Hepatitis B Vaccine Uptake among Voluntary Blood Donors in Jos: Implication on Blood Safety

Hepatitis B virus (HBV) is a transfusion-transmissible pathogen that poses a significant threat to blood safety. The virus' burden is high in the general population and among blood donors in Sub-Saharan Africa, leading to more donor rejection; blood discards, and increased risk of contamination of the blood supply. Hepatitis B Virus is vaccine-preventable; increased burden of infection may suggest a gap in vaccination. The study aimed to assess the level of hepatitis B virus vaccine uptake and identify factors affecting uptake of the vaccine among voluntary non remunerated blood donors (VNRBD) in Jos, Nigeria. A survey was conducted at the National Blood Transfusion Service (NBTS), Jos, among consenting VNRBD aged between 18 and 65 years from October to December 2020 using a structured questionnaire to collect information on vaccination status, socio-demographics and others. Of the 120 VNRBD interviewed, 36.7% received one or more doses of the HBV vaccine, while the majority (63.3%) were unvaccinated. Among the unvaccinated donors, 57.9% were unaware that HBV has a vaccine, 21.1% did not know where to get the vaccine, 7.9% had no time to get vaccinated; 3.9 % believed that there was no need to get vaccinated because they tested negative for the virus, while 9.2% gave no reason. Our study found a low uptake of HBV vaccine among VNRBD in our environment. We advocate for increased awareness and strong legislation to ensure universal access to the vaccine by Nigerians. Hepatitis B virus, Vaccine uptake, Voluntary non remunerated blood donors, Blood safety

chronic liver disease and hepatocellular carcinoma. The global burden of HBV is high, posing a significant 5 threat to the availability of safe blood worldwide. This threat is accentuated in resource-limited countries where frequent disruptions of basic testing kits are experienced in the background of the scarcity of 5 advanced screening methods. Several studies have documented a high prevalence of HBV among Voluntary non-remunerated Blood Donors (VNRBD) 6,7,8 in Sub-Saharan Africa. This high prevalence translates to more blood discards which come at an 6 enormous cost to the regional blood services. It also heightens the risk of introducing a positive unit into the transfusion chain with its attendant consequences on 9,10 blood safety.
Priority must be given to the vaccination of the population as blood donors are derived from the community. Available literature searched showed a paucity of studies that specifically addressed the status of HBV vaccination of blood donors in our environment. This study aimed to assess the level of hepatitis B virus vaccine uptake, identify factors affecting uptake of the vaccine among VNRBD in Jos, Nigeria and generate baseline data to influence policy decision on blood safety in our environment.
The study was conducted at the National Blood Transfusion Service (NBTS), North-Central Zone of Nigeria. The NBTS is located in Jos, the capital of Plateau State and serves the blood need of Plateau State and the neighbouring States of Bauchi, Kaduna, Benue, Nasarawa Taraba. This was a cross-sectional facility-based study conducted between October and December 2020. Participants were consenting VNRBD aged 18 -65 years presenting at the regional NBTS for blood donation. As the participants arrived for blood

Study area
Study design donation, the study objective was explained to them and their consent sought to participate in the study. All the participants gave informed consent and were consecutively recruited until the desired sample size of 120 was attained. A structured questionnaire was used to obtain socio-demographic, HBV immunization history and other information from subjects.
Ethical approval was obtained from the NBTS before the work was carried out. Informed consent was obtained from each subject before enrollment.
Data obtained were cleaned, coded and entered into a predesigned excel spreadsheet and subsequently analyzed using the IBM Statistics for windows, version 23.0 (Chicago, IL: IBM Corp). Mean, and Standard deviation were used to summarize normally distributed continuous variable. Chi-square was used to test the associations between categorical variables. Results were presented using tables and charts.
A total of 120 blood donors were interviewed, of which 86 (71.7%) were males and 34 (28.3%) females, giving a Male: Female of 2.5:1. They were aged between 18 and 58 years with a mean (± SD) of 36.12 ± 10.22 years, and a median age of 35 years. The highest number of donors belonged to the age group of 28-37 years. The majority of blood donors were self-employed 41 (34.2%), others were civil servants; 34 (28.3%), students; 26 (21.7%), business; 6 (5.0%) and security personnel and clergies; (10.8%). Ninety-six (80.0%) of subjects attained tertiary level education, while those with secondary and primary education were 18.3% and 1.7%, respectively. Sixty-four (53.3%) of subjects were married and 53 (46.7%) unmarried (  16.7% and 83.3%, respectively (Figure 1). The frequency of donation by subjects ranged from 2 to 34 times as the time the study was being conducted. The majority of repeat donors (70.7%) had donated up to ten times. (Table 2). Subjects who received the vaccine constituted 36.7%, while the majority (63.6%) were unvaccinated against the hepatitis B virus. Among the unvaccinated subjects, 44 (57.9%) were unaware that hepatitis B has a vaccine, 16 (21.1%) did not know where to get the vaccine, 3(3.9%) subjects felt they did not need the vaccine since they tested negative for the virus; 6 (7.9%) had no time to get vaccinated, while 7 (9.2%) gave no reason for their unvaccinated status. The majority (70.5%) of those that had the vaccine completed the recommended three doses, while the remaining 29.5% were yet to do so (Table 3).
In our study, only 44 (36.7%) of voluntary blood donors received one or more doses of HBV vaccine, of which 31 (70.5%) completed the recommended three doses of the vaccine that offer protection against HBV. However, the low uptake of vaccination found in our 11 study is higher than that reported by Bonsu et al, Abdo 12 13 et al. and El-Ghitny et al. from Ghana, Sudan and Egypt, respectively. The low uptake of HBV vaccine by VBD in this study may reflect that in the general population where donors are derived from. Among medical students, low uptake was reported in 14 15 Cameroun (26.05%), Kenya (44.3%), and Ghana 16 (30%). Among health care personnel, low uptake was 17 18 reported in Tanzania (33.6%), Ethiopia (27.6%) and 19 Enugu, South Eastern Nigeria (14.2%). However, higher uptake was found in developed countries such 20 21 as Italy (80%) and France (88.6%). The higher uptake seen in developed countries may be due to enhanced awareness and universal implementation of routine childhood anti HBV vaccination. Among the unvaccinated subjects, identified factors DISCUSSION affecting vaccine uptake included poor knowledge of the availability of HBV vaccine (57.9%), access to the vaccine (21.1%), and poor perception of the need for vaccination (3.9%). These identified negative factors affecting vaccine uptake can be reduced through targeted dissemination of the right information about the availability of vaccine and where it can be accessed. During pre-donation counselling, information about HBV vaccination should be sought, and donors counselled on the need to get vaccinated to ensure complete protection from the virus. The majority (83.3%) of our subjects were repeated donors, with donation frequency ranging from two to thirty-four. Most of them were young and have attained tertiary level education; therefore, commitment to blood donation is done from an informed position. Such blood donors needed to be protected against HBV to guarantee a stable pool of safe VNRBD that can be retained over several years. The expanded program on immunization (EPI) had 22 been in place in Nigeria for decades. Hepatitis B vaccine was incorporated as part of the routine childhood immunization in 1990, with the vaccine 22 given at birth, 6 and 14 weeks. The vaccine is safe and effective. Its introduction led to a decline in the proportion of under-five children chronically infected with the virus from 5% in the pre-vaccination era to 23 under 1% in 2019. The estimated global coverage of the vaccine in 2019 was 43%, while the coverage in 23 Africa was lower (6%). In Nigeria, a significant proportion of births are done outside the hospital 24 setting, depriving the newborns of the HBV vaccine. One of the strategies to improve access to vaccines for babies born outside the hospital setting is to educate the traditional birth attendants of the usefulness and availability of the vaccines. Such information can be passed to the mothers, who will be directed to immunization centres for vaccination of the newborns. As childhood immunization is being strengthened through well-articulated and nationally accepted policies, a well-defined strategy to bring the \39 unvaccinated adult population into the vaccine net must be developed. As adults cannot be forced to get vaccinated in contrast to newborns, the concept must be made attractive to them; aggressive and targeted dissemination of information on the benefits of the vaccine will facilitate voluntary acceptance. The right information can be passed to the population at health facilities, places of worship, billboards, health education in schools, print, and electronic media. Hepatitis B is vaccine-preventable; therefore, a high burden of it and other vaccine-preventable infections in any society suggests a gap in vaccination. The rational use of blood and blood products demands that recipients of blood and products be given only the 25 desired component. Whole blood, when separated into its various component, can benefit more than one recipient; the transfusion of such components from a donor with occult HBV puts more than one recipient at 26 risk of HBV infection. In a setting where the supply of basic donor testing kits are frequently erratic and advanced screening using individual donor nucleic acid amplification is unavailable in many blood banks, transfusion safety in Sub Saharan Africa cannot be guaranteed in the face of a high burden of HBV among 5 blood donors. Therefore, vaccination against HBV offers a cost-effective means of narrowing the existing gap in transfusion safety while availing an increased 27,28,29 number of voluntary blood donors for retention. The lifetime cost of managing a patient with chronic hepatitis B, liver cirrhosis, and HBV-induced hepatocellular carcinoma cannot be compared to the 30,31 cost of three doses of highly effective HBV vaccine. It is hoped that the negative factors affecting enhanced vaccine uptake among blood donors and, by extension, the general population identified in this study will attract the required attention of the policymakers and appropriately addressed to tackle the menace of HBV in our society. Universal HBV vaccine coverage in Nigeria is possible; the right political will and appropriate legislations are needed to actualize it.

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Our study found a low uptake of HBV vaccine among blood donors in our environment. Insufficient knowledge about the existence of the vaccine and where it can be accessed were some of the identified factors limiting vaccine uptake in the majority of the subjects. We advocate for increased awareness at governmental and non-governmental fora and the enactment of strong legislation that will ensure universal access to the vaccine by Nigerians.
Our study relied on self-reported hepatitis B vaccination by subjects. It did not confirm their seroconversion status, which could have allowed us to assess vaccine efficacy or failure.

Nil
None declared