diseases, tribal marks, incision, tattooing, circumcision, sharing of sharp objects and blood transfusion were observed not to affect the
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prevalence (P>0.05) of any of the viral STIs under investigation (Table 4). The explanations for such observations need to be explored in the future, probably, by using larger samples, more sophisticated screening methods such as ELISA or PCR or by using a control group of non-
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pregnant women.
STIs suggesting that sex is not the sole route of transmission of these infections (Table 4). It was
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observed in this study that previous contact with somebody with hepatitis infection in the past was a statistically significant predisposing factor (P0.05) with these viral
On the other hand, the HBV/HCV co-infection rate in this study is in agreement with the 0.57% co-infection rate recorded among pregnant women in Benin (28) but higher than the 0.15% (32) of HBV/HCV co-infection rate reported in Ekiti state from a similar study. The co-infections were however not statistically significant (P>0.05).
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The result of this study reveals prevalence of 7.1%, 2.7%, 4.9% and 24.2% for HBV, HCV, HIV and HTLV-1 respectively. This shows that there is a low prevalence of some of the sexually transmitted viral infections among pregnant women in Osogbo, however, with a prevalence of
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The result of this study also shows that there is low co-infection rate for the viral STIs as co-
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infection rate of 0.5% was obtained for HBV/HCV, HBV/HIV, HIV/HTLV-1 and HCV/HTLV-1 while 1.1% and 0% were recorded for HBV/HTLV-1 and HCV/HIV co-infections respectively.
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In addition, the findings of this study suggest the possibility of vertical transmission of one or more of the investigated viral STIs among the positive pregnant women who may be unidentified or undiagnosed due to the asymptomatic nature or the lack of routine screening for most of these
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infections in Nigeria.
From the analysis of the result of this study, except for occupation, marital status and history of
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contact with an infected person in the past which showed association with HBV infection, all
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other factors including history of surgery, circumcision, tattooing, incision, tribal marks, sharing of sharp objects, blood transfusion and sexually transmitted diseases seemed not to be risk factors of the viral STIs in this study. Particularly of interest is the lack of association between
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HTLV-1 and close to a high prevalence of HBV.
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24.2% and 7.1% for HTLV-1 and HBV, Osogbo can be said to be having a high prevalence of
history of multiple sexual partners and the viral STIs investigated in this study, suggesting that sex is not the sole route of transmission of these infections. The observed lack of association between most of the expected risk factors and the viral STIs suggest the need for a more elaborate study on this cohort.
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Notwithstanding the low prevalence recorded for some of these viral STIs, the devastating effect of all the viral STIs in this study cannot be underestimated. A comprehensive screening for all pregnant women is therefore necessary to prevent mother to child transmission of these viral
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infections.
Nigeria being one of the countries endemic for these viruses with higher prevalence reported in
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women (Ijoema et al., 2010; Uneka et al., 2007; Blatiner et al., 1989) coupled with the possibility of mother-to-child transmission, suggest the need to take appropriate measures in order to reduce
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the transmission of these viral STIs and curb maternal and perinatal morbidity in Nigeria, particularly in Osogbo. Such measures include: Routine screening of all pregnant women for HBV, HCV, HIV and HTLV-1 infections followed by appropriate counseling of positive pregnant women about the risk of transmission to their babies. Proper screening of blood for
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surgical equipment
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these viruses before transfusion should be done. There should equally be adequate sterilization of
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In addition, more elaborate studies, especially multicenter studies should be carried out to determine the national prevalence of sexually transmitted viral infections and co-infections in order to enable formulation of guidelines for the management and the establishment of
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Sexually transmitted viral infections are worldwide problems especially in developing countries.
preventive programs. Facilities should be upgraded in tertiary health centers for easy diagnosis, viral typing, viral load and neonatal or infant diagnosis of these viruses to prevent a loss to
follow-up which is often a common problem in Nigeria. Also infants and new born must be systematically immunized against the vaccine-preventable Hepatitis B virus infection.
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Furthermore, proper treatment of all STIs like the use of correct and effective medicines, contact tracing and treatment of sexual partners are highly recommended.
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Bassey EB, Moses AE, Udo SM, Umo AN: Online J Health Allied Scs 2009 8(1):4. Ijoema UN, Nwokediuko SC, Onyemekwe B., Ijeoma C.2010: Low prevalence of hepatitis B `E` antigen in asymptomatic adult subjects with hepatitis B virus infection Enugu, South East
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t
Nigeria. Internet J Gastroenterol, 10:1.
HIV infection and anaemia among pregnant women attending antenatal clinics in Southern
us
Nigeria. J Health Popul Nutr, 25:328-35.
Blatiner J, Pachon I, Gonzalez MP .1989: Seroprevalence of HIV and HTLV in a representative
ce
pt
ed
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sample of the Spanish population, Epidemiol Infect 125(1): 159-62.
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Uneka CJ, Duhlinska DD, Igbinedion EB.2007: Prevalence and public health significance of
21
Table 1: Prevalence of HBV, HCV, HIV and HTLV-1 Among Pregnant Women in Osogbo, Nigeria
Women tested
Women Positive
HBV
182
13(7.1)
HCV
182
5(2.7)
HIV
182
HTLV-1
182
t
P-value
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No. of Pregnant No. (%) of Pregnant χ2
0.628
8.226
0.222
9(4.9)
0.935
0.988
44(24.2)
9.043
0.171
ce
pt
ed
M an
us
4.363
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Test
22
χ2
P-value
HBV/HCV
1(0.5)
1.281
0.258
HBV/HIV
1(0.5)
0.225
HBV/HTLV
2(1.1)
0.590
us 0.442
0.267
0.605
1(0.5)
0.049
0.825
0.882
0.348
1(0.5)
ce
pt
HIV/HTLV
0.635
0(0.0)
ed
HCV/HTLV
M an
HCV/HIV
23
t
No. Positive
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Co-Infection
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Table 2: Co-Infection rate of the Viral STIs among Pregnant Women in Osogbo, Nigeria
Age
No.
HBV +ve HCV+ve
HIV+ve HTLV
group
Tested
(%)
(%)
(%)
(Yrs)
(%)
15-19
4(2.2)
0 (0)
0 (0)
0 (0)
20-24
18(9.9)
1 (5.6)
0 (0)
25-29
70(38.5)
30-34
49(26.9)
7(3.1)
ce
40-44
45-49
Total
1(0.5)
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t
+ve (%)
us
0 (0)
M an
1 (5.6)
3 (16.7)
6 (8.6)
5 (7.1)
3 (4.3)
24 (34.3)
1 (2.0)
0 (0)
3 (6.1)
12 (24.5)
4 (12.1)
0 (0)
2 (6.1)
4 (12.1)
1 (14.3)
0 (0)
0 (0)
1 (14.3)
0 (0)
0 (0)
0 (0)
0 (0)
5(2.7)
9(4.9)
44(24.2)
ed 33(18.1)
pt
35-39
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Table 3: Prevalence of the viral STIs According to Age
182(100.0) 13(7.1)
24
p-
HC
tic
Wom
+ve
val
V
en
(%)
ue
+ve
+v
(%)
e
Teste
χ2
HI
value
V
χ2
p-
HTLV χ2
p-
val
+ve
valu
ue
(%)
e
us
d (%)
p-
t
No. of HBV χ2
cr ip
Characteris
(%
M an
)
Level of Education
2(1.1)
0(0.0
Tertiary
0
0)
1.5 42
0.462
0(
0.24 0(0.0)
1.99
0.36
2
8
8
)
0(0.
0(
0)
0)
0.0
)
2.8
0.0 40
40(22. 1(2.5
ce
Secondary
5
pt
)
1.88 0.39 0(0.
ed
Primary
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Table 4: Socio-Demographic Characteristics and History of Possible Risk Factors of the Pregnant Women
7(17.5)
)
140(7
12(8.
5(3.
9(
37(26.
6.9)
6)
6)
6.4
4)
25
)
0.68 0.40 3(4.
1.6
5)
5
18
)
8
9)
0.203
3(
4.9 00
10(8.
6.5)
3)
1.01
0.31
0
5
4
2(1.
6(
M an
121(6
0.99 12(19.
us
)
Christianity
0.0
cr ip
61(33. 3(4.9
7)
5.0
7)
32(26. 4)
)
173(9
13(7.
0.72 0.69 5(2.
pt
Yoruba
ed
Tribe
Igbo
Hausa
5)
ce
5.1)
4(2.2)
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Islam
t
Religion
5(2.7)
8
5
9)
0.2 67
0.875
9
0.4
0.78 42(24.
0.05
0.97
(5.
93
2
0
5)
3)
2)
0(0.0
0(0.
0(0
)
0)
.0)
0(0.0
0(0.
0(0
26
1(25.0)
1(20.0)
)
0)
.0)
2.9
0)
3
79
5
2.5)
174(9
11(6.
4(2.
5.6)
3)
3)
Occupation
.0)
0.4
0.50 2(25.0) 0.00
0.95
35
9
6
.2)
17.6 0.00 0(0.
0.6
Worker
99
35
0)
ed
0
pt
0)
0(0
9(5
Health Care 20(11. 6(30. 0)
0.084
cr ip
4.02 0.04 1(1
M an
Married
2(25.
us
8(4.4)
0.426
3
42(24. 1)
2(1
1.2
0.26 4(20.0) 0.21
0.64
0.0
21
9
4
4
)
7(4.3
5(3.
7(4
40(24.
Care Worker
)
1)
.3)
7)
ce
Non Health 162(8 9.0)
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Single
t
Marital Status
History of STD
Yes
7(3.8)
0(0.0
0.56 0.45 0(0.
0.2
27
0.650
0(0
0.3
0.53 2(28.6) 0.07
0.78
)
4
0)
06
.0)
79
8
7
175(9
13(7.
5(2.
9(5
42(24.
6.2)
4)
9)
.1)
0)
2
No
2.43 0.11 1(3.
0.1
8)
)
9
09
155(8
13(8.
5.2)
4)
No
0.1
0.74 5(18.5) 0.55
0.45
.7)
04
7
7
39(25.
6)
.2)
2)
8)
9
96
pt
0.8
8
4
8(5
2.43 0.11 0(0.
)
1(3
4(2.
27(14. 0(0.0
ce
Yes
7)
ed
History of Incision
8
0.742
us
27(14. 0(0.0
M an
Yes
0)
0.344
0(0
1.6
0.19 7(25.9) 0.05
0.81
.0)
49
9
8
3
155(8
13(8.
5
9
37(23.
5.2)
4)
(3.2
(5.
9)
)
8)
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History of Tribal Marks
cr ip
t
No
0
28
History of Tattooing
0.1
(2.7)
0)
1
45
177(9
12(6.
5(2.
9(5
7.3)
8)
8)
.1)
8
0)
0.703
0(0
0.2
0.60 0(0.0)
1.63
0.20
.0)
64
5
9
0
M an ed pt ce 29
t
1.28 0.25 0(0.
cr ip
1(20.
us
No
5
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Yes
44(24. 9)
Journal of Immunoassay and Immunochemistry Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/ljii20
Seroprevalence of HIV, HBV, HCV and HTLV among Pregnant Women in Southwestern Nigeria a
a
a
Oluyinka Oladele Opaleye , Magdalene C Igboama , Johnson Adeyemi Ojo & Gbolabo Odewale
a
a
Department of Medical Microbiology and Parasitology, College of Health Sciences, Ladoke Akintola University of Technology, PMB 4400, Osogbo, Nigeria Accepted author version posted online: 16 Apr 2015.
Click for updates To cite this article: Oluyinka Oladele Opaleye, Magdalene C Igboama, Johnson Adeyemi Ojo & Gbolabo Odewale (2015): Seroprevalence of HIV, HBV, HCV and HTLV among Pregnant Women in Southwestern Nigeria, Journal of Immunoassay and Immunochemistry, DOI: 10.1080/15321819.2015.1040160 To link to this article: http://dx.doi.org/10.1080/15321819.2015.1040160
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Seroprevalence of HIV, HBV, HCV and HTLV among Pregnant Women in Southwestern Nigeria Oluyinka Oladele Opaleye1, Magdalene C Igboama1, Johnson Adeyemi Ojo1, Gbolabo Odewale1
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Corresponding author: Dr. O. O. Opaleye, Department of Medical Microbiology and Parasitology, College of Health Sciences, Ladoke Akintola University of Technology, PMB 4400, Osogbo, Nigeria. E-mail: [email protected]; Tel: +234 8160471660
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Email addresses of all authors, Oluyinka Oladele Opaleye - [email protected]; [email protected], Magdalene C Igboama - [email protected], Johnson Adeyemi Ojo - [email protected], Gbolabo Odewale - [email protected] Running title: Viral STIs in pregnant women in Nigeria Abstract
Sexually transmitted infections (STIs) are major public health challenge especially in developing
ed
countries. This study was designed to determine the prevalence of Hepatitis B virus (HBV), Hepatitis C Virus (HCV), Human immunodeficiency virus (HIV) and Human T-cell
pt
lymphotropic Virus type I (HTLV-I) among pregnant women attending antenatal clinic, in
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Ladoke Akintola University Teaching Hospital, Osogbo, and South-Western Nigeria. One hundred and eighty two randomly selected pregnant women were screened for HBsAg, antiHCV, anti-HIV and HTLV-1 IgM antibodies using commercially available ELISA kit. Of the182
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t
Department of Medical Microbiology and Parasitology, College of Health Sciences, Ladoke Akintola University of Technology, PMB 4400, Osogbo, Nigeria
blood samples of pregnant women screened whose age ranged from 15-49 years, 13 (7.1%), 5 (2.7%), 9 (4.9%) and 44 (24.2%) were positive for HBsAg, anti-HCV, anti-HIV and HTLV-1 IgM antibodies respectively. The co-infection rate of 0.5% was obtained for HBV/HCV, HBV/HIV, HIV/HTLV-1 and HCV/HTLV-1 while 1.1% and 0% was recorded for HBV/HTLV-
1
1 and HCV/HIV co-infections respectively. Expected risk factors such as history of surgery, circumcision, tattooing and incision showed no significant association with any of the viral STIs (p>0.05). This study shows that there is the need for a comprehensive screening of all pregnant
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Keywords: HBV, HCV, HIV, HTLV-1, co-infection, Seroprevalence, Sexually transmitted
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INTRODUCTION
us
infections
Sexually transmitted infections (STIs) constitute major public and reproductive health challenges worldwide especially in developing countries (1, 2). Pregnant women in Africa are the most hit
ed
by STIs (2, 3) and it has been estimated that the number of pregnant women with STIs is increasing by about 250 million a year in the developed countries (4) and double that number in
pt
the developing countries (5). Sexual intercourse accounts for more than 90 percent of infections
ce
in Sub-Saharan Africa. Although many people who know they are infected reduce their risk behaviors, studies in developed countries suggest that a substantial percentage nevertheless continue to engage in unprotected sex thereby transmitting the infection to their sex partners.
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these viral infections and its attending consequences.
t
women for HBsAg, anti-HCV, anti-HIV and HTLV-1 to prevent mother to child transmission of
Infections with sexually transmitted pathogens other than HIV impose a huge burden of morbidity and mortality in all countries irrespective of income level. Both short and long term sequelae of untreated STIs cause profound bio-medical, social and economic impact on
individuals and communities. (6, 7). STIs, especially in pregnant women, have been associated
2
with a number of adverse pregnancy outcomes including spontaneous abortion, stillbirth, preterm delivery, low birth-weight, postpartum sepsis, premature rupturing of membranes, cervical and other cancers, chronic hepatitis, congenital infection, neonatal pneumonia, neonatal blindness (2)
t
and various sequelae in surviving neonates who could get the infection from their mothers either
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Viral STI is associated with a high incidence of low birth weight prematurity, gestational
us
diabetes mellitus, preterm delivery, premature contractions, premature rupture of membranes spontaneous miscarriages, stillbirth, , placental separation, preterm delivery, preterm labor and
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low birth weight intra-partum and post-partum, fetal hepatitis and vertical transmission
(8,9
,10) which in turn is associated with fetal or neonatal hepatitis, chronic HBV infection, liver cirrhosis and hepatocellular carcinoma in young adulthood (11). About 25% of these HBV infected children may even die of HBV related chronic liver disease in adulthood (12).
ed
Meanwhile chronic active hepatitis C infection is associated with increased incidence of preterm
pt
delivery, intra-uterine growth retardation and vertical transmission (13). Approximately 20% of children vertically infected with HCV will develop active infection indicated by persistent
ce
viremia, elevated ALT, and hepatomegaly (14)]. On the other hand HIV infection in pregnancy leads to spontaneous abortion, premature delivery, intrauterine growth restrictions, low birth weight and vertical transmission (15). HIV infected children could suffer and die from AIDS
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before, during or after birth.
while HTLV-I which is mainly transmitted through breast milk could cause infective dermatitis (16), Adult T-cell leukemia/lymphoma (ATL) and HTLV-I-associated myelopathy/tropical spastic par paresis (HAM/TSP) in infected children. It may also cause death later in life.
3
Co-infection of these viruses in sexually active individuals such as pregnant women is common because of shared routes of transmission (17) and this presents a significant challenge to health care providers as this group of people are at increased risk of developing complications and life
t
threatening diseases (18). In those co-infected with either HBV or HCV, there is faster
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progression of HIV to AIDS-defining illness (19). Hepatitis B and Hepatitis C virus infections
us
hepatotoxicity from antiretroviral treatment and decrease survival time (20). During pregnancy or delivery there is increased risk of both sexual and vertical transmission (VT) of HCV and
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lower birth weights in mothers co-infected with HIV than in women with mono-infection (21). The viral STIs differ in prevalence from state to state and among study groups in Nigeria. In South-Western Nigeria, varying prevalence rates have been reported for these viral STIs in pregnant women. In Ibadan, Nigeria, a prevalence rate of 16.7% was reported for HTLV-I
ed
infection 7years ago (22) while in Osogbo, Kolawole et al. (23) reported a prevalence of 16.5%
pt
for HBV and Ogunro et al. (24) reported a prevalence of 9.2% for HCV. In view of these, this present study is designed to determine the prevalence of HBV, HCV, HIV and HTLV-1 among
ce
pregnant women attending antenatal clinic of the Ladoke Akintola Teaching Hospital in Osogbo, South Western Nigeria.
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impair immune reconstitution, lower overall level of CD4 count, increase the risk of
4
METHODS
t
Study population
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A total number of 182 pregnant women attending the antenatal clinic of the Ladoke Akintola
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consent has been obtained. Pregnant women who were unwilling to participate in the study were excluded from the study. The bio-data and information on the history of possible risk factors of
Serological testing
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the screened subjects were obtained using structured questionnaire.
The sera of these women were screened for HBsAg, anti-HCV, anti-HIV and HTLV-1 IgM
ed
antibodies using commercially available ELISA kit (HTLV-1-IgM ELISA Kit WKEA Med. Supplies, China), Immunochromatographic strip for HBV, HCV (Micropoint Rapid Diagnostic,
pt
Italy) and HIV (Alere Determine HIV 1/2 Matzuhidal, Japan) following the manufacturers
ce
instruction. Ethical approval was obtained from the ethical committee of the Ladoke Akintola Unversity Teaching Hospital.
Data analysis
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University Teaching Hospital Osogbo were recruited into this study after a verbal informed
The prevalence for HBV, HCV, HIV and HTLV-1 was calculated by using pregnant women with
positive samples as numerator and the total numbers of pregnant women enrolled in this study were the denominator. The generated data were presented in descriptive statistics. The data
5
generated were further subjected to chi-square and univerate statistical test for comparison of proportions to determine any significant relationship between infection rate and demographical characteristics of the subjects. Statistical Package for Social Sciences (SPSS) version 16.0 was
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used for chi-square and univerate statistical test.
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Of the 182 pregnant women screened whose age ranged from 15-49 years,13 (7.1%), 5 (2.7%), 9 (4.9%) and 44 (24.2%) were positive for HBV, HCV, HIV and HTLV-I respectively (Table 1).
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Co-infection rate of 0.5% was obtained for HBV/HCV, HBV/HIV, HIV/HTLV-I and HCV/HTLV-I while 1.1% and 0% was recorded for HBV/HTLV-I and HCV/HIV co-infections respectively (Table 2).
ed
A good number of the women (38.5%) were in the age group 25-29yrs and the highest prevalence of HBV, HCV and HTLV-I infections occurred among pregnant women within this
pt
age group while the highest prevalence of HIV infection occurred in pregnant women within the
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age group 25-34yrs. (Table 3).
Majority of the pregnant women screened 140 (76.9%) attained tertiary level of education while 23.1% had below tertiary level of education. The women with tertiary level of education
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RESULTS
however had the highest prevalence for HBV, HCV, HIV and HTLV-1 of 6.6%,2.7%, 4.9% and 20.3% respectively. A significant association was observed between occupation and HBV infection (p0.05) and the prevalence of the four viral infections was higher among
us
the largest population of the study group.
Marital status was shown to be significantly associated with HBV infection (P < 0.05) as 11/174
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(6.3%) of the married pregnant women and 2/8 (25.0%) of the unmarried pregnant women were positive with a higher prevalence being observed among the unmarried pregnant women. This could be related to indiscrete sexual life patterns of the unmarried women. Marital status however, did not affect the prevalence (P>0.05) of HCV, HIV and HTLV-1 infections (Table 4).
ed
A significant association was observed between occupation and HBV infection (P < 0.05) (Table 4) as 6/20 (30%) of the health care workers and 7/162 (4.3%) of the non-health care workers
pt
were positive. This finding correlates with that obtained from a study in Nnewi, Nigeria (Eke et
ce
al., 2011) where occupation was significantly associated with HBV infection. This association could be attributed to the fact that health care workers are more predisposed to acquiring infections. However, occupation seemed not to be a risk factor to the acquisition of the other
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subjects of the Yoruba ethnic group, which could be due to the fact that the Yorubas constituted
viral infections in this study (P>0.05). Expected risk factors including sexually transmitted diseases, tribal marks, incision, tattooing, circumcision, sharing of sharp objects and blood transfusion were observed not to affect the
10
prevalence (P>0.05) of any of the viral STIs under investigation (Table 4). The explanations for such observations need to be explored in the future, probably, by using larger samples, more sophisticated screening methods such as ELISA or PCR or by using a control group of non-
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t
pregnant women.
STIs suggesting that sex is not the sole route of transmission of these infections (Table 4). It was
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observed in this study that previous contact with somebody with hepatitis infection in the past was a statistically significant predisposing factor (P0.05) with these viral
On the other hand, the HBV/HCV co-infection rate in this study is in agreement with the 0.57% co-infection rate recorded among pregnant women in Benin (28) but higher than the 0.15% (32) of HBV/HCV co-infection rate reported in Ekiti state from a similar study. The co-infections were however not statistically significant (P>0.05).
11
The result of this study reveals prevalence of 7.1%, 2.7%, 4.9% and 24.2% for HBV, HCV, HIV and HTLV-1 respectively. This shows that there is a low prevalence of some of the sexually transmitted viral infections among pregnant women in Osogbo, however, with a prevalence of
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The result of this study also shows that there is low co-infection rate for the viral STIs as co-
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infection rate of 0.5% was obtained for HBV/HCV, HBV/HIV, HIV/HTLV-1 and HCV/HTLV-1 while 1.1% and 0% were recorded for HBV/HTLV-1 and HCV/HIV co-infections respectively.
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In addition, the findings of this study suggest the possibility of vertical transmission of one or more of the investigated viral STIs among the positive pregnant women who may be unidentified or undiagnosed due to the asymptomatic nature or the lack of routine screening for most of these
ed
infections in Nigeria.
From the analysis of the result of this study, except for occupation, marital status and history of
pt
contact with an infected person in the past which showed association with HBV infection, all
ce
other factors including history of surgery, circumcision, tattooing, incision, tribal marks, sharing of sharp objects, blood transfusion and sexually transmitted diseases seemed not to be risk factors of the viral STIs in this study. Particularly of interest is the lack of association between
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HTLV-1 and close to a high prevalence of HBV.
t
24.2% and 7.1% for HTLV-1 and HBV, Osogbo can be said to be having a high prevalence of
history of multiple sexual partners and the viral STIs investigated in this study, suggesting that sex is not the sole route of transmission of these infections. The observed lack of association between most of the expected risk factors and the viral STIs suggest the need for a more elaborate study on this cohort.
12
Notwithstanding the low prevalence recorded for some of these viral STIs, the devastating effect of all the viral STIs in this study cannot be underestimated. A comprehensive screening for all pregnant women is therefore necessary to prevent mother to child transmission of these viral
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t
infections.
Nigeria being one of the countries endemic for these viruses with higher prevalence reported in
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women (Ijoema et al., 2010; Uneka et al., 2007; Blatiner et al., 1989) coupled with the possibility of mother-to-child transmission, suggest the need to take appropriate measures in order to reduce
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the transmission of these viral STIs and curb maternal and perinatal morbidity in Nigeria, particularly in Osogbo. Such measures include: Routine screening of all pregnant women for HBV, HCV, HIV and HTLV-1 infections followed by appropriate counseling of positive pregnant women about the risk of transmission to their babies. Proper screening of blood for
pt
surgical equipment
ed
these viruses before transfusion should be done. There should equally be adequate sterilization of
ce
In addition, more elaborate studies, especially multicenter studies should be carried out to determine the national prevalence of sexually transmitted viral infections and co-infections in order to enable formulation of guidelines for the management and the establishment of
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Sexually transmitted viral infections are worldwide problems especially in developing countries.
preventive programs. Facilities should be upgraded in tertiary health centers for easy diagnosis, viral typing, viral load and neonatal or infant diagnosis of these viruses to prevent a loss to
follow-up which is often a common problem in Nigeria. Also infants and new born must be systematically immunized against the vaccine-preventable Hepatitis B virus infection.
13
Furthermore, proper treatment of all STIs like the use of correct and effective medicines, contact tracing and treatment of sexual partners are highly recommended.
t
References
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WHO: Global prevalence and incidence of selected curable sexually transmitted infections:
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Mullick S., Watson-Jones D., Beksinska M., Mabey D. 2005: Sexuallytransmitted infections in pregnancy: prevalence, impact on pregnancy outcomes, and approach to treatment in developing
M an
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Swai R .O., Somi G. R., Matee M.I., Kilewo J., Lyamuya E.F., Kwesigabo G., Tuli T., Kabalimu T.K., Ng'anga L., Isingo R., Ndayongeje J . 2006: Surveillance of HIV and syphilis infections
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among antenatal clinic attendees in Tanzania 2003/2004. BMC Public Health, 6:91. Centers for Disease Control and Prevention. 2007: Progress in hepatitis B prevention through
445.
pt
universal infant vaccination—China,. MMWR Morb Mortal Wkly Rep , 1997—2006, 56:441-
ce
UNAIDS .2004: Report of the Global HIV/AIDS Epidemics. Germain A, Holmes KK, Piot P, Wasserheit NJ: Reproductive tract infections. Global impact
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overview and estimates. Geneva 2001.
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cr ip
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21
Table 1: Prevalence of HBV, HCV, HIV and HTLV-1 Among Pregnant Women in Osogbo, Nigeria
Women tested
Women Positive
HBV
182
13(7.1)
HCV
182
5(2.7)
HIV
182
HTLV-1
182
t
P-value
cr ip
No. of Pregnant No. (%) of Pregnant χ2
0.628
8.226
0.222
9(4.9)
0.935
0.988
44(24.2)
9.043
0.171
ce
pt
ed
M an
us
4.363
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Test
22
χ2
P-value
HBV/HCV
1(0.5)
1.281
0.258
HBV/HIV
1(0.5)
0.225
HBV/HTLV
2(1.1)
0.590
us 0.442
0.267
0.605
1(0.5)
0.049
0.825
0.882
0.348
1(0.5)
ce
pt
HIV/HTLV
0.635
0(0.0)
ed
HCV/HTLV
M an
HCV/HIV
23
t
No. Positive
cr ip
Co-Infection
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Table 2: Co-Infection rate of the Viral STIs among Pregnant Women in Osogbo, Nigeria
Age
No.
HBV +ve HCV+ve
HIV+ve HTLV
group
Tested
(%)
(%)
(%)
(Yrs)
(%)
15-19
4(2.2)
0 (0)
0 (0)
0 (0)
20-24
18(9.9)
1 (5.6)
0 (0)
25-29
70(38.5)
30-34
49(26.9)
7(3.1)
ce
40-44
45-49
Total
1(0.5)
cr ip
t
+ve (%)
us
0 (0)
M an
1 (5.6)
3 (16.7)
6 (8.6)
5 (7.1)
3 (4.3)
24 (34.3)
1 (2.0)
0 (0)
3 (6.1)
12 (24.5)
4 (12.1)
0 (0)
2 (6.1)
4 (12.1)
1 (14.3)
0 (0)
0 (0)
1 (14.3)
0 (0)
0 (0)
0 (0)
0 (0)
5(2.7)
9(4.9)
44(24.2)
ed 33(18.1)
pt
35-39
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Table 3: Prevalence of the viral STIs According to Age
182(100.0) 13(7.1)
24
p-
HC
tic
Wom
+ve
val
V
en
(%)
ue
+ve
+v
(%)
e
Teste
χ2
HI
value
V
χ2
p-
HTLV χ2
p-
val
+ve
valu
ue
(%)
e
us
d (%)
p-
t
No. of HBV χ2
cr ip
Characteris
(%
M an
)
Level of Education
2(1.1)
0(0.0
Tertiary
0
0)
1.5 42
0.462
0(
0.24 0(0.0)
1.99
0.36
2
8
8
)
0(0.
0(
0)
0)
0.0
)
2.8
0.0 40
40(22. 1(2.5
ce
Secondary
5
pt
)
1.88 0.39 0(0.
ed
Primary
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Table 4: Socio-Demographic Characteristics and History of Possible Risk Factors of the Pregnant Women
7(17.5)
)
140(7
12(8.
5(3.
9(
37(26.
6.9)
6)
6)
6.4
4)
25
)
0.68 0.40 3(4.
1.6
5)
5
18
)
8
9)
0.203
3(
4.9 00
10(8.
6.5)
3)
1.01
0.31
0
5
4
2(1.
6(
M an
121(6
0.99 12(19.
us
)
Christianity
0.0
cr ip
61(33. 3(4.9
7)
5.0
7)
32(26. 4)
)
173(9
13(7.
0.72 0.69 5(2.
pt
Yoruba
ed
Tribe
Igbo
Hausa
5)
ce
5.1)
4(2.2)
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Islam
t
Religion
5(2.7)
8
5
9)
0.2 67
0.875
9
0.4
0.78 42(24.
0.05
0.97
(5.
93
2
0
5)
3)
2)
0(0.0
0(0.
0(0
)
0)
.0)
0(0.0
0(0.
0(0
26
1(25.0)
1(20.0)
)
0)
.0)
2.9
0)
3
79
5
2.5)
174(9
11(6.
4(2.
5.6)
3)
3)
Occupation
.0)
0.4
0.50 2(25.0) 0.00
0.95
35
9
6
.2)
17.6 0.00 0(0.
0.6
Worker
99
35
0)
ed
0
pt
0)
0(0
9(5
Health Care 20(11. 6(30. 0)
0.084
cr ip
4.02 0.04 1(1
M an
Married
2(25.
us
8(4.4)
0.426
3
42(24. 1)
2(1
1.2
0.26 4(20.0) 0.21
0.64
0.0
21
9
4
4
)
7(4.3
5(3.
7(4
40(24.
Care Worker
)
1)
.3)
7)
ce
Non Health 162(8 9.0)
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Single
t
Marital Status
History of STD
Yes
7(3.8)
0(0.0
0.56 0.45 0(0.
0.2
27
0.650
0(0
0.3
0.53 2(28.6) 0.07
0.78
)
4
0)
06
.0)
79
8
7
175(9
13(7.
5(2.
9(5
42(24.
6.2)
4)
9)
.1)
0)
2
No
2.43 0.11 1(3.
0.1
8)
)
9
09
155(8
13(8.
5.2)
4)
No
0.1
0.74 5(18.5) 0.55
0.45
.7)
04
7
7
39(25.
6)
.2)
2)
8)
9
96
pt
0.8
8
4
8(5
2.43 0.11 0(0.
)
1(3
4(2.
27(14. 0(0.0
ce
Yes
7)
ed
History of Incision
8
0.742
us
27(14. 0(0.0
M an
Yes
0)
0.344
0(0
1.6
0.19 7(25.9) 0.05
0.81
.0)
49
9
8
3
155(8
13(8.
5
9
37(23.
5.2)
4)
(3.2
(5.
9)
)
8)
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History of Tribal Marks
cr ip
t
No
0
28
History of Tattooing
0.1
(2.7)
0)
1
45
177(9
12(6.
5(2.
9(5
7.3)
8)
8)
.1)
8
0)
0.703
0(0
0.2
0.60 0(0.0)
1.63
0.20
.0)
64
5
9
0
M an ed pt ce 29
t
1.28 0.25 0(0.
cr ip
1(20.
us
No
5
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Yes
44(24. 9)
