Home About us Current issue Back issues Submission Instructions Advertise Contact Login   

Search Article 
  
Advanced search 
 
Saudi Journal of Kidney Diseases and Transplantation
Users online: 1039 Home Bookmark this page Print this page Email this page Small font sizeDefault font size Increase font size 
 


 
Table of Contents   
RENAL DATA FROM ASIA–AFRICA  
Year : 2018  |  Volume : 29  |  Issue : 4  |  Page : 939-945
Incidence and factors associated with seroconversion to hepatitis C virus seropositivity amongst patients on maintenance hemodialysis, Douala-Cameroon


1 Faculty of Medicine and Pharmaceutical Sciences, University of Douala; Department of Internal Medicine, Douala General Hospital, Yaoundé, Cameroon
2 Faculty of Medicine and Pharmaceutical Sciences, University of Douala, Yaoundé, Cameroon
3 Faculty of Medicine and Pharmaceutical Sciences, University of Douala; Department of Virology and Immuno-analysis, Douala General Hospital, Douala, Yaoundé, Cameroon
4 Department of Internal Medicine, Douala General Hospital, Yaoundé, Cameroon
5 Department of Internal Medicine and Specialities, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon

Click here for correspondence address and email

Date of Submission04-Mar-2017
Date of Acceptance06-Apr-2017
Date of Web Publication28-Aug-2018
 

   Abstract 

Hepatitis C virus (HCV) infection one of the most common blood-borne infections is endemic in Cameroon and a serious problem in hemodialysis (HD). We aimed to determine the annual incidence and factors associated with seroconversion to hepatitis C positivity amongst patients on maintenance HD after an exposition of two years in a center with a high prevalence of hepatitis C (20.6%) and where no isolation policy is practiced. This was a retrospective cohort study carried out in January 2015 in the HD unit of Douala General Hospital in Cameroon including 71 patients on maintenance HD who tested negative for HCV in January 2013. Socio-demographic characteristics and clinical data were recorded, while for each patient 10 mL of blood was collected and patients retested for HCV using a fourth-generation ELISA test (BIOREXR BXEO781A). Fisher's exact test was used for dichotomous variables and using Mann Whitney's test for quantitative variables. Statistical significance was set at P <0.05. Mean age was 47 ± 13 years with 60.6% male. Blood transfusion was the main means for anemia management (85.9%) with a median number of blood units received of 5 (1–44). Facility HCV prevalence was 19.3% in January 2015. Five out of the 71 patients developed anti-HCV antibodies giving us a seroconversion rate of 7.1% and an incidence of 3.6/100 patient years. There was no significant association between age (P = 0.4), number of blood units received (P = 0.8) origin of blood units (P = 0.8), scarifications (P = 0.09) and seroconversion. After two years of exposure seroconversion to HCV positivity was 7.1% in our center with no associated factors. In a setting with high prevalence of HCV, isolation of positive patient may help to reduce the rate of transmission.

How to cite this article:
Halle MP, Larry T, Okalla C, Mefo'o N, Hermine F, Ashuntantang G. Incidence and factors associated with seroconversion to hepatitis C virus seropositivity amongst patients on maintenance hemodialysis, Douala-Cameroon. Saudi J Kidney Dis Transpl 2018;29:939-45

How to cite this URL:
Halle MP, Larry T, Okalla C, Mefo'o N, Hermine F, Ashuntantang G. Incidence and factors associated with seroconversion to hepatitis C virus seropositivity amongst patients on maintenance hemodialysis, Douala-Cameroon. Saudi J Kidney Dis Transpl [serial online] 2018 [cited 2019 Oct 20];29:939-45. Available from: http://www.sjkdt.org/text.asp?2018/29/4/939/239664

   Introduction Top


Hepatitis C virus (HCV), a major blood–borne infection, is endemic worldwide with about 150 million chronic carriers in the world.[1] Central Africa including Cameroon belong to the region with the highest prevalence in Africa.[2],[3] HCV infection is a serious problem in patients receiving dialysis treatment as patients on hemodialysis (HD) are at higher risk for acquiring HCV than the general population.[4] The reported prevalence of HCV in HD varies from 1.9% to 80%.[5] HCV infections cause liver disease such as cirrhosis and hepatocellular carcinoma and is associated with all-cause as well as cardiovascular mortality in HD patients.[4],[6],[7],[8],[9] Most patients acquire the infection while on dialysis.[10] The rate of seroconversion to HCV seropositivity during HD varies from country to country and range from 0% to 42%. Various factors related to the patients and the HD procedure are responsible for the increase susceptibility to acquire the infection during HD. Identified risk factors for HCV seroconversion include a long duration on dialysis, blood transfusions, a high facility prevalence of HCV, sharing of dialysis machines among patients, performing HD in multiple centers, facility practices and the non adherence to universal infection control mechanisms.[11],[12],[13] In developed countries the implementation of tight infection control measures in dialysis units, stricter blood bank screening rules, use of erythropoiesis-stimulating agents instead of blood transfusions have reduced the prevalence of HCV infection in HD.[14],[15],[16] But HCV infection rates still remains high in the developing world including sub-Saharan Africa due mainly to the non-adherence to universal infection control measures.[17],[18],[19],[20],[21] In Cameroon HCV is endemic with a general population prevalence of 13%.[22] and is a serious problem in hemodialysis with a prevalence of 20.6%.[20] As in most countries in Social Security Administration the health system suffers from short-comings in structure and organization, scarcity of HD facilities, shortage of healthcare personnel, high patient load and a quality of healthcare that make difficult to adhere to universal infection control measures. There are currently two single center studies focusing on cumulative HCV seroconversion among HD patients in Cameroon. Ashuntantang et al reported a cumulative seroconversion rate of 25% amongst 40 patients on maintenance HD in Yaoundé[21] and Halle et al found a cumulative seroconversion rate of 11.8% with duration on dialysis being associated with seroconversion.[20] In both studies, baseline serology for anti-HCV antibodies was done using different tests for the patients, and the patients included had different period of exposure. These factors could have influenced the results obtained and real incidence in terms of patient-years is unknown in Cameroon. This study was designed to the annual incidence - HCV sero-positivity among patients on dialysis after two years of exposure.


   Materials and Methods Top


Study design and settings

This study was designed to determine the incidence of HCV seroconversion amongst patients on maintenance HD. This was a retrospective cohort study carried out in the HD units and immunoanalysis units of the Douala General Hospital from November 1, to January 31, 2015, which included 71 patients who were tested negative for HCV in January 2013. They were retested in January 2014 after an exposure period of two years. Socio-demographic and medical data including age, gender, marital status, level of education, multicentric dialysis, number of blood pints received, origin of blood pints, use of erythropoietin, use of intravenous iron, presence of scarifications and tattoos, comorbidities and etiology of chronic kidney disease were recorded on a pretested self-administered questionnaire by a final year medical student. After an exposition of two years on HD, 10 mL of blood was collected from each patient in January 2015 and taken to the immuno-analysis unit of the Douala General Hospital were detection of anti HCV antibodies was done years using a fourth generation ELISA test (BIOREXR BXEO781A). The cut-off was calculated using the formula cut-off = Nc + 0.12 were Nc = mean absorbance value for three negative controls = 0.14. Samples giving an absorbance >0.14 were considered positive while those <0.14 were considered negative. Administrative clearance was obtained from the Douala General Hospital ethical review board while ethical clearance was procured from the University of Douala institutional review board.

Study setting

This study was carried out in the HD and immune-analysis units of the Douala General Hospital, a referral Hospital in the littoral region of Cameroon. The HD unit was created in 1990 and had at the time of the study 20 Fresenius HD machines (Fresenius medical care Hamburg, Germany), two nephrologists, 12 nurses amongst which were four senior nurses, four nurses, two state registered nurses, two assistant nurses with over 180 patients on chronic HD. Patients were divided into three groups of 60 and undergo two 4-h dialysis sessions a week, with the centre running three dialysis shifts a day. The centre neither practices dialyzer re-use nor isolation policy for hepatitis B and C positive patients and it operates from Mondays to Saturdays, from 6:30 am to 10:30 pm. Nurses work in teams and shifts following a monthly roster. A team is made up of five state registered nurses. This gives a nurse to patient ratio of 1:5 per shift. There are two shifts: a day time shift (6:30 am to 2:30 pm) and a night shift (2:30 pm to 10:30 pm). Chemical disinfection of HD machines is carried out between sessions in accordance to manufacturer's protocol and lasting about 20 minutes. Recombinant erythropoietin in pre-filled syringes were available for those who could afford. Heparin in multidose vials was the main anticoagulant used with no sharing amongst patients. Screening of blood donors for HCV antibodies was routine since 2000 at the hospital blood bank. However patients obtain blood from other blood banks in the city. Blood samples were analyzed in the laboratory of the Douala General Hospital.


   Statistical Analysis Top


Data was analyzed using XL Stat 7.5.2 software (Addinsoft, New York, USA). Fisher's test was used for dichotomous variables. Mann–Whitney's test was used to compare quantitative variables. Statistical significance was set at P <0.05.


   Results Top


Characteristics of study population

Seventy one patients were included in this study. The mean age of the study population was 47 ± 13 years with a male predominance 43 (60.6%). The main causes of ESRD were unknown (29.6%), hypertension (25.4%), chronic glomerulonephritis (21.1%), diabetes (7.0%) and HIV (4.2%). Blood transfusion was the main means for management of anemia (85.9) and transfused blood was mainly obtained from the Douala General Hospital blood bank. The median number of blood pints received during this period was five (1–44) [Table 1]. Facility HCV prevalence was 19.3% in January 2015.
Table 1: Demographic and clinical characteristics of study population.

Click here to view


Incidence and factors associated with seroconversion

Five out of the 71 patients developed anti-HCV antibodies giving us a seroconversion rate of 7.1% and an incidence of 3.6 per 100 patient years [Table 2]. There was no significant association between age (P = 0.4), number of blood pints received (P = 0.8) origin of blood pints (P = 0.8) scarifications (P = 0.09) and seroconversion [Table 3].
Table 2: Incidence of hepatitis C virus seroconversion.

Click here to view
Table 3: Factors associated with hepatitis C virus seroconversion.

Click here to view



   Discussion Top


In a setting with a high HCV prevalence, this study evaluated the incidence and factors associated with seroconversion to HCV positivity in a retrospective cohort of seronegative patients after a period of two years on HD. The seroconversion rate was 7.1% for an estimated incidence of 3.6 per 100 patients per years with no associated factors found.

Studies have well established that HD patients are at high risk for contracting blood borne virus such as HCV. Protocols to minimize virus transmission have been put in place in HD units for many years but HCV sero-conversion persists within dialysis units and the reported annual incidence of HCV infections varies considerably between countries. The rate found in this study was in the range in most western countries (0–4 per patient per year).[16],[23] But our rate is higher compared to the incidence in some emerging countries: In Lebanon the incidence of HCV was 0.37 per 100 patients – years.[24] In Morocco Bahadi reported a seroconversion rate of 0.81 per 100 patients per year.[25] and the rate was 2.5 per 100 patient per year in Sudan.[4] On the contrary our result was lower than 9.4 per 100 patients per years found by Sekkat et al in a multi-centric study in Morocco.[26] These differences in incidences rate are in general due to differences in the quality of health care services, the prevalence of the HCV infection in HD unit and especially the standards of infection control practices in HD units. Risk factors for HCV seroconversion reported in literature are age, duration on dialysis, blood transfusion, and dialysis in multiple centers, a high patient to nurses ratio.[20],[21],[25],[27]

In the present study, there was no significant statistical association between age, duration on dialysis, number and origin of blood units used, scarifications and seroconversion to HCV positivity. Some reasons can explain these differences; firstly the duration on dialysis was not evaluated in our study because all participants were exposed for two years. Though majority of patients received blood transfusions from different blood banks for anemia treatment and these units were systematically tested in our blood bank before transfusion in the HD unit. Also, the low number of patients with seroconversion reduced the statistical power of the study. Hepatitis C infections in HD patients has been reduced considerably with the isolation of infected patients, and use of dedicated machines for seropositive patients, usage of sterile environment and failure to adhere to infection control measures.[14],[28],[29] Strict adherence to infections control measures have shown to be very efficient: in a multicentric study in Belgium the incidence rate of HCV sero-conversion declined from 1.41% to 0% over a 54 months period through the implementation of universal infection control measures alone,[30] and in a study done by Hussein et al in Saudi Arabia, no new cases of HCV was found over a two-year period after strictly following the recommendations of the Center for Diseases Control and Prevention (CDC).[31] In our setting many factors could have led to the non-respect of universal infection measures. We have a 5:1 patient to nurse ratio, with inexperienced nurses, three dialysis shifts a day, patients using the same non disposable instruments, no systematic washing of hands between two patients, and the use of multidose vials of heparin. These factors have been shown to favor nosocomial infection in HD.[16],[28] Arenas et al found a patient to nurse ratio of 3:1 and above to be an independent factor affecting hand washing before and after an activity, while a high number of dialysis shifts per day was associated to lower rates of glove use and fewer glove changes between patients on HD.[29] In the present study we had a 19.3% facility prevalence which is >13%.[22] HCV population prevalence in Cameroon. This high facility prevalence could also explain the seroconversion, as increased risk of serocon-version has been reported by several authors in facilities with a high HCV prevalence.[14] Furthermore, the risk of contracting HCV infection is increased with the sharing of dialysis machines among patients.[21] Barril and Traver reported a reduction in the prevalence of HCV among HD patients by practicing standard infection control measures and the isolation of seronegative (anti-HCV negative) patients.[15] This finding was supported by another study,[32] although it demonstrated that patients' isolation per se is ineffective in minimizing HCV transmission if it is not accompanied by adequate prophylactic care by the dialysis unit staff.[32] In our setting no isolation policy was practiced in spite of the high facility HCV prevalence. Therefore isolation of seronegative HCV patients could help reduce HCV transmission in this setting.

We acknowledge some limitations in this study. Patients were tested once for HCV with a 4th generation ELISA test which lacks sensitivity in situation of high prevalence. A single negative anti-HCV test cannot rule out HCV infection because of the potential latency between infection and seroconversion in patients on HD. The search of the viral RNA with polymerase chain reaction was not done due to the high cost. However despite these limitations, this study gives an idea about the annual incidence of HCV infection in HD in a country with high HCV prevalence.


   Conclusion Top


After two years of exposure, annual incidence of HCV seroconversion was 3.6% per patient – years which is comparable to the rates found in developed countries. No associated factors associated were found. In this setting with a high HCV prevalence, strict adherence to infection control measure and isolation of positive patients may help to reduce HCV transmission amongst patients on HD.


   Acknowledgement Top


We sincerely thank all patients who participated to the study.

Conflict of interest: None declared.

 
   References Top

1.
World Health Organization. Hepatitis C Key Facts, Fact sheet no. 164. Geneva, Switzerland: World Health Organization Media Centre; 2013. Available from: http://www.who.int/ mediacentre/factsheets/fs164/en/index.html.  Back to cited text no. 1
    
2.
Madhava V, Burgess C, Drucker E. Epidemiology of chronic hepatitis C virus infection in Sub-Saharan Africa. Lancet Infect Dis 2002;2:293-302.  Back to cited text no. 2
    
3.
Te HS, Jensen DM. Epidemiology of hepatitis B and C viruses: A global overview. Clin Liver Dis 2010;14:1-21, vii.  Back to cited text no. 3
    
4.
Elamin S, Abu-Aisha H. Prevention of hepatitis B virus and hepatitis C virus transmission in hemodialysis centers: Review of current international recommendations. Arab J Nephrol Transplant 2011;4:35-47.  Back to cited text no. 4
    
5.
Jadoul M, Poignet JL, Geddes C, et al. The changing epidemiology of hepatitis C virus (HCV) infection in haemodialysis: European multicentre study. Nephrol Dial Transplant 2004;19:904-9.  Back to cited text no. 5
    
6.
Kato A, Takita T, Furuhashi M, et al. Association of HCV core antigen sero-positivity with long-term mortality in patients on regular hemodialysis. Nephron Extra 2012; 2:76-86.  Back to cited text no. 6
    
7.
Reddy GA, Dakshinamurthy KV, Neelaprasad P, Gangadhar T, Lakshmi V. Prevalence of HBV and HCV dual infection in patients on haemodialysis. Indian J Med Microbiol 2005; 23:41-3.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Aghakhani A, Banifazl M, Eslamifar A, Ahmadi F, Ramezani A. Viral hepatitis and HIV infection in hemodialysis patients. Hepat Mon 2012;12:463-4.  Back to cited text no. 8
    
9.
Fabrizi F, Martin P, Dixit V, Bunnapradist S, Dulai G. Meta-analysis: Effect of hepatitis C virus infection on mortality in dialysis. Aliment Pharmacol Ther 2004;20:1271-7.  Back to cited text no. 9
    
10.
Taskapan H, Oymak O, Dogukan A, Utas C. Patient to patient transmission of hepatitis C virus in hemodialysis units. Clin Nephrol 2001;55:477-81.  Back to cited text no. 10
    
11.
Resic H, Sahovic V, Mesic E, Leto E. Prevalence and incidence of hepatitis C seroconversion in patients on hemodialysis. Acta Med Croatica 2003;57:39-42.  Back to cited text no. 11
    
12.
Rinonce HT, Yano Y, Utsumi T, et al. Hepatitis B and C virus infection among hemo-dialysis patients in Yogyakarta, Indonesia: Prevalence and molecular evidence for nosocomial transmission. J Med Virol 2013;85: 1348-61.  Back to cited text no. 12
    
13.
Alashek WA, McIntyre CW, Taal MW. Hepatitis B and C infection in haemodialysis patients in Libya: Prevalence, incidence and risk factors. BMC Infect Dis 2012;12:265.  Back to cited text no. 13
    
14.
Espinosa M, Martn-Malo A, Ojeda R, et al. Marked reduction in the prevalence of hepatitis C virus infection in hemodialysis patients: Causes and consequences. Am J Kidney Dis 2004;43:685-9.  Back to cited text no. 14
    
15.
Barril G, Traver JA. Decrease in the hepatitis C virus (HCV) prevalence in hemodialysis patients in Spain: Effect of time, initiating HCV prevalence studies and adoption of isolation measures. Antiviral Res 2003;60:129-34.  Back to cited text no. 15
    
16.
Fissell RB, Bragg-Gresham JL, Woods JD, et al. Patterns of hepatitis C prevalence and seroconversion in hemodialysis units from three continents: The DOPPS. Kidney Int 2004;65:2335-42.  Back to cited text no. 16
    
17.
de Jesus Rodrigues de Freitas M, Fecury AA, de Almeida MK, et al. Prevalence of hepatitis C virus infection and genotypes in patient with chronic kidney disease undergoing hemo-dialysis. J Med Virol 2013;85:1741-5.  Back to cited text no. 17
    
18.
Diouf ML, Diouf B, Niang A, et al. Prevalence of hepatitis B and C viruses in a chronic hemodialysis center in Dakar. Dakar Med 2000;45:1-4.  Back to cited text no. 18
    
19.
Khattab OS. Prevalence and risk factors for hepatitis C virus infection in hemodialysis patients in an Iraqi renal transplant center. Saudi J Kidney Dis Transpl 2008;19:110-5.  Back to cited text no. 19
[PUBMED]  [Full text]  
20.
Halle MP, Choukem SP, Kaze FF, et al. Hepatitis B, hepatitis C, and human immune deficiency virus seroconversion positivity rates and their potential risk factors among patients on maintenance hemodialysis in Cameroon. Iran J Kidney Dis 2016;10:304-9.  Back to cited text no. 20
    
21.
Ashuntantang G, Njouom R, Kengne AP, et al. Incidence and potential risk factors for seroconversion to hepatitis positivity in patients on maintenance hemodialysis in Sub-Saharan Africa. Health Sci Dis 2014;14:1-6.  Back to cited text no. 21
    
22.
Noubiap JJ, Joko WY, Nansseu JR, Tene UG, Siaka C. Sero-epidemiology of human immunodeficiency virus, hepatitis B and C viruses, and syphilis infections among firsttime blood donors in Edéa, Cameroon. Int J Infect Dis 2013;17:e832-7.  Back to cited text no. 22
    
23.
Izopet J, Sandres-Sauné K, Kamar N, et al. Incidence of HCV infection in French hemo-dialysis units: A prospective study. J Med Virol 2005;77:70-6.  Back to cited text no. 23
    
24.
Abou Rached A, El Khoury L, El Imad T, et al. Incidence and prevalence of hepatitis B and hepatitis C viruses in hemodialysis patients in Lebanon. World J Nephrol 2016;5:101-7.  Back to cited text no. 24
    
25.
Abdelaali B, Omar M. Hepatitis C viral prevalence and seroconversion in moroccan hemodialysis units: Eight year follow up. J Med Diagn Meth 2013;2:141.  Back to cited text no. 25
    
26.
Sekkat S, Kamal N, Benali B, et al. Prevalence of anti-HCV antibodies and seroconversion incidence in five haemodialysis units in morocco. Nephrol Ther 2008;4:105-10.  Back to cited text no. 26
    
27.
El-Amin HH, Osman EM, Mekki MO, et al. Hepatitis C virus infection in hemodialysis patients in Sudan: Two centers' report. Saudi J Kidney Dis Transpl 2007;18:101-6.  Back to cited text no. 27
[PUBMED]  [Full text]  
28.
Saxena AK, Panhotra BR. The impact of nurse understaffing on the transmission of hepatitis C virus in a hospital-based hemodialysis unit. Med Princ Pract 2004;13:129-35.  Back to cited text no. 28
    
29.
Arenas MD, Sánchez-Payá J, Barril G, et al. A multicentric survey of the practice of hand hygiene in haemodialysis units: Factors affecting compliance. Nephrol Dial Transplant 2005;20:1164-71.  Back to cited text no. 29
    
30.
Jadoul M, Cornu C, van Ypersele de Strihou C. Universal precautions prevent hepatitis C virus transmission: A 54 month follow-up of the Belgian multicenter study. The Universitaires Cliniques St-Luc (UCL) collaborative group. Kidney Int 1998;53:1022-5.  Back to cited text no. 30
    
31.
Hussein MM, Mooij JM. Methods used to reduce the prevalence of hepatitis C in a dialysis unit. Saudi J Kidney Dis Transpl 2010; 21:909-13.  Back to cited text no. 31
[PUBMED]  [Full text]  
32.
Al-Ghamdi SM. Nurses' knowledge and practice in hemodialysis units: Comparison between nurses in units with high and low prevalence of hepatitis C virus infection. Saudi J Kidney Dis Transpl 2004;15:34-40.  Back to cited text no. 32
[PUBMED]  [Full text]  

Top
Correspondence Address:
Dr. Marie Patrice Halle
Faculty of Medicine and Pharmaceutical Science, University of Douala, Douala
Cameroon
Login to access the Email id


DOI: 10.4103/1319-2442.239664

PMID: 30152433

Rights and Permissions



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

Top
   
 
 
    Similar in PUBMED
    Search Pubmed for
    Search in Google Scholar for
    Email Alert *
    Add to My List *
* Registration required (free)  
 


 
    Abstract
   Introduction
    Materials and Me...
   Statistical Analysis
   Results
   Discussion
   Conclusion
   Acknowledgement
    References
    Article Tables
 

 Article Access Statistics
    Viewed732    
    Printed11    
    Emailed0    
    PDF Downloaded68    
    Comments [Add]    

Recommend this journal