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Saudi Journal of Kidney Diseases and Transplantation
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RENAL DATA FROM THE ARAB WORLD  
Year : 2015  |  Volume : 26  |  Issue : 2  |  Page : 380-385
Prevalence and associated factors of hepatitis C virus infection among renal disease patients on maintenance hemodialysis in three health centers in Aden, Yemen: A cross sectional study


1 Faculty of Medicine and Health Sciences, Aden University, Aden, Yemen
2 Department of Community Medicine, International Medical University (IMU), Jalan Jalil Perkasa, Bukit Jalil, Kuala Lumpur, Malaysia
3 Tayba Hemodialysis Center, Al-Gamhuria Teaching Hospital, Aden, Yemen
4 Queen Mary, University of London, Barts and The London School of Medicine and Dentistry, Institute of Dentistry, London, United Kingdom
5 Faculty of Medicine and Health Sciences, Nottingham University Malaysia Campus, JalanBroga, Semenyih, Selangor DarulEhsan, Malaysia

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Date of Web Publication3-Mar-2015
 

   Abstract 

We aimed to assess the prevalence and factors associated with positive anti-hepatitis C virus (HCV) antibodies among patients on maintenance hemodialysis (HD) in three centers in Aden, Yemen. The data from 219 patients and their records over the period between 2000-2013, was extracted and analyzed. The mean ± SD age of the patients was 47.08 ± 13.9 years; 74.4% of them were married and 14.6% were employed. The prevalence of validated anti-HCV-positive cases was 40.2% (95%CI 33.64%-46.73%). The mean ± SD duration on HD of all the patients was 35.09 ± 38 months. On bivariate analysis, the duration on HD and attending more than one center for HD associated significantly with anti-HCV positivity (P <0.05). On multivariate fully adjusted Poisson regression modelling, controlled for age, Patients attending more than one center and those who underwent HD for longer durations were more likely to be positive for anti- HCV antibodies [P = 0.004, adjusted prevalence rate ratio (APRR) = 1.87, 95% confidence interval (CI): 1.22-2.88; P = 0.0005, APRR = 1.01, 95% CI: 1.00-1.02. In this study sample, the prevalence of HCV was significant. Patients attending more than one center and those who underwent HD for longer durations were found to be more likely to contract HCV. Enhancing existing infection control measures and allocating more resources to HD centers therefore warrants consideration.

How to cite this article:
Aman K, Al-Dubai SA, Aman R, Hawash A, Alshagga M, Kassim S. Prevalence and associated factors of hepatitis C virus infection among renal disease patients on maintenance hemodialysis in three health centers in Aden, Yemen: A cross sectional study. Saudi J Kidney Dis Transpl 2015;26:380-5

How to cite this URL:
Aman K, Al-Dubai SA, Aman R, Hawash A, Alshagga M, Kassim S. Prevalence and associated factors of hepatitis C virus infection among renal disease patients on maintenance hemodialysis in three health centers in Aden, Yemen: A cross sectional study. Saudi J Kidney Dis Transpl [serial online] 2015 [cited 2021 May 16];26:380-5. Available from: https://www.sjkdt.org/text.asp?2015/26/2/380/152555

   Introduction Top


Infection with hepatitis C virus (HCV) is a common nosocomial occurrence among hemodialysis (HD) patients. [1] It is considered a cause of end-stage liver disease and contributes to high mortality and morbidity among patients on maintenance dialysis. [2] The prevalence of contracting HCV during HD varies from country to country. Tight infection control measures implemented in developed countries has minimized the transmission rate, [3] while the prevalence still remains high in the developing world. [4],[5],[6],[7]

Patients with end-stage renal disease (ESRD) receive frequent blood transfusions to correct their chronic anemia. [8] Transfusion of blood or blood products still constitutes an important route of transmission of HCV. [9],[10] Although strict measures are in place, both with regard to criteria for the selection of blood donors [11] and sensitive laboratory screening tests, both of which have been proven to diminish the risk of transmission, [12] these measures may be unaffordable in some countries such as Yemen. [13] Additionally, the residual risk of transmission during the window period (the period between contracting HCV infection and detecting the antibodies in the donor's blood) cannot be ignored. [12]

Furthermore, the risk of contracting HCV infection is increased with the sharing of dialysis machines among patients. 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. [14] This finding was supported by another study, 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. [15] Moreover, performing HD in multiple centers as well as duration on HD have both been reported as risks associated with HCV transmission. [16],[17] Finally, the current literature demonstrates the role of socio-demographic factors such as age in contracting HCV. [13],[18]

There is currently a lack of information focusing on the levels of HCV and its associated factors among HD patients in Yemen. Bin Selm [13] reported that the prevalence of HCV positivity was high at 63% at a Government HD center in Aden. Yemen is one of the poorest countries in the world. The health system suffers from shortcomings in structure and organization, low staff, low quality of healthcare, shortages of essential medicines and a lack of equality in distribution of publicly funded facilities and human resources. [19] Additionally, the political and economic situation that accompanied the recent Arab Spring adversely affected Yemen and further burdened its flailing health system. Consequently, patients may be forced to travel to multiple centers for HD, and the few available health centers would therefore be used above their capacity. A preliminary multicenter study exploring the prevalence of HCV and its associated factors is crucially important to monitor and guide effectively the preventive and infection control measures within the existing material and human resources. This study was performed to retrospectively assess the prevalence of HCV infection as well as the factors associated with it among patients on maintenance HD in the three available centers in Aden, Yemen.


   Methods and Materials Top


The study was reviewed and approved by the Institutional Review Board at the University of Aden, Yemen. We undertook a review over the period from May to July 2013 and extracted and analyzed the data from the records of all the patients (n = 243) with ESRD undergoing maintenance HD in the three available centers in Aden, Yemen. Patients aged under 18 years, those positive for hepatitis B virus and those with dual infection with hepatitis B and C viruses were excluded from the study. Therefore, this study finally included a total of 219 adult patients' records who underwent HD over the period between 2000-2013 and provided supplementary data.

The results of investigations related to anti-HCV positivity and the outcome of interest for this study were obtained from the patients' clinical records and the related laboratory registry. Demographic and socioeconomic data of the patients (age, gender, occupation and marital state), duration on HD, history of blood transfusion(s), surgical intervention, travel, attending more than one HD center and type of vascular access for HD (arterio-venous fistula, catheter or graft) were all obtained from the patients'clinical records.

Data collected were checked for normality distribution and analyzed using SPSS for Windows version 16. The mean ± SD was considered for normally distributed continuous variables and median (range) if assumption was not met. Proportions were reported for categorical variables. Unpaired T test was employed to compare means of duration on HD and age with anti-HCV positivity. Unadjusted prevalence rate ratio using Poisson regressions (bivariate) was used to explore significant explanatory variables associated with anti-HCV positivity. Multivariate Poisson regression analysis, controlled for age, was used to model the associations between the explanatory variables, detected significant in bivariate analysis, and the anti-HCV positivity. Age, although not significantly associated with the dependent variable, was entered into the model on a theoretical basis as mentioned above. The level of significance was set for all analysis at a P-value <0.05.


   Results Top


A total of 219 patients were studied; their mean age was 47.08 ± 13.9 years (range 18-80 years). The majority of the patients were male [153 (69.9%)], 163 were married (74.4%) and 32 were employed (14.6%). Eighty-eight of 219 (40.2%) patients were anti-HCV positive. The mean ± SD duration on HD of all the study patients was 35.09 ± 38 months. Other socio-demographic characteristics of the patients are reported in [Table 1].
Table 1: Demographic and socio-economic characteristics and unadjusted Poisson analysis of factors associated with anti-hepatitis C virus positivity (n = 219).

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Unadjusted analysis revealed that receiving HD at more than one HD center was significantly associated with anti-HCV positivity (P = 0.024) [Table 1] and Unpaired T-Test showed that there was a statistically significant difference in the mean duration on HD between anti-HCV-positive and -negative cases (P = 0.0005). On multivariate analysis, both increase in the duration on HD as well as attending more than one center for HD were significantly associated with anti-HCV positivity [P = 0.0005, APRR = 1.01, 95% confidence interval (CI): 1.00-1.02; P = 0.004, APRR = 1.87, 95% CI: 1.22-2.88, respectively; [Table 2]. Age was not found to be significantly associated with anti-HCV positivity (P = 0.119, APRR = 1.01, 95% CI: 0.99- 1.03).
Table 2: Multivariate analysis of factors associated with anti-HCV positivity.

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   Discussion Top


This is to our knowledge the first study to report on the prevalence of HCV and its associated risk factors in patients receiving HD in multiple centers in Aden, Yemen. It is well established that maintenance HD renders patients with ESRD at increased risk of contracting blood-borne infections, such as HCV. [20]

In this study, an overall prevalence rate of 40.2% of HCV infection was found. Comparable figures have been observed in neighboring Mediterranean countries such as Egypt (42.2%), [21] Libya (31.1%) [18] and Syria (48.9%). [22]

However, the figure reported from this study is lower than that reported earlier by Bin Selm (62.7%). [13] One should take into consideration that this latter study had a relatively small sample size (n = 51) and all patients were recruited from a single HD center.

With respect to the factors associated with HCV infection, in this study sample, the duration on HD was found to be more commonly associated with HCV. This lends further support to the current literature. [4],[17],[23],[24] It has been reported previously that an increased duration on HD is an important risk factor for acquiring HCV infection. [25] Non-usage of sterile environment, failure to adhere to infection control measures by the patients [26] as well as the health-care professionals [27] may all play a role in viral transmission, especially HCV, in HD centers. Indeed, in one study from Saudi Arabia, no new cases of HCV were seen over a two-year period after strictly following the recommendations of the Kidney Disease Improving Global Outcome (KDIGO) initiative and the Center for Diseases Control and Prevention (CDC). [28]

Furthermore, the prevalence of HCV infection among HD patients was significantly associated with history of receiving HD at more than one HD center, which is in accordance with other studies. [29] It is fair to mention here that a number of patients in this study were transferred to other centers within Aden city due to constructive or maintenance work of a particular center, while others opted for other centers for social or surgical interventional reasons. [18] Finally, with respect to the dissociation of age with HCV, our results were not dissimilar from other studies. [25]


   Strengths and Limitations Top


The strength of this study lies in the fact that less time and resources were allocated to investigate HCV among the study patients on maintenance HD. However, one should take into account the fact that the review of patients' records meant that non-availability of data and accuracy of the records was beyond the researchers' control. Documented data for preventive and infection control measures such as screening on a semi-annual basis for isolation of susceptible patients, proper injection-medication practices and cleaning and disinfection [20] in these HD centers were not available. The availability of such data may have elucidated the contribution of these factors to the high prevalence of anti-HCV positivity seen in these centers. Finally, the nature of this study design (cross-sectional) precludes causality. [30]


   Clinical Implication and Future Work Top


A prevalence of HCV positivity of 40.2% in such a high-risk group has grave clinical implications, both for the individuals and for the propagation and transmission of the disease. Future research needs to be directed toward reducing the transmission of HCV within HD centers. A prospective study of the health centers would allow for auditing of infection control practices and subsequent implementation of improved measures. Future studies could also use a larger sample with the aim of quantifying the extent of the problem across Yemen.


   Conclusion Top


In this study sample, the prevalence of HCV was significant. Patients attending more than one center and those who underwent HD for longer durations were found to be more likely to contract HCV. Enhancing existing infection control measures and allocating more resources to HD centers therefore warrants consideration.


   Declaration of interest Top


All authors declare that they have no competing interest. This manuscript has not been published or is being considered for publication elsewhere. The whole data of this study is presented in this manuscript.

 
   References Top

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Correspondence Address:
Dr. Khadija Aman
Faculty of Medicine and Health Sciences, Aden University, Aden
Yemen
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DOI: 10.4103/1319-2442.152555

PMID: 25758898

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