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Babatope IO^*1, ¹Inyang NJ, ²Imhanrenezor K, ¹Aghahowa A.

 

Departments of:¹Medical Laboratory Sciences and ²Microbiology, Ambrose Alli University, Ekpoma, Edo State, Nigeria.

Correspondence: *E-mail:[email protected] Tel: +2348035637399

Citation: Babatope IO, Inyang NJ, Imhanrenezor K, Aghahowa A. Seroprevalence of Hepatitis B and C viruses among apparently healthy adults in Ekpoma, Edo State, Nigeria. Spec Vir Pathog J, 2015; 1(1): 01-06

 Abstract

Background: Infections with the hepatitis B virus (HBV) and/or the hepatitis C virus (HCV) are public health problems, which are highly endemic in the sub-Saharan Africa countries where Nigeria is located. Early and accurate diagnosis of co-infections with mono- and/or polymicrobial agents, in resource-limited settings, remains the key to effective interventions.

Objective: This study was carried out to determine the seroprevalence of hepatitis B and hepatitis C viruses among apparently healthy individuals in Ekpoma, Edo State, Nigeria.

Materials and Methods: In this cross-sectional laboratory-based study, three hundred blood samples were aseptically collected from apparently healthy individuals randomly selected from the Ekpoma community. Participants were screened for hepatitis B surface antigen and anti HCV antibody using standard methods. Ethical clearance and participant’s informed consent were sought and obtained from appropriate authorities and concerned participants. All data generated in this investigation were analyzed for statistical relevance using Pearson’s Chi-square software.

Results: Of the 300 samples screened, 8.3% were seropositive for hepatitis B surface antigen while 3% were seropositive for anti-HCV antibody. The sex-related prevalence of 4.7% in females and 3.6% in males were obtained for HBV while HCV recorded 2.3% for females and 0.7% for males. HBV and HCV infections were not significantly (p<0.05) associated with the sex of participants. Age-related prevalence for HBsAg were 4%, 3%, and 1.3% among the age groups 19-29, 30-39, and 40 and above years respectively while 1%, 1.3%, and 0.7% prevalence rates of anti-HCV were observed among the age groups (19-29, 30-39, 40 and above)years respectively.

Conclusion: The observed seroprevalence of HBV and HCV among apparently healthy individuals in Ekpomaemphasizes the significance of early detection of disease agents in the prevention and effective management of disease outbreaks especially in resource-limited settings.

 

Keywords: Hepatitis B virus, Hepatitis C virus, seroprevalence, apparently healthy individuals.

Introduction

Viral hepatitis is the inflammation of the liver caused by infection with the hepatitis viruses. Infections with the Hepatitis B virus (HBV) and/or the Hepatitis C virus (HCV) are public health problems, which are highly endemic in sub-Saharan Africa (1,2). Worldwide, chronic hepatitis caused by HBV infection is the tenth leading cause of death (3). The World Health Organization (WHO) estimates suggest that HBV results in 2 million deaths each year worldwide and 230,000 of these occurring in Africa (4)

The prevalence of hepatitis B is four times higher in blacks, 11.4% as compared to whites, 2.6% (5). It is approximately 90% for an infection acquired at the perinatal region and as low as 5% or even lower for adults (6). Perinatal or horizontal infection early in childhood is the main root of HBV transmission in high endemic regions such as Asia, Africa, Pacific Islands, and the Arctic and the rates of  HBsAg positivity ranges from 8-15%(7).

In low and endemic areas such as Western countries, HBV is predominantly a disease of adolescents and adults as a result of high-risk sexual behavior or injection drug use and the rate of positive HBsAg is less than 2%(6). In Nigeria, the carriage rate of hepatitis B surface antigen (HBsAg) is 10-17% in apparently healthy adults(8, 9, 10). In Jos, Plateau State in north-central Nigeria, the prevalence of HBsAg among apparently healthy blood donors was found to be 14.3%(9). Although horizontal transmission is widely recognized as the major means of HBV transmission in areas of high endemicity such as Nigeria(11), the vertical transmission rate in a Nigerian population of HBsAg – positive pregnant women were found to be 51.6% (12).

Hepatitis C virus (HCV) accounts for 20% of all acute cases of viral hepatitis C and it is a disease with a significant global impact (13). According to the WHO, there are 130 to 170 million people infected with hepatitis C virus (HCV) corresponding to 2 to 2.5% of the world’s total population. There are considerable regional differences in Hepatitis distribution. In Egypt, the prevalence is as high as 22%(14). Individuals infected with HCV are at risk of developing liver cirrhosis, cancer, or both. Infection with HCV is often asymptomatic with about 10% of individuals becoming jaundiced (15).

There has been an increase in information about viral hepatitis over the past 2 to 3 decades (16), but to date, a big chasm still exists between what is reported in other parts of Africa and the information presently available for healthcare providers in South Southern Nigeria on Hepatitis B and C viruses respectively. There is no regional hepatitis surveillance neither is there any database that connects the sporadic reports to have allowed for the prediction of future disease trends.

Hepatitis disease management

Presently most hepatitis disease management is based on presumptive diagnosis centered largely on classical signs and symptoms of the disease because even the cheap rapid diagnostic screening test kits are mostly affordable and available at regional referral or teaching hospitals and cost-prohibitive in private health establishments. Consequently, definitive diagnosis and specialized treatment for the general public becomes difficult due to poor resources.

Studies that provide information on the potential carriers and potential hepatitis patients from among the healthy individuals will impact regional competency in diagnosis, management, and prevention of disease outbreaks and ultimately reduce morbidity and mortality associated with hepatitis B and C respectively.

Objective

This study was therefore designed to outline the seroprevalence of HBV and HCV among apparently healthy adults in Ekpoma, Edo State, Nigeria, with the ultimate goal of providing data on potential carriers and potential patients which may be used to help patients before the disease becomes overt.

Materials and methods

This study was carried out in Ekpoma, the administrative headquarters of Esan West local government Area of Edo State, Nigeria. The area lies between latitudes 6⁰43^/ and 6⁰ 45^/ North of the equator and longitudes 6⁰ 5^/ and 6⁰ 8^/ East of the Greenwich median. Ekpoma area falls within the rain forest/ savanna transitional zone of south-south Nigeria. Ekpoma has a population of 89,628 and 127,718 as of 1991 and 2006 population census respectively (17), majority of which are civil servants, traders, teachers, lecturers, and students.

Informed consent was sought and obtained from the appropriate authorities and concerned participants anonymity must be maintained, good laboratory practice/ quality control ensured, and that every findings and results disclosure would be treated with the utmost confidentiality and for this research only. All work was performed according to international guidelines for human experimentation in clinical research.

The study design was a descriptive cross-sectional survey. This study was conducted among a total of three hundred healthy individuals of both sexes, in Ekpoma, Edo State between December 2013 and March 2014. The participants; healthy adults without jaundice were interviewed to obtained information on their socio-demographic data such as age, sex, history of previous blood transfusion, and jaundice.

Confirmed HBsAg positive and were on hepatitis medication or have any apparent ill health were excluded from the study. Written and informed consent was sought and obtained from each participant before sampling. Those who could not read/write were required to thumb-print on a designated section of the form to show their consent and this happened after they were informed about the study, cost, liberty, safety, and confidentiality.

For each participant, about two (2) ml of blood was collected from the antecubital vein into plain bottles under aseptic conditions. They were labeled and stood on the bench for at least one hour to allow clot retraction to take place before it was centrifuged. After centrifugation, the sera were harvested for analysis. They were screened for both HBsAg and HCV using Diaspot one-step hepatitis B surface antigen test strips and Diaspot one-step hepatitis C test strips respectively (Diaspot Diagnostics Inc., U.S.A.).

These are qualitative, lateral flow immunoassay test kit devices for the detection of both HBsAg and HCV in plasma with a relative sensitivity of 99.0% and relative specificity of 98.6%. The tests were done according to the manufacturer’s instructions. Positive and negative controls were included in each batch of tests to confirm the test procedure and also to verify proper test performance. The prevalence of each viral infection (HBV and HCV) was determined from the proportion of seropositive individuals in the total population under consideration. Pearson’s Chi-square software (18) was used to test for the independence of each frequency distribution observed at α= 0.05

Results

Table 1 reveals the prevalence of HBsAg and HCV among apparently healthy individuals in Ekpoma25 representing 8.3% was seropositive for HBsAg. 4% were in the age bracket of 30-39 years followed by 19-29yrs (3%) and 1.3% belonged to the age group of 40 years and above. According to sex, the females were more infected with HBV infection than the males, with a prevalence rate of 4.7% and 3.6% respectively.

Ninerepresenting 3% tested positive for HCV. 1.3% was in the age range of 30-39 years followed by age group 19-29years (1-0%) and 0.7% occurred in the age range of 40 and above. According to sex, the females were also more infected with HCV than the males with prevalence rates of 2.3% and 0.7% respectively.

Table 2 shows the socio-demographic characteristics of HBV/HCV positive subjects in Ekpoma. The subject was divided into two groups: those positive for HBV and those positive for HCV.  As shown, there were slightly more females (52.7%) than males (47.3%). 3.6% of males were HBsAg positive against 4.7% females. Also, 0.7% of the male subjects were positive for anti-HCV against 2.3% of the females.

Married men and women constitute the largest proportion of those infected by both viruses. 13.3% of the subjects were smokers and accounted for 20% of HBV infection against 11.1% for HCV. 28% of consumers of alcohol were HBV positive against 11.1% for HCV infection. About three quarter (73.3%) of the study population engaged in unprotected sex. Risk factors such as unprotected sex accounted for 52.0% and 44.4% of HBV and HCV infections among seropositive individuals in Ekpoma while previous surgery recorded 1.67%. Individuals that had previous surgery were not seropositive for both HBV and HCV.

 

Table1: Prevalence of HBsAg and HCV among apparently healthy individuals in Ekpoma (%)

Description	No of HBVexam	No of HVV exam	HBV Positive	HCV Positive	HBV Negative	HCV  Negative
Total	300	300	25(8.3)	9(3.0)	275(91.7)	291(97)
Age group
19-29	109(36.3)	88(29.3)	9(3)	3(1.0)	100(33.3)	85(28.3)
30-39	152(50.7)	134(44.7)	12(4)	4(1.3)	140(46.7)	130(43.4)
≥40	39(13)	78(26.0)	4(1.3)	2(0.7)	35(11.7)	76(25.3)
Sex
Male	142(47.3)	142(47.3)	11(3.6)	2(0.7)	131(43.7)	140(46.7)
Female	158(52.7)	158(52.7)	14(4.7)	7(2.3)	144(48.0)	151(50.3)

HBsAg= Hepatitis B surface antigen, HBV=Hepatitis B virus, HCV=Hepatitis C virus

Table 2: Socio-demographic characteristics of HBV/HCV positive subjects in Ekpoma

Characteristics	Number examined n=300(%)	HBV Positive n=25 (%)	HCV Positive n=9(%)
Sex
Male	142(47.3)	11(3.6)	2(0.7)
Female	158(52.7)	14(4.7)	7(2.3)
Marital status
Married	150(50)	15(60.0)	5(55.5)
Single	130(43.3)	5(20.0)	2(22.2)
Widow/ widower	20(6.7)	5(20.0)	2(22.2)
Social habits
Smokers	40(13.3)	5(20.0)	1(11.1)
Alcoholics	150(50.0)	7(28.0)	1(11.1)
Risk factors
Unprotected sex	220(73.3)	13(52)	4(44.4)
Previous blood transfusion	30(10.0)	5(20.0)	2(22.2)
Scarification marks	20(6.7)	1(4.0)	0 (0.0)
Previous surgery	5(1.7)	0 (0.0)	0 (0.0)
Intravenous drug users	0 (0.0)	0 (0.0)	0 (0.0)
Unsafe injection	7(2.33)	2(8.0)	1(11.1)
No identified risk factor	18(6.0)	4(16.0)	2(22.2)

n=number, %=percentage

 

Discussion

As the dynamics of disease management and intervention get more complex over the past three decades, research attention and questions have also shifted to preventive medicine from both curative and diagnostic medicine. Screening asymptomatic people for underlying diseases is an important approach to disease detection, prompt prevention, and intervention especially when silent killing disease agents like HBV and HCV infections (19)are involved or suspected.

This approach will assist healthcare providers, planners, policymakers, and other stakeholders to predict possible future outbreaks and plan for them and at the same time, make necessary laws to ensure effective implementation of interventions. Therefore harnessing the skills and resources which can allow for effective interventions to be in place long before the disease becomes overt is promising in the eventual reduction of the incidences of disease outbreaks to the barest minimum.

The result obtained in the present study (Table 1) showed a seroprevalence rate of 8.3% for HBsAg among apparently healthy individuals in Ekpoma. This finding is comparable with some earlier reports, for instance, the prevalence rates of 8.9% and 10.3% have been reported among women of child-bearing age in Lagos, Nigeria, and in the general population of Uganda in a national serosurvey by Agangaet al, (20) and Bwogiet al. (21) respectively.

Our finding also supports the WHO report(22)which classifies Nigeria as a highly endemic country. Endemicity may be defined as an HBsAg burden greater than 7% in an adult population. The  8.3% seroprevalence rate recorded in Ekpoma may be explained partly by the sub-urban nature of Ekpoma where disease prevalence practices that favor transmission (23) include poor adherence to vaccination schedules, relatively low vaccination coverage, sharing of drinking cups, and unprotected sex,

However, the 8.3% prevalence of HBV carriage reported in this study was higher than the seroprevalence rates of 3.2% by Odusanyaet al. (24), 4.98% by Ejele and Ojule(25), and 6.0% by Adogaet al(23). The population sampled by Odusanya, Ejele, and Ojulu, and Adogaet al. (24, 25,23), included a healthy pre-vaccination urban population, prospective blood donors, and medical students respectively which are different from our general population sampled. The reason for the lower prevalence rate of HBsAg in these areas as compared to ours and other Nigerian cities is not clear.

It would have been expected that the prevalence rate of HBsAg would have been higher in areas like Port Harcourt, Nigeria as compared to these other less industrialized and less cosmopolitan cities(25). The factors responsible for this discrepancy in expected prevalence rates need further study. These differences might also not be unconnected with the fact that some of the studies were carried out among the low-risk group and another possible reason may be the low sensitivity of the latex agglutination methods compared to the enzyme-linked immunosorbent assay (ELIZA) method (25-26)

In contrast, higher seroprevalence rates of 11.0% in Makurdi by Agwaleet al. (27); 12.6% in Lagos by Fasolaet al, (28), 12.8% in Minna by Egahet al,(29); 13.2% in a rural settlement in northern Nigeria by Jomboet al,(30) 15.1% in Maiduguri by Baba et al,(31), and 26.0% in Benin by Halim et al,(32) have been reported in Nigeria. Factors like difference in sample size, the sensitivity and reliability of viral assay reagents, the category of people studied, geographical location of the study population, and their socio-cultural practices might have contributed to the differences reported for HBV viral infection prevalence in these areas (33-34)

The seroprevalence of 3.0% was reported for hepatitis C virus among apparently healthy individuals in Ekpoma. The report of this finding is lower when compared with studies from Enugu, Jos, and Kaduna with seroprevalence rates of 14.9%, 5.2%and 11.9%respectively (35-36). Also, factors like the differences in the sample size, the sensitivity and reliability of viral assay reagents, the category of people, the geographical location of the study population, and their socio-cultural practices might have contributed to the differences reported for HCV viral infection prevalence.

However, the prevalence of HCV infection was found to be higher when compared to the reports of 0.1- 1.0%(37) for the United Kingdom and Scandinavia and 1.0-1.9% (38)for countries like the United States of America, Australia, Turkey, Spain, Italy, and Japan, but lower when compared to 15-20%reported in Egypt by (39). Prevalence of hepatitis B and hepatitis C vary from country to country and depend upon a complex interplay of behavioral, environmental, and host factors. In general, it is lowest in countries or areas with high standards of living and highest in countries or areas where the socio-economic level is lower (26).

It was observed that the prevalence of HBsAg and HCV were highest among 30-39 years old. This agrees with a previous report by Baba et al, (31) who observed a higher prevalence of some viral infections among this particular age group (30-39 years). Previous authors have also found a significant association with age (21, 24). Adewole et al, (40) also reported that individuals less than 40 years of age have the highest rate of getting infected with HCV and the age group of 30-39 years encompasses individuals with high sexual activities.

Considering the age group most affected in this study, one can infer that the major transmission mode in this population may be sexual intercourse because at age 30 to 39 years, is associated with high sexual activity during the marriage, premarital sexual activity, sex as a widow/widower, sex due to customs and tradition, sex for debt settlement, or sex as trade (41).

In the present study, the prevalence of HBV according to gender was higher (4.7%) among females than males (3.6%). Furthermore, the sex prevalence of HCV was 2.3% for females and 0.7% for males. Socio-economic, cultural, and biological factors might be responsible for the female gender’s vulnerability to both HBV and HCV infections. Royce et al, (42) reported that during unprotected vaginal intercourse, a woman’s risk of becoming infected with both HBV and HCV may go up to 4 times higher than the risk of a man.

However, there was no significant difference (p>0.05) between sex and HBV and HCV infections in Ekpoma.  Statistical significance is at variance with the report of Pennapet al, (43) who reported the males to be more prevalent to HBV infections than the females.  No concrete explanation can be given for a higher vulnerability of males to the infection than females.

The conspicuous absence of co-infection/comorbidities of both viruses despite the existence of factors (Table 2) that could have warranted such observation is a unique characteristic of this study. It is hard to imagine that there were no intravenous drug abusers among our selected 300 participants in the present Nigeria society with no specific drug prescription law in place and crime rates among adults remain on the increase. Although information retrieval from research participants is also a problem in social and public health research, poor disclosure or personal health challenges and social habits may explain our observation on no drug abuser in (Table 2).

The use of a poor diagnostic facility which only screened and named the serotype of the viral pathogens but could not outline the viral genotypes using molecular tools which could have allowed for the provision of more answers to deep epidemiologic, questions deserves attention for its implications in the future studies.

Conclusion

The seroprevalence of HBV and HCV in Ekpoma shows their endemicity and potential rising profile in apparently healthy individuals with the consequent risk of transmission of this virus to a potential susceptible host. The observed seroprevalence of HBV and HCV among apparently healthy individuals in Ekpoma emphasizes the significance of early detection of disease agents in the prevention and effective management of disease outbreaks, especially in resource-limited settings.

Conflict of interest: The authors hereby declare that there are no conflicts of interest.

Acknowledgment: The authors wish to acknowledge the management of the Medical Laboratory Sciences Department for providing the enabling environment for this research. We also thank the manuscript development team of the special viral pathogens journal for their assistance in providing relevant literature and proofreading the manuscript before publication. We also thank the participants whose consent made this work possible.

References

1. Madhava V, Burgess C, Drucker E. Epidemiology of chronic hepatitis C virus infection in sub-Saharan Africa. Lancet Infect Dis2002; 2:293-302.
2. Kramvis A, Kew M. Epidemiology of hepatitis B virus in Africa, its genotypes and clinical associations of genotypes. HepatolRes 2007; 37 supplement 1:59-519
3. Lavanchy D, HepatitisB. virus epidemiology, disease burden, treatment, and current and emerging prevention and control measures. J Viral Hepat 2004;11(2):97-107
4. Nwokedi EE, Emokpae MA, Dutse AI. Human immunodeficiency virus and hepatitis B virus co-infection among patients in Kano. Niger J Med2006; 15(3):227-229.
5. McQuillan GM, Coleman PJ. Kruszon-Moran D. et al. Prevalence of hepatitis B virus infection in the United States: the National Health and Nutrition Examination surveys, 1976 through 1994. Am J Public Health 1999; 89:14-18
6. Wasley AD and Alter J. Epidemiology of Hepatitis C. Semin Liver Dis. 2000; 20:1-16.
7. Hollinder FB, Liang TJ. Hepatitis B virus. In: Kimpe, D. M. et al., eds. Fields virology, 4^th Philadelphia, Lippincott Williams, and Wilkins, 2001:2971- 3036
8. Mustapha SK, Kudi AA, Asaka LE. Prevalence of hepatitis B surface antigen (HBsAg) and HIV among blood donors in Gombe. J Life Environ Sci2002; 4:231-235.
9. Uneke CJ, Ogbu O, Inyama PU, Anyanwu GI, Njoku MO, Idoko J. Prevalence of Hepatitis B surface antigen among blood donors and human immunodeficiency virus-infected patients in Jos, Nigeria. Mem Inst Oswaldo Crusz 2005; 100 (1):13-16.
10. Ugwuja EI. Seroprevalence of hepatitis B surface antigen and liver function tests among adolescents in Abakaliki, South Eastern Nigeria. The Internet Journal of Tropical Medicine. 2010; 6 (2): 1726-1732.
11. Kire C. The epidemiology and prophylaxis of hepatitis B in sub-Saharan Africa: a view from tropical and sub-tropical Africa: 1996; 36:5-12.
12. Eke AC, Eke UA, Okafor CI, Ezebialu IU, Ogbuagu C. Prevalence, correlates and pattern of hepatitis B surface antigen in a low resource setting. Virol J 2011; 8:12
13. Alter MJ. Epidemiology of hepatitis C. 1997; 26 C3 Suppl 1): 625-55.
14. World Health Organization Hepatitis B fact sheet. 2012: No 204. Available: http://www.Who.int /Media centre/Factsheets/Fs 204/en/ Accessed 20 February, 2013.
15. Cheesbrough M. Hepatitis viruses. In: District laboratory practice in tropical countries, Part 2. Low-priced edition. Cambridge University Press. 2006; 250-253
16. Hamilton JD. Hepatitis viruses. In: Joklik, W.K., Willet, H.P., Amos, D.B., Wilfert, C.M. (eds): Zinsser Microbiology, ed 20, Appleton and Lance, Norwalk; 1992 P. 1039-1043.
17. World Gazzetter Nigeria. Largest cities and towns statistics populations, 2007. http//worldgazzetter.com Accessed 01/01/20
18. Preacher KJ. The calculation for the chi-square test: An interactive calculation tool for chi-square tests of goodness of fit and independence [Computer software]. 2001. Available from http://www.quantpsy.org/ss
19. Dawurung JS, Bubbuk DN, Ajayi BB, Baba MM. Prevalence of hepatitis B and C virus co-infection among students of University of Maiduguri, Nigeria. Archives of Applied Sciences Research. 2012; 4(4): 1581-1584.
20. Aganga-Williams OM, Akanmu AS, Akinsete I. Prevalence of hepatitis B surface antigen among women of childbearing age in Lagos State. African Journal of Reproductive Health. 1999; 3:45-50.
21. Bwogi JB, Makumbi F, Mishra I, Bakamutumatio V, Nanyunja B, Opio M, Downing A, Biryahwaho R, Lewis BRF. Hepatitis B infection is highly endemic in Uganda: findings from a national serosurvey. African Health Sciences. 2009; 9: 98-108.
22. World Health Organization, Journal on viral hepatitis. Antwerp, Belgium 1999 10.1046/j. 1365-2893. 6120139.
23. Adoga MP, Gyar SD, Pechulano S, Bashayi OD, Emiasegen SE, Zungwe T, Iperepolu OH, Agupugo C, Agwale SM. Hepatitis B. virus infections in apparently healthy urban Nigerians: data from pre-vaccination tests. infects Devctries 2010;4(6):397-400
24. Odusanya OO, Meurice FP, Hoet B. Nigerian Medical students are at risk for hepatitis B infection. Trans R Soc Trop Med Hyg 2007; 101:465-468.
25. Ejele QA, Ojule AC. The prevalence of Hepatitis B surface antigen (HBsAg) among prospective blood donors and patients in Port-Harcourt, Nigeria. Niger J. Med. 2004; 13:336-338.
26. Dienstang JL and Isselbacher KJ. Acute Viral Hepatitis. In: Fauci AS, Braunwald E, Isselbacher KJ, Wilson JD, Martin JB, Kasper DL, Hauser SL, Long DL, editors. Harrison’s principles of Internal Medicine. NY: Mc Graw Hill; 1998. p1677-92
27. Agwale SM, Temina L, Womack O. Prevalence of HCV co-infection in HIV-Infected individuals in Nigeria and characterization of HCV genotypes J ClinVirol 2004; 31:3-6.
28. Fasola FA,Kotila TR, Akinyemi JO. Trends in transfusion transmitted viral infections from 2001 to 2006 in Ibadan, Nigeria. 2008; 51:427-431
29. Egah DZ, Banwat EB, Audu ES, Iya D, Mandong BM, Anele AA, Gomwalk, NE. Hepatitis B surface antigen, Hepatitis C, and HIV antibodies in a low-risk blood donor group in Nigeria. East Mediterranean Health J. 2007; 13(4): 961-966.
30. Jombo GI, Egah DZ, Banwat EB. Hepatitis B virus infection in a rural settlement of Northern Nigeria. Nig J Med. 2005; 14: 425-428.
31. Baba MM, Gashau W, Hassan AW. Detection of Hepatitis B surface antigenemia in patients with and without the manifestation of Acquired Immunodeficiency syndrome in Maiduguri, Nigeria. Niger Postgrad Med J 1998; 5:125-128.
32. Halim NKD, Offor E, Ajayi OI. Epidemiology study of the seroprevalence of hepatitis B surface antigen (HBsAg) and HIV-1 in blood donors. Niger J ClinPract.1999; 2: 42-45.
33. Lesi OA, Kehinde MO, Oguh DN, Amira CO. Hepatitis B and C virus infections in Nigerian patients with HIV/AIDS: Niger postgrad Med. J 2007; 14: 129-133
34. WHO Hepatitis B fact sheet No 204. 2009. Accessed 10 June 2014. Available: http:11www. Who. Int/csr/disease/hepatitis.
35. Ebie JC and Pela OA. Some socio-Cultural aspects of the problem of drug abuse in Nigeria. Drug and Alc Dep 2006; 8: 301-306
36. Strickland GT. HCV in developing countries. Doc. (Africa). 2002; 24:18-20
37. Global burden of disease (GBD) for hepatitis C. Clinpharmacol 2004; 44:20-29
38. Shepard CW, Finelli l, Fiore AE,Bell BP. Epidemiology of hepatitis B and hepatitis C infections in United States children Pediatrinfec Dis J 2005;5:755- 760
39. Frank C, Mohammed MK, Strickland GT,Lavanchy D, Arthur RR, Madgher LS, EL-Khoby T, Abdel Wahab Y, Aly Ohn ES, Anwar S, Sallam I. The role of antischistosomal therapy in the spread of hepatitis C virus in Egypt. Lancet, 2002; 355: 887-891.
40. Adewole OO, Andeyi E, Ajuwon Z, Wada I. Sero-prevalence of hepatitis B and C viruses co-infection in Nigerian patients with HIV infectionJ Infect DevCtries. 2009; 6(5): 369-375
41. Agwu E, Pazos V, Ihongbe JC &Ssengendo J. Appraisal of the inherent socio-demographic dynamics of HIV/AIDS epidemic in four districts of South-Western Uganda, SAHARA-J: Journal of Social Aspects of HIV/AIDS, 2011; 8:3, 150-155
42. Royce RA, Sena A, Cates W Jr, Cohen MS. Sexual transmission of HIV.NEngl J Med. 1997; 336(15): 1072-8
43. Pennap GR, Yakubu A, Oyige O, Forbi J. Prevalence of hepatitis B and C infections among people of a local community in Keffi, Nigeria Afr JMicrobiol Res. 2010; 4 (4): 274-278.