|Year : 2019 | Volume
| Issue : 2 | Page : 42-46
Prevalence of hepatitis C infection in hemodialysis patients: Report from 37 hemodialysis centers in Libya
Eman Gusbi1, Islam Elzouki2, Hafsa A Alemam1, Majda Musa3, Inas M Alhudiri1, Nabil Enattah1, Mokhtar Gusbi4, Adam Elzagheid5
1 Department of Genetic Engineering, Biotechnology Research Center, Tripoli, Libya
2 Department of Medicine, Tripoli Central Hospital, Tripoli, Libya
3 Ministry of Health, Tripoli University, Tripoli, Libya
4 Department of Community and Family Medicine, Tripoli University, Tripoli, Libya
5 Department of Genetic Engineering, Biotechnology Research Center, Tripoli; Department of Pathology, University of Benghazi, Benghazi, Libya
|Date of Web Publication||24-Jun-2019|
Dr. Adam Elzagheid
Department of Genetic Engineering, Biotechnology Research Center, Tripoli
Source of Support: None, Conflict of Interest: None
Background/Aims: Data on the prevalence of hepatitis C virus (HCV) infection in Libya, and particularly among hemodialysis patients, are scarce. The aim of this study was to assess the prevalence of HCV infection among hemodialysis patients at 37 dialysis centers in Libya and review the demographic features in this group of patients. Patients and Methods: The present cross-sectional study included a total of 2325 patients who had spent at least 3 months in hemodialysis at 37 dialysis centers in different cities across the three main regions of Libya (Western, Eastern, and Southern regions). There were 1028 (44.2%) female and 1297 (55.8%) male with mean age 53.4 ± 15 years. Hypertension (36.4%), diabetes mellitus (33.3%), renal diseases (10.9%), genetic diseases (7.5%), and unclear reasons (12%) were diverse underlying causes of end-stage renal disease in these patients. Anti-HCV antibody was screened by a third-generation enzyme-linked immunosorbent assay technique. Results: The overall seroprevalence of HCV infection among hemodialysis patients in Libya was 16.7% (388/2325), ranging from 0% to 26.3% at different centers. The overall frequency of anti-HCV antibodies was higher in Western region (18.9%) than Eastern (18.3%) and Southern (6.1%) regions of Libya. It is noteworthy that the prevalence of HCV was 0% in numbers of dialysis centers across the three regions. The duration of hemodialysis was significantly longer in HCV-positive hemodialysis patients than in HCV-negative patients (P = 0.01). Hepatitis B surface antigen was positive in 92 hemodialysis patients (4%), of them 8 patients (8.7%) had coinfection with HCV infection. Conclusion: The present study showed an intermediate-prevalence rate of HCV infection among hemodialysis patients in Libya. The relatively low prevalence of HCV infection in the general Libyan population and HCV infection associated with a longer duration of hemodialysis indicate nosocomial transmission due to inappropriate infection control practices as the main HCV route of infection in these health-care settings.
Keywords: Hemodialysis, hepatitis B virus-hepatitis C virus coinfection, hepatitis C, hepatitis C virus infection, Libya
|How to cite this article:|
Gusbi E, Elzouki I, Alemam HA, Musa M, Alhudiri IM, Enattah N, Gusbi M, Elzagheid A. Prevalence of hepatitis C infection in hemodialysis patients: Report from 37 hemodialysis centers in Libya. Libyan J Med Sci 2019;3:42-6
|How to cite this URL:|
Gusbi E, Elzouki I, Alemam HA, Musa M, Alhudiri IM, Enattah N, Gusbi M, Elzagheid A. Prevalence of hepatitis C infection in hemodialysis patients: Report from 37 hemodialysis centers in Libya. Libyan J Med Sci [serial online] 2019 [cited 2019 Sep 19];3:42-6. Available from: http://www.ljmsonline.com/text.asp?2019/3/2/42/261064
| Introduction|| |
Hepatitis C virus (HCV) is one of the leading causes of chronic hepatitis, liver cirrhosis, hepatocellular carcinoma (HCC), and related death. It is estimated that 130–150 million individuals worldwide (representing 2%–3% of the world population) are chronically infected with HCV and that 350,000–500,000 of those die each year from long-term complications, i.e., cirrhosis and HCC.,
The prevalence of HCV among patients with hemodialysis patients is considerably higher than in the general population, ranging from 10% to 50%, depending on the geographical region. Recently, the international prevalence of HCV among hemodialysis patients awaiting transplantation has been reported,, this prevalence varied from 4% in Belgium to 4.8% in the USA and to as high as 20% in the Middle East. Patients on hemodialysis are at higher risk for HCV infection if measures for effective control of HCV infection in the hemodialysis environment are not implemented. Whereas in developed countries, isolated small-scale HCV outbreaks in hemodialysis units are reported only occasionally, HCV transmission in the hemodialysis environment still represents a substantial problem in developing countries.,,
Libya is a country with approximately 6 million inhabitants located in North Africa and extends over 1,759,540 km2 (679,362 sq miles), making it the 16th largest nation in the world by size. It is located in demographic and epidemiologic transition, and chronic kidney diseases and its related complications are the 6th cause of death. Libya provides free access to maintenance hemodialysis for end-stage kidney disease through a rapidly expanding network of centers. Although there are no national dialysis practice guidelines or infection control policies enforced by health-care authorities, there is general agreement that patients on hemodialysis should be screened for hepatitis B virus and HCV infection before the initiation of hemodialysis and monitored every 3–6 months thereafter.
Data on the prevalence of HCV infection in Libya, and particularly among hemodialysis patients, are scarce. In a recent nationwide general population seroepidemiological study, the prevalence of HCV infection was found to be 1.3%. To the best of our knowledge, few studies of HCV on hemodialysis patients were conducted in three discrete dialysis centers in Libya with limited sample size,,, the prevalence was varies between 21% (71% of them confirmed by the presence of HCV-RNA with polymerase chain reaction [PCR] technique) to 42.5%. The aim of the present study was to determine the prevalence of HCV infection among hemodialysis patients at 37 dialysis centers across Libya and reviewed the demographic features as well as the etiologic factors in this specific health-care setting.
| Patients and Methods|| |
The present cross-sectional study included a total of 2325 patients who had spent at least 3 months in hemodialysis at 37 dialysis centers in different cities across the three main regions of Libya (Western, Eastern, and Southern regions). There were 1028 (44.2%) female and 1297 (55.8%) male, with mean age, 53.4 ± 15 years [Table 1]. These patients correspond to all chronic hemodialysis patients in these centers and were dialyzed 2 or 3 times/week, and each hemodialysis treatment session took around 4 h. Dialyzer membranes are disposable and single use. The duration of hemodialysis was <60 months in majority of patients (1755 patients, 75.5%). Majority of patients (>70%) had a history of blood transfusion; however, none of the patients was transfused before the introduction of blood screening for anti-HCV in Libya (1996) or had a history of intravenous drugs abuse.
|Table 1: Comparison of demographic and clinical characteristics of hemodialyzed patients based on the status of anti-hepatitis C virus antibodies in Libya|
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Hypertension (36.4%), diabetes mellitus (33.3%), renal diseases, include glomerulonephritis, pyelonephritis, and obstructive uropathy (10.9%), genetic diseases (7.5%), and unclear reasons (12%) where diverse underlying causes of end-stage renal disease in our hemodialysis patients [Table 1].
Anti-HCV, the body was determined by a third-generation enzyme-linked immunosorbent assay (ELISA) (ORTHO HCV 3/0 ELISA, Ortho-Clinical Diagnostics, NJ).
Statistical analysis was performed using SPSS software version 20 (International Business Machines Corporation (IBM), New York, USA) for windows. Data were expressed as mean ± standard deviation or frequencies (%), as appropriate. Differences between subgroups were assessed using a Chi-squared test, Student's t-test, and an analysis of variance test. P < 0.05 was considered statistically significant.
Ethical approval was conducted in accordance with the ethical principles of Helsinki Declaration. The protocol was approved by the Biotechnology Ethics Committee (BEC-BTRC-12-2019).
| Results|| |
The cohort comprises 2325 hemodialysis patients from 37 hemodialysis centers across the three regions of Libya (1573 patients from 24 hemodialysis centers at Western region, 403 patients from four hemodialysis centers at Eastern region, and 350 patients from nine hemodialysis centers at Southern region) [Table 2]. The overall seroprevalence of HCV infection among hemodialysis patients in Libya was 16.7% (388/2325 patients), ranging from 0% to 26.3% at different centers. [Table 1] shows the distribution of epidemiologic characteristics of hemodialysis patients based on HCV positivity status. The duration of hemodialysis was significantly longer in HCV-positive hemodialysis patients than in HCV-negative patients (P = 0.01). The frequency of anti-HCV antibodies was higher in Western region of Libya than Eastern and Southern regions (Western region: 18.9% [299/1579], Eastern region: 18.3% [65/355], and Southern region: 6.1% [24/391]) [Figure 1]. [Table 2] shows the distribution of anti-HCV antibody positivity across the 37 dialysis centers of the three regions of Libya. It is noteworthy that the prevalence of HCV was 0% in numbers of dialysis centers across the three regions of the country. Hepatitis B surface antigen was positive in 92 hemodialysis patients (4%), of them 8 patients (8.7%) had co-infection with HCV infection [Table 1].
|Table 2: Distribution of anti-hepatitis C virus antibodies in hemodialyzed patients according to their location across hemodialysis centers in the three regions of Libya (n=2325)|
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|Figure 1: Frequency of anti-hepatitis C virus antibodies among hemodialysis patient in the three main region of Libya|
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| Discussion|| |
The results of this study showed an intermediate overall prevalence rate of HCV infection among patients undergoing hemodialysis at large number of dialysis centers across all regions of Libya. The overall HCV seroprevalence among hemodialysis patients in Libya was 16.7%, ranging from 0% to 26.3% at different centers. A comparison of these results with those from 2012, showed that the overall prevalence of HCV infection in the hemodialysis setting in Libya significantly decreased from 31.1% to 16.7% in 6 years (P = 0.001). The reduction in the prevalence could be explained by implemented standard prevention measures at least in majority of dialysis centers in Libya.
The prevalence of HCV infection in hemodialysis patients in different countries in the region ranges from 22.2% and 46.5% in Tunisia,, 42.2% and 60.9% in Egypt,, to 54.1% and 68.3% in Morocco., However, in contrast to our study, all the regional studies mentioned above-reported HCV prevalence among hemodialysis patients originating from a single center, or a single region of a particular country, hence selection bias should be taken in account when interpreting and comparing data.
In contrast to hemodialysis patients, HCV seroprevalence in the Libyan general population, and blood donors in Libya is low (1.3% and 0.9%, respectively), indicating that the high prevalence of HCV infection among hemodialysis patients is not a result of a high baseline prevalence of HCV infection in patients entering hemodialysis centers. It is more likely due to nosocomial infection related to inappropriate infection control practices at dialysis centers and not necessarily with contaminated blood products because all blood donors in Libya have been mandatorily screened for the presence of anti-HCV antibodies since 1996. Unfortunately, HCV-RNA by PCR testing is still not part of the routine screening of blood donors in Libya, and therefore, some HCV-positive patients may have been missed. The use of blood transfusion among hemodialysis patients has declined significantly since the wide availability of erythropoietin in Libya, thus blood transfusion could not have contributed to the transmission of HCV among hemodialysis patients to such an extent.
Genotype 4 was the most frequent genotype among HCV-infected patients in Libya, followed by genotype 1. Unfortunately, HCV genotype distribution in hemodialysis patients in Libya has not been studied, which prevents us from concluding that these genotypes distribution pattern is specific to hemodialysis patients. Further molecular epidemiology analysis of HCV genotypes from hemodialysis patients in Libya might elucidate the routes of transmission at hemodialysis centers in Libya and irrevocably confirm the hypothesis that the high prevalence of HCV infection in hemodialysis patients in Libya is a result of nosocomial transmission.
A limitation of this study is that data were collected retrospectively which might lead to miss some clinical information, especially those are related to risk factors. Another limitation is that only few anti-HCV-positive and not anti-HCV-negative hemodialysis patients were tested for the presence of HCV-RNA. Because some studies reported a substantial proportion of HCV-infected hemodialysis patients with undetectable anti-HCV antibodies in their serum, most likely due to immune dysfunction, the prevalence of HCV infection in hemodialysis centers in Libya may be underestimated.
| Conclusion|| |
The present multi-dialysis centers study showed an intermediate prevalence rate of HCV infection among hemodialysis patients in Libya. The relatively low prevalence of HCV infection in the general Libyan population and HCV infection associated with a longer duration of hemodialysis indicate nosocomial transmission due to inappropriate infection control practices as the main HCV route of infection in these health-care settings. Strict adherence to standard infection control practices will remain the key to prevent transmission of HCV and other infections among hemodialysis patients in Libya.
The authors would like to thank Mr. Walid Mohamed Elmahdi Benbubaker for his assistance in statistical analysis. The authors gratefully acknowledge the support of the Authority of Natural Sciences Research, and Technology.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Perz JF, Armstrong GL, Farrington LA, Hutin YJ, Bell BP. The contributions of hepatitis B virus and hepatitis C virus infections to cirrhosis and primary liver cancer worldwide. J Hepatol 2006;45:529-38.
Malyszko J, Zawierucha J, Marcinkowski W, Prystacki T, Dryl-Rydzynska T, Malyszko JS, et al.
The prevalence of hepatitis C and B among patients on hemodialysis and on renal transplantation waiting list in Poland has significantly decreased during the last 10 years. Int Urol Nephrol 2018;50:1555-6.
Carvalho-Filho RJ, Feldner AC, Silva AE, Ferraz ML. Management of hepatitis C in patients with chronic kidney disease. World J Gastroenterol 2015;21:408-22.
Goodkin DA, Bieber B. International prevalence of hepatitis C positivity among hemodialysis patients awaiting transplantation. Kidney Int 2018;93:1249.
Jadoul M, Bieber BA, Martin P, Akiba T, Nwankwo C, Arduino JM, et al.
Prevalence, incidence, and risk factors for hepatitis C virus infection in hemodialysis patients. Kidney Int 2019;95:939-47.
Weber DJ, Rutala WA, Fried MW. Hepatitis C virus outbreaks in hemodialysis centers: A continuing problem. Infect Control Hosp Epidemiol 2016;37:140-2.
Ashkani-Esfahani S, Alavian SM, Salehi-Marzijarani M. Prevalence of hepatitis C virus infection among hemodialysis patients in the Middle-East: A systematic review and meta-analysis. World J Gastroenterol 2017;23:151-66.
Fadlalla FA, Mohamoud YA, Mumtaz GR, Abu-Raddad LJ. The epidemiology of hepatitis C virus in the Maghreb region: Systematic review and meta-analyses. PLoS One 2015;10:e0121873.
Mohamoud YA, Mumtaz GR, Riome S, Miller D, Abu-Raddad LJ. The epidemiology of hepatitis C virus in Egypt: A systematic review and data synthesis. BMC Infect Dis 2013;13:288.
Alashek WA, McIntyre CW, Taal MW. Provision and quality of dialysis services in Libya. Hemodial Int 2011;15:444-52.
Elzouki AN, Smeo MN, Sammud M, Elahmer O, Daw M, Furarah A, et al.
Prevalence of hepatitis B and C virus infections and their related risk factors in Libya: A national seroepidemiological survey. East Mediterr Health J 2013;19:589-99.
El-Zouki AY, Bendard AB, Sharif MS. HCV in hemodialysis patients in Benghazi, Libya. Ann Saudi Med 1993;13:203.
Elzouki AN, Bushala M, Tobji RS, Khfaifi M. Prevalence of anti-hepatitis C virus antibodies and hepatitis C virus viraemia in chronic haemodialysis patients in Libya. Nephrol Dial Transplant 1995;10:475-6.
Alashek WA, McIntyre CW, Taal MW. Hepatitis B and C infection in haemodialysis patients in Libya: Prevalence, incidence and risk factors. BMC Infect Dis 2012;12:265.
Ayed K, Gorgi Y, Ben Abdallah T, Aouadi H, Jendoubi-Ayed S, Sfar I, et al.
Hepatitis C virus infection in hemodialysis patients from Tunisia: National survey by serologic and molecular methods. Transplant Proc 2003;35:2573-5.
Sassi F, Gorgi Y, Ayed K, Abdallah TB, Lamouchi A, Maiz HB. Hepatitis C virus antibodies in dialysis patients in Tunisia: A single center study. Saudi J Kidney Dis Transpl 2000;11:218-22.
] [Full text]
Khodir SA, Alghateb M, Okasha KM, Shalaby Sel S. Prevalence of HCV infections among hemodialysis patients in al Gharbiyah governorate, Egypt. Arab J Nephrol Transplant 2012;5:145-7.
Senosy SA, El Shabrawy EM. Hepatitis C virus in patients on regular hemodialysis in Beni-Suef governorate, Egypt. J Egypt Public Health Assoc 2016;91:86-9.
Amar Y, Benamar L, Laouad I, Ezaïtouni F, Ouzeddoun N, Balafrej L. Hepatitis C virus infection in a Moroccan hemodialysis unit: Prevalence and risk factors. Gastroenterol Clin Biol 2005;29:746-7.
Sekkat S, Kamal N, Benali B, Fellah H, Amazian K, Bourquia A, et al.
Prevalence of anti-HCV antibodies and seroconversion incidence in five haemodialysis units in Morocco. Nephrol Ther 2008;4:105-10.
Elzouki AN, Beeching NJ, Mutton KJ, Garson JA. Anti-HCV antibodies and HCV RNA in Libyan blood donors. Vox Sang 1995;68:65.
Elzuoki AN, Elzouki I, Albarassi S, Gammo M, Burwaiss A. Hepatitis C genotypes in Libya: Correlation with patients' characteristics, level of viremia, and degree of liver fibrosis. Oman Med J 2017;32:409-16.
Barril G, Quiroga JA, Arenas MD, Espinosa M, García-Fernández N, Cigarrán S, et al.
Impact of isolated hepatitis C virus (HCV) core-specific antibody detection and viral RNA amplification among HCV-seronegative dialysis patients at risk for infection. J Clin Microbiol 2014;52:3053-6.
[Table 1], [Table 2]