Coinfections with Hepatitis B virus and Hepatitis C virus among tuberculosis patients in Jos, Nigeria

INTRODUCTION

The bacterium, Mycobacterium tuberculosis, is the etiologic agent of tuberculosis (TB) which mainly affects the lungs and remains a life-threatening disease in many parts of the globe.^[1] Approximately 1.6 million died due to TB in 2021. TB has been listed as a disease of high public health importance in Africa and has remained a leading cause of disability and death.^[2,3] Yearly global reports continue to rank Nigeria among the top burden countries for TB with Nigeria reporting second to the highest prevalence in Africa.^[2,3] Coinfections of TB with hepatitis B virus (HBV) and hepatitis C virus (HCV) potentially lead to treatment failure and poor patient outcomes. TB cases are generally treatable; however, there are reports of complications due to hepatotoxicity as a result of viral hepatitis in some individuals.^[4,5]

HBV and HCV have been suggested as key drivers of liver disease (Viral hepatitis) therefore, of public health concern globally.^[4,6] Despite programmed HBV vaccination for neonates which began in 1992, there is still a recorded worldwide prevalence of 7.8% and 1.1% for hepatitis B surface antigen (HBsAg) and HCV, respectively, in which case about 93 million individuals reportedly may have life-long HBV infections. In Nigeria, however, the prevalence of HBsAg and HCV was 11.1% and 2.2%, respectively, in 2018.^[6,7]

The seroprevalence of HBsAg and HCV infection among TB-positive individuals has been noted to vary across different regions. For HBsAg, a prevalence of 8.7–14.9% and 2.2–15.5% was reported in Northern and Southern Nigeria, respectively, in Pakistan, Sudan, and Brazil, a prevalence of 5.5%, 9.5%, and 26.5% was reported, respectively.^[7,8] For HCV, a prevalence of 5.4–14.8% and 0.7–7.0% was reported in Northern and Southern Nigeria, respectively, and a prevalence of 3.5–10.0% in other countries.^[7]

The probability of liver damage while undergoing therapy for TB has been shown to increase when there are coinfections of HBV or HCV among TB-positive subjects.^[6] Therefore, life-threatening liver damage can occur as a result of deferred treatment and subsequent poor treatment outcomes. The drugs (e.g., rifampicin, isoniazid, and pyrazinamide) used for TB therapy when there is coinfection with hepatitis B or C or both increase the risk of serious damage to the liver. Screening TB-positive subjects for hepatitis B and C will help identify those that are likely to develop hepatotoxicity so that they could be monitored closely and treated early if they develop drug-induced hepatotoxicity.^[9,10] There is a need to carry out routine screening for hepatitis B and C viruses among TB patients for proper disease management and increased treatment success. Given the notable regional variation in the seroprevalence of HBsAg and HCV among TB-positive individuals, this study thus seeks to find out the seroprevalence of HBV and HCV among TB-positive subjects in Jos metropolis, Plateau State, North-Central Nigeria.

MATERIALS AND METHODS

RESULTS

Blood samples from 71 TB-positive individuals were screened for HBV and HCV surface antigens and 4 (5.6%) had HBV, while 2 (2.8%) had HCV. [Table 1] shows the prevalence of HBV and HCV among TB-positive subjects in relation to age and sex in Jos metropolis. Most of the study subjects, 22 (31%), were within the age range of 26–30 years, followed by 15 (21%) who were within ages 19–25 years. Most of the participants, 37 (52.1%), were female and 34 (47.9%) were male [Table 1]. In addition, [Table 1] shows that the seroprevalence of HBV and HCV was highest in the age group 26–30 years, 13.1% and 9.1%, respectively. Female subjects in this study had the same prevalence of HBV and HCV (5.4%), however, only HBV was reported among male subjects (5.9%).

[Table 2] shows the seroprevalence of hepatitis B and C virus among TB-positive individuals according to risk factors: Type of TB patients (newly diagnosed and those on treatment); newly diagnosed patients had a higher prevalence of 4.2% and 0.0% respectively. Similarly, both HBV and HCV prevalence (5.7%) was higher among those who had safe sexual intercourse (used condom) than among those who had unsafe sex with HBV and HCV prevalence of 5.7% and 0.0% respectively. In relation to blood transfusion, both hepatitis B and C had a high prevalence rate of 6.5% and 4.2%, respectively, among those who have engaged in blood transfusion. Based on Tattooing, HBV had a high prevalence of 7.6% among those who had never received a tattoo before while for hepatitis C, the prevalence was higher, 6.3% among those who received tattoos in the past.

For vaccination, both HBV and HCV had a high prevalence rate of 6.0% and 4.0%, respectively, among those who have never been vaccinated. The prevalence rate of HBV and HCV was higher among HIV-positive subjects with 6.9% and 3.4% prevalence respectively. HBV prevalence (7.5%) was higher among those who do not use sharp objects while HCV had a higher prevalence rate (3.4%) among those who use sharp objects than those who do not (2.5%). There was a prevalence of HCV (6.3) among those who have not heard about the virus and none among subjects who have heard about HCV. HBV had a higher prevalence (6.3%) among those who have not heard about the virus compared to 5.1% among those who have not heard about HBV. The result showed that there is no significant association (P > 0.05) between the variables [Table 1].

[Table 2] shows the proportion of participants who had positive HBsAg and HCV in relation to risk factors. A greater proportion of participants who had positive HBsAg and HCV results had a history of blood transfusion and had not received any vaccination. The proportion of participants with positive HBsAg and HCV results was equal despite the HIV status. No statistically significant association was observed between the HBsAg and HCV results and the occurrence of any risk factors.

DISCUSSION

Viral hepatitis in TB patients has been demonstrated to potentiate the risk of hepatotoxicity induced by therapy against TB.^[6,9,11,12] The seroprevalence rate of HBV and HCV among the 71 TB patients (aged 15–55 years) studied was 5.6% and 2.8%, respectively. The prevalence of viral hepatitis varies across regions in Nigeria and beyond. Most of the participants, 22 (31%), were in the age category of 26–30 years, and mostly females, 37 (52.1%). The overall seroprevalence of HBsAg and HCV infection among TB patients in our sample population was 5.6% and 2.8%, respectively. This finding differed from that of a similar study conducted in Sokoto State (both in Northern Nigeria) which showed a much higher prevalence of HBsAg and HCV of 14.9% and 5.4%, respectively.^[7] Similarly, another study in Kano, Northern Nigeria, which used sputum smears showed a higher prevalence of 8.7% for HBsAg and 14.8% HCV among TB patients compared to our study.^[13] In southern Nigeria, a prevalence of 2.2–15.5% and 0.7–7.0% has been reported for TB coinfection with HBsAg and HCV, respectively.^[7] Furthermore, studies in other countries such as Pakistan, Sudan, and Brazil showed a prevalence of HbsAg among TB patients of 5.5–26.5%, respectively;^[14-16] and a prevalence of HCV of 3.5–10.0%.^[15,16] These regional variations in prevalence can be attributed to different environmental and hygienic conditions. Elsewhere, Akhtar et al. reported a 5.5% and 10.0% prevalence of HBV and HCV, respectively, in Pakistan.^[17] Nail et al. and Kuniholm et al. documented 9.5% and 4.3% of HBV and 3.5% and 12.0% of HCV in Sudan and Thailand, respectively.^[18,19]

The variations in the prevalence rate of HBV and HCV among TB patients observed in our study compared to these reports could be attributed to the differences in screening methods, different sample sizes, geographical location, economic, and hygiene status of the studied populations.

Patients aged 26–30 years had the highest seroprevalence of HBV and HCV infection of 13.6% and 9.1%, respectively, which agrees with the previous reports.^[7,8] The high prevalence of HBV and HCV recorded in this study could be due to high sexual activity among people of this age category. In relation to sex, males had the highest HBV prevalence of 5.9% with females recording higher HCV infections of 5.4%. This may be due to the assertion that women are more exposed to sexual activity than men due to economic challenge.^[20] This is in concordance with the related prevalence reported by Imoru et al. with the prevalence of HBV and HCV being 15.9% and 7.5% among females and 14.01% and 3.8% among males, respectively.^[7]

TB patients who had a previous history of blood transfusion had a higher prevalence of HBV and HCV which are 6.5% and 4.3%, respectively. This was in line with the earlier reported prevalence by Muayad et al. which was 16% for HBV and 4% for HCV, respectively.^[21] This may be due to the fact that the blood being transfused to these patients was not properly screened for HCV and HBV before being transfused to them in the past.^[21]

Knowledge of HBV and HCV reports indicates that there was good knowledge of the virus which was 54.9%. However, 5.1% of these patients who claimed knowledge of HBV were positive for HBV. This may be due to the fact that these patients were reluctant to take preventive measure against HBV and HCV infections.^[20]

In this study, 70.4% of study subjects were not vaccinated with HBV vaccine (based on the information obtained from the questionnaires administered to study participants) and there was seroprevalence of HBV and HCV among the study subjects not vaccinated; 6.0% and 4.0%, respectively. This may be due to the fact that there is less coverage of vaccination by primary healthcare services. This agrees with a previous study carried out in Brazil.^[14]

HBV had a higher prevalence rate (7.5%) among those that do not share sharp objects while HCV had a similar prevalence rate among those who shared sharp object and those who do not share sharp objects. This may be due to the fact that these same patients were involved in one or more risk factors like receiving blood transfusion in the past or having unprotected sex. However, this disagrees with the reported prevalence of HBV and HCV which were 5.1 and 1.8%, respectively by Imoru et al. in Sokoto, Nigeria.^[7] Although HBV and HCV seropositivity in this study was lower compared to other studies in Nigeria, the individuals seropositive for HBV and/or HCV were referred to physicians for appropriate management given the complications envisaged due to TB coinfection and treatment with anti-TB drugs. It is recommended that HBV and HCV screening tests should be carried out among diagnosed TB patients to guide therapeutic decisions. This will help improve public health education on the transmission of these viral infections and assist in reducing the complications and mortality rate among TB patients.

CONCLUSION

From this study, it was observed that the prevalence of HBV and HCV infection among TB patients in Jos Metropolis was 5.2% and 2.8%, respectively. This suggests that there is a low seroprevalence of HBV and HCV in the population studied. HBsAg and HCV rapid tests can misdiagnose some patients due to the low sensitivity of rapid test kits compared to enzyme-linked immunosorbent assay (ELISA) or polymerase chain reaction (PCR). Therefore, it is recommended that HBV/HCV ELISA/PCR should be used in further studies rather than rapid tests. In addition, TB patients seropositive for HBV or HCV were referred to physicians for appropriate management to prevent complications and the risk of anti-tuberculous drug-induced liver damage.