Epidemiology of hepatitis B and C virus infections among patients who booked for surgical procedures at Felegehiwot referral hospital, Northwest Ethiopia.

BACKGROUND: Hepatitis B virus(HBV) and hepatitis C virus(HCV) are the main causes of cirrhosis, liver cancer, and death. This study aimed to determine the seroprevalence and associated factors of HBV surface antigen(HBsAg) and anti-HCV among patients screened for surgery at Felegehiwot referral hospital, Northwest Ethiopia.
METHODS: A hospital-based cross-sectional study was conducted among 433 patients in 2018. Data on socio-demographic and risk factors were collected by an exit interview using a pretested structured questionnaire. A venous blood sample of 5ml was collected from each participant, and serum was tested for HBsAg and anti-HCV using one-step rapid test kits and enzyme-linked immunosorbent assay. Multivariable logistic regression analysis was computed to identify factors associated with HBV and HCV infections. The odds ratio with 95%CI was used to describe the strength of association and statistical significance.
RESULTS: A total of 422 patients gave data and included in the analysis. The mean age of patients was 36±5 years. About two-thirds, 269(64%) and 274(65%) patients were males, and from rural areas, respectively. The seroprevalence of HBsAg was 34(8%) followed by 18(4.3%) anti-HCV and 4(0.9%) co-infections. Being single(AOR = 1.96, 95%CI = 1.12-3.10), rural residence (AOR = 2.68, 95%CI = 1.28-5.61), ever heard about HBV (AOR = 2.41, 95%CI = 1.18-5.20), having multiple sexual partners(AOR = 2.85, 95%CI = 1.30-5.58), HIV positive(AOR = 3.14, 95%CI = 1.31-7.61), history of tooth extraction(AOR = 3.0, 95%CI = 1.40-6.56), hospitalization history(AOR = 2.95, 95%CI = 1.26-5.81), sharing of sharp instruments (AOR = 3.86, 95%CI = 1.82-8.79), and had blood contact(AOR = 2.64, 95%CI = 1.14-5.42) were statistically significant factors to HBV infection. Similarly, sharing of sharp instruments(AOR = 4.65, 95%CI = 1.32-15.1), tooth extraction practice(AOR = 2.81, 95%CI = 1.12-6.56), surgical history (AOR = 3.68, 95%CI = 1.64-9.82), hospitalization history(AOR = 4.51, 95%CI = 1.62-8.35) and had blood contact(AOR = 3.2, 95%CI = 1.56-8.51) were significant factors to HCV infection.
CONCLUSION: The seroprevalence of HBsAg and ant-HCV was high compared to WHO and previous study findings. Giving special attention to awareness creation, rural settings, improving personal behaviors, infection prevention activities of health facilities, quality of healthcare procedures is crucial to prevent viral hepatitis infection.

Introduction

Viral hepatitis, caused by five types of hepatotropic virus (A—E), becomes one of the world’s infectious diseases causing acute and chronic hepatitis that leads to cirrhosis, liver cancer, and death[1, 2]. Viral hepatitis is a serious bloodborne, sexually, vertically, and feco-orally transmitted systemic communicable disease[1, 3]. It can also be transmitted through the reuse of inadequately sterilized medical equipment, surgical procedures, and tooth extraction practices[4-6]. HBV and HCV are responsible for 96% of all hepatitis mortalities worldwide[7]. Globally, over 257 and 71 million people were living with chronic HBVand HCV infections in 2015, respectively[1, 2]. The WHO African Region and the Western Pacific Region accounted for 68% of the global HBV epidemic. Globally, about 2.3 million people have both HBV and HCV co-infections[1]. The prevalence of HBV infection varied from high(≥ 8%) to intermediate(2–7%) and low(<2%). Likewise, HCV infection is high(>3.5%), moderate (1.5–3.5%) and low(<1.5%) prevalence[8].

The African countries accounted for the second-largest number of chronic hepatitis carriers next to Asian countries[9]. There were over 60 million HBV carriers in sub-Saharan Africa[10] and the prevalence of HBsAg ranges from 10–20%[11]. Similarly, Ethiopia is one of the high hepatitis epidemic countries as per the WHO classification criteria[8, 12]. A study from Addis Ababa supported this fact where the sero-prevalence of HBsAg and anti-HCV were 35.8% and 22.5%, respectively among chronic patients[13]. A recent study from Southern Ethiopia also showed 9% HBV and 5.5% HCV prevalence among surgical patients[6]. Moreover, a systematic meta-analysis in Ethiopia reported a 6% pooled prevalence of HBV[14]. Based on study findings from Ethiopian pregnant women, the prevalence of HBsAg ranges from 2.4%[15] to 6.3%[16]. Similarly, the prevalence of anti-HCV ranges from 1.8%[3] to 8.0%[15, 17]. The increased surgical practices, injuries, blood transfusion, and unsafe healthcare practices might lead to high hepatitis infection in Ethiopia.

The prevalence of HBsAg and anti-HCV is high in hospitalized surgical patients[1, 2, 7, 8, 13]. However, there is limited evidence about the magnitude of viral hepatitis at the community level and during patient screening for surgery in Ethiopia. Therefore, this study aimed to assess the sero-prevalence of HBsAg and anti-HCV and associated factors among patients who booked for surgery at Feleghiwot referral hospital, Bahir Dar city, Northwest Ethiopia. The findings of this study will be important to health planners, hospital managers, and health workers to know the magnitude of HBV and HCV infections and make informed decisions to fight hepatitis infection.

Materials and methods

Study design and setting

A hospital-based cross-sectional study was conducted at Felegehiwot referral hospital located in Bahir Dar City, Northwest Ethiopia. The hospital is established in 1963 and has Emergency, Surgery, Medical, Pediatrics, Obstetrics and Gynecology, Psychiatry, Dental, and Orthopedics units with outpatient, inpatient departments, and follow-up departments. It has about 415 beds and 600 staff in different departments. It has provided its specialized services for over seven million people living in its catchment area. It also offers referral services coming from different parts of the Amhara Region and neighboring regions[18].

Source and study population

All patients visiting the surgical ward in 2018 were the source population. Whereas, all patients who prescreened and booked for surgical procedures in the medical ward within the specified period were study population to this study.

Sample size determination and sampling procedures

The sample size of this study was determined using Epi Info version 7 using the following assumptions: 35.8% HBV proportion (P)[13], 5% precision error, and 97% confidence level. Then, the final sample size became 433. A systematic random sampling technique (every other) was applied to select each participant.

Data collection tool and techniques

Two data sources were included in this study: data on socio-demographic and associated risk factors, and data about HBV and HCV prevalence from blood samples. A pretested structured questionnaire was used to collect data on socio-demographic and risk factors (S1 Table). The questionnaire was validated for its consistency by using Cronbach’s alpha test and the value was (α = 0.87). Two trained health officers collected data through a face-to-face exit interview. Also, the venous blood sample of 5ml was collected from each study participant by a well-trained laboratory technologist. Then, the serum was separated by centrifugation at 5000 r/min for 15 minutes and tested for HBsAg, anti- HCV using one step HBsAg test strip (Nantong Diagnosis Technology Co., Ltd., China) and one step HCV test strip (Nantong Diagnosis Technology Co., Ltd., China), respectively following the instructions of the manufacturer. The sensitivity and specificity of rapid test Kits were 99.1% and 99.6%, respectively[19]. Then, the samples were further tested using enzyme-linked immunosorbent assay(ELISA) (Dialab GmbH, Wiener Neudorf, Austria) machine as per the manufacturer’s manual[20]. Sample collection and process were conducted based on the WHO[21] and Ethiopian national laboratory guidelines for specimen collection, processing, and handling[22].

Data quality assurance

The questionnaire was pretested on a 5% sample, and validated by Cronbach’s alpha test before the actual data collection. Data collectors were trained for two days with practice before data collection. Regular supportive supervision was given to data collectors. The WHO and national guidelines were used to collect, process, and test serum samples. Data completeness and consistency were checked daily, during data entry and analysis.

Data management and analysis

Data were entered, cleaned, and analyzed using SPSS version 25 software. In this analysis, single marital status means living alone and it is the sum of not married, divorced, and widowed. Descriptive statistics including proportions, the measure of central tendency, and cross-tabulations were computed to describe study participants and state the prevalence of HBsAg, anti-HCV. Bivariate and multivariable logistic regression analyses were used to identify risk factors associated with HBV and HCV infections. Variables with a p-value of less than 0.2 at bivariate analysis were considered to fit the final multivariable logistic regression model through a stepwise (forward) method. Odds ratio with 95%CI and p-value less than 0.05 were used to describe the strength of association and level of significance.

Ethical clearance

The study was conducted as per the Helsinki Declaration for biomedical research. The study was ethically cleared and approved by the ethical review committee of Amhara Regional Health Bureau (Protocol No: Re/TS/RTT/01/367/09) with a supporting letter to Felegehiwot referral hospital. Data were collected after getting approval from the hospital medical director and written informed consent from each study participant. Participation in the interview and blood sample collection was fully voluntary based. Data confidentiality was kept through avoiding personal identifiers and anonymity of personal data records.

Results

Socio-demographic and behavioral variables of study participants

Of the total 433 samples, 422 surgical patients provided complete data and included in the analysis with a response rate of 97.5%. About two-third, 269(64%), 274(65%), and 266(63%) of the study participants were male, rural residents and in union marital status, respectively. The mean and standard deviation age was 36 ±5 years. Over a third, 152(36%) of the respondents had no formal education. Over half, 249(59%) of the respondents were farmers and 102(24%) had more than one sexual partner. Only 110(26%) respondents ever heard about HBV infection. About 25(5.9%) and 36(8.5%) respondents were HIV positive and had blood transfusion history, respectively. Sixty-two(15%) patients had tooth extraction practices. Also, 42(10%) patients had hospitalization history and 28(6.6%) had a history of surgical procedures. Moreover, 38(9%) of the patients had blood contact history with unknow status in their life (Table 1).

Table 1

Factors of HBV infection on surgical patients in Felegehiwot referral hospital, 2018.

Variables	HBsAg status		COR (95%CI)	AOR (95%CI)
	Positive (%)	Negative (%)
Age in years
≤ 36	9 (2.0)	110 (26.1)	0.88 (0.40–1.94)	--
> 36	25 (6.0)	278 (65.9)	1
Sex
Male	18 (4.2)	251 (59.5)	0.61 (0.30–1.24)	--
Female	16 (3.8)	137 (32.5)	1
Residence
Rural	28 (6.6)	246 (58.3)	2.80 (1.18–6.64)	2.68 (1.28–5.61)
Urban	6(1.4)	142 (33.7)	1	1
Marital status
Single	19 (4.5)	137 (32.5)	2.32 (1.14–4.71)	1.96 (1.12–3.10)
In union	15 (3.5)	251 (59.5)	1	1
Education level
No formal education	10 (2.4)	142 (33.7)	0.72 (0.34–1.60)	--
Formal education	24 (5.6)	246 (58.3)	1
Occupation
Farmer	11 (2.6)	139 (33.0)	0.67 (0.30–1.55)	--
Non-employed	15 (3.5)	130 (31.0)	1.71 (0.70–4.20)	--
Employed	8 (1.9)	119 (28.0)	1
HIV sera-status
Positive	6 (1.4)	19 (4.5)	4.16 (1.54–11.3)	3.14 (1.31–7.61)
Negative	28 (6.6)	369 (87.5)	1	1
Ever hear about HBV
Yes	16 (3.8)	94 (22.3)	2.78 (1.36–5.67)	2.41 (1.18–5.20)
No	18 (4.3)	294 (69.7)	1	1
History of multiple sexual partners
Yes	16 (3.8)	86 (20.4)302	3.12 (1.53–6.40)	2.85 (1.30–5.58)
No	18 (4.2)	(71.6)	1	1
Sharing of sharp instruments
Yes	7(1.6)	18 (4.3)	5.33 (2.05–13.87)	3.86 (1.82–8.79)
No	27 (6.4)	370 (87.7)	1	1
History of blood transfusion
Yes	5 (1.2)	31 (7.3)	1.99 (0.72–5.50)	--
No	29 (6.9)	357 (84.6)	1
Tooth extraction practice
Yes	10 (2.4)	52 (12.3)	2.70 (1.22–5.95)	3.0 (1.40–6.56)
No	24 (5.7)	336 (79.6)	1	1
History of hospitalization
Yes	8 (1.9)	34 (8.0)	3.20 (1.35–7.62)	2.95 (1.26–5.81)
No	26 (6.2)	354 (83.9)	1	1
History of surgical procedures
Yes	5 (1.2)	23 (5.4)	2.73 (0.89–7.73)	--
No	29 (6.9)	365(86.5)	1
History of direct blood contact
Yes	7 (1.6)	31 (7.3)	2.98 (1.20–7.41)	2.64 (1.14–5.42)
No	27 (6.4)	357 (84.6)	1	1
History of needle stick anywhere
Yes	6 (1.4)	58 (13.8)	1.22 (0.48–3.10)	--
No	28 (6.6)	330 (78.2)	1

Sero-prevalence of HBV and HCV infections

The overall prevalence of HBsAg and anti-HCV were 34(8%) [95% CI = 5.6–10.4%], and 18(4.3%) [95%CI = 3.0–6.2%], respectively. Four of the infected respondents (0.9%) had HBV and HCV coinfection. The positivity rate for both infections was relatively higher among males, people above 36 years, rural residents, people who shared sharp instruments, who had no history of blood transfusion and surgery procedures (Tables 1 and 2).

Table 2

Factors of HCV on surgical patients in Felegehiwot referral hospital, 2018.

Variables	Anti-HCV status		COR (95%CI)	AOR (95%CI)
	Positive (%)	Negative (%)
Age in years
≤ 36	6 (1.4)	113 (26.8)	1.30 (0.47–3.51)	--
> 36	12 (2.8)	291 (70.0)	1
Sex
Male	10(2.4)	261 (61.8)	0.66 (0.26–1.80)	--
Female	8 (1.9)	143 (33.9)	1
Residence
Rural	8 (1.9)	266 (63)	0.42 (0.16–1.07)	--
Urban	10(2.4)	138 (32.7)	1
Marital status
Single	6 (1.4)	150 (35.6)	0.85 (0.31–2.30	--
In union	12 (2.8)	254 (60.2)	1
Education level
No formal education	7 (1.6)	145 (34.3)	1.14 (0.43–3.00)	--
Formal education	11 (2.6)	259 (61.4)	1
Occupation
Farmer	5 (1.2)	145 (34.3)	0.70 (0.21–2.33)	--
Non-employed	7 (1.7)	138 (32.7)	1.02 (0.33–3.13)	--
Employed	6 (1.4)	121 (28.7)	1
History of multiple sexual partners				--
Yes	7 (1.7)	95 (22.5)	2.10 (0.78–5.50)
No	11 (2.6)	309 (73.2)	1
Sharing of sharp instruments
Yes	6 (1.4)	19 (4.5)	9.50 (3.43–29.5)	4.65 (1.32–15.1)
No	12 (2.8)	385 (91.3)	1	1
History of blood transfusion
Yes	3 (0.7)	36 (8.5)	2.00 (0.57–7.40)	--
No	15 (3.6)	368 (87.2)	1
Tooth extraction practice
Yes	6 (1.4)	56 (13.3)	3.11 (1.12–8.62)	2.81 (1.11–6.56)
No	12 (2.8)	348 (82.5)	1	1
History of hospitalization
Yes	7 (1.7)	35 (8.3)	6.71 (2.45–18.4)	4.51 (1.62–8.35)
No	11 (2.6)	369 (87.4)	1	1
History of surgical procedures
Yes	5 (1.2)	23(5.4)	6.4 (2.10–19.0)	3.68 (1.64–9.82)
No	13 (3.1)	381(90.3)	1	1
History of direct blood contact
Yes	6 (1.4)	32 (7.6)	5.81 (2.10–16.51)	3.2 (1.56–8.51)
No	12 (2.8)	372 (88.2)	1	1
History of needle stick
Yes	5 (1.2)	59 (14.0)	2.25 (0.77–6.54)	--
No	13 (3.1)	345 (81.7)	1

Factors associated with HBV infection

Based on the multivariable logistic regression model, patients from rural areas were over double times more likely to have HBV infection compared to patients from urban areas(AOR = 2.68, 95% CI = 1.28–5.61). Similarly, patients with single marital status and ever heard about HBV were twice to get HBV infection than patients in union and who did not hear about HBV(AOR = 1.96, 95%CI = 1.12–3.10, and AOR = 2.41, 95%CI = 1.18–5.20), respectively. Also, patients who practiced sharing of sharp instruments, tooth extraction, and had HIV positive status were over three times more likely to acquire HBV infection compared to their counterparts (AOR = 3.86, 95%CI = 1.82–8.79; AOR = 3.0, 95%CI = 1.40–6.56; AOR = 3.14, 95%CI = 1.31–7.61), respectively. Moreover, the odds of having HBV infection were 2.85 times more among patients who had a history of multiple sexual practices compared to patients who had no history (AOR = 2.85, 95%CI = 1.30–5.58). Patients who had hospitalization history were 2.95 times more likely to get HBV infection than patients with no hospitalized history (AOR = 2.95, 95%CI = 1.26–5.81). Also, patients who encountered direct blood contact were over two-folds to have HBV infection compared to patients with no blood contact history(AOR = 2.64, 95%CI = 1.14–5.42) (Table 1).

Factors associated with HCV infection

In the multivariable logistic regression analysis, the odds of getting HCV infection were four times more among patients who shared sharp instruments and had hospitalization history compared to the counterpart patients(AOR = 4.65, 95%CI = 1.32–15.1, and AOR = 4.51, 95%CI = 1.62–8.35), respectively. Similarly, patients with surgery history were over three times to have HCV infection than patients who had no history of surgery (AOR = 3.68, 95%CI = 1.64–9.82). Also, patients with blood contact and tooth extraction history were more likely to have HCV infection than patients with no history of blood contact and tooth extraction (Table 2).

Discussion

This study tried to assess the magnitude of HBV and HCV infections among patients who are going to have surgery at Felegehiwot Referral hospital. The current prevalence of HBV(8%) and HCV(4.3%) (Table 1) are high according to WHO classification criteria[8]. This finding was slightly in agreement with study findings from Ethiopian studies in Addis Ababa[23], Hawasa[6], and Gambella[24], where HBV prevalence was 7.8%, 9%, and 7.9%, respectively.

The current HBV and HCV prevalence were, however, found to be higher compared to study findings from Bahir Dar city among blood donors that reported 3.9% HBV and 0.6% HCV prevalence[25]. These discrepancies might be attributed to differences in age, sample size, study participants (patient vs healthy blood donors), and study design. Residence might also contribute to this variation where most of the patients were from different parts of the Amhara region, while the blood donors are from Bahir Dar city and adjacent districts.

Similarly, this finding was also slightly higher compared to study findings among community members from Southern Ethiopia[26] that revealed 7.2% HBV and 1.9% HCV sero-prevalence. This variation might be related to differences in study participants (chronic patients vs community members), and diagnostic methods used to report participants’ status; for example, the current study used ELISA as a confirmatory test which was not applied by the previous study.

Besides, this HBV prevalence was found to be higher compared to study findings among pregnant women attending antenatal care services in Ethiopia; 2.4% from Oromia region[15], 4.5% from Southern Ethiopia[3] and 6.3% from Harar[16]. These discrepancies might be related to differences in residence, health status (pregnant women vs chronic patients), and the research methods used (using only rapid kits vs both rapid kits and ELISA). It is also higher than findings from a systematic study in Ethiopia that revealed a 6% pooled prevalence[14]. This difference might be attributed to variations in facility type (health centers vs referral hospital), gender where most papers reported higher prevalence among males[7, 13, 27], and personal behaviors between females and males.

This finding on the other hand was lower compared with study findings among chronic patients in Addis Ababa Ethiopia[13] where HBV and HCV prevalence were 35.8% and 22.5%, respectively. This discordant might be related to differences in sample size(129 vs 422), study period(2011 vs 2018), and study area where the former study was among patients from Black lion, Set Pawul, and Zewuditu memorial hospitals which are national specialized hospital serving as referral sites to Ethiopia. Thus, viral hepatitis will be higher in those hospitals compared to Felegehiwot referral hospital since more chronic cases will be referred to those national hospitals.

Also, the present HBV prevalence was found to be lower than a pooled prevalence from a systematic meta-analysis study in Sudan in which HBV was 12%[27]. This might be due to research design where the systematic review included more research works having various prevalence. But in our study, it is a single study from one hospital, thus the prevalence is lower.

Concerning HCV infection, the present HCV prevalence was higher than a pooled prevalence of HCV(2.74%)[27]. This discrepancy might be attributed to variations in study design (survey vs meta-analysis), study settings, and population behaviors. Similarly, it was higher than study findings from Southern Ethiopia(1.8%)[3] and Bahir Dar city(3.8%)[17]. These variations might be due to differences in the history of hospitalization, blood transfusion, unsafe healthcare procedures, and traditional practices.

On the contrary, the prevalence of HCV was found to be lower compared to a study finding from Hawasa where HCV prevalence was 5.5%[6]. It was also lower compared to study findings from the Oromia region[15, 28] and Hawasa referral hospital[6] where HCV prevalence were 8% and 9%, respectively.

Based on this study, the positivity rate of HBV and HCV was higher among males and elders (≥36years) although not statistically significant in the multivariable logistic regression model. The previous studies also supported this finding[13, 17, 29]. This might be due to variations in genetic make-up[30], status of immune system, exposure to sexual practices, history of health facility visit, tooth extraction practices, and history of blood transfusion.

In high hepatitis epidemic areas, the co-infection of HBV and HCV is reported since the two viruses share common routes of transmission[6, 26, 31, 32]. Similarly, 0.9% co-infection of HBV and HCV was reported in this study. This finding was lower compared to study findings from Ethiopia[13], India[31], and Mongolia[32] where 2.5%, 5.9%, and 7.7% co-infections of HBV and HCV were reported among chronic patients, respectively. Differently, it was relatively higher than study finings from Southern Ethiopia[6, 26] which reported 0.2% and 0.3% co-infections. This might be due to differences in behaviors of study participants, geographic locations, and types of diagnostic tools used to screen out the study participants. For example, the two studies from Southern Ethiopia did not use ELISA as a confirmatory test which was applied in our study.

This study identified various risk factors for HBV and HCV infections (Tables 1 and 2). Patients from rural residences were over twice to have HBV infection. This implies the presence of high hepatitis infections among rural communities with unknown status as a result of poor screening practices. This might be related to low community awareness, limited access to healthcare facilities, less precaution to blood and body fluids, sharing of sharp instruments, and high prevalence of traditional practices including home-based delivery, tooth extraction, and female genital mutilation in rural areas[3, 28]. Similarly, being single in marital status was found to be an important factor to acquire HBV infection. In this analysis, single marital status is to mean the sum of number of patients who are divorced, widowed and not married. Thus, these people might have sexual exposure to more than one partner whose hepatitis status is unknown compared to patients who are in union.

Having a history of multiple sexual partners was an important risk factor to acquire HBV infection. This indicates the presence of unsafe sexual practices within the community which is a serious practice to expose people not only to hepatitis but also to HIV and other sexually transmitted infections. Similar study findings from Ethiopia and abroad also supported this finding[3, 6, 16, 24, 27, 28, 33, 34]. This is because of unsafe sexual practices with more partners whose status is unknown since blood and body fluids are key infection sources. Likewise, the odds of being positive to HBsAg was triple times among HIV positive patients. This will make the situation more serious among surgical patients due to more comorbidities (HBV, HIV, and surgery cases). This was also reported by the previous studies from Ethiopia[16, 25]. This might be due to having multiple sexual partners with unsafe sexual practices. Both hepatitis and HIV are bloodborne diseases transmitted by sexual contact, direct blood contact, through blood-contaminated equipment, and mother-to-child during pregnancy and delivery[1, 3, 7].

Moreover, history of hospitalization, tooth extraction practice, sharing sharp instruments, and direct contact to blood with unknown status were statistically significant factors to HBsAg and anti-HCV(Tables 1 and 2). This implies that hospital services and tooth management practices are unsafe and main sources of infections for patients coming for healthcare services. It is to mean patients have a chance to get infections other than the disease that makes them visit health facilities[1, 2] which is a serious issue that requires special attention from the health bureau and health facilities. This was in agreement with previous study findings that reported these variables as risk factors to hepatitis infection[6, 13, 16, 35]. This could be due to poor infection control practices in health facilities, using poorly sterilize medical equipment, improper healthcare procedures, traditional tooth extraction practices, sharing sharp instruments, blood contact with bare hand[1-4]. Tooth extraction, reuse of equipment without proper sterilization, and sharing sharp instruments (blade, needle, pin, syringe…) are common among rural communities in Ethiopia[13, 16]. All these can facilitate the transmission of HBV and HCV infections[1–4, 35] and might be happened due to poor infection prevention practices, absence of protective equipment, and low awareness of the community and traditional practitioners.

Patients with surgical history were triple times more likely to have HCV infection. This implies that health facilities are key sources of hepatitis infection. Therefore, evaluating the quality of healthcare services and procedures, application of healthcare ethics, presence and adherence of infection prevention protocols, and accountability and awareness of health workers is needed. Previous studies also reported the same finding on patients’ history of surgical procedures and HCV infection[2, 6, 23, 35]. In line with this, patients who shared sharp instruments with others were 4.65 times more likely to get HCV infection compared to the counterpart patients.

Based on the hepatitis management guideline and literature, a history of blood transfusion was statistically significant factor to HBV and HCV infections[15, 25, 28]. Blood transfusion with inadequate screening can indeed transmit blood-borne diseases. Also, due to the absence of quality screening tools at the window periods, blood screening results might be negative. Thus, blood transfusions based on such screening results can transmit infections. Unlike the previous studies[1–3, 16, 28], history of blood transfusion was not statistically significant to HBV and HCV infections in this study. This might be due to a small number of patients who had blood transfusion history due to low awareness, attention, and practice of blood transfusion.

Conclusions

This study depicted a high prevalence of HBV and HCV infection among patients who screened for surgical procedures. The positivity rate was higher among male, rural residents, and elder patients. Being from rural areas, single marital status, having HIV infection, sharing sharp instruments, history of hospitalization, tooth extraction practices, and blood contact with bare hand were risk factors of HBV infection. Similarly, history of hospitalization, surgical procedures, blood contact, and sharing sharp instruments were risk factors of HCV infection. Improving awareness of community and health workers, access to HBV and HCV screening services, enhancing infection prevention practices, adherence to healthcare service guidelines, and practicing medical ethics are important to prevent acquiring HBV and HCV infections.

Personal descriptions and risk assessment questionnaire.

(PDF)

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HBV and HCV data set.

(SAV)

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2 Apr 2020

PONE-D-20-06821

Epidemiology of hepatitis B and C virus infections among patients who booked for surgical procedures at Felegehiwot referral hospital, Northwest Ethiopia

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3. We noticed you have some minor occurrence of overlapping text with the following previous publication(s), which needs to be addressed:

- Taye, Meseret, et al. "Magnitude of hepatitis B and C virus infections and associated factors among patients scheduled for surgery at Hawassa University comprehensive specialized Hospital, Hawassa City, southern Ethiopia." BMC research notes 12.1 (2019): 412.

The text that needs to be addressed involves some sentences of the Introduction

In your revision ensure you cite all your sources , and quote or rephrase any duplicated text outside the methods section. Further consideration is dependent on these concerns being addressed.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The paper by Pr Asemahagn (PONE-D-20-06821) describes the prevalence of HBsAg and anti-HCV in patients enrolled for surgery in a referral hospital in Northwest Ethiopia.

Major remark:

The Author points out that a study population of blood donors means that most participants come from the large city of the region. In this case the study population comes from all parts of the Amhara region and even some from neighboring regions. However, one can wonder whether the population studied in this paper is really representative of the general population. There are 2 major biases. As could be expected for a group enrolled for surgery, the patients tend to be older, with more than 70% being older than 36 years. There is also a gender bias, with almost two-thirds of the patients being male. These limitations could be discussed in more detail.

Minor remarks:

1) The names of the kits and the manufacturers of the kits used for detecting HBsAg and anti-HCV should be given.

2) Page 5, line 1. “suppression” is certainly not what the Author meant to say. Could it be “supervision”?

3) Also page 5 in the Ethical clearance section, the Author writes “getting ok”. This is too colloquial. “getting permission” would be better.

4) Throughout the paper the Author talks about “sharps”. This is imprecise. “sharp tools” or “sharp instruments” should be used.

5) In Table 1, for tooth extraction/HBsAg negative, the % are missing

6) In Table 2, the value 121 on the line non-employed/anti-HCV negative belongs on the line below.

7) Page 9, line 5. It should be “high” and not “higher”

8) Page 9, second from last line. It should be “from”

9) Page 11, first line. It should be “odds”

10) Page 11, line 3. It should be “previous” instead of “former”.

11) Page 13. Since there is only 1 Author, the Competing interests section should read “The Author declares that he has no competing interests in this work”. Similarly, in the Author’s contributions section it should read “MAA did the conception …………………….interpretation of data and drafting of the manuscript”

12) In references 5 and 6 “et al” should be spelled out in full and not abbreviated to “ea”

**********

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Reviewer #1: Yes: Alan Kay

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28 Apr 2020

Cover letter to PLOS ONE journal editor

Isabelle Chemin, PhD 216th April 2020

Academic editor

PloS ONE journal

Subject: Submitting review response to Epidemiology of hepatitis B and C virus infections among patients who booked for surgical procedures at Felegehiwot referral hospital, Northwest Ethiopia [PONE-D-20-06821]

Dear Dr. Isabelle Chemin,

Thank you for your email enclosing the reviewers’ comments and continuous email reminders. I, the authors have great thanks to the journal editor and the reviewers for reviewing and giving insightful comments to our manuscript. I have carefully reviewed the comments, suggestions, clarity questions, and revised the manuscript accordingly. I made significant revisions to all sections of a manuscript for language, clarity, concept, shortening sentences, changing words, adding explanations, incorporating missed findings, avoiding misleading words or phrases, and using appropriate punctuation. For details, please refer the general reflection to the journal editor, and a point by point responses to each reviewer below. In the one by one response, comments of the reviewers are indicated in italics, and replies to the comments are shown by the normal font style. Similarly, changes to the manuscript are shown by track changes in the manuscript. As evidence, we attached the track changed manuscript besides this point by point response.

Note: Activities and strategies that we have used to make this remarkable revision are presented below as a general direction or an introduction to a point by point response.

I hope, the revised version is now suitable for publication and look forward to hearing from you in due course.

Sincerely,

Mulusew Andualem Asemahagn

Associate professor of public health

School of Public Health, CMHS, Bahir Dar University, Ethiopia

Response to Reviewers

General reflections to the PLoS one journal editors

Dear Plos one journal editors and reviewers, I hearty acknowledged your efforts made in each section of our manuscript. I am very happy with all the given comments and clarity questions that you raised. I know that the purpose of the review is improving the quality and readability of the manuscript. I fully accept them and did our possibilities by giving time to each section of a manuscript to address the given comment and clarity questions. My approaches were not focusing on answering only the raised issues, but revising each section by taking the raised issues as triggering points. Frankly speaking, I see this as an excellent opportunity to revise the manuscript and increase its quality.

Activities that I made are incorporating comments/suggestions, giving answers/explanations/ justifications/reasons/to clarity questions, adding concepts, inserting new words/phrases/ sentences/ paragraphs, deleting less important words/phrases/sentences/paragraphs, improving language problems (type errors, wording, clarity, and sentence parallelism and complexity). Removing unnecessary spaces between words, sentences, paragraphs…are made. NB: The reordering of paragraphs was also made to the discussion section to better idea coherence. I also included new paragraphs to the discussion section that were missed to discuss in the former manuscript (about co-infection). About information to HBV was also included in the abstract and the result sections (Table). The revisions are made to each section. I am sure that most of the clarity questions and comments given by the respected reviewers are addressed as much as possible.

A. Responses to the academic editor

Comment 1: “1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming.”

Replay 1: I fully accept your comments and tried to be inline as per the PLoS ONE journal format.

Comment 2: “Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information. Moreover, please include more details on how the questionnaire was pre-tested, and whether it was validated.”

Replay 2: The author fully accepts this valuable comment to adhere to the journal format since it is a key criterion. Based on the comment, I added the questionnaire in both the local and English language format. The questionnaire was developed by referring related papers and based on the author’s study objective. It was validated among patients from other hospital and modifications to clarity and order was made. It was also validated by the Cronbach alpha with a value of 0.87 at SPSS version 25. It is stated on page 4, data collection tool, and technique subheading.

Comment 3: “We noticed you have some minor occurrence of overlapping text with the following previous publication(s), which needs to be addressed: Taye, Meseret, et al. "Magnitude of hepatitis B and C virus infections and associated factors among patients scheduled for surgery at Hawassa University comprehensive specialized Hospital, Hawassa City, southern Ethiopia." BMC research notes 12.1 (2019): 412. The text that needs to be addressed involves some sentences of the Introduction. In your revision ensure you cite all your sources and quote or rephrase any duplicated text outside the methods section. A further consideration is dependent on these concerns being addressed.”

Replay 3: I thank you much for the concern you raised. Unfortunately, I did not have access to that document during the manuscript preparation. However, there was one line which was matching with that document. Hence, thank you for your notice. The similarity has happened since the two authors used the same reference document to talk about HBC and HCV in Africa where there is limited literature since hepatitis is getting attention late by the WHO and regional governments. Now, I downloaded and cited as literature to my manuscript. Thus, thank you again for showing updated literature. Based on your comment, the introduction section is highly revised using recent WHO and research articles to make it strong. I also included researched for updated literature and got about eight literature important to update my manuscript and increase my references from 24 to 32, which is because of your comment. Thus, paragraph 2 of the introduction, which you commented as it has some similarity without citation from the former study is revised as follows:

The African countries accounted for the second-largest number of chronic hepatitis carriers next to Asia 9]. There were over 60 million HBV carriers in sub-Saharan Africa [10] and the prevalence of HBsAg ranges from 10-20% [11]. Similarly, Ethiopia is one of the high hepatitis epidemic countries as per the WHO classification criteria [8, 12]. A study from Addis Ababa also supported this fact where HBsAg and anti-HCV were 35.8% and 22.5%, respectively among chronic patients [13]. A recent study from Southern Ethiopia also showed 9% HBV and 5.5% HCV prevalence among surgical patients [6]. A systematic meta-analysis in Ethiopia also reported a 6% pooled prevalence of HBV [14]. Based on study findings from Ethiopian pregnant women, the prevalence of HBsAg ranges from 2.4% [15] to 6.3% [16]. Similarly, the prevalence of anti-HCV ranges from 1.8% [3] to 8.0% [15, 17]. The increased surgical practices, injuries, blood transfusion, and unsafe health practices might lead to hepatitis infection in Ethiopia.

Comment 4: “As we note that data collection was performed by a cooperative group, we would recommend that you consult our authorship requirements page: https://journals.plos.org/plosone/s/authorship, to ensure that everyone who meets our criteria for authorship is listed as an author.”

Replay 4: Thank you for your invitation. All the data collectors were recruited to collect and perform laboratory data with pay. Hence, they did not participate in a fee and did not contribute more other than data collection and processing.

Comment 5: “In your Data Availability statement, you have not specified where the minimal data set underlying the results described in your manuscript can be found...Upon re-submitting your revised manuscript, please upload your study’s minimal underlying data set as either Supporting Information files or to a stable, public repository and include the relevant URLs, DOIs, or accession numbers within your revised cover letter.”

Replay 5: I thank you very much for your reminder. I have included all the data set and questionnaire. I did not take consent from each study participant to share the data sets to the third party, but, your office urge me to share it. This is my first time to share the private data sets of participants without taking consent to share with the third party. My fear is the reuse of such data set by other researchers without taking consent from the original author. Because, we can not control them since it will be online. Even, students are doing such types of unethical actions to their thesis work without collecting data. It is to mean duplication of others' work with out any efforts. Have you think such issues while asking for data set attachment from authors who got it through various difficulties and the ethics issue. I have encountered with this issue to my student who took the data sets from some where for his research. He did not do any thing except downloading such data set and changing the working places. I have disqualified his attempt, but how about others????? anyways, i fill very much discomfort for two things; sharing my data set without taking consent from each study participants 2). contributing more for false research activities among some authors who are using others' data set from online sources with out any efforts.

B. Response to Reviewer #1

Dear respected reviewers, I am happy and lucky for your insightful comments and clarity questions in each part of the manuscript. I have accepted all the comments and incorporated them into the manuscript as indicated below and on the track change manuscript. I also did a complete revision to all sections of the manuscript taking your comments as triggering points.

Comment 1: “The author points out that a study population of blood donors means that most participants come from the large city of the region. In this case, the study population comes from all parts of the Amhara region and even some from neighboring regions. However, one can wonder whether the population studied in this paper is representative of the general population. There are 2 major biases. As could be expected for a group enrolled for surgery, the patients tend to be older, with more than 70% being older than 36 years. There is also a gender bias, with almost two-thirds of the patients being male. These limitations could be discussed in more detail.”

Replay 1: Thank you for raising this important issue. I fully accept and revised the issue that you mentioned regarding representativeness to the community. The author stated as the sample could be relatively representative of the population compared to blood donors by assuming that they are coming from different directions. When the author said this, it is not to mean they are representatives of the community. But, when we compared these findings with findings from the blood donor in Bahir Dar city, it is different. So, as per the author’s view, the variation might be related to differences in residence, health conditions, age groups, sample size, study participants (patient vs blood donors), and study design (survey vs retrospective). Thus, it is not to mean the sample or studied people are representatives of the community. Because they are patients who can not represent healthy people. The majority were males that might not represent the proportioning of the community. Most of the patients were also elders, so they might not be real representatives of the community. Thus, by considering these, I have revised the manuscript not to be understood as you mentioned above. Thus, the author deleted sentences that lead to representatives from the last paragraph of the background on page 3. It is also revised on page 9, discussion section, paragraph 1 and 2.

Comment 2: “The names of the kits and the manufacturers of the kits used for detecting HBsAg and anti-HCV should be given.”

Replay 2: I fully accept your comment and mentioned all the names and manufacturers of the rapid kits and ELISA on page4, under data collection tools and techniques section as:

“Then, the serum was separated by centrifugation at 5000 r/min for 15 min and tested for HBsAg, anti- HCV using one step HBsAg test strip (Nantong Diagnose Technology Co., Ltd., China) and one step HCV test strip (Nantong Diagnose Technology Co., Ltd., China), respectively following the instructions of the manufacturer. The sensitivity and specificity of rapid test Kits were 99.1% and 99.6%, respectively[18]. Then, the samples were further tested using enzyme-linked immunosorbent assay (ELISA) (Dialab GmbH, Wiener Neudorf, Austria) machine as per the manufacturer’s manual[19]. Sample collection and process were conducted based on the WHO[20] and Ethiopian national laboratory guidelines for specimen collection, processing, and handling[21].”

Comment 3: “Page 5, line 1. “suppression” is certainly not what the author meant to say. Could it be “supervision”?

Replay 3: Yes, you are. It is to mean supervision and corrected there.

Comment 4: “Also page 5 in the Ethical clearance section, the Author writes “getting ok”. This is too colloquial. “getting permission” would be better.”

Replay 4: I fully accept your comment and revised as getting approval from…

Comment 5: “Throughout the paper, the author talks about “sharps”. This is imprecise. “sharp tools” or “sharp instruments” should be used.”

Replay 5: Thank you for giving this comment and I revised the phrase as “sharp instruments” throughout the document and tables.

Comment 6: “In Table 1, for tooth extraction/HBsAg negative, the % is missing”

Replay 6: Thank you much for showing this editorial comment and corrected as per your comment.

NB. To Table 1, I also include a variable “ever heard about HBV” to assess their rough awareness.

Comment 7: “In Table 2, the value 121 on the line non-employed/anti-HCV negative belongs on the line below.”

Replay 7: I accept it and corrected it as required.

Comment 8: “Page 9, line 5. It should be “high” and not “higher”

Replay 8: I accept your comment and I revised it as “high” since the classification criteria say high, intermediate, low…

Comment 9: “Page 9, second from the last line. It should be “from”

Replay 9: Thank you for your comment. It is revised from “form” to “from”

Comment 10: “Page 11, first line. It should be “odds”

Replay 10: I accept it and corrected it as “odds” throughout the document.

Comment 11: “Page 11, line 3. It should be “previous” instead of “former”.

Replay 11: It is corrected as “…reported by previous studies from Ethiopia.”

Note: To the discussion section, page 10, I included a paragraph that discussed HBV and HCV co-infection which was missed in the former manuscript. As a result, new references are also included since we used them to discuss this paragraph.

Comment 12: “Page 13. Since there is only 1 Author, the Competing interests section should read “The author declares that he has no competing interests in this work”. Similarly, in the Author’s contributions section, it should read “MAA did the conception ……………………interpretation of data and drafting of the manuscript”

Replay 12: I fully accept and correct the indicated points as per the given comments. The conflicts of interest section is revised as “The Author declares that he has no competing interests in this work.”

Similarly, the author’s contribution section is revised as “MAA did the conception, design of the research, data collection, analysis and interpretation of data and drafting of the manuscript.”

Comment 13: “In references 5 and 6 “et al” should be spelled out in full and not abbreviated to “ea”

Replay 13: Thank you much. I accept your comment and revised all references that have et.al.

Thank you much for your contributions!

3 Jun 2020

Epidemiology of hepatitis B and C virus infections among patients who booked for surgical procedures at Felegehiwot referral hospital, Northwest Ethiopia

PONE-D-20-06821R1

Dear Dr. Asemahagn,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Isabelle Chemin, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: 1) On lines 207 and 252 it should be "non-agreement" and not "in-agreement"

2) On lines 288 and 312 it should be "bare" and not "bear"

3) In Table 2, in the History of multiple sexual partners section, all the numbers should be brought down one line to match up with the Yes and No

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Alan Campbell Kay

5 Jun 2020

PONE-D-20-06821R1

Epidemiology of hepatitis B and C virus infections among patients who booked for surgical procedures at Felegehiwot referral hospital, Northwest Ethiopia

Dear Dr. Asemahagn:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Mrs Isabelle Chemin

Academic Editor

PLOS ONE