What are the risk factors associated with Hepatitis B Virus infection in Somalia?

doi:10.21203/rs.3.rs-4121041/v1

Download PDF

Research Article

What are the risk factors associated with Hepatitis B Virus infection in Somalia?

https://doi.org/10.21203/rs.3.rs-4121041/v1

This work is licensed under a CC BY 4.0 License

Version 1

posted

You are reading this latest preprint version

Background

The Hepatitis B virus (HBV) is transmitted through contaminated blood or bodily fluids. Globally, over 81 million blood units are donated annually, a crucial therapeutic procedure without alternatives. However, blood-borne infections, including HBV, pose a significant hurdle to safe transfusions, especially in HBV-endemic regions like Somalia with limited screening. Therefore, this study aims to estimate the prevalence of Hepatitis B virus infection and identify risk factors associated with it among blood donors in Mogadishu, Somalia.

Method

A hospital-based cross-sectional study was conducted between February and April 2023. Research tools included a 5-ml blood sample and a structured questionnaire. The presence or absence of HB markers was determined using a multi-HB rapid test and CDC’s HB marker interpretation guideline. Logistic regression was used in univariate and multivariate models to identify risk factors associated with HBV infection, with significance set at a p-value < 0.05 in the final model.

Result

A total of 494 blood donors were recruited for this study; 93.9% were male, with a mean age of 31.5 (SD = 8.11). The prevalence of Hepatitis B virus (HBV) infection among blood donors was 9.7%, with a 95% CI of 7.1–12.3. In multivariable logistic regression, those with a monthly income of less than 200 USD (AOR = 5.20, 95% CI = 1.61–16.79), those with an income between 200 and 400 (AOR = 3.59, 95% CI = 1.38–9.34), Jobless blood donors (AOR = 3.78, 95% CI = 1.17–12.20), those in business occupations (AOR = 3.35, 95% CI = 1.24–9.08), those with a history of STDs (AOR = 4.83, 95% CI = 2.03–11.50), those without a history of HB vaccine (AOR = 13.81, 95% CI = 2.46–77.41), those with a history of tooth extraction (AOR = 6.90, 95% CI = 2.66–17.88), and those who shared sharp equipment (AOR = 2.90, 95% CI = 1.07–7.82) were more likely to become infected with the Hepatitis B virus (HBV) compared to their counterparts.

Conclusion

This study highlights a high prevalence of Hepatitis B virus (HBV) infection. Implementation efforts against HBV infection should specifically focus on low-income individuals, the jobless, and donors with a history of STD to mitigate the burden of HBV infection and promote safer blood donation. In addition, discouraging the sharing of sharp equipment, improving infection control practices during tooth extraction procedures, and enhancing HB vaccination uptake, particularly among individuals lacking a history of HB vaccine, is highly recommended.

Infectious Diseases

Prevalence

factors associated with HBV infection

Hepatitis B vaccine

Mogadishu

Somalia

The Hepatitis B virus (HBV) belongs to the Hepadnavirus family, causing hepatitis and transmitting through contaminated blood or other bodily fluids [1]. HBV poses a life-threatening liver disease, often remaining asymptomatic, and carriers may unknowingly spread it [2]. Globally, approximately 240 million people live with chronic HBV infection, resulting in over 300 thousand complications related to liver diseases such as damage, cirrhosis, or liver cancer, contributing to 68,600 deaths [3, 4]. The prevalence of HBV exceeding 8% is categorized as high, while 2 to 7% is considered medium, and less than 2% is labeled as low endemicity [4, 5].

Globally, more than 81 million blood units are donated each year, and blood transfusion stands as a crucial therapeutic procedure without a viable alternative, essential for saving millions of individuals requiring transfusions [4–6]. However, blood-borne infections, such as HBV, present a significant hurdle to ensuring safe transfusions, particularly in HBV-endemic regions where effective screening methods are limited [5]. The transfusion of contaminated blood contributes to as many as 16 million new HBV infections worldwide, with each blood unit carrying a 1.0% risk of transmitting blood-borne infections [6, 7]. Moreover, unsafe blood transfusions are projected to lead to approximately 45,000 new HBV infections in Africa alone, and about 1.6 million blood units are discarded annually due to blood-borne infections, including HBV [1]. As a result, 12.5% of transfusion recipients in Africa are at risk of contracting hepatitis following transfusions [8].

Hepatitis B Virus has remained a neglected concern in Africa, with over 60 million Africans infected [8]. Among African blood donors, the prevalence of HBV ranges from 5 to 7% [1]. In different regions of Africa, the prevalence of HBV among blood donors varies it's 18.60% in Southwest Nigeria, 4.10% in Calabar Nigeria [9, 10], 5.60% in Kenya [11], 10.90% in Jijiga Ethiopia [12], and 2.0% in Eritrea [13]. The primary HBV risk factors include having unprotected multiple sexual partners, sharing injected needles or syringes, using unsterilized medical equipment, and exposure to contaminated objects such as poorly sterilized medical, surgical, and dental equipment [1, 6, 7, 9, 11, 14].

Somalia confronts a shortage of data concerning HBV infection among blood donors, particularly in Mogadishu, its capital and most densely populated city. Clinical facilities in Somalia contend with a substantial demand for blood transfusions, coupled with a high prevalence of HBV infection, attributed to factors such as frequent disaster incidents, road traffic accidents, endemic malaria, childhood anemia, and blood loss from surgical and obstetric procedures [15–19]. A 19.0 and 2.1% HBV prevalence among Somali blood donors were reported in 1995 and 2023 respectively [15, 16]. A meta-analysis disclosed an 18.9% pooled HBV prevalence among the general population in Somalia and 7.3% of HBV prevalence among hemodialysis patients were also reported [17, 18]. Although studies excise an investigation into associated risk factors has been lacking. Acquiring current information about the associated risk factors in Somalia is crucial to ensure a safe blood supply and reduce the risk of spreading blood-borne infections, particularly HBV. This information is vital for both preventing and treating HBV, supporting national and international HBV prevention strategies, and eradicating programs. Hence, this study aims to estimate the prevalence of Hepatitis B virus infection and identify risk factors associated with blood donors in Mogadishu, Somalia.

Study Design

A hospital-based cross-sectional study was conducted between February and April 2023 at Banadir Public Hospital in Mogadishu, Somalia.

Study Setting

The study was carried out at Banadir Hospital, situated in Mogadishu, the capital, and a densely populated city. It stands as one of the largest teaching and referral hospitals and is one of the two public hospitals in the capital city run by the Somali Government. Since its establishment in 1976, the hospital has offered medical and surgical services to over 3 million patients. With more than 700 beds and a staff of 400, the hospital admits between 2,500 to 3,000 patients monthly. Due to its high admission rates and it conducts blood donation campaigns to meet the demand for blood transfusions the substantial number of blood donors from across the city makes it an ideal choice as the study hospital [20, 21].

Study Population

The study population was all blood donors attending the Banadir Hospital's blood bank during the data collection period, providing five-milliliter blood samples for screening and consenting to participate in the study.

Inclusion and Exclusion Criteria

The study included all blood donors attending the blood bank of the study hospital during the data collection period to donate blood or blood components. Exclusions were made for those not mentally fit, unwilling to provide consent or a blood sample, unable to communicate verbally or hear, and those who had received a dose of the hepatitis B vaccine within the last 30 days. The Centers for Disease Control and Prevention (CDC) suggested that individuals who received the HB vaccine within the past 30 days might transiently exhibit HBsAg positivity without infection [22].

Sample Size and Sampling Technique

A standardized formula for cross-sectional studies was utilized to calculate the required sample size [23]. The formula used was n = Z²_α/2 *P*(1 - P) /d²: Where Z²_α/2 is 1.96, P represents the proportion of prevalence, determined to be 18.6% based on a similar study conducted in Nigeria [14], and d is the desired precision level set at 0.05. Consequently, this study necessitated a minimum sample of 256 participants, with an additional 10% accounting for potential non-response. However, the study had the necessary resources to accommodate a sample size of up to 494, exceeding the minimum requirement of 256. This larger sample size ensures a representative subset of the population, contributing to accurate outcome inference, enhanced representativeness, increased precision of estimates, improved generalizability of findings, and facilitation of more robust subgroup analyses [23–25]. Meanwhile, the reported prevalence of HBV infection in African countries between 1995–2023 has varied, ranging from 2.1–19.0% [2, 9, 12, 15, 17, 18]. In addition, a systematic sampling technique was used, involving the selection of blood donors one and five in every 10 blood donors.

Research Instrument

A 5 mL blood sample and a well-structured, reliable, validated questionnaire were developed from a literature review and used as research tools. The questionnaire was initially developed in English and was verbally translated during the interviews for data collection. The Item Objective Congruence (IOC) technique, performed by three external field experts (an infectious disease specialist, a public health researcher, and a clinical epidemiologist), was used to validate the questionnaire [26]. Subsequently, a pilot study involving 30 respondents with similar characteristics was conducted at the study hospital, yielding an acceptable Cronbach's alpha of 0.76. The CDC's standardized HB serological interpretation guideline was utilized to interpret HB markers [22].

The questionnaire comprises four sections

i) Socio-demographic characteristics, including blood donors’ age, sex, marital status, level of education, occupation, monthly income, and residential area. ii) Sexual, behavioral, and blood donation characteristics, including the number of previous marriages and HBV screening before marriage if ever married, history of STDs, cigarette smoking, chewing khat, and condom use, history of receiving blood, frequency and type of donation, history of HB vaccination, and doses of HB vaccine received. iv) Risk characteristics, such as the history of sharing injected needles, history of sharing sharp equipment, history of tooth extraction, history of sharing tissue transplantation, history of haemodialysis, history of surgical operations, history of hospitalizations, history of sharing accidental needle injuries, ensuring barber changing the blade, and having HBV-infected family members. Individuals who had previously experienced STDs such as syphilis, herpes, human papillomavirus (HPV), chancroid, gonorrhea, and chlamydia within the last two years were identified as having a history of STDs [27].

Laboratory and Outcome Definitions

A rapid, qualitative immunoassay (Advanced Quality One-Step Multi-HBV test) was employed to determine the presence or absence of HBV markers in human blood, serum, or plasma. The sensitivity and specificity of HBV markers were as follows: HBsAg (99.85% sensitivity and 99.90% specificity), HBsAb (99.70% sensitivity and 99.41% specificity), HBeAg (100% sensitivity and specificity), HBeAb (99.34% sensitivity and 90.93% specificity), and HBcAb (99.78% sensitivity and 99.74% specificity) [28]. The Centers for Disease Control and Prevention (CDC) standardized HB serological interpretation guideline was utilized for interpreting HB markers [22]. Any blood sample showing positive HBsAg and/or anti-HBs was considered to have HBV infection, after excluding those with anti-HBc negative, indicating an absence of HBV exposure and no evidence of recent, past, resolved, or chronic HBV infection [22].

Data Collection Procedure

Three licensed medical professionals collected data after undergoing five days of training to enhance their understanding of the questionnaire content and blood sample collection procedures. They assessed blood donors' eligibility for study participation, informed eligible donors about the study, and requested their participation. Agreed participants signed a consent form or provided a fingerprint for illiterate donors. Subsequently, a 5 mL blood sample was collected, and a face-to-face interview was conducted with each participant, following the research instrument, lasting approximately 20 minutes individually.

Data Analysis Procedure

The collected data were cleaned, coded, and entered into a spreadsheet, then imported into SPSS version 20 (SPSS, Chicago, IL License) for analysis. Descriptive statistics were used by presenting frequencies with percentages for all categorical characteristics and means with standard deviations (SD) for continuous variables. The overall prevalence of HBV infection was presented as frequency with percentage and its 95% CI. Logistic regression in univariable and multivariable models was used to determine factors associated with HBV infection. Variables with a p-value < 0.20 in the univariable model were selected as candidates for inclusion in the multivariable model. Bursac et al. [29] suggested that a p-value < 0.20 for univariable logistic regression might indicate some reasonable association with the outcome in the final model due to the possibility of confounding variables. In the multivariable logistic regression model, the Hosmer-Lemeshow goodness-of-fit test was used to assess the final model's goodness of fit [30]. Variables with a p-value < 0.05 were considered statistically significant.

The prevalence of hepatitis B virus (HBV) infection among blood donors was 9.7% with a 95% confidence interval of 7.1–12.3 (Table 1).

Table 1

Prevalence of hepatitis B virus infection among blood donors
Characteristics	n	%	95%CI
Prevalence of hepatitis B virus (HBV)
Infected	48	9.7	7.1–12.3
Non-infected	446	90.3	87.7–92.9

Most of the study participants (93.9%) were male, with a mean age of 31.58 (SD = 8.11). Over half (57.1%) were single, and 30.5% were illiterate. Most participants (42.5%) were employed, 38.9% had a monthly income higher than 400 USD, and 80.6% were urban residents (Table 2).

Table 2

Socio-demographical characteristics between HBV-infected and non-infected
Characteristics	HBV infection		Total n (%)	p-value
Characteristics	Infected n (%)	None Infected n (%)	Total n (%)	p-value
Sex
Male	46 (95.8%)	418 (93.7%)	464 (93.9%)	0.757^a
Female	2 (4.2%)	28 (6.3%)	30 (6.1%)
Age
18–28	17 (35.4%)	161 (36.1%)	178 (36.0%)	0.887
29–39	25 (52.1%)	219 (49.1%)	244 (49.4%)
≥40	6 (12.5%)	66 (14.8%)	72 (14.6%)
Min = 18, Max = 60, Mean = 31.58, SD = 8.116
Marital status
Single	29 (60.4%)	253 (56.7%)	282 (57.0%)	0.976^a
Married	14 (29.2%)	134 (30.0%)	148 (30.0%)
Window	3 (6.2%)	37 (8.3%)	40 (8.1%)
Divorced	2 (4.2%)	22 (4.9%)	24 (4.9%)
Level of Education
Illiterate	16 (33.3%)	135 (30.3%)	151 (30.6%)	0.664
Read or write	15 (31.1%)	114 (25.6%)	129 (26.0%)
Primary level	11 (22.9%)	137 (30.7%)	148 (30.0%)
Post-primary	6 (12.5%)	60 (13.5%)	66 (13.4%)
Occupation
Employee	19 (39.6%)	191 (42.8%)	210 (42.5%)	0.068
Business	12 (25.0%)	118 (26.5%)	130 (26.3%)
Healthcare	3 (6.2%)	67 (15.0%)	70 (14.2%)
Jobless	14 (29.2%)	70 (15.7%)	84 (17.0%)
Residential area
Rural	7 (14.6%)	89 (20.0%)	96 (19.4%)	0.371
Urban	41 (85.4.3%)	357 (80.0%)	398(80.6%)	0.371
Monthly Income USD $
<200	18 (37.5%)	112 (25.1%)	130 (26.3%)	0.072
200–400	18 (37.5%)	154 (34.5%)	172 (34.8%)
>400	12 (25.0%)	180 (40.4.8%)	192 (38.9%)
Min = 0, Max = 3000, Mean = 440.58, SD = 335.80

*Significant level at a p-value < 0.05.

^a Fisher's exact test

This study revealed that 39.2% of ever-married respondents had previously married three times. over half (55.2%) of them did not screen for HBV infection before marriage. Slightly less than two-thirds (61.7%) did not use a condom, 83.6% did not have a history of sexually transmitted diseases (STDs), 78.1% did not smoke cigarettes, and 83.6% did not chew khat. In addition, 58.9% of the participants were first-time blood donors, 61.9% were voluntary donors, and more than two-thirds (76.9%) had a history of blood receiving. Only 15% of the study participants had previously received the hepatitis B vaccine, and almost half of them (55.4%) had only one dose of HB vaccination (Table 3).

Table 3

Behavioral, sexual, and blood donation characteristics between HBV-infected and non-infected
Characteristics	HBV infection		Total n (%)	p-value
Characteristics	Infected n (%)	None Infected n (%)	Total n (%)	p-value
If ever married, the number of previous marriages
1 Marriage	2 (10.5%)	31 (16.1%)	33 (15.6%)	0.213^a
2 Marriages	5 (26.3%)	61 (31.6%)	66 (31.0%)
3 Marriages	6 (31.6%)	77 (39.9%)	83 (39.2%)
≥4 Marriages	6 (31.6%)	24 (12.4%)	30 (14.2%)
If ever married, Screen HBV before marriage
We do both	2 (10.5%)	29 (15.0%)	31 (14.6%)	0.075^a
One of us do	2 (10.5%)	47 (24.4%)	49 (23.1%)
We do not do both	11 (57.9%)	106 (54.9%)	117 (55.2%)
Not sure/do not remember	4 (21.1%)	11 (5.7%)	15 (7.1%)
Condom use
Yes (Every time)	4 (8.3%)	60 (13.5%)	64 (13.0%)	0.319
Yes (Sometimes)	5 (10.4%)	34 (7.6%)	39 (7.9%)
No	34 (70.8%)	271 (60.8%)	305 (61.7%)
I do not do sex	5 (10.4%)	81 (18.2%)	86 (17.4%)
History of STD
Yes	26 (54.2%)	55 (12.3%)	81 (16.4%)	< 0.001*
No	22 (45.8%)	391 (87.7%)	413 (83.6%)
Cigarette smoking
Yes	20 (41.7%)	88 (19.7%)	108 (21.9%)	< 0.001*
No	28 (54.3%)	358 (80.3%)	389 (78.1%)
Chewing khat
Yes	16 (33.3%)	65 (14.6%)	81 (16.4%)	0.001*
No	32 (66.7%)	381 (85.4%)	413 (83.6%)
Frequency of blood donation
First time donner	37 (77.1%)	254 (57.0%)	291 (58.9%)	0.007*
Repeated donner	11 (22.9%)	192 (43.0%)	203 (41.1%)
Type of blood donate
Relative donation	20 (41.7%)	168 (37.7%)	188 (38.1%)	0.588
Volunteer donors	28 (58.3%)	276 (61.9%)	306 (61.9%)
History of receiving blood
Yes	20 (41.7%)	94 (21.1%)	114 (23.1%)	0.001*
No	28 (58.3%)	352 (78.9%)	380 (76.9%)
History of HB vaccination
No	46 (95.8%)	374 (83.9%)	420 (85%)	0.027*
Yes	2 (4.2%)	72 (16.1%)	74 (15%)
Doses of HB vaccine received
One dose	0 (0.0%)	41 (56.9.0%)	41 (55.4%)	0.017*^a
Two doses	0 (0.0%)	23 (31.9%)	23 (31.1%)
Three doses	2 (100.0%)	8 (11.1%)	10 (13.5%)

*Significant level at a p-value < 0.05.

^a Fisher's exact test

The study showed that 11.7% of the participants had a history of sharing injected needles, 43.9% of their barbers did not change the blade, 23.3% shared sharp equipment, 20.0% had a history of tooth extraction in the last two years, 21.7% had a history of tissue transplantation, 24.7% had a history of toothbrush (Miswak) or razor sharing, 0.4% had a history of hemodialysis, 20.6% had a history of surgical operation, 22.1% had a history of hospitalization, 17.0% had an HBV infected family member, and 17.6% had a history of accidental needle stick injury (Table 4).

Table 4

Risk characteristics between HBV-infected and non-infected
Characteristics	HBV infection		Total n (%)	p-value
Characteristics	Infected n (%)	Non-infected n (%)	Total n (%)	p-value
History Sharing injected needles
Yes	14(29.2%)	44(9.9%)	58(11.7%)	< 0.001*
No	34(70.8%)	402(90.1%)	436(88.3%)
Ensuring the barber changing the blade
Yes (Every time)	16(33.3%)	148(33.2%)	164(33.2%)	0.002*
Yes (Sometimes)	20(41.7%)	93(20.9%)	113(22.9%)
No	12(25.0%)	205(46.0%)	217(43.9%)
History Sharing sharp equipment
Yes	33(68.8%)	82(18.4%)	115(23.3%)	< 0.001*
No	15(31.2%)	364(81.6%)	379(76.7%)
History of tooth extraction
Yes	33(68.8%)	66(14.8%)	99(20.0%)	< 0.001*
No	15(31.2%)	380(85.2%)	395(80.0%)
History of tissue transplantation
Yes	19(39.6%)	88(19.7%)	107(21.7%)	0.002*
No	29(60.4%)	358(80.3%)	387(78.3%)
History of hemodialysis
Yes	1(2.1%)	1(0.2%)	2(0.4%)	0.185
No	47(97.9%)	445(97.9%)	492(99.6%)
History of surgical operation
Yes	19 (39.6%)	83 (18.6%)	102 (20.6%)	0.001*
No	29 (60.4%)	363 (81.4%)	392 (79.4%)
History of hospitalized
Yes	21 (43.8%)	88 (19.7%)	109 (22.1%)	0.001*
No	27 (56.2%)	358 (80.3%)	385 (77.9%)
HBV-infected family member
Yes	13 (271.1%)	71 (15.9%)	84 (17.0%)	0.118
No	31 (64.6%)	345 (77.4%)	376 (76.1%)
I do not know	4 (8.3%)	30 (6.7%)	34 (6.9%)
History of sharing accidental needle injury
Yes	20 (41.7%)	67 (15.0%)	87 (17.6%)	< 0.001*
No	28 (58.3%)	379 (85.0%)	407 (82.4%)

*Significant level at a p-value < 0.05.

^a Fisher's exact test

In univariable logistic regression analysis, seventeen (17) variables were found to be significantly associated with HBV infection at a p-value < 0.20. These variables included respondents' occupation, income, history of STD, cigarette smoking, chewing khat, frequency of blood donation, history of blood receiving, history of HB vaccine, history of sharing injected needles, history of sharing sharp equipment, ensuring barber changing the blade, history of tooth extraction, history of tissue or organ transplantation, history of hemodialysis, history of surgical operation, history of hospitalization, and history of accidental needle stick injuries. These seventeen variables were candidates in multivariable logistic regression, and six were found to be significantly associated with HBV infection among blood donors at a p-value < 0.05.

Those with a monthly income of < 200 USD had 5.20 times greater risk (95% CI = 1.61–16.79), those with income between 200 to 400 had 3.59 times (95% CI = 1.38–9.34) greater risk of HBV infection compared to those with income > 400 USD. Jobless blood donors had a 3.78 times greater risk (95% CI = 1.17–12.20), while those in business occupations had a 3.35 times greater risk (95% CI = 1.24–9.08) of HBV infection compared to employees. Those with a history of STD were 4.83 times (95% CI = 2.03–11.50) more likely to be HBV infected compared to those without. The odds of HBV infection were 13.81 (95% CI = 2.46–77.41) for those without a history of HB vaccine compared to those with. Those with a history of tooth extraction were 6.90 times (95% CI = 2.66–17.88) more likely to be HBV infected compared to those without. Those who shared sharp equipment were 2.90 times (95% CI = 1.07–7.82) more likely to be HBV infected compared to those who did not share (Table 5).

Table 5

Factors Associated with HBV Infection in Multivariable logistic regression analysis.
Characteristics	AOR (95%CI)	p-value
Occupation
Employee	1.00
Business	3.35(1.24–9.08)	0.017*
Healthcare	1.76(0.37–8.26)	0.468
Jobless	3.78(1.17–12.20)	0.026*
Income USD $
<200	5.20 (1.61–16.79)	0.006*
200–400	3.59 (1.38–9.34)	0.009*
>400	1
History of STD
Yes	4.83 (2.03-11. 50)	< 0.001
No	1
History of HB vaccination
Yes	1
No	13.81 (2.46–77.41)	0.003*
History of Tooth extraction
Yes	6.90 (2.66–17.88)	< 0.001*
No	1
History of sharing sharp equipment
Yes	2.90 (1.07–7.82)	0.036*
No	1
*Significant level at a p-value < 0.05

Blood donors in Mogadishu, Somalia face a substantial prevalence of hepatitis B virus (HBV) infections, particularly among low-income and unemployed donors, individuals with a history of sexually transmitted diseases (STDs), those with a history of tooth extraction, individuals who engage in the sharing of sharp equipment, and those lacking a history of HB vaccine. Remarkably, only 15.0% of the study participants reported a history of HB vaccine, underscoring the endemic nature of HBV in Somalia [17].

The prevalence reported in this study, even though is high, is equal to a similar study conducted in the Democratic Republic of Congo [34]. However, it falls below the rates observed in comparable studies conducted in Nigeria [9], Jijiga Ethiopia [12], Djibouti [31], Ghana [32], Equatorial Guinea [33], and Burkina Faso [34]. Conversely, this prevalence surpasses that observed in Calabar Nigeria [10], Kenya [11], Eritrea [13], the USA [35], Brazil [36], Mexico [37], Canada [38], Colombia [39], Australia [40], various periods in China [41, 42], India [43], Karachi and Lahore, Pakistan [44, 45], Nepal [46], Thailand [47], Tanzania [48], and Ethiopia [49].

These disparities can be attributed to diverse blood donor risk factors, variations in population and geographical location, discrepancies in vaccine coverage and availability, differential levels of infection exposure, distinct risk factors, individual beliefs, cultural influences, demographic and economic differences, variations in immunity status, and discrepancies in sample sizes.

This study revealed that the likelihood of HBV infection is higher among low-income and jobless blood donors compared to their counterparts. Generally, poverty and infectious diseases are interlinked, particularly HBV infection due to lower socioeconomic status often associated with poorer living habits [50, 51]. For instance, sharing personal items like razors or nail clippers among individuals in poverty may increase the risk of infection, as HBV can survive outside of the body for at least seven days [52]. Furthermore, in the study area, individuals with low income often engage in low-paid jobs, such as farming and waste scavengers using bare hands, which expose them to a higher risk of infection through injuries caused by sharp instruments in the waste including healthcare waste since this study discovered that those who shared sharp equipment were two times more likely to be HBV infected compared to those who did not share. Occupying such high-infection exposure occupations without the use of protective items, coupled with low HB vaccination coverage, poses a significant risk, and may worsen the situation. In addition, financially disadvantaged Somali individuals face challenges in accessing healthcare, as HBV is endemic, and its vaccine is not provided for free in the study area. A similar study supports these findings, indicating that low-income and unemployed individuals would be less willing to pay for the HB vaccine [53]. Moreover, individuals with low income often have a lower level of education, leading to a reduced awareness of HBV infection, which adds to the overall risk. Similar research studies are supported with these observations [52–58].

One notable identified risk factor was that those with a history of STD were four times more likely to be HBV-infected compared to those without. Individuals with a history of STDs may engage in risky behaviors, such as having multiple sexual partners without protection or engaging with high-risk group sex partners, thereby increasing the risk of contracting Hepatitis B [58]. Moreover, individuals infected with STDs may be susceptible to HBV transmission through similar modes, with certain STDs like Syphilis, Herpes, Human Papillomavirus, Chancroid, Gonorrhea, and Chlamydia causing genital sores, warts, or ulcers. These genital lesions create a direct pathway for the HBV virus to enter the bloodstream during sexual contact, posing an elevated risk of HBV transmission. A parallel study also noted that individuals co-infected with STDs and HBV are more likely to transmit HBV through these genital ulcers during sexual contact compared to those without co-infections [59]. Several studies supported these findings [60].

This study highlights that individuals without a history of HB vaccine face a higher risk of HBV infection compared to those who have been vaccinated. Only 15.0% of the study participants had received at least one dose of the HB vaccine, indicating a notably low vaccination coverage compared to the recommended standards. The HB vaccine has proven to be an effective preventive measure, leading to a significant reduction in global HBV epidemiology. Unfortunately, in the study area, limited availability, and high costs of the vaccine act as barriers to achieving national HB vaccination coverage, thereby increasing the risk of infection. A separate study assessing HB vaccination coverage among Somali people found that 2.8%, 16.0%, and 33.4% of healthcare workers and medical students were not fully HB vaccinated and cited vaccine unavailability and high vaccine costs as reasons for not getting vaccinated [61–63]. This study underscores the importance of improving vaccine uptake by addressing issues related to vaccine availability and reducing associated costs.

This study revealed that individuals with a history of tooth extraction or dental repair are at a higher risk of HBV infection compared to those without such a history. This association may be attributed to the potential contamination of dental instruments and inadequate or insufficient sterilization practices. In regions where HBV is endemic, such as the study area, improper infection control measures during tooth procedures can pose a significant risk due to the involvement of blood or other bodily fluids. Implementing effective infection control practices among healthcare workers, which include the sterilization of medical instruments and the use of gloves, masks, and eye protection, is crucial in preventing HBV infections during dental procedures [64–66]. These practices are strongly recommended in the study area. A study conducted in Ethiopia reached similar conclusions and recommended educational and awareness programs for healthcare workers to discourage traditional dental procedures that may increase the risk of HBV infection [66–69]. Other studies have also supported these findings [70–73].

While the study exhibits various strengths, it is essential to recognize its limitations. Firstly, the cross-sectional design's nature hinders the establishment of causal relationships. Furthermore, the study questionnaire wasn't translated into the Somali language; instead, verbal translation occurred during data collection, as English serves as the common language among educated individuals and officials.

The blood donors in Mogadishu, Somalia, experiencing a high prevalence of Hepatitis B virus (HBV) infection, particularly among individuals with low income and joblessness, those with a history of sexually transmitted diseases (STD), those with a history of tooth extraction, those sharing sharp equipment, and those lacking a history of HB vaccination. Implementation efforts against Hepatitis virus (HBV) infection should specifically focus on low-income individuals, the jobless, and donors with a history of STD to mitigate the burden of HBV infection and promote a safer blood donation environment, ultimately contributing to public health improvement in the region. In addition, discouraging the sharing of sharp equipment, improving infection control practices during tooth extraction procedures, and enhancing HB vaccination uptake, particularly among individuals lacking a history of HB vaccine, is highly recommended.

HBV; Hepatitis B Virus.

CDC; Centers for Disease Control and Prevention.

STD; sexual transmission disease.

HBsAg; hepatitis B surface antigen.

Ethical Approval and Consideration of the Study

Ethical approval was obtained from the Ethical Committee on Human Research at Mae Fah Luang University, Thailand. The Ethical Committee on Human Research at Mae Fah Luang University approved the study procedure under protocol number (22205-18). All eligible participants were briefed on the study's objectives and invited to participate. Those who agreed, and were literate, provided written informed consent by signing a form. For illiterate participants, their legally authorized representative provided written informed consent and explained its contents to them. Illiterate participants who agreed to take part provided a fingerprint instead of a signature, ensuring their decision was made freely and without coercion. Furthermore, all participants were informed of their full rights to participate or withdraw from the interview at any time. Confidentiality was maintained, questionnaires remained anonymous, and data were presented only as aggregate information without disclosing individual details.

Acknowledgment

The authors acknowledge the healthcare workers of the study hospital and respective blood donors for their cooperation and for providing necessary information.

Author Contribution.

All authors developed the study design, reviewed the literature, and developed data collection tools. Najib coordinated data collection. Khalif and Inchon analysed data, wrote a report, drafted a manuscript, and formulated a timeframe. All authors read and approved the final manuscript.

Availability of data

All datasets generated and analysed during the current study are included in this article.

Funding

N/A

Competing interest

All authors declare that they do not have any competing interests

Consent for publication

Not applicable

Mekonnen D, Solomon T, Nigatu M. Prevalence of Hepatitis B virus and its predictors among volunteer blood donors in Jimma, Ethiopia, 2018: A cross-sectional study. Journal of Clinical Virology Plus. 2022 Nov 1;2(4):100122.
Ishizaki A, Bouscaillou J, Luhmann N, Liu S, Chua R, Walsh N, Hess S, Ivanova E, Roberts T, Easterbrook P. Survey of programmatic experiences and challenges in delivery of hepatitis B and C testing in low-and middle-income countries. BMC Infectious Diseases. 2017 Nov;17(1):129-40.
Aboyans V, Causes of Death Collaborators. Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. The Lancet (British edition). 2015 Jan 10;385(9963):117-71.
World Health Organization. Guidelines for the prevention care and treatment of persons with chronic hepatitis B infection: Mar-15. World Health Organization; 2015 Aug 5.
Abebe M, Alemnew B, Biset S. Prevalence of hepatitis B virus and hepatitis C virus among blood donors in nekemte blood bank, Western Oromia, Ethiopia: retrospective 5 years study. Journal of blood medicine. 2020 Dec 31:543-50.
Bonja F, Hussein M, Alemu J, Gemechu D, Birhaneselassie M. The prevalence of transfusion transmitted infections: a focus on hepatitis B virus among blood donors at Hawassa blood bank center, southern Ethiopia. Int J Blood Transfus Immunohematol. 2017;7:7-14.
Weldearegay GM. Prevalence and associated risk factors of Hepatitis B and Hepatitis C virus among volunteer blood donors in Arba Minch Blood Bank SNNPR, Ethiopia. Journal of Medical Laboratory and Diagnosis. 2016 May 31;7(4):20-7.
WHO. Hepatitis B virus | WHO | Regional Office for Africa [Internet]. https://www.afro.who.int/health-topics/hepatitis. 2018 [cited 2022 Oct 16]. Available from: https://www.afro.who.int/health-topics/hepatitis
Buseri FI, Muhibi MA, Jeremiah ZA. Sero-epidemiology of transfusion-transmissible infectious diseases among blood donors in Osogbo, south-west Nigeria. Blood Transfusion. 2009;7(4):293–9.
Okoroiwu HU, Okafor IM, Asemota EA, Okpokam DC. Seroprevalence of transfusion-transmissible infections (HBV, HCV, syphilis and HIV) among prospective blood donors in a tertiary health care facility in Calabar, Nigeria; An eleven years evaluation. BMC Public Health. 2018 May 22;18(1).
Bartonjo G, Oundo J, Ng’ang’a Z. Prevalence and associated risk factors of transfusion transmissible infections among blood donors at regional blood transfusion center nakuru and tenwek mission hospital, Kenya. Pan African Medical Journal. 2019;34.
Mohammed Y, Bekele A. Seroprevalence of transfusion transmitted infection among blood donors at Jijiga blood bank, Eastern Ethiopia: Retrospective 4 years study Infectious Diseases. BMC Res Notes. 2016 Feb 27;9(1).
Siraj N, Achila OO, Issac J, Menghisteab E, Hailemariam M, Hagos S, Gebremeskel Y, Tesfamichael D. Seroprevalence of transfusion-transmissible infections among blood donors at National Blood Transfusion Service, Eritrea: a seven-year retrospective study. BMC infectious diseases. 2018 Dec;18(1):1-9.
Lucky TTA, Seed CR, Keller A, Lee J, McDonald A, Ismay S, et al. Trends in transfusion-transmissible infections among Australian blood donors from 2005 to 2010. Transfusion (Paris). 2013 Nov;53(11):2751–62.
Nur YA, Groen J, Elmi AM, Ott A, Osterhaus AD. Prevalence of serum antibodies against bloodborne and sexually transmitted agents in selected groups in Somalia. Epidemiology & Infection. 2000 Feb;124(1):137-41.
Mohamed MO, Ebar MH. Seroprevalence of Hepatitis B, Anti-Hepatitis C, Human Immunodeficiency Viruses and Treponema Pallidum among Random Blood Donors at Somali Sudanese Specialized Hospital (SSSH), Mogadishu, Somalia. Journal of Drug Delivery and Therapeutics. 2023 Apr 15;13(4):42-5.
Hassan-Kadle MA, Osman MS, Ogurtsov PP. Epidemiology of viral hepatitis in Somalia: systematic review and meta-analysis study. World Journal of Gastroenterology. 2018 Sep 9;24(34):3927.
Jeele MO, Addow RO, Adan FN, Jimale LH. Prevalence and risk factors associated with hepatitis B and hepatitis c infections among patients undergoing hemodialysis: a single-centre study in Somalia. International Journal of Nephrology. 2021 Nov 13;2021.
Mohamud MH, Aweis AD, Adam AS, Mohamed FA, Fidow SQ, Mohamed LM. Distribution and Frequency of ABO and Rhesus (D) Blood Groups in Somalia: A Retrospective Study on Students of Jazeera University, Mogadishu-Somalia. BioMed Research International. 2022 Jan 30;2022.
Mohamud AK, Ahmed OA, Mohamud AA, Dirie NI. Prevalence of and factors associated with depression among adult patients living with HIV/AIDs undergoing ART unit in Banadir hospital, Mogadishu Somalia. BMC psychiatry. 2023 Dec;23(1):1-8.
Mohamud AK, Ahmed OA, Ali IA, Dirie NI. Demographical, clinical, and complication differences between vaccinated and unvaccinated hospitalized children with measles in Mogadishu Somalia: a hospital-based retrospective cohort study. Annals of Medicine and Surgery. 2023 May;85(5):1550.
Centers for Disease Control and Preventions(CDC). Interpretation of Hepatitis B Serologic Test. https://www.cdc.gov/hepatitis/hbv/interpretationOfHepBSerologicResults.htm#print
Charan J, Biswas T. How to calculate sample size for different study designs in medical research? Indian journal of psychological medicine. 2013 Apr;35(2):121-6.
Kadam P, Bhalerao S. Sample size calculation. International journal of Ayurveda research. 2010 Jan;1(1):55.
Pourhoseingholi MA, Vahedi M, Rahimzadeh M. Sample size calculation in medical studies. Gastroenterology and Hepatology from bed to bench. 2013;6(1):14.
Turner RC, Carlson L. Indexes of item-objective congruence for multidimensional items. International journal of testing. 2003 Jun 1;3(2):163-71.
DiClemente RJ, Wingood GM, Sionean C, Crosby R, Harrington K, Davies S, HOOK III EW, Oh MK. Association of adolescents' history of sexually transmitted disease (STD) and their current high-risk behavior and STD status: a case for intensifying clinic-based prevention efforts. Sexually transmitted diseases. 2002 Sep 1:503-9.
In-Tec PRODUCTS INC. Advanced Quality One Step Multi-HBV Test is a rapid, qualitative, immunoassay for the determination of HBV Markers Available from: https://www.intecasi.com/one-step-multi-hbv-test-device_p19.html
Bursac Z, Gauss CH, Williams DK, Hosmer DW. Purposeful selection of variables in logistic regression. Source code for biology and medicine. 2008 Dec;3(1):1-8.
Hosmer Jr DW, Lemeshow S, Sturdivant RX. Applied logistic regression. John Wiley & Sons; 2013 Apr 1.
Dray X, Dray-Spira R, Bronstein JA, Mattera D. Prevalences of HIV, hepatitis B and hepatitis C in blood donors in the Republic of Djibouti. Medecine Tropicale: Revue du Corps de Sante Colonial. 2005 Jan 1;65(1):39-42.
Dongdem JT, Kampo S, Soyiri IN, Asebga PN, Ziem JB, Sagoe K. Prevalence of hepatitis B virus infection among blood donors at the Tamale Teaching Hospital, Ghana (2009). BMC research notes. 2012 Dec;5(1):1-5.
Xie DD, Li J, Chen JT, Eyi UM, Matesa RA, Obono MM, Ehapo CS, Yang LY, Yang H, Yang HT, Lin M. Seroprevalence of human immunodeficiency virus, hepatitis B virus, hepatitis C virus, and Treponema pallidum infections among blood donors on Bioko Island, Equatorial Guinea. PloS one. 2015 Oct 8;10(10):e0139947.
Nagalo MB, Sanou M, Bisseye C, Kaboré MI, Nebie YK, Kienou K, Kiba A, Dahourou H, Ouattara S, Zongo JD, Simporé J. Seroprevalence of human immunodeficiency virus, hepatitis B and C viruses and syphilis among blood donors in Koudougou (Burkina Faso) in 2009. Blood transfusion. 2011 Oct;9(4):419.
Dodd RY, Notari EP, Stramer SL. Current prevalence and incidence of infectious disease markers and estimated window-period risk in the American Red Cross blood donor population. 2002.
Pessoni LL, Aquino ÉC de, Alcântara KC de. Prevalence and trends in transfusion-transmissible infections among blood donors in Brazil from 2010 to 2016. Hematol Transfus Cell Ther. 2019 Oct 1;41(4):310–5.
López-Balderas N, Bravo E, Cámara M, Hernández-Romano P. Seroprevalence of hepatitis viruses and risk factors in blood donors of Veracruz, Mexico. J Infect Dev Ctries. 2015 Mar 15;9(3):274–82.
Chiavetta JA, Escobar M, Newman A, He Y, Driezen P, Deeks S, et al. Incidence and estimated rates of residual risk for HIV, hepatitis C, hepatitis B and human T-cell lymphotropic viruses in blood donors in Canada, 1990-2000. CMAJ. 2003 Oct 14;169(8):767–73.
Bedoya JA, Cortés Márquez MM, Cardona Arias JA. Seroprevalence of markers of transfusion transmissible infections in blood bank in Colombia. Revista de Saúde Pública. 2012;46:950-9.
Lucky TTA, Seed CR, Keller A, Lee J, McDonald A, Ismay S, et al. Trends in transfusion-transmissible infections among Australian blood donors from 2005 to 2010. Transfusion (Paris). 2013 Nov;53(11):2751–62.
Song Y, Bian Y, Petzold M, Ung COL. Prevalence and trend of major transfusion-transmissible infections among blood donors in Western China, 2005 through 2010. PLoS One. 2014;9(4):e94528.
Li C, Xiao X, Yin H, He M, Li J, Dai Y, et al. Prevalence and prevalence trends of transfusion transmissible infections among blood donors at four chinese regional blood centers between 2000 and 2010 [Internet]. 2012. Available from: http://www.translational-medicine.com/content/10/1/176
Giri P, Deshpande J, Phalke D, Karle L. Seroprevalence of transfusion transmissible infections among voluntary blood donors at a tertiary care teaching hospital in rural area of India. J Family Med Prim Care. 2012;1(1):48.
Arshad A, Borhany M, Anwar N, Naseer I, Ansari R, Boota S, et al. Prevalence of transfusion transmissible infections in blood donors of Pakistan. BMC Hematol. 2016;16(1).
Attaullah S, Khan S, Khan J. Trend of transfusion transmitted infections frequency in blood donors: Provide a road map for its prevention and control. J Transl Med. 2012 Jan 31;10(1).
Shrestha AC, Ghimre P, Tiwari BR, Rajkarnikar M. Transfusion-transmissible infections among blood donors in Kathmandu, Nepal. 2009.
Nimnuch P, Jeumjanya N, Intharanut K, Nathalang O. Prevalence of transfusion-transmitted infections in donated blood at Thammasat University. Vol. 31, J Hematol Transfus Med. 2021.
Matee MI, Magesa PM, Lyamuya EF. Seroprevalence of human immunodeficiency virus, hepatitis B and C viruses and syphilis infections among blood donors at the Muhimbili National Hospital in Dar Es Salaam, Tanzania. BMC public health. 2006 Dec;6(1):1-6.
Tessema B, Yismaw G, Kassu A, Amsalu A, Mulu A, Emmrich F, Sack U. Seroprevalence of HIV, HBV, HCV and syphilis infections among blood donors at Gondar University Teaching Hospital, Northwest Ethiopia: declining trends over a period of five years. BMC Infectious diseases. 2010 Dec;10:1-7.
Mohamud AK, Ali IA, Ali AI, Dirie NI, Inchon P, Ahmed OA, Mohamud AA. Assessment of healthcare workers' knowledge and attitude on Ebola virus disease in Somalia: a multicenter nationwide survey. BMC Public Health. 2023 Aug 28;23(1):1650.
Mohamud AK, Ahmed OA, Mohamud AA, Dirie NI. Magnitude of opportunistic infections and associated factors among adult people living with human immune deficient virus on art at selected public hospital, mogadishu somalia: cross-sectional study. Annals of Medicine and Surgery. 2023 Jul 1;85(7):3364-71.
Ismoilova UI. DISEASE HEPATITIS B. Journal the Coryphaeus of Science. 2023 Feb 8;5(1):118-28.
Babanejad M, Izadi N, Najafi F, Alavian SM. The HBsAg Prevalence among blood donors from Eastern Mediterranean and Middle Eastern countries: a systematic review and meta-Analysis. Hepatitis monthly. 2016 Mar;16(3).
Farah ID, Visetnoi S. Assessment of Farmworker’s Level of Knowledge in Banana Cultivation and its Implication on Productivity Improvement in the Lower Shabelle Region of Somalia. InIOP Conference Series: Earth and Environmental Science 2024 (Vol. 1291, No. 1, p. 012006). IOP Publishing.
Moniri R, MOSAYEBI Z, MOUSAVI GA. Seroprevalence of cytomegalovirus, hepatitis B, hepatitis C and human immunodeficiency virus antibodies among volunteer blood donors.
Sallam TA, Tong CY, Cuevas LE, YA RA, Othman AM, Al-Kharsa KR. Prevalence of blood-borne viral hepatitis in different communities in Yemen. Epidemiology & Infection. 2003 Aug;131(1):771-5.
Sawyerr HO, Yusuf RO, Adeolu AT. Risk factors and rates of hepatitis B virus infection among municipal waste management workers and scavengers in Ilorin, Kwara State, Nigeria. Journal of Health and Pollution. 2016 Dec;6(12):1-6.
Apidechkul T. Seroprevalence and factors associated with hepatitis B virus infection among the hill tribe youths, northern Thailand. BMC Infectious Diseases. 2019 Dec;19(1):1-1.
Hashemi-Shahri SM, Sharifi-Mood B, Kouhpayeh HR, Moazen J, Farrokhian M, Salehi M. Sexually transmitted infections among hospitalized patients with human immunodeficiency virus infection and acquired immune deficiency syndrome (HIV/AIDS) in Zahedan, Southeastern Iran. International journal of high risk behaviors & addiction. 2016 Sep;5(3).
Dasgupta A. Sexually transmitted viral infections. InViral Infections and Antiviral Therapies 2023 Jan 1 (pp. 85-98). Academic Press.
De Souza RL, dos Santos Madeira LD, Pereira MV, da Silva RM, de Luna Sales JB, Azevedo VN, Feitosa RN, Monteiro JC, de Oliveira Guimarães Ishak M, Ishak R, Ribeiro AL. Prevalence of syphilis in female sex workers in three countryside cities of the state of Pará, Brazilian Amazon. BMC Infectious Diseases. 2020 Dec;20:1-8.
Ali AS, Hussein NA, Elmi EO, Ismail AM, Abdi MM. Hepatitis B vaccination coverage and associated factors among medical students: a cross-sectional study in Bosaso, Somalia, 2021. BMC Public Health. 2023 Dec;23(1):1-8.
Hussein NA, Ismail AM, Jama SS. Assessment of Hepatitis B Vaccination Status and Associated Factors among Healthcare Workers in Bosaso, Puntland, Somalia 2020. BioMed Research International. 2022 Mar 21;2022.
Hassan YS, Hassan SA, Ahmed NR. Uptake of hepatitis B vaccination and associated factors among health sciences students, Mogadishu, Somalia. Frontiers in Public Health. 2023;11.
Redd JT, Baumbach J, Kohn W, Nainan O, Khristova M, Williams I. Patient-to-patient transmission of hepatitis B virus associated with oral surgery. The Journal of infectious diseases. 2007 May 1;195(9):1311-4.
Mohamud AK, Inchon P, Suwannaporn S, Prasert K. Associations between Knowledge, Attitudes, and Practices Regarding Hepatitis B Virus Infection and HBV Infection among Blood Donors in Mogadishu, Somalia: A Hospital-based Cross-sectional Study.
Bancha B, Kinfe AA, Chanko KP, Workie SB, Tadese T. Prevalence of hepatitis B viruses and associated factors among pregnant women attending antenatal clinics in public hospitals of Wolaita Zone, South Ethiopia. PloS one. 2020 May 7;15(5):e0232653.
Dirie NI, Adam MH, Garba B, Dahie HA, Nur MA, Mohamed FY, Mohamud AK, Hassan J. The prevalence of urolithiasis in subjects undergoing computer tomography in selected referral diagnostic centers in Mogadishu, Somalia. Frontiers in Public Health. 2023;11.
Ali AI, Aden AI, Mohamud AK. Dermoscopic findings in Tinea Capitis among under 18 children in dermatology polyclinic patients: a hospital-based cross-sectional study. Annals of Medicine and Surgery. 2024 Jan 1;86(1):121-6.
Mohamud AK, Inchon P, Suwannaporn S, Prasert K, Dirie NI. Assessment of prevalence and risk factors associated with Hepatitis B virus infection among blood donors in Mogadishu Somalia. BMC Public Health. 2024 Mar 4;24(1):690.
Batool A, Bano KA. Antenatal screening of women for hepatitis B and C in an out-patient department. Journal of the Dow University of Health Sciences (JDUHS). 2008 Mar 18;2(1):32-5.
MOHAMUD AK, MOHAMUD BI. Knowledge, Attitude, and Practice of pregnant women toward Intermittent preventive treatment during pregnancy in selected medical centers in banadir region, Mogadishu Somalia.; A Cross-Sectional Study.
Kao JH, Chen DS. Transmission of hepatitis C virus in Asia: past and present perspectives. Journal of gastroenterology and hepatology. 2000 May;15:E91-6.

The authors declare no competing interests.

Download PDF

Version 1

posted

You are reading this latest preprint version

What are the risk factors associated with Hepatitis B Virus infection in Somalia?

Status:

Version 1

Abstract

Background

Method

Result

Conclusion

Background

Method

Study Design

Study Setting

Study Population

Inclusion and Exclusion Criteria

Sample Size and Sampling Technique

Research Instrument

Laboratory and Outcome Definitions

Data Collection Procedure

Data Analysis Procedure

Result

Discussion

Conclusion

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1