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Correlates of Hepatitis B Virus Infection among Antenatal Clinic Attendees of Volta Regional Hospital, Ho, Volta Region, Ghana

Hepatitis B virus (HBV) infection remains a global health problem. With 
about 380 million chronic carriers of the HBV virus, there are over two million 
global deaths annually. Ghana is among the high endemic countries in Africa, 
with HBV prevalence ranging from 4.8% to 12.3% in the general population, 10.8% 
to 12.7% in blood donors and about 10.6% in antenatal clinic (ANC) attendees. 
The main objectives of this study were to test how socioeconomic factors, risky 
behaviors, knowledge and awareness of HBV infection correlate with actual HBV 
status among antenatal clinic attendees and to determine the predictors of HBV 
testing among ANC attendees. The study employed 
random sampling technique to sample 500 pregnant women, at mothers’ clinic of Volta Regional Hospital, Ho, Ghana. A structured questionnaire was 
used to collect information on socio-demographic characteristics, Hepatitis B 
status, possible risk factors, awareness and knowledge levels of HBV infection. Cross tabulation and the chi-square (χ2) 
statistic were used to determine statistical independence or association of 
study variables. Kruskal-Wallis test 
was applied to test for the differences in HBV knowledge scores across HBV 
status and levels of HBV awareness; and the binomial regression model was used 
to determine the predictors of HBV testing among ANC attendees. It is evident 
that age, religion, ethnicity, educational level, blood transfusion, number of 
blood transfusions, gravidity, parity, awareness of HBV and monthly income were 
associated with HBV status. Results of the Binomial Logistic Regression model 
indicate that Age (p = 0.03), 
Education level (p = 0.04), Religion 
(p = 0.04), Ethnicity (p = 0.00) and Blood transfusion (p = 0.04) were significant (p 0.05) 
predictors of HBV testing. Knowledge of HBV status enables patients to seek 
early treatment, facilitates referral for social support and counseling. We recommend that the Ministry of Health 
should carry effective education on HBV and its prevention for women of 
child-bearing age.


Introduction
With about three hundred and eighty million chronic carriers of Hepatitis B virus (HBV) globally and over two million global deaths annually, HBV infection remains a global health problem [1]. HBV is among a group of viruses known as hepatotropic virus, belonging to the family hepadnavirus [2]. The natural host is only humans. The blood transports HBV to the liver, where replication of the virus only occurs [3]. Among hepatitis A, B, C, D and E, HBV is the most important hepatitis virus during pregnancy [4]. Hepatitis B virus-related liver diseases include chronic hepatitis, liver cirrhosis and hepatocellular carcinoma [5].
Hepatitis B virus infection is a major global health problem associated with high prevalence, significant morbidity and mortality [5]. An estimate of about 2 billion people are infected with the HBV worldwide, of which about a quarter would develop chronic infection with increasing risk of progressing to liver disease and hepatocellular carcinoma (HCC). Chronic carriers of the HBV are over 380,000,000 worldwide with HBV related diseases contributing to over 2,000,000 deaths annually [4].
The likelihood that infection with the virus becomes chronic depends upon the age at which a person becomes infected. Children less than 6 years of age who become infected with the hepatitis B virus are the most likely to develop chronic infections. 80% -90% of infants infected during the first year of life develop chronic infections and 30% -50% of children infected before the age of 6 years develop chronic infections. Less than 5% of otherwise healthy persons who are infected as adults would develop chronic infection, with 20% -30% of adults who are chronically infected developing cirrhosis and/or liver cancer [6].
Ghana is among the high endemic countries in Africa, with HBV prevalence ranging from 4.8% to 12.3% in the general population, 10.8% to 12.7% in blood donors and about 10.6% in ANC attendees [7]. Although, perinatal transmission of HBV infections is common in endemic areas, the reduction of vertical transmission rate is achievable by increasing the awareness and knowledge level in the general public including pregnant women.
Various studies conducted in Ghana indicate that HBV is endemic in Ghana with sero-prevalence rates ranging from 6.7% to 10% in blood donors [8] pregnant women in Accra, Ghana, increased from 6.4 % in1994 [9].
The modes of transmission of HBV include having sexual contacts with multiple sexual partners, being transfused with infected blood or other infected human blood products through the re-use of contaminated needles and syringes, and vertical transmission from mother to child during childbirth [11]. Without intervention, a mother who is positive for HBsAg confers a 20% risk of passing the infection to her offspring at the time of birth. This risk is as high as 90% if the mother is also positive for HBeAg. HBV can be transmitted horizontally between family members within households, and among children possibly by contact of non-intact skin or mucous membrane with secretions containing HBV.  [12].
The most common mode of HBV transmission worldwide is perinatal transmission [5]. Perinatal period however, is from the 28th week of gestation to the 28th day after delivery [13]. There is 70% -90% chance of perinatal transmission of Hepatitis B for a baby born to a mother who is positive for both HBsAg and Hepatitis B envelope antigen HBeAg [5], while those born to seropositive mother with HBsAg but negative to HBeAg have 25% chance of acquiring perinatal HBV [14]. This notwithstanding, a seropositive mother with low titres of both HBsAg and HBeAg still has the chance of infecting the unborn child perinatally [5].
Babies are one of the vulnerable groups for HBV infection. This is because of the risk of transmitting the HBV infection from mothers who are infected to their babies [4]. Transplacental viral infection is uncommon, and Towers et al. [15] reported that viral DNA is rarely found in amniotic fluid or cord blood.
However, HBV DNA has been found in ovaries of HBV-positive pregnant women, and the highest levels were found in women who transmitted HBV to their fetuses [16] [17] [18]. A prospective cohort study between 2011 and 2013 with the aim of determining the effects of hepatitis B during pregnancy on birth outcomes in Ghana, and consisting of 512 pregnant women who attended antenatal clinic at the Cape Coast Teaching Hospital, indicated that there is a higher risk of transmission from mothers with positive HBsAg to their babies with adverse neonatal consequences [19]. In a related study, babies of women with acute HBV infection are likely to be premature [20].
One in 8 pregnant women is infected with HBV because the risk of transmitting HBV contaminated blood remains high [21]. Pregnant women with Acute Open Journal of Applied Sciences Hepatitis B infection are likely to have premature labour while chronic HBV infection in pregnancy results to intra-partum and post-partum haemorrhage, because vitamin K dependent clotting factors are not produced [20].
Hepatitis B infection is a serious public health threat in Ghana and considering the fact that pregnant women are a high-risk group [22], there is the need to research into the correlates of HBV infections among pregnant women.

Data
The study is a cross sectional study. Structured questionnaires were used to find The data (available as Additional Material) was obtained through face-to-face interview and interpretation of the question was either carried in English, Ewe and Twi; and in the participants' dialect. The population includes pregnant women reporting for routine antenatal check-up between 1st February, 2017 and 27th April, 2017.
A systematic random sampling was adopted to give all potential respondents an equal chance of being selected for the study. With an average daily attendance at the booking clinic of about 50, an average of five questionnaires was administered per day giving a sampling interval of 10. Using the booking records books at the antenatal clinic the first respondent was selected from the first 10 attendants randomly by balloting. The next respondent was therefore the 10th attendant after the first attendant sampled and then it followed. If an attendant declined to participate, the third attendant after her was selected. Predetermined criteria were the bases for this sampling method. Sample size was determined as expressed in Equation (1): where; n is the estimated sample size; E is the desired margin of error (0.05), z is Open Journal of Applied Sciences the statistic for the level of confidence (95%) = 1.96; p is the (10.6%) prevalence of HBV infection among pregnant women in the Eastern Region of Ghana in a previous study in 2012 [23]. From Equation (1), the minimum sample size is 137. Adding 20% gives a sample size of 164 which catered for unforeseen circumstances such as uncompleted questionnaires. However, the final study size was 500 participants.

Analysis
The data for the study was analyzed with the R statistical software (R Core team [24] HBV status had four independent groups: respondents with "positive status", "negative status", "do not know status" and "have not tested status". Also, HBV awareness had three independent groups: respondents with "very aware", "somehow aware" and "not aware". The study also formulated a Binomial regression model to determine the predictors of HBV testing among antenatal clinic attendees. In formulating the binomial regression model, HBV testing was used as binary (Bernoulli) response variable and was denoted by The binomial regression model specification is given as: In this study, the chosen significance level (α) was 5% (less than 1 in 20 chance of being wrong) and all estimated probability (p-value) less than α was considered significant. The choice of the α-value was arbitrary. Education: χ 2 = 73.822 and p = 0.00 for education vs. HBV status, has a zero probability of the observed data under the null hypothesis of no relationship.

Chi-Square (χ 2 ) Test and Cross Tabulation
The null hypothesis is rejected, since p < 0.05. This test result implies that there is a relationship or association between education and HBV status of antenatal attendees. The ϕ value of 0.384 indicates that the magnitude of association is approximately 38% which is weak positive relationship or association between education and HBV status of antenatal attendees. Clearly the ϕ-values (Table 1) indicate that, all the significant variables had weak positive associations with HBV status of antenatal attendees. The approximate magnitude or size of association of these factors with HBV status ranged from 18% to 41% and with degrees of freedom (DoF) also ranging from 3 to 30. Table 2 captures the distribution of HBV knowledge cores, HBV status and HBV awareness levels in terms of median, minimum and maximum scores. The number of positive HBV attendees who are very aware of HBV were 14, the number of negative HBV attendees who are very aware of HBV were 339 and so on.

Analyses of Variance HBV Status and HBV Awareness Levels with HBV Knowledge Scores as
Comparing the median HBV knowledge scores of the attendees that are "Very aware" to attendees that are "Somehow aware" and "Not aware", it is clear from  "Very aware of HBV". Also attendees with negative HBV status had higher HBV knowledge scores compared with attendees with positive HBV status.
The information in the forgoing paragraphs is well captured by the box and whiskers plot in Figure 1 Results from Table 3 indicate that there is a significant difference in HBV knowledge scores between HBV status i.e. Positive, Negative, Do not know and Have not tested (p-value = 0.00). In the context of pairwise comparison, there is also a significant difference in HBV knowledge scores across HBV status. Specifically, Negative against Do not know (p-value = 0.00) and Do not know against Have not been tested (p-value = 0.03).
Also, there is a significant difference in HBV knowledge scores between HBV awareness levels (p-value = 0.00). In the context of pairwise comparison, there is also a significant difference in HBV knowledge scores across HBV awareness levels. Specifically, Very aware against Somehow aware (p-value = 0.00); Very aware against Not aware at all (p-value = 0.00); and Somehow aware against Not aware at all (p-value = 0.03).

Binomial Logistic Regression for HBV Testing
The Binomial Logistic Regression model was built to determine the predictors of HBV testing (Table 4). The result indicate that, Age (p-value = 0.03), Education level (p-value = 0.04), Religion (p-value = 0.04), Ethnicity (p-value = 0.00) and Blood transfusion (p-value = 0.04) were significant predictors of HBV testing. Open Journal of Applied Sciences

Discussion
Screening asymptomatic people is an important instrument of disease detection, prompt diagnosis and intervention especially concerning a typically asympto-  [26], transfusion with blood could account for the 5.9% respondents who had HBV infection. This is similar to many studies carried out elsewhere as most often at least one risk factor is identified.
Blood transfusion was identified as the single risk factor for HBsAg positivity in Mexico [27].
A previous study [21] documented the association of history of blood transfusion or multiple blood transfusion with HBV infection. The Chi-square model of association (Table 1) affirms that the number of multiple blood transfusion correlates with HBV status of antenatal clinic attendees of Volta Regional hospital.
Data from the antenatal clinic attendees of Volta Regional hospital showed that, 59% (296 out of 500) scoring less than 50.4% warrant the need for sustained and continuous education not only about HBV but other diseases of similar transmission and burden.
HBV test is one of the basic tests for all pregnant women that attend antenatal clinic at the Volta Regional hospital but the HBV test is not free, it comes with a fee. Consequently, some antenatal clinic attendees of the hospital do not undergo this test due to the cost. Findings from the binomial logistic regression model indicate that Age (p-value = 0.03), Education level (p-value = 0.04), Religion (p-value = 0.04), Ethnicity (p-value = 0.00) and Blood transfusion (p-value = 0.04; Table 4) were significant predictors of HBV testing.

Conclusions
The study employed a cross tabulation with Chi-square statistic to test how socioeconomic factors, risky behaviors, knowledge and awareness of HBV infection correlate with HBV status among antenatal clinic attendees. The study also used other measures of association, including the Phi-value to describe the degree with which the values of one variable predict or vary with those of the other variable if a dependency or association between variables does exist. Scores of respondents on knowledge of HBV infection were converted to 100% and the Kruskal-Wallis test was applied to the data to test for the differences in HBV knowledge scores across HBV status and levels of HBV awareness. Also, a Box and Whiskers plot was used to visualize the variation or differences in HBV know-Open Journal of Applied Sciences ledge scores, HBV status and levels of HBV awareness. The study also formulated a Binomial regression model to determine the predictors of HBV testing among antenatal clinic attendees.
The results indicate that age, religion, ethnicity, educational level, blood transfusion, number of blood transfusion, gravidity, parity, awareness of HBV and monthly income are associated with HBV status of antenatal clinic attendees of Volta Regional Hospital, Ho.