Journal of Womens Health, Issues and Care ISSN: 2325-9795

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Research Article, J Womens Health Issues Care Vol: 2 Issue: 2

Socio-demographic Characteristics as Risk Factors for Hepatitis C Virus Infection among Pregnant Women in Iraq

Waqar A. Al-Kubaisy1* and Amjad D. Niazi2
1Faculty of Medicine, Department of Population Health and Preventive Medicine, Universiti Teknologi MARA (UiTM), Malaysia
2Faculty of Medicine, Al-Nahrain University, Baghdad, Iraq
Corresponding author : Waqar A. Al-Kubaisy
Faculty of Medicine, Department of Population Health and Preventive Medicine, Universiti Teknologi MARA (UiTM), Sungai Buloh Campus, Sungai Buloh, Malaysia
Tel: +6 03-6126 7173
E-mail: [email protected]
Received: January 25, 2013 Accepted: March 23, 2013 Published: March 27, 2013
Citation: Al-Kubaisy WA, Niazi AD (2013) Socio-demographic Characteristics as Risk Factors for Hepatitis C Virus Infection among Pregnant Women in Iraq. J Womens Health, Issues Care 2:2. doi:10.4172/2325-9795.1000106

Abstract

Socio-demographic Characteristics as Risk Factors for Hepatitis C Virus Infection among Pregnant Women in Iraq

Hepatitis C virus (HCV) infection is a major public health, affecting approximately 180 million persons worldwide. It was documented that HCV are accounting for 70%-90% of hepatocellular carcinoma (HCC) cases worldwide. Interestingly, Ly et al. predicted that by year 2020, the annual death rate due to liver cirrhosis or HCC is expected to be around 18,000 persons. HCV infection considered as a significant major public health burden in both industrialized and developing countries. However, region specific variation in prevalence of HCV infection was detected with the highest prevalence were (15-20%) in Egypt.

Keywords: Pregnant woman; HCV infection; Risk factors; Life style; Cultural environment

Keywords

Pregnant woman; HCV infection; Risk factors; Life style; Cultural environment

Abbreviations

HCV: Hepatitis C Virus; HCC: Hepatocellular Carcinoma; HCW: Health Care Worker; HW: House Wife; Abs: Antibodies; RNA: Ribonucleic Acid; RT-PCR: Reverse Transcription Polymerase Chain Reaction; OR: Odds Ratio; 95% C.I: 95% Confidence Interval; M.O.H: Ministry of Health; Anti-HCV: HCV Antibodies; DEIA: DNA Enzyme Immunoassay; EIA-3: Third Generation Enzyme Immunoassay; IDU: Intravenous Drug Abuse; LiaTek-III: Third Generation Immunoblot Assay; HIV: Human Immunodeficiency Virus

Introduction

Hepatitis C virus (HCV) infection is a major public health, affecting approximately 180 million persons worldwide [1]. It was documented that HCV are accounting for 70%-90% of hepatocellular carcinoma (HCC) cases worldwide [2,3]. Interestingly, Ly et al. [1] predicted that by year 2020, the annual death rate due to liver cirrhosis or HCC is expected to be around 18,000 persons. HCV infection considered as a significant major public health burden in both industrialized and developing countries [4,5]. However, regionspecific variation in prevalence of HCV infection was detected with the highest prevalence were (15-20%) in Egypt [6]. Despite the clinical sequel associated with HCV, its epidemiology and risk factors are poorly understood, especially in developing countries where intravenous drug abuse (IDU) is uncommon. Several studies documented that HCV is transmitted by blood transfusion and other percutaneous exposure and possibly sexual or household contact with HCV infected persons [5-8]. Interestingly a controversial opinion about the relation between socio demographic-characteristics (age, marital status, occupation education and tattooing) and anti- HCV seropositive rate [7,9-11]. Moreover, it has been shown that the six genotype (1 to 6) of HCV that recognized in different prevalence and geographic distribution, have been associated with specific mode of transmission [5,12,13].Therefore, there is an evidence reported that the risk factors for the transmission of HCV infection varies substantially between countries and geographic regions [5,14].
Chronic hepatitis C was seen commonly in women of child bearing age and may have a great effect on pregnancy and neonate [15]. However, only few studies have attempted to assess the prevalence rate of HCV infection in pregnant women [15,16].
In Iraq, accurate data on HCV distribution are elusive, and this situation is compounded by a lack of understating of its natural history. In addition, routine diagnosis of infection with this virus is often limited to blood donors. Little or no published data exist on the distribution of the HCV infection particularly among pregnant women. Therefore, a multi-central cross-sectional study was conducted. We were soughed to determine the prevalence of HCV markers (Abs, RNA and Genotypes) among pregnant women against the backdrop of their socio demographic-characteristics and to identify the possible risk factors.

Materials and Methods

A cross-sectional study was conducted for approximately 22 months period from October 2000 through August 2002. Nineteen health care institutes distributed all over Baghdad province (the capital of Iraq) were chosen randomly. A random sample of 3491 pregnant women during their third trimester attending the 19 health care centres was collected. There were no exclusion criteria. Formal consent was obtained from each participant. Interviewing each mother was carried out, using a standardized questionnaire emphasizing on the socio demographic information (age, residency, education attainment, occupation, history of tattooing, and numbers of marriages) were recorded. Blood sample was taken from each participant.
Laboratory analysis
Serum samples of each participant was dispensed into two frozen tubes, one stored at -20°C for the detection of HCV antibodies (Anti-HCV), and the other at -70°C for the molecular analysis. Initial screening of HCV specific antibodies was carried out on 3491 pregnant women’s sera, using third generation enzyme immunoassay (EIA-3 “UBI HCV- EIA-3 NY, USA”). Further confirmation of the positive samples was carried out, using third generation immunoblot assay (LiaTek-III, Organon, Belgium). In addition, 94 mother’s sera of those stored at -70° were transferred to the laboratories of Sorin Biomedica “Sallugia-Italy”, to be subjected to molecular analysis, for the detection of HCV-RNA and subsequently their genotypes, using an advanced molecular method. This method is a combination of two techniques, the RT-PCR and DNA enzyme immunoassay (DEIA) techniques [17]. Depending upon nomenclature by Simmond et al. [18], classification of HCV genotypes was done.
Depending upon probability of exposure to an overt or covert risk factor, mother’s occupation was classified into housewives (HW), health care workers (HCWs) and other official work.
Statistical analysis
Data were entered to computer using Epi-Info-3 plus SPSS 16.0. Descriptive information was summarized as the total number of subjects with or without potential risk factor along with the number and percentage of subjects with HCV. The whole variables were analyzed using chi-square test (X2) and student-t-test, to determine which factor associated with HCV infection. Each sociodemographic factor was categorized into several strata. OR and 95% C.I. for each stratum was computed in order to identify the potential risk of exposure to HCV. Stepwise logistic regression analysis was used to identify the combination of factors associated with HCV. Multivariate results were summarized as the adjusted OR and 95% C.I. for each independent risk factor identified by multiple logistic regression models. All statistical tests were performed using P<0.05.
The study protocol was approved by the relevant institutional review board at the university and M.O.H.

Results

The socio-demographic characteristics profile of the (3491) study women were as follows. Maternal mean age was 25.7 ± 0.6 years (range: 14-50 years). More than half (55.1%) of the mothers were at age 20-29 years. Educational attainment was skewed towards less advanced education, were only 26.4% with high school certificate and over. About 79% were residing the urban. Most women (3444) had once experience of marriage (Table 1).
Table 1: Prevalence of anti-HCV (by Lia-Tek-III) in relation to socio-demographic characteristics of 3491 Iraqi pregnant women.
The prevalence of anti-HCV was 3.2% as 112/3491 sera were confirmed positively by Lia-Tek-III. By molecular analysis (RT-PCR and DEIA method), HCV-RNA was detected in 59/94 (62.7%) serum samples. Five (1, 1a, 1b, 4, and 3a) genotypes/subtypes of HCV were identified either as a single (1, 1a, 1b and 4) or as a mixed (1 and 4, 1b and 4, 3a and 4) pattern of infection. We found that HCV-4 is the most predominative genotype circulating in our population as a single or mixed pattern of infection (50.8%, 22.8% respectively) and HCV-1b is the second most frequent genotype (35.98%).
Risk factors
In pregnant women with positive anti-HCV sera, their mean age was (30.33 ± 7.82 years) significantly higher compared to those with anti-HCV negative, p=0.0001 (Table 2).Our study revealed that anti-HCV seropositivity rate was increasing as the age of the mother increased, with a significant direct correlation, r=0.84, p=0.015 (Table 1). An inverse relationship between level of maternal education and seropositive rate of anti-HCV was detected. Illiterate mothers showed significantly higher rate of positive anti-HCV serum, p=0.049. HCWs had significantly the highest (17.85%) anti-HCV seropositivity (more than four times) compared to HW and other official job, p=0.0001. Also HCWs showed significantly higher anti-HCVseroprevalence than non HCWs, p<0.001. Mothers residing rural area had higher anti- HCV prevalence (4.23%) than those residing urban (2.43%), however, this difference was not significant p=0.09. No significant association between numbers of marriages and anti-HCV seropositivity. No significant association between history of tattooing and positive anti- HCV prevalence was found, p=0.95 (Table 1).
Table 2: Positive HCV marker (Abs, RNA and genotypes) prevalence in relation maternal mean age (years) of 3491 women in Iraq.
In order to identify the potential risk of exposure to HCV infection, each socio demographic factor was categorized into several strata. Using as a reference groups those mothers, at age <20 years, accomplished college and above, or house wife mothers. Then OR and (95% C.I.) for each stratum was calculated. Interestingly we found that both the illiterate and HCWs women were significantly at a high risk for exposure to HCV infection, ORs, 1.67 (1.04-2. 69) and 6.82 (2.91-15.99) respectively. Similarly mothers of ≥ 30 years old be considered as a high risk mothers for acquiring HCV infection in which ORs 1.72 (1.18-2.5) and 3.51 (1.97-6.18) for those mothers at age 30-39 and ≥ 40 years respectively. Also second marriage and residency at rural area were risk factors for contracting HCV infection, OR=2.877 (1.06-7.78) and OR=1.46 (1.0-2.23) respectively. On the other hand, history of tattooing was found as insignificant risk factor (OR=1.1 (0.42-2.6).
Using multivariate regression analysis, all the variables were analyzed. Interestingly, we gave an evidence that only old age of the women (30 years and older) acts independently as unconfounding risk factor for contracting HCV infection (adjusted OR=1.1, 95% C.I.=1.0-1.1) (Table 1).
Regarding the molecular analysis our study revealed that women with positive HCV-RNA their mean age was significantly greater (30.7 ± 7.69 years) than those with negative HCV-RNA, p=0.01 (Table 2). Moreover, HCV-RNA seropositive rate was significantly increasing with increased age of the mother (Table 3). No significant relation between maternal age and various genotypes of HCV. However, we detected that women infected with HCV-1b were significantly older than those infected with HCV non 1b (33.9 ± 5.4 vr 27.9 ± 9.5 years) p=0.046 (Table 2). No significant association between HCV-RNA seropositivity and occupation as well as history of tattooing (Table 3). Sera of both women with history of tattooing that subjected to molecular analysis demonstrated positive HCV-RNA. Interestingly, neither of them showed single HCV infection, both of them were coinfected with dual HCV genotypes that are HCV-1b and 4 (Table 3).
Table 3: Sero-positive rate of HCV-RNA and genotypic isolated by RT-PCR and DEIA method in relation to socio- demographic characteristics of 94 Iraqi pregnant women.

Discussion

The high prevalence (3.2%) of anti-HCV among Iraqi pregnant women may explain the possible risk factors that may be associated with pregnancy as some researchers mentioned [19]. Although our prevalence is identical to that in USA [20] but it much higher than Algeria, Saudi Arabia, and Taiwan [19,21,22], while much lower than that in Cameroon [23]. These discrepancies in anti-HCV prevalence may be attributed to variation in the social or cultural characteristics of population, standard of living, existence of certain behavioural risk factors, and perhaps difference in HCV genotypes or analysis method. Our most serious finding, that the age of woman was documented as unconfounding risk factor for acquiring HCV infection (adjusted OR=1.06). In addition, we gave an evidence that HCV infection is age dependent disease, by which our study revealed that HCV markers (Abs, RNA) as well as the risk of acquiring HCV infection (ORs) are significantly increasing steadily with increased maternal age, particularly women at age 30 years and older be considered as a high risk group for contracting HCV infection. This found a concurrence with other investigators [8-10,24-26], while contradicting others [27,28]. The most acceptable explanation for our result is the possibility that those women (age ≥ 30 years) being mostly as multiparous or even grand multiparous, nosocomial way of transmission as well as the accumulative exposure to various sources (family, hospital, occupation,...etc). This may be due to the prolonged period of incubation of this virus and effect of time spanning particularly with infection of HCV-1b, all these lead to increase risk of acquiring HCV. In addition, compatible to several authors [29,30], we found that mothers infected by HCV-1b were significantly older than others. This HCV genotype possesses long duration of clearance compared to other HCV genotypes.
An alternative to multiple sexual partners which is ethically not accepted in our community, an involvement in polygamous marriage (second marriage) was considered to be investigated to reflect this risk factor. In accordance with several studies, [31,32] and disagreement by others [7,10,11], the monogamous stable sexual partners in our study showed lower prevalence of anti-HCV while polygamous marriage acts as a possible risk factor for contracting HCV infection. Supporting Darwish et al. [28], our study detected that inhabitants at rural areas be at greater risk of exposure to HCV infection [23]. This finding most probably attributed to folk medication, use of undisposable, syringes, needles and medical equipments. In addition tattooing, polygamous and parity could account for the high rate of HCV infection. Moreover, illiteracy which is more prevalent among rural inhabitant and which was detected as risk factor for acquiring HCV infection in our study. Notably, the high anti-HCV prevalence (4%) that we detected among mothers with college education and above, may be due to the attending chiropodist or manicurist at barbers shop that may play a role in HCV transmission [14,33]. In addition five of them were HCWs. Three dentists were involved in this study, one of them demonstrated positive anti-HCV also, and 4 out of 20 (20%) nurses demonstrated seropsitive anti-HCV. Interestingly, this serum showed HCV-RNA positively, and this nurse was found harbouring genotype HCV-1. Therefore, in agreement to other authors [34], we could say that Iraqi HCWs are at great risk of acquiring HCV infection and they should not be overlooked as occupational risk. Contradicting several authors, [32,33,35,36] our study could not confirmed that tattooing acts as a possible risk factor for HCV infection. This most probably attributed to the variation in social as well as cultural life between Iraqi population and others from western countries, in which tattooing is most probably prevalent among high risk (I.VDUs, HIV, and homosexual) group [14,36]. Moreover, tattooing in Iraq is carried out within family members so there is low chance of contamination. Particularly we found that both sera of tattooed women with positive HCV-RNA, demonstrated mixed pattern (HCV-4 and 1a) of HCV infection.

Conclusion

The prevalence of HCV infection is high among Iraqi pregnant women. There were several significant factors associated with this health problem as age, illiteracy, residing rural area, occupation, etc. Therefore, HCV screening of pregnant women is recommended particularly for old age mothers.

Acknowledgment

We thank all pregnant women involved in this study and the scientific research committee for granting us the approval and assistance in conducting the study.

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