DEDICATION………………………………………………………………………...…i
ABSTRACT……………………………………………………………………………...ii
CERTIFICATION/DECLARATION……………………………………………..…..iii
ACKNOWLEDGEMENT……………………………………………………………...iv
TABLE OF CONTENTS………………………………………………………………..v
LIST OF TABLES………………………………………………………………….…..vii
LIST OF FIGURES……………...…………………………………………………….viii
CHAPTER ONE………………………...……………………………………………….1
INTRODUCTION………………………………………………………………………..1
1. Mode of transmission…………………………………………………………………2
2. Aim……………………………………………………………………………………4
3. Objective………………………………………………………………………………4
CHAPTER TWO………………..……………………………………………………….5
LITERATURE REVIEW………………...…………………………………………….…5
2.1 Hepatitis C virus: a historical perspective……………………………….…………....6
2.2 Classification…………………………………………………………………………..6
2.3 Pathogen……………………………………………………………………………….6
2.4 Clinical features of acute infection……………………………………………………7
2.5 Chronic infection and consequences……………………………………………….….7
2.6 Means of transmission………………………………………………………………...7
2.7 Prevalence……………………………………………………………………………..8
2.8 Diagnosis……………………………………………………………………………....9
2.9 Treatment…………………………………………………………………………….10
2.10 Prevention……………………………………………………………………….….10
CHAPTER THREE………..………………………………………………………...…13
METHODOLOGY…………………………………………………………………..…..13
3.1 Study site…………………………………………………………………………….13
3.2 Study design………………………………………………………………………….13
3.3 Blood sample collection and testing………………………………………………....14
3.4 Study approval……………………………………………………………………….14
3.5 Principles behind strip performance………………………………………………....14
CHAPTER FOUR………………...…………………………………………………….16
ANALYSIS OF RESULTS…………………………………………………………...…16
CHAPTER FIVE………………..………………………………………………...……21
DISCUSSION……………………………………………………………………………21
CHAPTER SIX………………..………………………………………………………..23
CONCLUSION AND RECOMMENDATION…………………………………………23
6.1 Conclusion……………………………………………………………………...……23
6.2 Recommendation………………………………………………………………….…23
REFERENCES………………………………..……………………………………..…25
APPENDIX………………………………………………………………………..…….29
Table of results…………………………………………………………………………..29
LIST OF TABLES PAGE
Hepatitis C estimated prevalence and number infected by WHO Region…………….. 9
LIST OF FIGURES PAGES
Figure 1: Age distribution among donors……………………………………….16
Figure 2: History of hepatitis in families of donors……………………………..18
Figure 3: History of transfusion among donors…………………………………19
Figure 4: Donors transfused having HCV……………………………………….20
CHAPTER ONE
INTRODUCTION
Although blood transfusion saves millions of lives worldwide each year, recipients of transfusions risk
becoming infected with bloodborne pathogens. An example of such a pathogen is the hepatitis C virus
(HCV). The HCV causes hepatitis C in people infected and is usually detectable in the blood within 1
to 3 weeks after infection, and antibodies to the virus are generally detectable within 3 to 12 weeks.
Hepatitis C virus is a single stranded RNA blood borne virus accounting for 1520% of all cases of
viral hepatitis. Hepatitis C is a slowly progressive disease with long term sequelae, including cirrhosis
and hepatocellular carcinoma (HCC). Risk factors for infection are well described, with direct
percutaneous exposure the most efficient mode of transmission. Current evidence suggests that vertical
transmission may occur, particularly in highly viraemic and antihuman immunodeficiency (HIV)
positive mothers.
In contrast to most other types of hepatitis, more than 80% of hepatitis C (HCV) infections become
chronic and lead to liver disease. Hepatitis C, in combination with hepatitis B, now accounts for 75% of
all cases of liver disease around the world. Liver failure due to hepatitis C is the leading cause of liver
transplants in some countries. Since hepatitis C infection is typically mild in its early stages, it is rarely
diagnosed and is often not recognized until its chronic stages when it has caused severe liver disease.
With a typical cycle of disease from infection to symptomatic liver disease taking as long as 20 years,
the true impact of this disease on our growing infected population will not be apparent for many years.
For this reason, it is often referred to as the "silent epidemic".
It is estimated that there are, at present, more than 170 million people around the world (3% of the
world’s population) who are infected making it one of the greatest public health threats faced in this
century, and perhaps one of the greatest threat to be faced in the next century. A vaccine against
hepatitis C may not be available for many years to come, and there are already many people infected
with HCV as have the Human Immunodeficiency virus (HIV), (the virus that causes Acquired
Immune Deficiency Syndrome, HIV). Without prompt intervention to treat infected populations and
prevent the spread of disease, the death rate from hepatitis C will surpass that from AIDS.
Mode of transmission
HCV transmission is predominantly parenteral (via shared drug injection equipment, infected blood
products [almost entirely before screening was introduced in February 1990], unsterile skin penetration
practices [e.g., tattooing, ear/skin piercing, acupuncture], needlestick injuries and shared personal
items, such as toothbrushes and razors. However, patienttopatient transmission (via contaminated
anaesthetic circuitry) and surgeontopatient transmission (via percutaneous injury) have both been
demonstrated. Sexual transmission without blood contact appears rare, but the risk of blood exposure
may be increased by sexual contact during menstruation and anal intercourse.
Effective blood screening for the virus was developed and implemented by 1990, which lowered the
rates of posttransfusion hepatitis to less than 5% from 19901993. Since then, improved testing has led
to drastic reductions in risk, down to less than 1% after 1993. However, anyone who had a blood
transfusion prior to that time is at risk for having been infected.
There is growing evidence that HIV, HBV and HCV infections have actually been transmitted to
individuals while they were in prison (Haber et al., 1999; Hutchinson et al., 1998; Mutter et al., 1994;
Skoretz et al., 2004; Stark et al., 1997; Taylor et al., 1995, 2000).
The prevalence of chronic hepatitis C virus (HCV) among blood donors has been assessed in a few
West African countries; most recent estimates range from 1.1% to 6.7 %. (Etard, et al., 2003). The
seroprevalence of HCV is between 1.3 and 8.4 % among blood donors in Ghana (Ampofo et al., 2002;
Candotti et al., 2001; Sarkodie et al., 2001; WansbroughJones et al., 1998), 5.4 % among children in
some rural communities in Ghana (Martinson et al., 1996).
As indicated above, HCV can be transmitted through blood transfusion and data is not readily available
necessitating the conducted of this study to determine the prevalence of HCV infection among blood
donors in the Mampong District Hospital.
AIM
The current study was aimed at screening all blood that was donated at the Mampong District Hospital
for hepatitis C virus from April to June 2007 to document the prevalence of the virus among blood
donors.
OBJECTIVES
1. To determine the prevalence of HCV among blood donors in the district.
2. To estimate the prevalence of HCV among donors who have ever received blood or blood
products.
CHAPTER TWO
LITERATURE REVIEW
Hepatitis C is a viral infection of the liver which had been referred to as parenterally transmitted "non
A, non B hepatitis" until identification of the causative agent in 1989. The discovery and
characterization of the hepatitis C virus (HCV) led to the understanding of its primary role in post
transfusion hepatitis and its tendency to induce persistent infection.
HCV is a major cause of acute hepatitis and chronic liver disease, including cirrhosis and liver cancer.
Globally, an estimated 170 million persons are chronically infected with HCV and 3 to 4 million
persons are newly infected each year. HCV is spread primarily by direct contact with human blood. The
major causes of HCV infection worldwide are use of unscreened blood for transfusion and reuse of
needles and syringes that have not been adequately sterilized.
No vaccine is currently available to prevent hepatitis C and treatment for chronic hepatitis C is too
costly for most persons in developing countries. Thus, from a global perspective, the greatest impact on
hepatitis C disease burden will likely be achieved by focusing efforts on reducing the risk of HCV
transmission from nosocomial exposures (e.g. blood transfusions, unsafe injection practices) and high
risk behaviours (e.g. injection drug use).
Hepatitis C virus: a historical perspective
In the mid 1970s, Harvey J. Alter, Chief of the Infectious Disease Section in the Department of
Transfusion Medicine at the National Institutes of Health (NIH), and his research team demonstrated
that most posttransfusion hepatitis cases were not due to hepatitis A and B viruses. Despite this
discovery, international research effort to identify the virus, initially called nonA, nonB hepatitis
(NANBH), failed for the next decade. In 1987 Michael Houghton, QuiLim Choo, and George Kuo at
Chiron Corporation utilized molecular cloning to identify the unknown organism. In 1988, the virus
was confirmed by Alter by verifying its presence in a panel of NANBH specimens. In April of 1989,
the discovery of the virus, renamed hepatitis C virus (HCV), was published in two articles in the
journal Science. (Wikepedia Encyclopedia, 2007).
Classification
The Hepatitis C virus (HCV) is a small (50 nm in size), enveloped, singlestranded, RNA virus in the
families Flaviviridae.
Pathogen
Hepatitis C virus (HCV) is one of the viruses (A, B, C, D, and E), which together account for the vast
majority of cases of viral hepatitis. It appears to have a narrow host range. Humans and chimpanzees
are the only known species susceptible to infection, with both species developing similar disease. An
important feature of the virus is the relative mutability of its genome, which in turn is probably related
to the high propensity (80%) of inducing chronic infection. HCV is clustered into several distinct
genotypes that may be important in determining the severity of the disease and the response to
treatment. (WHO, 2000).
Clinical features of acute infection
The incubation period of HCV infection before the onset of clinical symptoms ranges from 15 to 150
days. In acute infections, the most common symptoms are fatigue and jaundice; however, the majority
of cases (between 60% and 70%), even those that develop chronic infection, are asymptomatic.
Chronic infection and consequences
About 80% of newly infected patients progress to develop chronic infection. Cirrhosis develops in 10 to
20% of persons with chronic infection, and liver cancer develops in 1 to 5% of persons with chronic
infection over a period of 20 to 30 years. Most patients suffering from liver cancer who do not have
hepatitis B virus infection have evidence of HCV infection. The mechanisms by which HCV infection
leads to liver cancer are still unclear. Hepatitis C also exacerbates the severity of underlying liver
disease when it coexists with other hepatic conditions. In particular, liver disease progresses more
rapidly among persons with alcoholic liver disease and HCV infection.
Means of transmission
Hepatitis C virus is spread primarily by direct contact with human blood. Transmission through blood
transfusions that are not screened for HCV infection, through the reuse of inadequately sterilized
needles, syringes or other medical equipment, or through needlesharing among drugusers, is well
documented. Sexual and perinatal transmission may also occur, although less frequently. Other modes
of transmission such as social, cultural, and behavioural practices using percutaneous procedures (e.g.
ear and body piercing, circumcision, tattooing) can occur if inadequately sterilized equipment is used.
HCV is not spread by sneezing, hugging, coughing, food or water, sharing eating utensils, or casual
contact.
Prevalence
WHO estimates that about 170 million people, 3% of the world's population, are infected with HCV
and are at risk of developing liver cirrhosis and/or liver cancer. The prevalence of HCV infection in
some countries in Africa, the Eastern Mediterranean, SouthEast Asia and the Western Pacific (where
prevalence data are available) is high compared to some countries in North America and Europe. In
West African countries the seroprevalence of HCV among blood donors ranges from 1.1% to 6.7%.
Whiles in Ghana there is a seroprevalence of 1.3% to 8.3% among the blood donors.
Table 1: Hepatitis C estimated prevalence and number infected by WHO Region
Diagnosis
Diagnostic tests for HCV are used to prevent infection through screening of donor blood and plasma, to
establish the clinical diagnosis and to make better decisions regarding medical management of a
patient. Diagnostic tests commercially available today are based on Enzyme immunosorbant assays
(EIA) for the detection of HCV specific antibodies. EIAs can detect more than 95% of chronically
infected patients but can detect only 50% to 70% of acute infections. A recombinant immunoblot assay
(RIBA) that identifies antibodies that react with individual HCV antigens is often used as a
supplemental test for confirmation of a positive EIA result.
Testing for HCV circulating by amplification tests RNA (e.g. polymerase chain reaction or PCR,
branched DNA assay) is also being utilized for confirmation of serological results as well as for
assessing the effectiveness of antiviral therapy. A positive result indicates the presence of active
infection and a potential for spread of the infection and or/the development of chronic liver disease.
Treatment
Antiviral drugs such as interferon taken alone or in combination with ribavirin can be used for the
treatment of persons with chronic hepatitis C, but the cost of treatment is very high. Treatment with
interferon alone is effective in about 10% to 20% of patients. Interferon combined with ribavirin is
effective in about 30% to 50% of patients. Ribavirin does not appear to be effective when used alone.
Prevention
There is no vaccine against HCV. Research is in progress but the high mutability of the HCV genome
complicates vaccine development. In the absence of a vaccine, all precautions to prevent infection must
be taken including:
1. Screening and testing of blood and organ donors
2. Virus inactivation of plasma derived products
3. Implementation and maintenance of infection control practices in health care settings, including
appropriate sterilization of medical and dental equipment
4. Promotion of behaviour change among the general public and health care workers to reduce
overuse of injections and to use safe injection practices; and risk reduction counseling for
persons with highrisk drug and sexual practices. (WHO, 2000)
According to Etard JF et al 2001 the prevalence of chronic hepatitis C virus (HCV) among blood
donors has been assessed in a few West African countries; most recent estimates range from 1.1% to
6.7%. A recent metaanalysis of studies, including a confirmation test, yielded an average prevalence of
HCV infection of 3.0%. Until 2001, no systematic screening of HCV infection occurred among blood
donors in Senegal, and blood donation legislation was still pending. They reported an assessment of the
proportion of blood donors from the Hôpital Principal de Dakar who had HCV antibodies in 2001.
Transfusiontransmissible infections among 808 blood donors in Ghana were investigated in 1999.
Antibody seroprevalences of 3.8, 0.7, 8.4, and 13.5%, respectively, for human immunodeficiency virus,
human Tcell lymphotrophic virus type 1, hepatitis C virus (HCV), and Treponema pallidum were
obtained. The seroprevalence of HCV infection was confirmed to be 0.9% after supplementary testing,
and the transfusion risk potential.
Adjei A. A et al in 2005 took a research on prison inmates and prison officers. After the research, a
seroprevalence of 19.2% among inmates and a seroprevalence 23.2% among the prison officers was
realised. The data indicate a higher prevalence of HCV in correctional facilities (both prison inmates
and officers) than in the general population in Ghana, suggesting their probable transmission in prisons
in Ghana through intravenous drug use, unsafe sexual behaviour and tattooing as pertains to prisons
worldwide.
The seroprevalence of HCV is between 1∙3 and 8∙4 % among blood donors in Ghana (Ampofo et al.,
2002; Candotti et al., 2001; Sarkodie et al., 2001; WansbroughJones et al., 1998), 5∙4 % among
children in a rural district in Ghana (Martinson et al., 1996) and 2∙5 % among parturients in Accra,
Ghana (Lassey et al., 2004).
More research needs to be undertaken on this virus especially in our communities so that effective
preventive measures may be undertaken to help fight against its transmission to bring it under control.
CHAPTER THREE
METHODOLOGY
Study site
The study was undertaken between April and May, 2007 at the Mampong District Hospital in the
Sekyere West District of Ashanti. The total population of the District is estimated at 143.206(2000
Population Census) with 71,378 males and 71,828 females. The growth rate of the District is 1.4 percent
which is lower than the National one of 2.7 percent and a Regional Population growth rate of 3.4
percent. The District has a low age dependency ratio of 1:0.69. About 35.5 percent of the District
population are children (below 15 years). The population density of the District is 61 persons per square
kilometre. This is far lower than the Regional figure of 131 persons per square kilometre and also lower
than the National figure of 73 persons per square kilometre.
Study design
The study was a point prevalence one involving blood donors who came to donate blood for family
members or relatives and voluntary donors during the period of the study. All donors who came to the
hospital during the period qualified to be part of the study. People were recruited into the study as they
came in.
Blood sample collection and testing
Two milliliters of venous blood was collected from each participant using sterile syringe and needle
using aseptic techniques. Blood was allowed to clot in a sterile test tube. It was then centrifuged at 3000
rpm for 5min. Ten microlitres of serum was taken with a sterile pipette and dropped into the test device
sample well. Two drops of buffer (diluent) was then added into the buffer well and HCV test strip was
allowed to stand for 520 min. The results were then interpreted as, if double lines (one from the control
and the other from the test window) then it means sample is HCV positive. Always the control must
show before conclusions were drawn.
A questionnaire was also administered to collect demographic and other relevant data including:
gender, marital status, occupation, history of blood donation, history of hepatitis in family, history of
blood transfusion and history of intravenous drug use.
Study approval
Approval for the study was given by the hospital authorities before commencement of the study. The
study was carefully explained to participants and verbal consent obtained. Data was not collected from
any person who refused to give consent (verbal).
Principles behind strip performance
Hepatitis C virus rapid test device (Flavicheck; Qualpro Diagnostics) an immunochromatographic test
for the qualitative detection of antibodies to HCV was used to test for HCV. As the sample is added to
the sample well, it flows through the membrane test assembly the coloured HCV specific recombinant
antigen colloidal gold conjugate complexes with HCVantibodies in the sample. This complex moves
further on the membrane to the test region T where it is immobilized by the HCV specific recombinant
antigens coated on the membrane leading to formation of a coloured band, which confirms a positive
test result. Absence of this coloured band in the test region indicates a negative test result. The
unreacted conjugate and unbound complex, if any, along with rabbit IgG gold conjugate move further
on the membrane and are subsequently immobilized by the goat antirabbit antibodies coated on the
membrane at the control region C forming a coloured band. This control band serves to validate the
reagent and assay performance.
The strip might have some small limitations and further confirmatory tests like PCR or ELISA may be
required. Also some donors might not have developed detectable antibodies using this test. But the
device has a sensitivity of 99% and specificity of 99.4%.
After the data was collected it was then analysed with excel and seroprevalence of HCV among the
donors was obtained. Also data on donors who have received blood or blood products were obtained
using the questionnaire which asked about history of transfusion and intravenous drug use and after
testing blood, HCV prevalence among them was obtained.
CHAPTER FOUR
ANALYSIS OF RESULTS
A total of 60 donors were involved in the survey. This was made up of 35 (58%) males and aged 17 to
50 years (Fig. 1). The overall prevalence of HCV infection was 6.7% (4/60). Three out of the four
donors infected were (3/4) males. Thus among the 35 males three were HCV positive with a prevalence
level of 8.6% whilst out of the 25 females one was HCV positive giving a prevalence of 4%. The
difference in infection among the sexes was however not significant (p>0.05). Fig.1 shows the age
distribution among donors.
Among the donors the HCV positives were between the ages of 21 and 35. The marital status of the
donors was also considered and the data obtained showed that 50% were single, 42% were married, 5%
were divorced and 2% were widowed. Among the HCV positive donors 3 were married while 1 was
single. No infection was found among the divorced or widowed.
The occupational distribution of the donors were also considered and 21% were farmers, 18.3% were
traders, 16.7% were unemployed, 11.7% were public servants, 6.1% were health workers, 10% were self
employed and 15% were students. The prevalence of HCV was seen in a student, a trader, a farmer and
a public servant.
Most of the donors had not donated blood before and others had. Those with the history of donation
were 18.3% and the others without any history were 81.7%. But none of those with history of donation
was HCV positive so it is only those with no history of donation that were.
Those with history of hepatitis in family were also identified because it increases susceptibility to the
virus. From the responds of the donors it was seen that only 7% reported history of hepatitis in family.
Some did not have any of such history while others said they do not know.
.
But among the 7% none was HCV positive. Twenty percent of the participants had ever been transfused
(Fig. 3). Among the 20% who had been transfused before 8% were HCV positive.
Intravenous drug use is also one of the causes of hepatitis C and 3% of the donors responded to have
been involved in it before while the rest 97% had not. But among the 3% none was HCV positive.
CHAPTER 5
DISCUSSION
Blood samples of voluntary donors were screened during the months of April and May, 2007 to
determine the prevalence of HCV among blood donors at the Mampong District Hospital in the
Sekyere West District of Ashanti. A seroprevalence rate of 6.7% was documented for the health facility
during the period. Seroprevalence levels of between 1.3% and 8.4% have been documented for Ghana
(Ampofo et al., 2002; Candotti et al., 2001; Sarkodie et al., 2001; WansbroughJones et al., 1998). A
seroprevalence of 6.7% therefore fall within the national average.
The ages of the donors coming to donate also ranges from 1750 years with majority of them between
the ages of 17 and 30 and this may be due to the fact that at this youthful age donors appear stronger
and healthier and are mostly preferred to donate than the old. Those between the ages of 31 and 45 also
may have physical features similar to those between the ages of 17 and 30 but only 33% of the donors
belonged to this age group. Among the HCV seropositive donors their ages were between 21 and 35 and
this may be due to the fact that they are very active and may be involved in certain activities which
make them more exposed to the virus.
The marital status of the donors has the majority (50%) been single followed by the married (42%) but
among the HCV seropositives 75% were married and 25% were single. The high prevalence rate among
the married donors was due to the fact that most of them were males and male had the highest
prevalence rate. When a mother brings a child to be transfused and the child’s condition is not very
critical, she goes home to call to the father to donate and this happened most of the time. But the risk
involved in the married been HCV positive is its high transmission among other members of the family
especially when the mother becomes pregnant.
The occupational distribution of the donors did not contribute to been HCV positive since there was no
occupation with high seropositivity. Even the health workers who came to donate none was HCV
seropositive.
The results on history of donation showed that 18.3% of the donors have donated before and 87.1% had
not but none of those with history of donation was HCV seropositive. This suggests that firsttime
donors had the risk for presenting a positive test result. In addition firsttime donors are less likely to
report exposure to risk factors for HCV infection.
There also donors with history of hepatitis in family (7%) but none them was HCV seropositive. Due to
this transmission of HCV in family was not recorded since none of the donors with HCV seropositive
had a history of the disease in the family. Donors who had been transfused were 20% as can be seen in
fig. 3 and HCV is acquired mostly through blood transfusions. Among the 20%, 8% were HCV positive
as can be seen in fig.4 this suggests the exposure to blood was and is still the main risk factor for HCV
infection. For this reason blood screening for HCV started in our hospitals and some hospitals are still
doing the screening while others have stopped. This should not be the case for every blood has the
potential of carrying HCV. Most people have obtained the virus from transfusions that were not
screened for HCV and this practice in some of our hospitals should be brought to a halt.
CHAPTER 6
CONCLUSION AND RECOMMENDATION
Conclusion
Though there was a limitation of the test strip not been able to detect HCV in donors who might not
have developed detectable HCV antibodies, the project was successful. The seroprevalence of 6.7%
among the blood donors obtained, when compared with the national prevalence of 1.3% to 8.3%
confirms the research carried out by others. These further confirms that the virus is still present in our
donors and effective ways such as screening of blood before transfusions should be made a daily routine
in our hospitals.
Also due to the fact that most patients might have been transfused due to low haemoglobin levels which
might have occurred for several reasons, donors who might have donated for such people and were not
screened for the virus poses threat to these patients and can contribute to them easily getting the virus.
Due to this any one who might have been transfused before should go for the test in other to help curb
the virus and bring it under control.
Recommendation
I will recommend that more efforts should be put in place by scientists in bringing out a vaccine that
can be used to immunize people since there no such vaccine available now. More research must be also
done in most of our communities to find out the variability of seroprevalence in one community from
the other with more emphases laid on the modes of transmission of the virus in such communities.
I will also recommend that a research is carried out on our hospitals especially these that were doing
the test to find out their reasons for stopping it.
Also the prevalence of HCV and some other infectious diseases has surprisingly received very little
attention in our educational agenda for curtailing infectious diseases in Ghana so they must be
intensified to deal with the challenge HCV has imposed on as. Lastly periodic study of HCV should be
made a top priority by the health institutions of the country for effective management and control.
LIST OF TABLES PAGE
Table 1: Hepatitis C estimated prevalence and number infected by WHO Region…. 14
Table 2: Results obtained after study…………………………………………………..31
LIST OF FIGURES PAGES
Figure 1: Age distribution among donors……………………………………….22
Figure 2: History of hepatitis in families of donors……………………………..24
Figure 3: History of transfusion among donors…………………………………25.
Figure 4: Donors transfused having HCV……………………………………….26
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