Sero-prevalence of hepatitis b virus and associated factors among pregnant women’s attending antenatal clinics in public hospitals of Hawassa City, Sidama, Ethiopia, 2021. Multicenter cross sectional study

Introduction: Estimated 350 million people had been diagnosed for chronic HBV infection and 686,000 people die each year which is an important global public health. This study is expected to provide area-specic information for decision-makers by visualizing prevalence and its associated factors OF HBV. Objective: The aim of this study to access prevalence HBV sero-prevalence and associative factors among pregnant women’s attending ANC in public hospitals of Hawassa City , 2021. Method: A analytic cross sectional study was conducted among pregnant women at Public Hospital in Hawassa city from May 20-July 30/2021. A total of 320 participants were selected. Data were entered and analyzed using SPSS version 25.0. Descriptive statics used to determine prevalence of HBV; Bivariate and multivariate logistic regression analysis was done to identify the independent predictors of HBV status at p-value <0.05. Results: Results: From total of 320 pregnant women participated in the study twenty two are HBV positive which makes overall prevalence From total of 320 pregnant women participated in the study twenty two are HBV positive which makes overall prevalence [6.9 % (95%,CI (6.6%, 7.2%))]. in study area history of transfusion (AOR = 18.99, 95%CI, (2.1–171)). Pregnant women having history of vulvar ulcer were nearly fteen times more likely to acquire HBV infection comparing having no history of vulvar ulcer (AOR = 14.78; 95%CI (1.12–194.4)) and Women who had history and those with contact jaundice patients (AOR = 127.6; 95%CI (12–134)) were independently predictors of HBV. Conclusion: Intermediate endemicity of prevalence of hepatitis HBV was detected in study area. Blood transfusion, history of Vulvar ulcer and history of contact with jaundice patient were found to be the determinant factors of sero-positivity of HBV. Awareness creation on HBV transmission and early screening of HBV at blood donation site important to reduce HBV endemicity.


Introduction
Background Viral hepatitis is an emerging global health problem globally; approximately 350-400 million persons are chronically infected with hepatitis B virus (HBV), over 65 million of whom are in Africa. One in four people with chronic hepatitis B develop serious health problems (1). Hepatitis B virus (HBV) infection is a serious public health problem in sub-Saharan Africa pregnant women (2). There are several epidemiological studies available on hepatitis B virus among pregnant women in Ethiopia. These individual studies revealed wide variation over time and across geographical areas. Up to 20% of patients who develop HBsAg sero conversion may reactivate, becoming HBeAg positive again. Thus, regular follow-up with quantitative measurement of hepatitis B virus DNA and aminotransferase levels is required after sero conversion to ensure its durability (3).prevalence of Hepatitis B virus infected pregnant women increasing and its burden was exceedingly high in Ethiopia, there is a still literature gap in study area which clearly shows the prevalence and associated factors of Hepatitis B virus. Hence, this study is expected to provide area-speci c information for decision-makers by visualizing prevalence and its associated factors.  (2).This prevalence are used to calculate the minimum sample size for this study. Single proportion formula with 95% con dence level (Z (1-ά/2) = 1.96) and 3% marginal errors will be used to determine sample size; n= z 2 α/2 (P (1-P)) d 2 Where n=maximum sample size P =7.3% (prevalence from Previous study) d= (0.03) marginal error between sample and population Z α/2 = (1.96) critical value at 95% con dence interval n = (1.96) 2 ×.073 × .927 /0.0009=. By adding 10% non-respondents rate gives total sample size 320 respondents.
Inclusion criteria: All pregnant women who are visited ANC clinic of Hawassa University College of medicine and health science comprehensive specialized hospital, Adare General Hospital Sidama Region in Hawassa city and other Hawassa City Tula primary Hospital in Tulla Sub-city in the study period and those who are volunteers are included in the study.

Exclusion criteria
Pregnant women who have gotten HBV vaccination, don't talk, mental ill and Critical sick was excluded from the study Data collection tool and collection methods Data was collected by face to face interview using the prepared questionnaires after four hour training given for four female nurses who has at least diploma, one laboratory technology & laboratory technician for sample collection and testing processes. The training focused mainly on the aim of the study. On each part questionnaires that will be developed after reviewing literature will be used. To ensure data quality the data collection process will be supervised by two trained supervisors and the principal investigator at each step daily. Data was collected From June 20-July 30/2021.
The primary data sources were responses of sampled women household in which women's 15 to 49 year was respondents of the interviews. To secure accurate and complete data on prevalence and associated factors data collection tool questionnaire were adapted by reviewing different literatures and guidelines in line with the objectives of study. The tool has different parts; socio-demographic characteristics, associated factors HBV and Reproductive history. All collected serum specimens were tested for HBsAg using rapid diagnostic test kits according to the manufacturer's guidelines (Chromatist HBsAg rapid test from LINEAR Chemicals P.L.C). To ensure the quality of the data the following measures were undertaken. The questionnaires were designed in English. A total of four hours intensive training was given for all supervisors, data collectors and sample collectors. Data were daily checked for completeness, clarity and consistency by the supervisors and the principal investigator. Overall activity will be controlled by the principal investigator, who supervised carefully during data collection and nally data will be validated through double data entry by Epi-data 3.1 software.

Operational de nition
Sero-prevalence: presence of hepatitis B virus in serum sample Tattoo: arti cial rapping of body by using sharp materials Trimester: fetal development stage which is divided by 3 months Data processing and analysis Data were entered in to Statistical Package for Social Sciences (SPSS) version 25.0. To assess associated factors P-value of <0.05 was regarded as signi cant. The sero-prevalence for HBsAg among pregnant women was express in percentages for the entire study group and results are obtained presented, in tables. The statistical logistic Regression was used to determine the association between variables. (OR) and 95% (CI) was used a measure of the strength of association.

Data quality assurances
The validity and completeness of the data was veri ed by the principal investigator daily. The performance of the rapid HBsAg test kit was evaluated using known positive and negative controls obtained from HBsAg rapid tested pregnant women. Furthermore, the formation of a color band at the control line will be acted as a procedural control and further validated the results

Ethics Approval and Consent to Participate
The study was conducted after getting approval from pharma college institutional review board (IRB) to conduct the study. A formal support letter was written to three of selected hospitals, where the study conducted. Both verbal and written consents were obtained from the study participants. For those who are unable to read and write verbal consent were obtained after explaining the purpose of the study while for those who are able to write and read, written consent were obtained. During the consent process rst IRB-approved version of consent form in Amharic (the local language) language prepared. Con dentiality is keep at each step of data collection and processed. In addition, positive HBsAg test results of the study participants were communicated with their physician for farther investigation and better management of the patients.

Socio -Demographic Characteristics
A total of 326 pregnant mothers attending public health facilities of Hawassa city for ANC service were included in the study with a response rate of 98.2%. Maximum and minimum age of participant was 39 and 15 respectively with the mean of 28.73 (SD + 6.64 years). Majority, 335(681%) were in the age ranged from 25-29 years. The study participants predominantly 306 (95.6 %) were married. More than half of women's 306(95.6) were married. Around 131(40.9%) were protestant religion followers. Concerning the occupation more than half 171 (53.4%) was house wife. Regarding the educational status, 126(39.4%) of the respondents and were completed secondary school. Regarding monthly income 153(47.8) were >3001 (Table 1).

Reproduce health factor
From the participants included in this study, 262 (81.9%) and 249 (77.8%) were multi-gravid and multi-Para respectively. Total participants, majority of them 180 (56.3%) had more than two ANC follow up visit in current pregnancy. Regarding gestational age of current pregnancy, less than half of them were less than 2nd trimester (44.7%). Almost equal magnitude 277(86.6) have no history of abortion and no sexual multiple contact respectively (Table 3).  1-171)). Pregnant women having history of vulvar ulcer were nearly fteen times more likely to acquire HBV infection comparing having no history of vulvar ulcer (AOR = 14.78; 95%CI (1. 12-194.4)) and Women who had history and those with contact jaundice patients (AOR = 127.6; 95%CI (12-134)) were independently predictors of HBV (Table 4).

Discussion
The aim of this study was to access prevalence and associated factors of hepatitis B virus in pregnant women's of Hawassa town, Sidama region. In this study, the overall prevalence of HBV in the study area was 6.9 %. The study revealed that blood transfusion, vulvar ulcer and history of contact jaundice were remained as major predictors of HBV prevalence. This shows a level of endemicity of HBV infection qualifying as almost intermediate according to the criteria of the World Health Organization (4).
The current prevalence was lower than different countries reports which is Cameroon 25.3% (5), Gambia 9.20%(6), Ghana7.7%(7) and higher than research done in Rwanda with prevalence of HBV 3.7% (8) , Turkey 2.1% (9). This prevalence rate is higher than different regions of Ethiopia which has been reported West Hararge public hospital 6.1% (1) Another study done in Amhara region and Addis Ababa shows that prevalence in Amhara region and 1 % (10) in Addis Ababa city was 36 % respectively. and lower than study from Southern Ethiopia, Gedeo Zone prevalence of 9.2% (11).
The prevalence of HBV infection among pregnant mothers in Addis Ababa was 7% (12) which is approximately similar with the current nding higher than other city Bahir Dar 4.7% (13) and West Hararge 6.1%(1) The prevalence was lower than that of a research conducted in Ethiopia's Gambela region in case prevalence was 7.9 % (14). The variation in prevalence could be due to difference in geographical, socio cultural and behavioral factors of study participants. The study revealed that, vulvar ulcer and history of contact jaundice were remained as major predictors of HBV prevalence.

Recommendations
Recommendation based on the study nding, the following recommendations were forwarded to concerned bodies in order to reduce transmission of HBV from the mother to child and its consequences.
Health education programs on the mode of HBV transmission, especially on prevention of contact with jaundice patients.
Early screening on blood before blood donation and transfusion were suggested Reduction of high-risk behaviors including having unprotected contact with vulvar ulcer and methods of preventions should be given to communities as well as to ANC attendants at antenatal care clinics to raise the awareness of mothers and community.
It is also advisable to implement to screen blood donation to prevent HBV transmission at blood bank and transfusion site.
Further study should be performed by using more sophisticated diagnostic methods like ELISA, molecular HBV-Deoxyribonucleic acid test.

Strength And Limitations Of The Study
Study involved specialized, General hospitals and districts hospitals it is good to estimate pooled prevalence in city Laboratory technologists performed all testing blinded through use of coded specimens.