Prevalence of hepatitis C virus infection among pregnant women in a rural district in Egypt

Master's Thesis, 2015

64 Pages



List of Tables











List of Tables

Table (1): Prevalence of HCVAbs in different villages

Table (2): Prevalence of the pregnant women in different age groups.

Table (3): Distribution of the pregnant women according to sociodemographic characteristics

Table (4): Distribution of the pregnant women according to the risk factors for HCV

Table (5): Distribution of the pregnant women according to their past antenatal history

Table (6): Distribution of the studied sample according to Sociodemographic characteristics of the husband

Table (7): Distribution of the studied sample according to risk factors of HCV in the husband

Table (8): Relationship between PCR results and different parameters of pregnant women

Table (9): Relationship between PCR and different parameters of husbands


Figure (1): Distribution of the pregnant women according to HCVAbs

Figure (2): Prevalence of HCV Ab in different villages

Figure (3): Distribution of the pregnant women according to the prevalence of HCV Abs among each age group.

Figure (4): Distribution of the studied pregnant women to the mean age of the husband and HCV Abs

Figure (5): Distribution of the pregnant women according to education of the husband and HCV Abs

Figure (6): Distribution of the pregnant women according to prescence of chronic liver disease in the husband and HCV Abs

“This book is dedicated to my brilliant wife without whom I would be nothing. She always comforts and consoles, never complains or interferes, asks nothing, and endures all.

Hossam Khamis


Dr. Hosaam Hassan Khamis is the corresponding author of this research, he is a tropical medicine resident doctor in Alexandria fevers hospital.

This research was submitted in partial fulfillment of the requirements for the master degree of public health from the high institute of public health in Alexandria university, Egypt.

Prof. Dr. Azza Galal Farghaly, Professor of Tropical Health ,Department of Tropical Health ,High Institute of Public Health,University of Alexandria.

She participated in this research by supervising the laboratory diagnosis of HCV seropositivity using ELISA technique, and She also helped the student in interpreting results and revising the thesis.

Prof. Dr. Hanan Zakaria Shatat, Professor of Tropical Health , Department of Tropical Health ,High Institute of Public Health,University of Alexandria.

She participated in this research by helping the student in data interpretation and revising all thesis sections.

Assistant Prof. Dr. Engy Mohamed El-Ghitany,

Department of Tropical Health, High Institute of Public Health, University of Alexandria.

She supervised the student in preparation of questionnaire form and she guided him in interpreting and presenting the results and revising all sections of thesis.



It is estimated that 130–170 million people, or approximately 3% of the world's population, are living with chronic hepatitis C. About 3–4 million people are infected per year, and more than 350,000 people die yearly from hepatitis C-related diseases.(1) Rates have increased substantially in the 20th century due to intravenous drug use, intravenous medication and poorly sterilized medical equipment.(2)

With 75–85% rate of chronicity ,(2) cirrhosis develops in around 10% of chronic cases in 20 years and the percentage increases to 20% in 30 years. The annual rate of mortality in cirrhotic patients is approximatly 1–5% per year and that of hepatocellular carcinoma is 12.8 % per year. Among those chronically infected, the risk of cirrhosis after 20 years varies between studies but has been estimated at approximately 10-15% for men and approximately 1-5% for women. The reason for this difference is not known. (3)

In the United States, about 2% of people have hepatitis C with about 35,000 to 185,000 new cases a year. Rates have decreased in the Western world since the 1990s due to improved screening of blood before transfusion and infection control measures. Annual deaths from HCV in the United States range from 8,000 to 10,000.Expectations are that this mortality rate will increase, as those infected by transfusion before HCV testing become apparent. (4)

Prevalence is higher in some countries in Africa and Asia.(5)Countries with particularly high rates of infection include Egypt (22%), Pakistan (4.8%) and China (3.2%) .(6)

HCV in Egypt:

A recent study has been made about HCV in Egypt and had found that the incidence was about 7/1000 rate with prevalence of 14.7%. One in every 10 Egyptians is a carrier of the HCV infection, which means that there are at least 4,459,000 persons infected with HCV who are infectious to others. This is the largest reservoir of HCV infection in the world. The study estimates that more than 500,000 new HCV infections occur in Egypt every year, likely signalling an epidemic in a country of more than 85 million people. The authors suggest that this high rate of HCV transmission may be due to the lack of sufficient standard safety precautions in medical and dental facilities. Although the high prevalence of hepatitis C in Egypt has been well established for many years, and linked in part to limited safety measures during anti-bilharzia campaigns, published estimates of prevalence from different Egyptian communities failed to provide a nationwide picture of the magnitude of ongoing HCV infection transmission.(7)

Modes of transmission and risk factors

Case-control studies before 1989 of patients with newly acquired, symptomatic non-A, non-B hepatitis found a significant association between disease acquisition and a six-months prior to illness history of blood transfusions, injection drug use, health care employment with frequent exposure to blood, personal contact with others who had hepatitis, multiple sexual partners or low socioeconomic status.(8)

Blood transfusion/receipt of blood products :

Today, HCV is rarely transmitted by blood transfusion or transplantation of organs due to thorough screening of the blood supply for the presence of the virus and inactivation procedures that destroy blood borne viruses. In the last several years, some blood banks have instituted techniques that utilize nucleic acid amplification of the hepatitis C virus (NAT), which will detect the presence of virus even in newly-infected patients who are still hepatitis C antibody-negative. These techniques are estimated to have prevented 56 transfusion-associated HCV infections per year in the U.S. since 1999, and have lowered the current risk of acquiring HCV via transfused blood products to 1 in 2 million.(9)Although NAT is very beneficial as it becomes positive more quickly and remains positive as long as the virus is present but it is very expensive in developing countries so other much cheaper tests like ELISA can be used as it has objective results , much lower cost, and appreciable sensitivity(99.7%) (10)

Injection drug use:

Injection drug (IDU) use has been the principal mode of transmission of HCV since the 1970's.(11)Rates of HCV infection among young IDU are four times higher than HIV infection.(12)Studies of IDU have demonstrated that the prevalence of HCV infection in them is extremely high, with up to 90% having been exposed.(13)In addition, the incidence of new infections is also high, with seroconversion rates of 10-20 percent per year.(14)Duration of being IDU is the strongest single predictor of risk of HCV infection among them.(15)

Sexual transmission:

Sexual transmission of HCV has been controversial. It is believed that HCV can be transmitted sexually, but that such transmission is inefficient. The likelihood of HCV infection increases with the number of lifetime sexual partners. A history of a sexually transmitted disease, sex with a prostitute, more than five sexual partners per year, or a combination of these has been independently associated with positive HCV serology.(16)Distinction appears to exist between the specific sexual behaviors listed above, and stable, monogamous sexual activity, which is rarely associated with HCV transmission. The frequency of HCV transmission between monogamous sexual partners is very low according to most published studies.(17,18)

Prenatal transmission:

Although mother to infant transmission of HCV is comparatively uncommon, it is the major route of infection to infants. Transmission may occur during pregnancy, delivery or postnatally through breastfeeding or other contact methods. Infants who are born to HCV Ab positive mothers found to have (81%) seropositivity for HCV antibody at the first month, but only (13%) were positive for HCV RNA. After 6 months, only (3.8%) remained positive for HCV RNA. The chance of infection is greater (17%) with higher serum level of HCV RNA (above 106 copies per mL) and in mothers co-infected with HIV (14%).(19)

Other modes of transmission:

Household transmission:

In Egypt the strongest predictor of incident HCV was having an anti-HCV-positive family member. Among those who have HCV positive family member incidence was 5.8/1,000 per year, compared with 1.0/1,000 per year among those who have not.(20) Although the prevalence of HCV among household contacts of people with HCV infection is detectable the study of HCV transmission among household contacts is complicated by the difficulty in ruling out other possible modes of acquisition. Therefore, other routes of transmission might be under estimated. (21)

Occupational exposures:

Health care workers who have exposure to blood are at risk of infection with HCV and other bloodborne pathogens. The prevalence of HCV infection, however, is not greater in health care workers, including surgeons, than for the general population. According to the Centers for Disease Control and Prevention (CDC), the average rate of anti-HCV seroconversion after unintentional needlesticks or sharps exposure from an HCV-positive source is 1.8% (range 0%-7%). An Italian study of 4,403 needlestick exposure among healthcare workers only 14(0.31%) seroconversions were reported.(22) Close follow-up of health care workers after a needlestick from a patient with chronic HCV, with early interferon and ribavirin therapy for the healthcare worker if they develop HCV viremia can be a beneficial management strategy.(23)

No Identifiable Source of Infection:

According to the CDC, injection drug use accounts for approximately 60% of all HCV infections, while other known exposures account for 20-30%.(12)Approximately 10-12% of patients in most epidemiological studies, however, have no identifiable source of infection.HCV exposure in these patients may be from a number of uncommon modes of transmission, including vertical transmission, and parenteral transmission from medical or dental procedures prior to the availability of HCV testing. There are no conclusive data to show that persons with a history of exposures such as intranasal cocaine use, tattooing or body piercing are at an increased risk for HCV infection based on these exposures solely. It is believed, however, that these are potential modes of HCV acquisition in the absence of adequate sterilization techniques.(24)

HCV and pregnancy:

Estimates of the prevalence of HCV infection in pregnant women vary widely among studies, ranging from 0.1% to 4.5% worldwide but in Egypt it was estimated to be about 10.8%.(25) The presence of HCV infection does not appear to result in a higher risk pregnancy or a higher incidence of poor obstetric outcome. (26)

The rate of vertical transmission of HCV has also been estimated with widely varying results. The difficulty of obtaining accurate measurement of vertical transmission risk includes persistence of maternal antibodies in the newborn, failure to identify all infected mothers and loss of infants born to HCV positive mothers to follow-up. The prevalence of vertical transmission of HCV is in the range of 5%. Although HCV/ HIV co-infection appears to increase the risk of vertical transmission, other risk factors have not been consistently identified. Even the identification of the timing of such transmission between intrauterine versus intrapartum exposure has not been satisfactorily delineated. It is not clear that high viral load or viral genotype increases the risk of transmission.(26)

Testing for the presence of HCV in infants born to HCV(+) mothers should not begin until at least 18 months following delivery.(20)

Prophylactic caesarian section is not recommended in HCV infected or HCV/HIV coinfected mothers. In cases of labor with prolonged rupture of membranes, the increased risk of HCV transmission may affect the decision for operative delivery. The risk of postnatal transmission through breastfeeding or any other contact methods cannot be excluded but is likely to be low for most HCV-infected women.(26)

Pregnancy, however, may be an important time to screen for HCV infection. Many women will already have reached their peak likelihood of becoming infected by the time they become pregnant, making the yield of testing near its maximum. Screening at this point in a woman’s life can also provide early diagnosis and treatment that may offset the future burden of HCV on the health care system. Further, testing for HCV during pregnancy may help to identify infected newborns, allowing for appropriate follow-up.

HCV in children:

The natural history of HCV infected infants is poorly understood at this time. HCV is the most common cause of chronic liver disease of infectious etiology in children. In a research which is made among school children in Alexandria, HCV seroprevalence of 5.8% was found, with HCV viraemia in 75% of the studied children. The prevalence of anti-HCV increased with age from 0% in children aged 6-7 years to 16% in those of 15 years old. (27)

Previous blood transfusion ,intravenous injections, surgical intervention, dental treatment, circumcision for boys by informal health care providers, age above 10 years ,very low socioeconomic class and rural area residence are the most significant risk factors for HCV infection in children.(28)

Globally, while the number of new HCV infections in adults is declining, new infections in children continue to occur as a result of maternal-neonatal transmission. A sizeable number of children acquired HCV via blood and blood products. Vertical transmission, or infection transmitted from mother to newborn, accounts for another sizeable group of children with HCV infection. Horizontal transmission, either from adult to child in a household, or child-to-child at home or at school does not seem to be an important risk factor. (28)

Acute HCV infection in children is rarely observed unless there are special circumstances such as a transfusion-associated outbreak. Fulminant hepatic failure from HCV has not been described in children. (28)

Most chronically infected children with HCV are asymptomatic (without complaints) or have non-specific fatigue and/or abdominal pain. Most children with HCV infection have normal or mildly abnormal serum transaminase levels. Natural history studies in children are few, and it is difficult to separate the effects of age and mode of acquisition. Further, depending upon the underlying disease that required a transfusion, the natural history of transfusion-associated HCV infection may differ. (28)

There are no reports of treatment of acute HCV infection in children. A review of the use of interferon as monotherapy in children demonstrates a sustained virologic response (SVR) of 33-45%. This is significantly better then the sustained virologic response rate for interferon monotherapy observed for adults. When the data is further scrutinized, the SVR for genotype 1 is 26% and 70% for genotypes 2 and 3. The higher response rate observed in children might be the result of the earlier stage of the disease, higher relative interferon dosage, or lack of comorbid conditions Side effects can be seen as mild symptoms e.g: nausea, vomiting, heartburn, loss of appetite, changes in taste, dry mouth, dry cough, diarrhea, or severe as chest pain, heart attack, congestive heart failure, stroke, low or high blood pressure, decrease in kidney function and failure, jaundice and changes in vision. The experiences with therapy in children with chronic hepatitis C are based on earlier and continuing data from adult trials.Further researches are so much needed to provide the scientific tools to prevent and treat HCV infection in children. (29)

Preventive measures:

The principle components of the National CDC HCV Prevention Strategy are: (30)

Primary prevention activities include:

Screening and testing of blood, plasma, organ, tissue, and semen donors.

Virus inactivation of plasma-derived products.

Adequate sterilization of reusable material such as surgical or dental instruments.

Risk-reduction counseling and services.

Implementation and maintenance of infection-control practices

Needle and syringe exchange programs

Secondary prevention activities include:

Identification, counseling, and testing of persons at risk

Medical management of infected persons

Professional and public education

Surveillance and research to monitor disease trends and the effectiveness of prevention activities and to develop improved prevention methods.

Prevention of spread of infection should be the main goal at the current time until cost effective therapies become available.


General objective:

To study the prevalence of HCV infection among pregnant women in Al-Nobareya town, Al-Beheira Governorate.

Specific objectives:

1- To estimate anti-HCV seropositivity rate among pregnant women in Al-Nobareya town, Al-Beheira Governorate.
2- To identify risk factors of HCV infection among pregnant women in Al-Nobareya town, Al-Beheira Governorate.


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Prevalence of hepatitis C virus infection among pregnant women in a rural district in Egypt
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Dr. Hossam Hassan Khamis (Author)Prof. Dr. Azza Galal Farghaly (Author)Prof. Dr. Hanan Zakaria Shatat (Author)Assistant Prof. Dr. Engy Mohamed El-Ghitany (Author), 2015, Prevalence of hepatitis C virus infection among pregnant women in a rural district in Egypt, Munich, GRIN Verlag,


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