Awareness of Hepatitis B Infection in Jeddah Population of Saudi Arabia View PDF

The hepatitis B virus (HBV) is considered a global problem which threatens the public health [1-4]. It may cause chronic infection which develops to liver cirrhosis and leads to death. The population infected with HBV has been found to be about 2 billion people, whereas annually 360 million people getting chronic liver disease and 600 thousand facing death either from chronic liver disease or liver cancer globally [5]. It has been demonstrated that various regions were different for prevalence of HBV infection and were classified as high, low and moderate epidemiologically [6].

The lifetime risk of HBV infection in areas of intermediate endemicity is 20-60% where acute hepatitis B infection is the most common and a variety of infections occur in adults [6,7]. The average prevalence of chronic HBV infection in developed countries is 6.6% and in developing countries 7.6% [8,9]. World Health Organization (WHO) estimated high prevalence of 6.1 % in the African and 6.2 % in Western Pacific regions [10].

Saudi Ministry of Health (MOH) reported in 2007 that HBV infection is the second most common viral disease after Chickenpox Virus [11]. In Saudi Arabia, HBV chronic infection is considered as a serious condition. Hepatitis B virus (HBV) infection is endemic in the Kingdom of Saudi Arabia which is between 7% and 8% [12]. Depending on the regions, studying the prevalence of HBV in Saudi Arabia, at the last 2 years showed marked variations according to regions such as southwestern regions as 8.7%, the eastern region as 6.7%, and the northwestern region as 3.0% [12]. According to cities, Madina was considered having higher prevalence as 9.02 % but the central city of Riyadh was considered having lowest prevalence that was estimated as 1.5% [13-15]. In the last two decades in Saudi Arabia, prevalence of HBV infection among the general population and the infection in different age groups [8,16-19], in blood donors [13,20], health care workers [21], pregnant women [22], virus genotypes and its relation to hepatocellular carcinoma have thoroughly been studied [23,24]. These studies show that HBV infection is endemic in Saudi Arabia [13].

The first Saudi seaport is Jeddah city where millions of pilgrims from various countries come annually has a greater number of HBV infection, since it is multicultural costal city [11]. A study showed that prevalence among pilgrims was 4.1%, and was higher in males (87.5%), age group of 40-59 years (60%) and in Nigerian pilgrims [25].

The prevalence of HBsAg in 1990s was high in Saudi Arabia among infants and children but when the national vaccination program was established, the HBV infection decreased in the early stage life in infants and children groups. However, the prevalence in the adults was still high since they did not take the vaccine doses earlier before their exposure to the infection [17,26]. When an individual is a non-responder to the first dose of vaccine, he/she should take second dose to be boosted [27]. Factors that affect a person's immunity and make someone a non-responder to HBV vaccine includes obesity, genetics, smoking, immune deficiency, male gender and technical errors in vaccine storage [28-31]. Since no study has precisely been carried out to have awareness about hepatitis B in Saudi Arabia, our aim in the present study was to estimate the awareness of hepatitis B virus among Saudi population in Jeddah city.

Awareness about the hepatitis B infection has been viewed in various perspectives [2-4,32-34]. However, further studies with various angles are required to have better awareness of the HBV and other infections.

The present study was conducted in Jeddah city of Kingdom of Saudi Arabia (KSA). The prospective study was survey (questionnaire) based. The sample size in the study is 5106 subjects (total male subjects: 975; total female subjects: 4131). The age ranged between 21 to 36 years. The general status of the subjects (sex, marital status, region and education) is given in Table 1. Employment status of the subjects is given in Table 2.

Table 1: General status of participants.

No: number of subjects; total number of subjects/participants: 5106.

Table 2: Employment status of the subjects.

No: number of subjects; total number of subjects/participants: 5106. *prisoners and students obtained regular stipend.

The detailed questionnaire was designed by including the specific criteria. Aims and objectives of research were explained to all study subjects. After taking the consent of subjects, the detailed questionnaire was filled out by them. The questionnaire was used to collect sociodemographic and HBV-related awareness data from each study participant. The sociodemographic factors were: age, sex, marital status (single, married, divorced or widowed), education (primary, middle, high school, university) and occupation (employed, unemployed, healthcare, student etc). Data were collected during the period from 25 Nov 2017 to 10 Feb 2018. The z score test was applied for the comparison of percentage values. The p value < 0.05 was considered statistically significant. The collected data was initially analyzed statistically by SPSS software version 16.

The present study included 5106 participants in Jeddah city of KSA. Most participants were single 49.92% (n=2549), followed by married 46.59% (n=2379), widow 0.59% (n=30) and divorced 2.90% (n=148). The majority of the sample is of Saudi nationality (95%; n=4849). For geographical distribution, most of the participants were from the south region 54.58 % (n=2787) compared to north region 45.22% (n=2309) while few of them from east region 0.20% (n=10). The economic status of most participants (81.94%; n=4184) was medium (Table 1).

The highest answer for the relationship with the infected person was cousin 13.9% (n= 708) followed by a friend 4.2% (n=216), and other reported relationships (prisoner, neighbor, husband, patient, wife, chief, workers) were found as about 4.99% (255), and only 0.7% (n=37) of the respondent revealed that they were the infected persons.

The participants in the present study were having different level of education: primary (1.74%; n=89), middle (6.07%; n=310), high school (31.79%; n=1623) and university (60.40%; n=3084) (Table 1). Majority of the participants were unemployed (43.22%; n=2207), but 28.30% (n=1445) were employed in different jobs, 5.27% (n=269) of them represented healthcare workers, 4.56% (n=233) represented prisoner and 18.65% (n=952) were students. In total the employed subjects were 56.78 % (n: 2899) (Table 2). Employed subjects were quite high in number and hence statistically significantly different from unemployed subjects (z score: -9.6017; p<0.00001) in the present study.

Regarding the knowledge about hepatitis B virus epidemiology among participants, 65.35% (n: 3337) had little or more information about HBV infection, whereas 34.65% (n=1769) had no any knowledge about HBV infection (z: 20.97; p<0.00001; Table 3).

The participants with high level education having awareness of HBV infection were 22.8% of total participants (n=1169) and in the groups of having and not having awareness of HBV infection differed with high significance (p<0.00001; Table 3), whereas 7.85% of total subjects (n=401) of high school education showed significant variation for those having compared to those not having awareness of HBV infection (p <0.00001; Table 3). The results for the group of middle education (n:120; 2.35% of total subjects) indicated significantly decreased awareness of HBV infection (p=0.0001; Table 3). The participants having primary education who were 0.4% (n:21) of total subjects with primary education were more in number for those having no awareness of HBV infection compared to those having awareness of HBV infection (p<0.00001; Table 3).

Knowledge regarding HBV was found to associate with the age of the participants (association present and association not present was noted in 22.15 % (n:1131) and 77.85 % (n: 3975) respectively showing z as -34.77 and p<0.00001) (Table 3). About 41.56% (n=2122) of participants had view that hepatitis B virus is not contagious while the rest of 58.44 % (n=2984) thought it as contagious (z: 11.89; p<0.00001; Table 3).

The 75.91% (n=3876) of participants believed that there are cases of HBV infection in Saudi Arabia, whereas only 24.09% (n=1230) revealed that they know some patients with Hepatitis B virus infection (z:32.05; p<0.00001; Table 3). The 75.09 % (n= 3834) of them believed that there is a vaccine that protects against this disease. The remaining 24.91 % (n: 1272) did not know that there is a vaccine that protects against this disease (z: 32.05; p<0.00001; Table 3).

Table 3: Knowledge of HBV infection and its association with other factors.

n: no of subjects; total number of subjects/participants: 5106.

The present study determining the awareness of hepatitis B virus infection is quite similar to the previous studies though the prevalence and awareness of HBV infection in the mentioned studies differed in view of the applied methodologies for selecting, collecting and analyzing the data [15,35,36].

A substantial number of participants in the present study provided their views that there are ways hepatitis B virus can be controlled whereas in the previous study even higher number of participants viewed that hepatitis B infection is curable [36].

Furthermore, quite high percent of participants in the current study thought that there might be a vaccine for prevention against hepatitis B virus compared to the results in another study quite close to our study.

Available data provides us information that there is a relationship between awareness level and age. Furthermore, there is a tendency of awareness to increase as educational level increases. It is recommended that the general public should have awareness about their life style interventions especially by decreasing the risk factors that may lead to better healthy life with fewer complications. It also seems equally essential to have training programs at the governmental level to provide awareness and general knowledge to masses about healthcare, hygiene and disease. Further survey studied are needed with this perspective to have idea about the attitudes of people about HBV and related infections that might help the general public to have knowledge and awareness of HBV infection, and better health care.

The authors acknowledge that the research has been funded by Research and Innovation unit of Faculty of Science at KAU and Mawakeb Alajer. Also, this research has been approved by the local Committee of Ethical Approval of Faculty of Medicine in Umm Al-Qura University (HAPO-02-K-012-2018-02-252; 02/06/1439H).

1. Locarnini S, Hatzakis A, Chen DS, Lok A (2015) Strategies to control hepatitis b: Public policy, epidemiology, vaccine and drugs. J Hepatol 62: S76-S86.
2. Liu Y, Tang K, Long J, Zhao C (2017) The association between hepatitis b self?awareness and depression: Exploring the modifying effects of socio?economic factors. J Viral Hepat 24: 330-336.
3. Jaquet A, Wandeler G, Tine J, Diallo MB, Manga NM, et al. (2017) Prevention and care of hepatitis b in senegal; awareness and attitudes of medical practitioners. Am J Trop Med Hyg 97: 389-395.
4. Roupa Z, Noula M, Farazi E, Stylianides A, Papaneophytou C, et al. (2019) Vaccination coverage and awareness of hepatitis b virus among healthcare students at a university in Cyprus. Mater SocioMed 31: 190.
5. Aljarbou AN (2013) The emergent concern of hepatitis b globally with special attention to Kingdom of Saudi Arabia. Int J Health Sci 7: 333-340.
6. World Health Organization (2007) Workers' Health: Global Plan of Action. Sixtieth World Health Assembly Agenda item 12.13.
7. World Health Organization (2009) WHO vaccine-preventable diseases: monitoring system: 2009 global summary. World Health Organization.
8. Al-Faleh FZ (2003) Changing pattern of hepatitis viral infection in Saudi Arabia in the last two decades. Ann Saudi Med.
9. Chen CJ, Wang LY, Yu MW (2000) Epidemiology of hepatitis b virus infection in the Asia-Pacific region. J Gastroenterol Hepatol 15: E3-E6.
10. World Health Organization (2017) Global hepatitis report 2017. World Health Organization.
11. Almalki M, FitzGerald G, Clark M (2011) Health care system in Saudi Arabia: an overview.
12. Bashawri LA, Fawaz NA, Ahmad MS, Qadi AA, Almawi WY (2004) Prevalence of seromarkers of HBV and HCV among blood donors in eastern Saudi Arabia, 1998-2001. Clin Lab Haematol 26: 225-228.
13. El-Hazmi MM (2004) Prevalence of HBV, HCV, HIV-1, 2 and HTLV-I/II infections among blood donors in a teaching hospital in the Central region of Saudi Arabia. Saudi Med J 25: 26-33.
14. El Beltagy KE, Al Balawi IA, Almuneef M, Memish ZA (2008) Prevalence of hepatitis b virus markers among blood donors in a tertiary hospital in Tabuk, northwestern Saudi Arabia. Int J Infec Dis 12: 495-499.
15. Alqahtani JM, Abu-Eshy SA, Mahfouz AA, El-Mekki AA, Asaad AM (2014) Seroprevalence of hepatitis b and c virus infections among health students and health care workers in the Najran region, southwestern Saudi Arabia: The need for national guidelines for health students. BMC Pub Health 14: 577.
16. Al-Faleh FZ (1988) Hepatitis b infection in Saudi Arabia. Ann Saudi Med 8: 474-480.
17. AI-Faleh FZ, Mohammad AJ, Ramia S, Rashed AR, Arif M, et al. (1999) Seroepidemiology of hepatitis B virus infection in Saudi children 8 years after a mass hepatitis b vaccination programme. J Infec 38: 167-170.
18. Al-Faleh FZ, Ayobanji Ayoola E, Al-Jeffry M, Arif M, Al-Rashed RS, et al. (1993) Integration of hepatitis B vaccine into the expanded program on immunization: The Saudi Arabian experience. Ann Saudi Med 13: 231-236.
19. Al-Faleh FZ, Ayoola EA, Arif M, Ramia S, Al-Rashed R, Al-Jeffry M, et al. (1992) Seroepidemiology of hepatitis B virus infection in Saudi Arabian children: a baseline survey for mass vaccination against hepatitis b. J Infect 24: 197-206.
20. Shatoor AS, Zafer MH (2002) Hepatitis b virus markers in male blood donors. Bahrain Med Bull 24: 1-17.
21. Almuneef MA, Memish ZA, Balkhy HH, Otaibi B, Helmi M (2006) Seroprevalence survey of varicella, measles, rubella, and hepatitis A and B viruses in a multinational healthcare workforce in Saudi Arabia. Infect Cont Hospital Epidemiol 27: 1179-1183.
22. Alrowaily MA, Abolfotouh MA, Ferwanah MS (2008) Hepatitis b virus sero-prevalence among pregnant females in Saudi Arabia. Saudi J Gastroenterol 14: 70-72.
23. Abdo AA, Al-Jarallah BM, Sanai FM, Hersi AS, Al-Swat K, et al. (2006) Hepatitis b genotypes: relation to clinical outcome in patients with chronic hepatitis b in Saudi Arabia. World J Gastroenterol 12: 7019-7024.
24. Ayoola EA, Gadour MO (2004) Gadour, Hepatocellular carcinoma in Saudi Arabia: role of hepatitis b and c infection. J Gastroenterol Hepatol 19: 665-669.
25. Al Ghamdi AA, Safi MA (2015) Safi, prevalence of hepatitis b surface antigen and its association with anti-hepatitis c virus antibodies among pilgrims. J King Abdulaziz Univer Med Sci 22: 1-7.
26. Madani TA (2007) Trend in incidence of hepatitis b virus infection during a decade of universal childhood hepatitis b vaccination in Saudi Arabia. Transac Royal Soc Trop Med Hyg 101: 278-283.
27. Su FH, Chu FY, Bai CH, Lin YS, Hsueh YM, et al. (2013) Efficacy of hepatitis b vaccine boosters among neonatally vaccinated university freshmen in Taiwan. J Hepatol 58: 684-689.
28. Al Ghamdi SS, Fallatah HI, Fetyani DM, Al?Mughales JA, Gelaidan AT (2013) Long?term efficacy of the hepatitis b vaccine in a high?risk group. J Med Virol 85: 1518-1522.
29. Chathuranga LS, Noordeen F, Abeykoon AM (2013) Immune response to hepatitis b vaccine in a group of health care workers in Sri Lanka. Int J Infect Dis 17: e1078-e1079.
30. Posteraro B, Pastorino R, Di Giannantonio P, Ianuale C, Amore R, et al. (2014) The link between genetic variation and variability in vaccine responses: systematic review and meta-analyses. Vaccine 32: 1661-1669.
31. Spradling PR, Xing J, Williams R, Masunu-Faleafaga Y, Dulski T, et al. (2013) Immunity to hepatitis b virus (HBV) infection two decades after implementation of universal infant HBV vaccination: association of detectable residual antibodies and response to a single HBV challenge dose. Clin Vaccine Immunol 20: 559-561.
32. Ashri NY (2008) Hepatitis b and c knowledge among Saudi dental patients. Saudi Med J 129: 1785-1790.
33. Bakir TM, Kurbaan KM, Fawaz IA, Ramia S (1995) Infection with Hepatitis viruses (b and c) and human retro viruses (HTLV-1 and HIV) in Saudi children receiving cycled cancer chemotherapy. J Tropi Pediatr 41: 206-209.
34. Chan HL, Leung NW, Hussain M, Wong ML, Lok AS (2000) Hepatitis b e antigen-negative chronic hepatitis b in Hong Kong. Hepatol 31: 763-768.
35. Wedhaya MA, Abyadh DA, Alhabi HA, Alrehaily SS, Kurban MA, et al. (2017) Assessment of knowledge, attitude and practice towards hepatitis b among healthy population in Saudi Arabia, 2017. Egy J Hospital Med 69: 1973-1977.
36. Kurdi M, Abughararah M, Mulike M, Yamani O, Bugdady M, et al. (2014) Molecular detection of hepatitis b virus (HBV) among voluntary ELISA positive blood donors in Almadinah Almunawwarah. J Taibah Univer Med Sci 9: 166-170.