PREVALENCE OF HBV AND HCV; AND THEIR ASSOCIATED RISK FACTORS AMONG PUBLIC HEALTH CENTER CLEANERS AT SELECTED PUBLIC HEALTH CENTERS IN SANA'A CITY-YEMEN

Objective: Occupational exposure of public health center cleaners (PHCCs) to blood and body fluids after skin injury or mucous membrane contact constitutes a risk for transmission of blood-borne pathogens. In the industrialized world, occupational surveillance is performed to assess and monitor health hazards related to blood borne pathogens. In contrast, in developing countries as Yemen, exposure and health impacts are rarely monitored and much remains to be done to protect PHCCs. The objective of this study was to determine the prevalence of HBV and HCV and their potential risk factors among PHCCs. Methods: A cross sectional prospective study was conducted among 388 PHCCs. Data was collected using pre-tested and structured questions. Venous blood was collected and the sera were tested for HBV surface antigen and anti-hepatitis C antibodies using enzyme-linked immune sorbent assay technique. The data were analysis by EPI-Info. Chi square and Odds ratio tests were used to assess the association of risk factors with HBV and HCV positivity. Results: Results revealed that among the total 388 PHCCs examined, HBV and HCV were detected in 32 (8.2%), and 4 (1.03%) of them respectively. There was significant risk factors of hepatitis viruses with age group 20-24 years (OR=2.8), exposure to patients blood (OR=3), accidental stick of used needles (OR=2.3), sharp injury (OR=5.6), history of blood transfusion (OR=2.5), and hospital admission (OR=2.7). Also significant protected roles for HBV vaccine was found with infection. Conclusion: In conclusion high prevalence rates of HBV and HCV occurred in PHCCs. Unfortunately; all workers did not take training on medical waste and few workers use protective measures consistently as vaccination. There is needed to make vaccination of health care workers against HBV infection a firm policy and ensure complete and consistent adherence to work standard safety measures.


INTRODUCTION
Hepatitis B virus (HBV) infection is a major global public health problem. There are approximately 2 billion people who have been infected worldwide and more than 350 million of them are chronic carriers of HBV 1,2 . WHO estimated also that approximately 170 million people are infected with hepatitis C virus (HCV) and about 130 million are carriers and three to four million persons are newly infected each year and more than 350,000 people estimated to die from hepatitis C-related liver diseases each year worldwide 3 . In the industrialized world, occupational surveillance assesses and monitors the health hazards related to blood borne pathogens and prevention measures reduce the risk of transmission. In contrast, in developing countries as Yemen, exposure and health impacts are rarely monitored and much remains to be done to protect health care workers (HCWs) from such risks that cause infections, illness, disability and death that may in turn impact on the quality of health care 4 . The aim of this study was to fill the information gap on the prevalence of HBV and HCV infection among PHCCs because these types of studies are absent or at least limited in Yemen. In addition it can be help health clinicians to consider hepatitis viruses' in general patient management. More over this study serves as one important input for Yemen health planners and care providers for designing control and prevention strategy among the study group; and can also used as a growing source of evidence for the control of hepatitis viruses.

SUBJECTS AND METHODS Study Design and Area
A cross-sectional study was conducted at selected public health hospitals and centers in Sana'a city. A total of 33 public hospitals and health centers were included from all distracts of Sana'a city. They selected randomly based on parts per size sampling method and of having almost 50% chance to make representative in the study area.

Study Period
The study was conducted from May to December, 2015.

Sampling
The samples size for the study was determined prevalence of HBV infection among people at high risk for infection 5 . By assuming the prevalence of HBs Ag in health centers cleaners to be 6.3% at 95% Confidence interval and 3% margin of error. Accordingly the calculated final sample size was found to be 388. Probability sampling technique was applied to select the public hospitals and health centers. The thirty three hospitals and health centers were selected randomly based on parts per size (PPS) sampling method and the study participants were selected using convenient sampling technique.

Data Collection
Participant's Socio demographic variables, HBV vaccination status, knowledge of infectious agents, provision of personal protective equipments and risk factors of HBV and HCV were carefully collected using pre-tested standard questionnaire to obtain relevant information.

Specimen Collection and Laboratory Investigation
After obtaining informed consent, 5 ml of venous blood was drawn under aseptic conditions from 388 PHCCs. Then sera were screened for hepatitis B surface antigen (HBsAg) and antibody to hepatitis C virus (anti-HCV) using Enzyme Linked Immunosorbent Assay (ELISA). Results greater than or equal to the cut off value and the percent neutralization is > 50%, the sample is considered confirmed positive for both HBsAg and HCV and results less than the cut off value are considered negative for both.

Statistical Analysis
To relate possible risk factors for HBV and HCV infection, the data were examined in a case-control study format. For HBV or HCV, persons with evidence of previous or current infection with HBV or HCV positive were matched up with those who were HBV or HCV negative. The chi square was used to see the association Odds ratios (OR) and their 95% confidence intervals (CI). Values (OR, CI, χ 2 ) were estimated using 2x2 tables to identify possible odds ratio on occurrence of HBV and HCV and their significance. The result at p-value 0.05 was considered as statistically significant.

Ethical Consideration
Ethical clearance for the study was taken from the Faculty of Medicine and Health Sciences Research Review Committee. Informed Consent was taken from the volunteers before the collecting specimens.

RESULTS
Almost all 318 (81.9%) of the PHCCs were males (male to female ratio = 4.5:1). Most of the participants, 221 (57%)) were between the age of 25 and 29 years ranging from 20 to 51 years. The mean (±SD) age was 26.8(±3.3) years ( Table 1). The mean services year as public health center cleaner was 4.2 years. Most of PHCCs tested, their work experience was in 6-10 years (51%) ( Table 2). Among 388 PHCCs tested, HBV and HCV were detected in 32 (8.2%) and 4 (1.03%) respectively. Almost 8 times differences were observed in the detection rates of HBV when compared with HCV (Table 3). had a habit of washing injury site with soap and water during injury (Table 4).  (Table 6).

DISCUSSION
HBV infection and HCV infection are among the commonest occupational risks healthcare workers including hospital cleaning staffs. The infections are acquired in the hospital setting via needle prick injuries from contaminated needles, eye contact of infected body fluids or from contact of infected body fluids with broken skin 6 . The present study has found that 8.2% and 1.03% of cleaners had HBV and HCV respectively. Test results show a low frequency of HCV antibody in PHCCs at Sana'a city, which is in accordance with similar international studies, confirming the fact that the possibility of developing HCV infection in PHCCs is 10 times smaller than the possible infection with HBV with an average exposure risk 7 . Lower and higher prevalence rates of HBV and HCV among PHCCs were also detected from different parts of the world. Lower prevalence was found in Thailand and Ethiopia with reported rates of 2.02% and 3.57% for HBV respectively 8, 9 . Also current results for HBV and HCV were lower than that of Pakistan in which a higher rate of (18.8%) for HBV and (8.5%) for HCV were reported among PHCCs, respectively 10 . The higher prevalence of HBV than HCV in current study might reflect the prevalence of these viruses among the general population in Sana'a city in which HBV and HCV were estimated to be 4% and 0.5% respectively 11 . But a study from Sana'a city among Dental workers showed that the prevalence of HBV and HCV were 18% and 5% respectively higher than present study among PHCCs 12 .
ISSN: 2456-8058 66 CODEN (USA): UJPRA3  Table 6). The chances of contracting HBV after an HBV-contaminated accidental needle stick average one in 20 while chance of contracting HCV after an accidental needle stick is 3.5 in 100 16 . Also there was a significant risk factor of hepatitis viruses occurred with history of blood transfusion and hospital admission (Table 6). This high risk for blood transfusion could be explained by that small proportion of HBV infected donor's circlet HBV in their blood at levels to low to be detected by currently available methods, in Yemen in blood banks. This result confirms the important of introduction of Genetic screening, which is effectively going to exclude those donors who are persistent, low level carriers, and those in the window period of their acute infection 17 .

CONCLUSION
The prevalence of hepatitis B virus is higher than hepatitis C virus. The presence of a higher (8.2% ) and (1.03%) hepatitis B virus and hepatitis C viruses prevalence respectively when compared to the national prevalence (4% and 0.5%) rate are due to occupational related risks like: collection, transportation, disposal with inappropriate containers, inadequate supply of PPE, needle stick and sharp injuries, blood and body fluid splashes and poor vaccination status. Therefore, Occupational exposure prevention should be the primary strategy to reduce the risk of blood borne pathogens among PHCCs in Sana'a city. Also there is needed to make vaccination of health care workers against HBV infection a firm policy and ensure complete and consistent adherence to work standard safety measures.