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Hepatitis B and C viral infection: prevalence, knowledge, attitude and practice among barbers and clients in Gharbia governorate, Egypt

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S. Shalaby,1 I.A. Kabbash,1 G. El Saleet,1 N. Mansour,1 A. Omar1 and A. El Nawawy2

الانتشار، والمعرفة، والتوجهات، والممارسات بين الحلاقين والزبائن في محافظة الغربية، مصر :C والعدوى بفيروس B الالتهاب الكبدي

صافي ناز شلبي، إبراهيم علي كباش، جمالات السليط، نديرة منصور، أسماء عمر، علي النواوي

الخلاصـة: أجريت الدراسة في مصر لتحديد انتشار الالتهاب الكبدي  308 ( في محافظة الغربية، وجرى تقييم للمعرفة، وللتوجهات، وللممارسات أثناء قص الشعر والحلاقة. واكتشِف المستضد السطحي للفيروس %في 12.3% من الحلاقين، و12.7 C بين 4.2% من الحلاقين، و3.9% من الزبائن )في المدن أكثر من الأرياف(. واكتشف الضد للفيروس HBsAg الكبدي هو 9.1% بين كل من الحلاقين والزبائن )وفي المدن أكثر من الأرياف(. وكان لدى غالبية المشاركين معرفة ولوحظ HCV-RNA من الزبائن. وكان معدل على غالبية الحلاقين اتباع ممارسات جيدة أثناء الحلاقة وقص الشعر. ويبدو أن الحلاقين ليس لديهم تأمين من الخطر الوظيفي بالتعرض للإصابة بالالتهاب الكبدي.

ABSTRACT: A study in Egypt determined the prevalence of hepatitis B and C virus infections among barbers (n = 308) and their clients (n = 308) in Gharbia governorate, and assessed knowledge, attitude and practices during hair-cutting and shaving. HBsAg was detected among 4.2% of barbers and 3.9% of clients (more urban than rural). Anti-HC antibodies were detected in 12.3% of barbers and 12.7% of clients. HCV-RNA prevalence was 9.1% among both barbers and clients (more rural than urban). Knowledge was high among the majority of participants and good practices during shaving and hair-cutting were observed for the majority of barbers. Barbers appeared to have no job-related risk of acquiring viral hepatitis.

Infection par les virus de l’hépatite B et de l'hépatite C : prévalence, connaissances, attitudes et pratiques chez les coiffeurs pour hommes et leurs clients dans le gouvernorat de Gharbia (Égypte)

RÉSUMÉ: Une étude réalisée en Égypte a déterminé la prévalence des infections par les virus de l’hépatite B (VHB) et de l'hépatite C (VHC) chez les coiffeurs pour hommes (n = 308) et leurs clients (n =dans le gouvernorat de Gharbia, et évalué les connaissances, les attitudes et les pratiques pendant la coupe de cheveux et le rasage. L’antigène de surface (Ag HBs) du VHB a été détecté chez 4,2 % des coiffeurs et 3,9 % des clients (plutôt citadins que ruraux). Des anticorps anti-HC ont été trouvés chez 12,3 % des coiffeurs et 12,7 % des clients. La prévalence de l’ARN du VHC était de 9,1 % chez les deux groupes (plutôt ruraux que citadins). Les connaissances étaient élevées chez la plupart des participants et de bonnes pratiques ont été observées lors du rasage et de la coupe des cheveux chez la plupart des coiffeurs. Ceux-ci ne semblaient pas courir de risque de contracter une hépatite virale dans le cadre de leur travail.

1Department of Public Health, Social and Preventive Medicine, University of Tanta, Tanta, Egypt (Correspondence to S. Shalaby: This email address is being protected from spambots. You need JavaScript enabled to view it.).
 2Department of Public Health and Community Medicine, Al-Azhar University, Cairo, Egypt. Received: 14/02/08; accepted: 09/04/08 

EMHJ, 2010, 16(1):10-17

Introduction

Bloodborne diseases impose heavy burdens on national economies and individual families due to costs arising from acute and chronic morbidity and mortality. Globally, 2 billion people are infected with hepatitis B virus (HBV). An estimated 170 million persons are chronically infected with hepatitis C virus (HCV) and 3–4 million persons are newly infected each year [1,2].

The highest HCV prevalence in the world is in Egypt, where the prevalence of infection increases steadily with age. High rates of infection are observed among all age groups although there are regional differences in the average overall prevalence [3–5]. The prevalence ranges from 10% to 20% of the general population, and rural populations show a higher prevalence than urban ones. This difference has been attributed to past infection and treatment of schistosomiasis [6–8].

The barber shop is a place where hair-cutting, shaving and hair reforming for men are practised. Negligence during the use of sharp instruments may be a risk factor for bloodborne infections, causing serious health problems for both the barber and the clients [9]. Razor sharing and shaving in barber shops has been identified as a key risk factor for HBV infection in Italy [10]. It has also been identified as a risk factor for HCV among institutionalized patients [11].

The objectives of this study were to determine the prevalence of both HBV and HCV infections among barbers and a sample of their clients in Gharbia governorate, Egypt, and to assess the knowledge and attitude of the study population regarding viral hepatitis and their practices during hair cutting and shaving. 

Methods

Study setting

This study was carried out during the year 2007 in Gharbia governorate, one of the governorates of the Nile Delta area. Two out of 8 administrative areas of the governorate were randomly chosen as the study location (Tanta and Mahalla El-Koubra). The 2 cities (Tanta and Mahalla El-Koubra) were included to represent urban localities, while 3 villages (from 42 villages related to Tanta and 55 villages related to Mahalla) were selected randomly from the list of total villages to represent rural localities. Gharbia governorate has a population of nearly 3 million, with an urban to rural ratio of residents of 1:2.

Sample

The target population of the study was people working in barber shops and practising hair-cutting and shaving and 1 regular client from each shop who had attended for at least 1 year.

Based on the lowest reported prevalence of 3% for hepatitis B surface antigen (HBsAg), the sample size that could detect a prevalence ranging from 1%–5%, at a 95% confidence level, was estimated as 280 in each group (barbers and clients). In fact 616 subjects (308 barbers and 308 clients) were enrolled as follows. All barbers in the chosen 6 villages who agreed to participate in the study were included (a total of 147 barbers out of 159 barbers) and the same number of clients, plus a total of 161 barbers from urban areas in both Tanta and Mahala cities and the same number of clients. The proportion of individuals who refused to participate ranged from 4% to 8% at different localities of the study. Efforts were made to explain the objectives of the study and its bene­fits to the participating person and the whole community in order to minimize refusals, which were mainly due to fears about discovering their serostatus or giving a blood sample.

A block sampling technique with a map was used. Regarding the urban areas, a multistage random sample was used. Both Tanta and Mahalla El-Koubra cities were classified into 2 large strata, based on the socioeconomic standard of the dwellings (high and medium-low). Each stratum was further divided into clusters and 5 clusters were chosen randomly from each stratum. A list of barber shops in the study areas was prepared with the help of senior barbers living in the study area. Direct personal communication with barbers in their working shop was made to get their consent and cooperation before being enrolled in the study. While collecting data from the barber, one of the attending clients at that time was approached and invited to participate in the study after the purpose of the study was explained. In case of refusal by the client another person was chosen in the same setting.

Data collection

A pre-designed, structured questionnaire sheet was filled inside the barber shop through direct personal interview with both the barber and the client. Direct observation of the place and the practice of the barber during his work were also carried out. The questionnaire sheet included the following data: sociodemographic data; know­ledge, awareness and beliefs related to HBV and HCV infection; attitude to HBV and HCV; risky behaviours that might contribute to infection with both types of hepatitis; and an observational checklist for barbers’ practice during hair-cutting/shaving. The cut-off for a high level knowledge was defined as> 50% of questions correct.

Before starting data collection the research team reviewed thoroughly the questionnaire and received an orientation training on communication skills and were trained on the methods of data collection. The validity of the questionnaire was tested by expert and peer review and the reliability was tested by the test–retest method in a pilot study including 30 barbers and 30 clients not included in the study sample.

A blood sample (5 mL) was taken from each study subject through venepuncture using a vacutainer device. The sample was allowed to clot naturally to separate the serum for analysis and was stored upright in an ice box/refrigerator at a temperature of 2–8 °C (for up to 3 days) until it was sent to the laboratory for analysis.

For diagnosis of HBV infection, an in vitro diagnostic kit for the detection of HBsAg in human serum was used (Biorex Diagnostics, UK). This test is an enzyme-immunoassay based on a “sandwich” principle.

For diagnosis of HCV, a 3rd-generation enzyme-linked immunosorbent assay (ELISA) kit for qualitative detection of antibodies to HCV in human serum or plasma was used (Biorex Diagnostics, UK). Samples found to be negative on the preliminary screening were considered HCV-seronegative. Initially positive and borderline samples were confirmed by qualitative HCV-RNA detection assays using classic polymerase chain reaction using a commercial kit (HEPA-Check-C, Nuclear Laser Medicine, Italy).

Standard techniques were applied according to the manufacturer’s guidelines. Laboratory investigations were carried out in a specialized private laboratory (Al-Ahram Laboratory, Tanta).

Ethical considerations

The people recruited to the study were informed about the objectives of the study and that they were free to refuse participation. A verbal witnessed consent was obtained from each study participant. Clients or barbers < 18 years old were not included in the study as they were unable to give legal consent. The confidentiality of collected data and for the results of investigations was assured. Only the principal investigator held the results of blood samples tested. The participants were informed about their HBV/HCV test results if they expressed a desire to be informed. These results were delivered in person in a sealed envelope.

Statistical analysis

The collected data were organized, tabu­lated and statistically analysed using SPSS, version 12. The chi-squared test was used for testing the significance of differences between the study groups. When the chi-squared test was not appropriate, Fisher exact test was used. The level of significance was 5%.

Results

A total of 616 subjects (308 pairs of barbers and clients) were included: 322 from urban areas (161 pairs) and 294 from rural settings (147 pairs).

The majority of the study subjects (64.3% of barbers and 59.4% of clients) were aged 20–40 years. Nearly one-half of barbers (49.7%) and 41.2% of clients had intermediate education. About one-third of clients (36.7%) were highly educated compared with only 7.8% of barbers.

HBsAg was detected in 25 individuals (13 barbers and 12 clients), an overall prevalence of 4.1%. The rate was similar among barbers and clients (4.2% versus 3.9%) (Table 1). The prevalence of HBsAg among urban barbers and clients was higher than that among rural ones (6.2% versus 2.0%), although not significantly so. Anti-HCV antibodies were detected in 77 individuals with an overall prevalence of 12.5%. Again, the rate was almost the same among barbers and their clients (12.3% versus 12.7%). The infection rate was highest among rural clients (13.6%) followed by rural barbers (12.3%). The prevalence of anti-HCV was equal among urban barbers and their clients (11.8%). Detection of HCV-RNA revealed similar figures among both barbers and clients (9.1%). The prevalence in rural subjects was higher than that of urban subjects (10.2% and 8.1% respectively). Double infection was detected in 3 subjects (1 barber and 2 clients). There was no statistically significant difference between barbers and clients in the rate of HBV or HCV infection (Table 1).

Table 1 Prevalence of hepatitis B (HBV) and C virus (HCV) infection among barbers and their clients

The level of knowledge about modes of transmission was high among the majority of the study participants (over 80% for most questions). Knowledge about the existence of protective drugs and vaccines was to low; about 40% knew about the presence of an HBV vaccine and around one-quarter claimed to know about a protective vaccine for HCV. Friends and relatives were the main source of information for both barbers (46.1%) and clients (49.7%), followed by television, newspapers and doctors (Table 2).

Table 2 Knowledge of barbers and clients about hepatitis B (HBV) and C virus (HCV) infection  

About two-thirds of the barbers (67.9%) and more than half of the clients (55.5%) were concerned about the status of shaving blades used (P = 0.002) (Table 3). Positive attitudes towards antiseptic use after shaving and safe injections was found among 55.8% and 49.0% of barbers compared with 70.5% and 66.9% of clients respectively (P < 0.001). It was also found that 217 (70.5%) of the barbers would not mind being tested for viral hepatitis and 145 (47.1%) would be willing to have periodic screening for viral hepatitis and other bloodborne diseases.

Table 3 Attitude of barbers and clients towards risk factors for hepatitis

The practice of barbers during shaving showed that changing the blade for each client was the practice of 291 barbers (94.5%); 93.2% of urban and 95.9% of rural ones. Disinfection of used instruments was practised by 76.9% and washing hands by 63.0% of them. Wearing protective clothes, especially gloves, was practised by 52.8% of urban barbers and only 9.6% of rural ones. The difference between rural and urban barbers regarding these practices was not statistically significant, except for wearing protective clothes/gloves and washing used instruments (P < 0.001) (Table 4).

Table 4 Shaving practices of barbers in their shops by residence

The shaving practices of the clients revealed that the practice of urban clients was better than that of rural ones regarding verification of the status of used instruments before shaving (P < 0.001), bringing their own instruments (P = 0.019) and asking the barber to wash his hands before shaving (P = 0.012). The practice of rural clients was better regarding refusing shaving with used instruments (P < 0.001) and asking the barber to disinfect used instruments (but not statistically significant) (Table 5).

Table 5 Shaving practices of clients at barber shops by residence

On observing barber’s shops and their practice during shaving it was found that, in general, the majority of shops were well-equipped, clean and neat. Rural shops were significantly better than urban shops regarding the electric supply and ventilation while urban shops were better regarding the presence of washing facilities and good decoration. Observations during shaving revealed that using a razor machine, throwing used blades in the waste bin and disinfection of skin cuts were practised by more than three-quarters of barbers with a significantly higher rate of use of a razor machine among urban compared with rural barbers (P < 0.001). Using alum as antiseptic for skin cuts was practised by a higher percentage of urban than rural barbers, while rural clients were more likely to change the blade for each client (P < 0.001) (Table 6).

Table 6 Observations of conditions in barber shops and barbers’ shaving practices

Conclusions 

This study revealed a very similar infection rate of HBV and HCV among barbers and their clients to that reported nationally. The prevalence of HBV and HCV among barbers was similar to that among clients. Barbers appeared to have no job-related risk of acquiring viral hepatitis. This may be due to the relatively good knowledge among barbers about modes of transmission and positive attitude towards protecting themselves and their clients and also due to good practices by the majority of the studied barbers and good hygiene conditions in barber shops.

Acknowledgements

This study received technical and financial support from the joint WHO Eastern Mediterranean Regional Office (EMRO), Division of Communicable diseases (DCD) and the WHO Special Programme for Research and Training in Tropical Diseases (TDR): the EMRO/TDR Small Grants Scheme for Operational Research in Tropical Medicine and other Communicable Diseases.

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