HEPATITIS B VIRUS INFECTION IN NIGERIA: A REVIEW

Abstract
Background: Hepatitis B virus is highly infectious and about 100 times more infectious than
HIV. It is a major global health problem and concerned experts bemoan the fact that although
HBV infection causes chronic liver disease, it has received little or no attention in Nigeria,
thereby making it a major public health hazard in the country.
This review was carried out to assess the prevalence of HBV infection in Nigeria in order to
enlighten the public on the danger, mode of transmission and risk factors associated with the
infection.
Materials and Method: Source of information was the results of published studies and
unpublished thesis in Ahmadu Bello University, Zaria conducted on HBV in Nigeria from 2000-
2014.
Result: The results of the studies reviewed showed that HBV Infection appears to be increasing
with prevalence ranged from 3.9 to 50.7%. Analysis of the data in relation to gender showed that
the HBV Infection was more prevalent in males than females. The studies reviewed reported
HBV Infection to peak in the age group 20 to 30years. The most important risk factors found in
the studies to be associated with HBV were blood contact, sexual activity, and intravenous drug
use. The mean prevalence of 13.3% showed that Nigeria is highly endemic.
Conclusion: The high prevalence of 13.3% questions the effectiveness of the Nigerian HBV
vaccination programme. Therefore, there is a need for health promotion awareness campaign to
educate the general public on the danger, mode of transmission and the risk factors associated
with HBV infection especially among youth population.

1
 Introduction

Hepatitis B virus (HBV), a DNA virus of the family Hepadnaviridae is the causative agent of
hepatitis B infection. Hepatitis B is one of the most common infectious diseases in the world and
a major health problem. According to the most recent World Health Organization estimate, 2
billion people worldwide have serologic evidence of past or present HBV infection, and 350
million are chronically infected and at risk for HBV-related liver disease. [1] It is 50 to 100 times
more infectious than HIV and 10 times more infectious than hepatitis C virus (HCV) with many
carriers not realizing they are infected with the virus. It is an important cause of liver diseases
such that chronic infection with HBV is a common cause of death associated with liver failure,
cirrhosis and liver cancer. [2]

The virus has caused severe endemic in parts of Africa and Asia. [3] The prevalence of HBV
varies between 2% in developed countries where the prevalence is low to about 8% in
developing countries where infection is endemic with sex, age and socio-economic status as
important risk factors for infection. [4] The degree of HBV endemicity often correlates with
predominant mode of transmission. The disease has an enormous impact on health and national
economy of many countries and the severity of the disease is highly variable and often
unpredictable. The minimum infectious dose is so low that such practices like sharing of tooth
brush or a razor blade can transmit infection. [5]

Hepatitis B virus is a blood borne and sexually transmitted pathogen that is spread through
contaminated blood or other body fluids (saliva, sweat, semen, vaginal secretions, breast milk,
urine, and feaces). Transmission can occur when using the same syringe as an infected person,
from blood transfusions prior to 1975 (now screened in most countries), having tattoos or body
piercing, from mother to child during childbirth, during medical procedures, occupational
exposure, during sexual intercourse. Hepatitis B virus also shares similar routes of transmission
with HIV. [6] Currently, there are four recognized modes of transmission (Viral Hepatitis
Prevention Board, 1996) which are; from mother to child at birth (prenatal), by contact with
infected person (horizontal), by sexual contact and by exposure to blood or other infected fluids.
Because HBV can remain stable and infectious on environmental surfaces for at least 7 days,
transmission may occur indirectly via contaminated surfaces and other objects such as tooth brush,
baby bottles, razors, eating utensil, hospitals equipments, by contact with mucous membranes or
open skin breaks. [7]
2
The disease affects people of all age groups, but in most studies conducted recently HBV infection
is predominant in young adults and are acquired sexually or through injecting drug use. [1] Most
people who become infected with HBV are able to clear the virus from their blood stream within 6
months of post infection and develop immunity. Those who have not cleared the virus after 6
months are considered to have chronic hepatitis B infection. The risk of death from HBV related
liver cancer or cirrhosis is approximately 25% for persons who acquire chronic infection at
childhood. Moreover, 8% to 10% of people in the general population in developing countries
become chronically infected and most acquire infection with HBV at childhood. [2, 8]
Nigeria is classified among the group of countries highly endemic for HBV infection. About 75%
of the Nigerian population is reportedly likely to have been exposed to HBV at one time or the
other in their life. Although hepatitis B vaccination is highly effective in preventing infection with
HBV and consequent acute and chronic liver disease, this infection is still a major problem in
Nigeria as reported by various workers. [2, 4, 9]

3
Materials and Methods
The current review work analyzed 74 results of published studies and unpublished thesis in
Ahmadu Bello University, Zaria conducted on HBV in Nigeria from 2000-2014. The study
population comprised of blood donors, HIV patients, pregnant women, students, prostitutes,
adolescents, patients, inmates, surgeons and children.
The prevalence rate, age group most affected, gender most affected and the risk factors associated
with the infection were analyzed.

Results
HBV infection appears to be increasing (3.9% to 50.7%). 3.9% has been reported among pregnant
women, 12.5% among Students, 17% among Prostitutes, 26% among HIV Patients, 25.7%
among Surgeons, 44.7% among Children and 50.7% Blood donors. A mean prevalence of 10.7%
for HBV was obtained from these studies for Nigeria.
From the 74 works reviewed, 23 are Blood donors, 17 are Pregnant women, 14 are HIV Patients,
10 are other Patients, 4 are Students and 1 each of the following: Adolescent, Prostitutes,
Butchers, Surgeons and Children.
Majority (75%) of the works were from the north; 17 from Kaduna State (23.1%), 6 from
Nasarawa, 5 from Borno, 4 from Kano, 3 from Gombe, 3 from Abuja, 3 from Plateau, 2 from
Katsina, 2 from Niger, 1 each from Adamawa and Benue. While the rest are from other part of the
country which include; 8 from Oyo, 5 from Edo, 3 each from Lagos and Rivers, 2 each from Imo
and Anambra, and 1 each from Bayelsa, Ogun, Osun, Abia and Ebnyi.
Considering the percentage prevalence based on age group, HBV infection peaked in the age
group 20-30 years followed by 30-40 years (Table 2).
Only 36 of the studies had information on gender, HBV Infection was more prevalent in males
subjects (31.1%: 23/74) than females subjects (14.9%: 11/74).
The results was also analysed according to risk factors associated with HBV. The result showed
the major risk factors identified with HBV infection were sexual activity, followed by blood
contact, blood transfusion, intravenous drug use, scarification mark, socio-economic status,
unawareness, vertical transmission, marital status, lack of vaccination and contraceptive use
(Table 2).

4
Most of the tests done using ELISA (28.4: 21/74), five of them were confirmed with ELISA while
others used Rapid diagnostic test kits.

Table 1: Sero-prevalence of hepatitis virus infection in Nigeria: 2000-2014

No. No. of Prevalence Study

Reference examined positive rate (%) Study area population

Pregnant
Aba et al., 2012 800 31 3.9 Kaduna women
Ugwuja et al., 2010 785 32 4.1 Ebonyi Adolescent
Pregnant
Ezechi et al., 2012 2,391 101 4.2 Lagos women
Pregnant
Akani et al., 2005 600 26 4.3 Rivers women
Pregnant
Okeke, 2011 210 9 4.3 Kaduna women
Ejele & Ojule, 2004 7,226 354 4.9 Rivers Blood donors
Bdliya, 2014 100 5 5 Kaduna Blood donors
Nwolisa et al., 2013 139 8 5.8 Imo HIV Patients
Umolu et al., 2005 130 7 5.8 Edo Blood donors
Taura et al., 2008 200 12 6 Kano HIV Patients
Pregnant
Oluboyo et al., 2014 100 6 6 Anambra women
Adoga et al., 2010 1,891 114 6 Nasarawa Blood donors
Alabi, 2014 100 7 7 Kaduna Blood donors
Pregnant
Yakasai et al., 2012 303 34 7.9 Kano women
Ibrahim & Pondei, Pregnant
2013 365 29 7.9 Bayelsa women
Tremeau et al., 2012 443 35 7.9 Abuja HIV Patients
Pregnant
Olokoba et al., 2011 231 19 8.2 Adamawa women
Ahizechukwu et al., Pregnant
2011 480 40 8.3 Anambra women
Abubakar, 2009 188 16 8.5 Gombe Blood donors
Abdulkadir, 2011 100 9 9 Kaduna HIV Patients
Eze et al., 2007 370 34 9.2 Edo HIV Patients
Ola et al., 2010 180 17 9.4 Oyo Butchers
Sama'ila & Aminu,
2012 117 11 9.4 Katsina Blood donors
Ejele et al., 2004 342 33 9.7 Rivers HIV Patients
Aminu & Aminu, 2012 100 10 10 Kaduna Patients

5
Osazuwa et al., 2011 1,039 107 10.3 Abuja Blood donors
Sirisena et al., 2002 524 54 10.3 Plateau Blood donors
Okechukwu et al., 2014 300 32 10.7 Imo HIV Patients
Pregnant
Maikudi, 2011 93 10 10.8 Kaduna women
Odemuyiwa et al., 2001 331 36 10.9 Oyo Students

Oronsaye & Oronsaye,

2004 5,737 609 11 Edo Blood donors
Pregnant
Mbaawuaga et al., 2008 300 33 11 Benue women
Nkwokedi et al., 2010 6,395 703 11.4 Kano Patients
Pregnant
Maikudi, 2009 200 23 11.5 Katsina women

Pregnant
Olanisun et al., 2009 200 30 11.5 Abuja women
Pennap et al., 2011 200 23 11.5 Nasarawa Blood donors
Otegbayo et al., 2008 1,779 211 11.9 Oyo HIV Patients
Abubakar, 2011 100 12 12 Kaduna Patients
Hamza et al., 2013 440 54 12.3 Kano HIV Patients
Pregnant
Ndams et al., 2008 261 32 12.3 Niger women
Denue et al., 2012 569 70 12.3 Borno HIV Patients
Pregnant
Ugbebor et al., 2011 5,760 720 12.5 Edo women
Aminu et al., 2013 200 25 12.5 Kaduna Blood donors
Borno &
Obi et al., 2014 109 14 12.8 Gombe HIV Patients
Odoh, 2011 93 12 12.9 Kaduna Students
Aminu & Okachi, 2011 200 23 13 Kaduna Students
Pennap et al., 2010 113 15 13.2 Nasarawa Blood donors
Omosigho et al., 2010 250 33 13.2 Niger HIV Patients
Pregnant
Daura, 2009 150 20 13.3 Kaduna women
Lawal et al., 2009 200 29 14.5 Oyo Blood donors
Uneke et al., 2005 175 25 14.5 Plateau Blood donors
Otaru, 2006 100 15 15 Kaduna Blood donors
Daramola et al., 2004 60 9 15 Oyo Patients
Alhassan et al., 2010 100 15 15 Kaduna Blood donors
Alebiosu, 2010 138 22 15.9 Ogun Blood donors
Pregnant
Kolawole et al., 2012 200 33 16.5 Osun women
Forbi et al., 2008 720 123 17.1 Nasarawa Prostitutes

6
 Adekanle et al., 2010 234 40 17.1 Nasarawa Blood donors
Odaibo et al., 2003 300 55 18.3 Oyo Patients
Joseph, 2010 100 19 19 Kaduna Blood donors
Onyekwere et al., 2002 100 20 20 Lagos Patients
Otegbayo et al., 2003 170 37 21.3 Oyo Blood donors
Angyo & Yakubu, 2001 507 115 22.7 Plateau Patients
Adoga et al., 2009 300 69 23 Nasarawa Inmates
Belo, 2000 167 43 25.7 Lagos Surgeons
Sani, 2011 93 24 25.8 Kaduna Students
Mustapha & Jibrin,
2004 200 53 26.5 Gombe HIV Patients
Muhammad, 2010 100 27 27 Kaduna HIV Patients
Bello et al., 2011 472 136 28.8 Borno Blood donors
Halim et al., 2001 150 44 29.3 Edo Patients
Baba et al., 2000 517 197 38 Borno Patients
Ola et al., 2002 45 17 38 Oyo Patients
Bukbuk et al., 2005 150 67 44.7 Borno Children
Iloh et al., 2013 140 71 50.7 Abia Blood donors

Mean prevalence: 10.7%

7
Table 2: Seroprevalence of Hepatitis B infection according to Age group, Gender most affected, Risk factors associated with the disease and Method used.

Gender
AG most AG least most risk factors assoc.
Reference affected affected affected with HBV Method use

Aba et al., 2012 21-25 NA NA NA ELISA kit

Ugwuja et al., 2010 NA NA Male Blood contact NA
Ezechi et al., 2012 20-29 NA NA Blood transfusion NA
Akani et al., 2005 NA NA NA NA Rapid ELISA kit
Okeke, 2011 23-30 47-54 NA Vertical transmission NA
Ejele & Ojule, 2004 NA NA
Bdliya, 2014 10--15 NA Male NA ELISA kit
Nwolisa et al., 2013 NA NA Male NA Rapid test strip
Umolu et al., 2005 18-25 NA
Taura et al., 2008 21-30 41-50 Female Intravenous drug use Rapid test strip
Oluboyo et al., 2014 15-30 NA
Adoga et al., 2010 21-30 < 10
Alabi, 2014 21-30 11--20
Yakasai et al., 2012 NA NA NA NA ELISA kit
Ibrahim & Pondei,
2013 21-30 17-20
Tremeau et al., 2012 > 34 NA Both NA ELISA kit
Olokoba et al., 2011 25-29 40-44 NA Unawareness ELISA kit
Ahizechukwu et al.,
2011 20-24 NA NA Vertical transmission Rapid ELISA kit
Abubakar, 2009 25-29 NA Female Sexual activity NA
Abdulkadir, 2011 25-34 45-56 Female Blood contact NA
Eze et al., 2007 NA NA
Ola et al., 2010 20-29 40-49 Male Blood contact ELISA kit
Sama'ila & Aminu,
2012 22-25 NA
Ejele et al., 2004 33-39 NA Female Sexual activity Chinotech HBsAg
Aminu & Aminu, 2012 NA NA
Osazuwa et al., 2011 30-39 20-29 Female NA NA
Sirisena et al., 2002 NA NA Female NA ELISA kit
Okechukwu et al., 2014 25-34 55-64
Maikudi, 2011 31-35 21-25 NA Blood transfusion NA
Odemuyiwa et al., 2001 NA NA NA NA NA
Oronsaye & Oronsaye,
2004 NA NA NA NA NA
10--19 40-49 NA Contraceptive use ELISA kit

8
Mbaawuaga et al., 2008
Nkwokedi et al., 2010 < 10 NA NA NA NA
Maikudi, 2009 16-20 41-50 NA Lack of vaccination NA
Olanisun et al., 2009 < 40 > 40 NA Sacrification mark NA
Pennap et al., 2011 31-35 > 36 Male Sexual activity ELISA kit
Otegbayo et al., 2008 25-34 > 65
Abubakar, 2011 25-34 45-56
Hamza et al., 2013 < 40 NA Male NA ELISA kit
Ndams et al., 2008 26-30 11--15 NA Unawareness NA
Denue et al., 2012 30-39 50-59 Both Intravenous drug use NA
Ugbebor et al., 2011 32-36 27-31
Aminu et al., 2013 NA NA
Obi et al., 2014 20-29 50-59 Male NA ELISA kit
Odoh, 2011 26-30 31-35 NA Sexual activity ELISA kit
Aminu & Okachi, 2011 19-29 30-39
Pennap et al., 2010 < 40 > 40 Male Sacrification mark NA
Omosigho et al., 2010 21-30 < 20
Daura, 2009 21-25 NA NA Blood transfusion NA
Lawal et al., 2009 34-42 NA Male Sexual activity NA
Uneke et al., 2005 20-30 31-40 Male Sexual activity ELISA kit
Otaru, 2006 20-24 NA Female Blood contact NA
Daramola et al., 2004 NA NA NA NA ELISA kit
Alhassan et al., 2010 30-39 15-19 Male NA HBsAg latex kit
Alebiosu, 2010 21-30 NA Male Blood contact NA
Kolawole et al., 2012 30-34 NA NA NA ELISA kit
Forbi et al., 2008 31-35 > 36
Adekanle et al., 2010 21-30 51-60 NA Blood contact ELISA kit
Odaibo et al., 2003 NA NA Male NA NA
Joseph, 2010 10--20 NA Male Socio-economic status NA
Onyekwere et al., 2002 NA NA NA NA NA
Otegbayo et al., 2003 NA NA NA Sacrification mark NA
Angyo & Yakubu, 2001 NA NA NA NA NA
Adoga et al., 2009 NA NA NA Sexual activity NA
Belo, 2000 31-40 51-60 NA Socio-economic status ELISA kit
Sani, 2011 21-26 26-35 NA Sexual activity ELISA kit
Mustapha & Jibrin,
2004 40-49 < 19 Female Sexual activity ELISA kit
Muhammad, 2010 33-41 24-32 Male Blood transfusio NA
Bello et al., 2011 1--30 31-59 Male Marital status NA
Halim et al., 2001 NA NA NA Blood transfusion ELISA kit
NA NA Male NA NA

9
Baba et al., 2000
Ola et al., 2002 NA NA NA NA ELISA kit

Bukbuk et al., 2005 > 13 10--11 Male NA NA

Iloh et al., 2013 71 40-60 NA NA One step test strip

Figure 1: Study population

10
 Figure: Gender most affected.

Discussion

The classification of high endemicity for HBV has been defined as HBsAg greater than 7% in an
adult population, [10] hence, the mean prevalence of 10.7% calculated confirms that Nigeria is
highly endemic for HBV infection and this is a cause for alarm.
Most of the work reviewed showed that sexual activity increased the carriage of HBsAg (Table
2). Ola et al.[11] Found that butchers from Ibadan had higher infection rate and showed high risk
of behaviour, which may lead to the spread of infection in slaughter-houses in Nigeria. Belo. [12]
Showed a higher prevalence of HBV infection among surgeons in Lagos than the general public.
The prevalence rate for HIV/HBV co-infection was high (27%) in a study conducted in Zaria. [13]
The higher value could be because HIV and HBV share similar modes of transmission and risk
factors. Many HIV positive individual have also been exposed to HBV. Studies suggest that as
many as 70-90% HIV positive people have evidence of past or current HBV infection. Since
majority of patients spontaneously clear HBV without treatment, however the rate of active
infection is much lower. [14]
The high prevalence of 50.7% in a study conducted in Abia state might be due to unawareness of
HBV infection among the public.

11
The reviewed studies showed that the prevalance of HbsAg among pregnant women increased
with lack of vaccination and decreases with increasing social status. [15, 16, 17] Generally,
pregnant women have depressed immunity, thus infection of HBV is of clinical importance.
Considering the percentage prevalence based on age group, people within the age group 20-30
had the highest prevalence (Table 2). Age is an important factor in epidemiology studies.
The age of acquiring infection was found to be the major determinant of the incidence of HBV in
one of the studies. [18] Given the sexual transmission of HBV, the high sexual activity of
individuals within these age brackets might explain this. One can speculate that the major
transmission mode in this population is sexual intercourse and properly intravenous drug use,
which is reported to be highest among Nigerians in their third decade of life. [1] The age group
20-30 shows that the youth which are sexually active should be the target for HBV infection since
sexual activity is one of the major risk factor associated with the infection.
The higher seroprevalence in male subjects than female subjects may be due to multiple sexual
partnerships and promiscuity which are habits occuring with higher frequency among males than

females as indicated by United Nation System in Nigeria. The finding of higher Seroprevalence in
male subjects compared with female subjects was also reported by Chu et al. [20] Chu and co-
workers tried to adduced the higher prevalence of hepatocellular carcinoma observed in men in
their studies to a physiologic mechanism that increase the vulnerability of men to HBV. [21]
The result showed the major risk factors identified with HBV infection were sexual activity,
followed by blood contact and then blood transfusions (Table 2). The following are among the list
of risk factors for acquisition of HBV infection; prenatal transmission from mother to child, use of
infected syringes and needles among intravenous drug users, improper wound dressing, sharing of
knives which may explain the high infection amongst the butchers. Health education and
information would thus play a major part of transmission. A higher rate of infection amongst
young adults may reflect greater sexual activity among this age group, as has also been seen in
patients with HIV infection. [11]

The persistant high prevalence in Nigeria could be attributed in part to, the fact that, though WHO
adopted HBV immunization as part of EPI in 1991 it was not until 2003 that it was incorporated
into NPI and it was mostly not available until recently. It was also noted that HBV infection is not

12
commonly perceived problem in Africa. This is because infections are often sub clinical and there
is long interval before the consequences of chronic carriage manifest.

Conclusion

The mean prevalence of 10.7% in this review confirms that Nigeria is highly endemic for HBV
infection which is cause for alarm. Such a high prevalence questions the effectiveness of the
Nigerian HBV vaccination programme. Therefore, there is a need for health promotion
awareness campaign to educate the general public on the danger, mode of transmission and the
risk factors associated with HBV infection especially among youth population.

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