Sero-Prevalence and Determinants of Hepatitis C Virus Infection Among Healthcare Workers of a Private Tertiary Care Hospital in Karachi

: Health care workers (HCWs) are at high risk of exposure to hepatitis B virus (HBV), hepatitis C virus (HCV) and HIV transmission due to occupational exposure to injuries, from sharp needles


Introduction
Hepatitis C virus (HCV) infection is a major public health concern worldwide and affecting millions of people each year [1,2]. Hepatitis C virus infection can cause acute and chronic hepatitis and potentially leads to the development of liver cirrhosis, liver cancer, or death [2,3]. In 2019, World Health Organization (WHO) estimated that globally, 58 million persons were chronically infected and living with hepatitis C and among them approximately 400 000 people were died, with a disproportionately high burden in low-and middle-income countries (LMICs) [4]. In Pakistan, according to the national prevalence survey, the prevalence of hepatitis C virus infection was 4.8 % in the general population and HCV could affect nearly 10 million peoples in Pakistan [5,6].
Common mode of transmission of HCV includes intravenous drug use, blood or its product transfusion, reuse of syringes or needles, unsterilized surgical equipment, dental procedures, piercing ear and nose, tattoos, transmission during sexual intercourse, vertical transmission from infected mother to newborn [7].
Healthcare workers (HCWs) are at higher risk of acquiring blood borne pathogens such as HBV, HCV and HIV as compared to any other occupational group [8]. This is because of occupational exposure to injuries, from sharp needles, and scalpels during the execution of their health care duties. Globally, two million health care workers suffer from accidental needle stick injury (NSI) each year [9]. In Pakistan, around 49.7% of health care workers experienced NSI in the last one year [10]. Hassnain S et al reported that prevalence of NSI was found to be 85 (44%) in public and 51 (26.4%) in the private sector hospital of Lahore [11]. Another study reported that the NSI at ever in life, was 66% among HCWs in public sector hospitals of Karachi [12].
In 2007-2008, during the national hepatitis prevalence survey, 11 670 HCWs were screened for HCV in the whole province of Sindh. Out of the total screened HCWs for HCV, 713 (6.2%) were HCV antibody positive [13]. Other studies from Pakistan have also reported the HCV prevalence of 5 to 6 % among the HCWs [14,15]. Most of the HCV prevalence studies among HCWs are being conducted in the public sector hospitals. There is a dearth of data that reports the burden of HCV infection among the HCWs of a private health care hospital. Furthermore, no study reports the viraemic prevalence of HCV among the RDT positive HCWs. Current study was aimed to estimate the sero-prevalence and associated risk factors of HCV among the HCWs of Kharadar General Hospital (KGH), a 250 bedded private tertiary care hospital, located in the old city area (Lyari town) of Karachi.

Study Design, Setting and Duration
The cross-sectional study was conducted at Kharadar General Hospital (KGH), one of the private tertiary care hospital, located in the south, near costal line of Karachi, the provincial capital of Sindh. Study data was collected during the month of October 2022.

Study Population, Eligibility Criteria, Sample Size and Consent
Study participants were the health care workers (Doctors, Nurses, Technicians, and other workers) of KGH, who employed for the last 6 months, and willing to participate in the study. Study sample size was 300, based on universal sampling technique. Informed consent was taken. Purpose of study was explained to all the participants before enrollment into the study.

Data Collection Procedure, Laboratory Tests and Quality Control
Structure questionnaire was used for data collection. Detail demographic data (name, age, education, marital status, designation & work experience), occupational exposure data (NSI, posting place), and non-occupational exposure data (H/O injections use/ H/O blood transfusion/ previous surgeries/ dental procedure/ HCV infection in spouse/ piercing of ear or nose/ tattoo) were collected by the trained nursing students. Rapid diagnostic test (RDT) kit, manufactured by Abbott Company, was used for the detection of anti HCV antibody. RDT positive cases were further confirmed for HCV infection through doing quantitative PCR by looking HCV-RNA. All PCR positive HCV cases were offered WHO recommended direct acting antivirals HCV treatment.
The confidentiality of data was ensured by proper coding and keeping it in a key and lock with limited access.

Data Entry and Statistical Analysis
Study data were entered in the excel sheet and analyzed by using statistical package for Social Science (SPSS) version 19. Frequency and percentage were calculated for categorical variables (gender/ H/O blood transfusion/ injection/ previous C/Section etc). Whereas mean and standard deviation were calculated for continuous variables (Age/ Experience in years). Correlation between HCV determinants variables (age, gender, years of work experience, H/O blood transfusion, Use of injection, previous surgeries, dental Procedures, piercing of ear or nose) and outcome variable (Presence of HCV) were determined by using persons chi square test. P-value < 0.05 were considered as statistically significant.

Ethical Consideration
Study approval was taken from the Ethics Review Committee (ERC) of Kharadar General Hospital.

Characteristics and Correlation of HCV Positive Cases
All three diagnosed HCV positive cases were coming out from the indirectly expose (Housekeeping staff/ security guard) population. (See table 1

Discussion
The main finding of this study was low sero-prevalence (1%) and high needle stick injury (57%) as occupational exposure, at a private tertiary care hospital, which continuously pose a threat to increase HCV spread among HCWs. Study hospital mainly deals with gynae and pediatric patients. All the pregnant women who came for delivery already screened for HBV and HCV infection during the ANC visits. Those women who were positive for HBV or HCV, must be labeled in their hospital records, which was available for all the relevant healthcare workers. Seeing patient records, all HCWs were vigilant while doing any intervention like intra-venous cannulation, injections, blood transfusion or any surgical procedure. Whereas Paediatric population may have less chance of HCV infection because of low prevalence of HCV in children as compare to adult population [16]. Furthermore, in children HCV may occur mainly through vertical transmission from their mother. A study reported that chance of vertical transmission from mother to child was less than 5% [17].
The difference in low prevalence rate in this study and high prevalence in previously published studies from Pakistan were mainly from multiple possible reasons. Firstly, HCV prevalence survey among HCWs were mostly conducted in public sector tertiary care hospitals which reported the HCV prevalence from 3.2 % to 5.6% [18][19][20][21][22]. Whereas current study was conducted at a private tertiary care hospital, where standard practice of care was comparatively better. The main difference of care was the handling of the HCV risk factors at workplace differently at public and private hospitals. In study private hospital, the screening of HCV among admitted patients were mandatory before undergoing any invasive procedures (surgery or caesarean section delivery) or even during emergency caesarian section. Furthermore, before blood transfusion, all the donors or donated blood must be screened for HCV. These standard practices of care would alert the HCWs to take appropriate personal protective measures before handling the any HCV infected patients. Secondly, in Pakistan previous HCV prevalence surveys were mostly conducted more than a decayed ago. For instance, national hepatitis prevalence survey was carried out in 2008, and it reported prevalence of HCV was 4.8% in general population [14]. Only a single study conducted at tehsil headquarter hospital, Hasilpur in 2018, in last 5 years, which reported the HCV prevalence of 5.2%. [21]. With the passage of time awareness about HCV risk factors, transmission, diagnosis and treatment were raised, which impact on decrease transmission rate among HCWs. Thirdly, literatures revealed that there was the variation in the distribution of HCV within the different geographical regions of Pakistan. Rural area has more prevalence of HCV as compared to urban cities [13]. Similar finding to current study, was reported from PIMS hospital, Islamabad in 2010, which reported the low prevalence (1.6%) of HCV among HCWs which may be due to less work experience of HCWs (41% of HCWs had service length between 1-5 years) [23].
Nearly 80% of the hepatitis infections in health care workers are attributed to sharp injuries [24]. Current study reported the frequency of NSI (57%) among HCWs was lower than reported from the public sector tertiary care hospitals of Karachi (66%) [12]. This difference may be due to the shortage of HCWs in the facility, different work environment, training, availability of resources and use of personal protective equipment. Contrary to current study, the prevalence of needle-stick injuries was reported low (26.4%) by a study conducted at a tertiary care private hospital in Lahore. [11]. Efforts should be made to reduce the risk of occupational exposures (NSI) by enhancing the capacity of HCWs to follow the standard practice of care and universal precautions by introducing safer devices and techniques.

Limitation and Strength
Study sample was small due to single center study followed by only offered to those HCWs who did show willingness to participate. Strength of the study was all the identified RDT-HCV positive HCWs further evaluated and confirmed HCV diagnosis through GeneXpert by looking presence of HCV-RNA. All HCV positive HCWs were provided direct acting antiviral treatment free of cost.

Conclusion & Recommendation
This study reported the low sero-prevalence and high occupational exposure of needle stick injuries among HCWs. There is a need to raise HCWs awareness, effective implementation of infection control programs, adherence to universal precautions on safe practice, and proper training to reduce HCV infection among HCWs.