Risk factors associated with transfusion transmissible infections among blood donors at Karongi Regional Centre for Blood Transfusion-Western Province of Rwanda

Olivier Nsekuye^{1,2, &}, Eric Matsiko², Jean Claude Niyoyita², Henri Desire Uwayo³, Fabrice Ndicunguye³, Moise Tuyishimire³, Thomas Muyombo³, Jared Omolo⁴, Ziad El-Khatib^5,6,7

 

¹HDPC/Public Health Surveillance, Emergency Preparedness and Response Division, Rwanda Biomedical Center (RBC), Kigali, Rwanda, ²Department of Epidemiology and Biostatistics; Rwanda Field Epidemiology and Laboratory Training Program, University of Rwanda, Kigali, Rwanda, ³BIOS/Blood Transfusion Division, Rwanda Biomedical Center (RBC), Kigali, Rwanda, ⁴Center for Global Health, Rwanda Country Office, US Centers for Disease Control and Prevention, Kigali, Rwanda, ⁵Bill and Joyce Cumming Institute of Global Health, University of Global Health Equity, Kigali, Rwanda, ⁶Department of Global Public Health, Karolinska Institutet, Solna, Sweden, ⁷World Health Programme, Université du Québec en Abitibi-Témiscamingue, Rouyn-Noranda, Canada

 

 

^&Corresponding author
Olivier Nsekuye, Biomedical Center (RBC), P.O.Box 7162, Kigali, Rwanda. nsolly03@gmail.com

 

 

 

 

Blood transfusion is one of the modern medical interventions used to save patients' life. But, it is not risk-free because some blood-borne pathogens might be transmitted through blood to patients [1]. Human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV), and Syphilis are the major infections that cause Transfusion-transmissible infections (TTIs) [2], which can threaten the life of patients and reduced the quality of blood.

 

The World Health Organization (WHO) suggested compulsory screening of all blood donors for HIV 1&2, HCV, HBV, and syphilis infections to prevent the risk associated with exposure to TTIs [3]. The combination of TTIs screening and the development of sensitive screening tests have contributed to the reduction of the incidence and prevalence of TTIs in different countries [1]. However, TTIs risk is still high in low-income countries compared with high-income countries [4]. According to WHO report, the prevalence of HBV, HCV, and HIV infections among blood donors in different parts of the world varies from 0.008% to 6.08%, 0.004% to 1.96%, and 0.0004% to 2.0%, respectively [5]. In Africa 5-10% of HIV transmission is a result of transfusing contaminated blood [6]. In sub-Saharan Africa, 12.5% of transfused patients are at risk of post-transfusion hepatitis [7].

 

Prevention of TTIs is more cost-effective than allowing the further spread of TTIs which causes additional avoidable pressures on the healthcare system including morbidity and mortality which have a high impact, not only on the recipients but also on their families, their communities, and the entire society. In addition, a lower prevalence of TTIs in the donor population also reduces the discard of donated blood and hence results in improved efficiency and use of resources [8,9].

 

Different studies indicated that TTIs might be significantly associated with age, sex, occupation, number, and place of donation, and marital status. A study conducted in Northwest Ethiopia indicated that the blood donors´ age, sex, occupation, number, and place of donation were significantly associated with HBV infection while blood donors employed by the government and unemployed were more likely to have HCV infection. However, HIV and syphilis infections among blood donors were found to be highly associated with the regularity of donations and occupations [9-11]. Another study conducted in Eritrea revealed that male blood donors were less likely to be seropositive to TTIs compared to female donors and a study conducted in Kenya also showed that being married and a male were high-risk factors associated with TTIs [10,12].

 

In Rwanda, to reduce TTI-associated risk, different strategies have been established including improvements in blood donor recruitment and selection and more effective TTIs detection techniques [13]. Also, continuous monitoring of TTIs and evaluation of trends in the prevalence of TTIs are crucial elements for the assessment of blood safety and the effectiveness of the blood safety strategies [12].

 

Despite the known importance of monitoring TTIs with their trend´s evaluation, published information on TTIs burden in Rwanda is limited and also there is no report in our knowledge on the relationship between the prevalence of TTIs and associated donor characteristics. The Western province has reported a high rate of major TTIs in the general population [14-16]. In a study conducted in 2019, the prevalence of Hepatitis B Virus in the general population of Western Province varied from 3% to 8% while in the whole country, its prevalence was at 3.9% [14]. Also, another study published in 2019 showed that the prevalence of Hepatitis C Virus in the Western province was 5.9% [15]. In 2019, the Rwanda Population-Based Impact Assessment indicated that HIV prevalence in Western Province and the whole country was 3% [17]. A study conducted in 2016 showed the prevalence of 1.5% for Syphilis among the general population in Western Province and 0.9% in the whole country [16]. However, to our knowledge, factors associated with this high prevalence of TTIs in the western province are less known. Knowing that contaminated blood can threaten life, therefore, this study aimed to determine the prevalence of TTIs (Hepatitis B&C, HIV and Syphilis) and to explore risk factors associated with TTIs among blood donors in Karongi Regional Centre for Blood Transfusion that serves the Western province between 2015 and 2019.

 

 

Study setting

 

The current study analyzed secondary data cross-sectionally collected by the Regional Center for Blood Transfusion (RCBT) Karongi among blood donors who donated blood from 2015 to 2019. RCBT Karongi is one of the five Regional Centers composing the Blood Transfusion Division (BTD). RCBT Karongi is based in Karongi district, Western province of Rwanda but serves 5 districts in the Western province including Karongi, Nyamasheke, Rusizi, Rutsiro, and Ngororero Districts.The five districts, as per the data provided by the National Institute of Statistics of Rwanda (NISR), have a combined population of 2,200,335 individuals [18].

 

Each blood donor received in RCBT Karongi is registered using a donor file and information from the file is later entered in the online system known as eProgesa used to manage blood donor´s database.

 

Study population

 

The study population consisted of blood donors who donated blood at RCBT Karongi from January 2015 to December 2019. Blood donors with valid positive or negative results for HBV, HCV, HIV, and Syphilis were included. Blood donors with indeterminate results: results that are inconclusive for being either positive or negative, for any of the four Transfusion Transmissible Infections (TTIs) were excluded from the study.

 

Data collection and extraction

 

In this study, data variables including age, gender, residence, blood group, and serological results of TTIs were extracted from the eProgesa software. Additionally, variables related to occupation, marital status, and blood donor regularity were obtained from the blood donor's files.

 

Serological testing was done by using serum or plasma samples collected from blood donors were screened for HBV, HIV, HCV using Enzyme Immuno-Assay (EIA)/Chemiluminescence Immunoassay which has a sensitivity of 100% and specificity of 99.7%, and for Syphilis with Rapid Reagin Plasma (RPR) which has a 100% sensitivity. Confirmation of HIV was done by using the Western blot technique while HBV and Syphilis were confirmed through HBsAg Neutralization Test and Treponema Pallidum Hemagglutination method (TPHA) respectively. All tests were performed according to the manufacturer´s instructions [19-21]

 

Study variables

 

In this study, the presence of HBV, HCV, HIV, or Syphilis served as the dependent variable. An individual was categorized as having a transfusion-transmissible infection (TTI) if they tested positive for any of these four diseases. The independent variables encompassed age, sex, residence area type, occupation, district of residence, marital status, blood group, and the donor's regularity status (one-time donor or repeat donor).

 

Data analysis

 

The data from this study were extracted, cleaned, and imported into Stata software version 15 for analysis. Descriptive statistics, including frequencies, median with range, and proportions with 95% confidence intervals (95% CI), were calculated and reported. The proportion of transfusion-transmissible infections (TTIs) per year was determined by dividing the number of blood donations with positive TTI serologic markers in a year by the total number of blood donations in that year. The overall prevalence of all TTIs was determined by summing up the total number of cases for each TTI (HIV, HBV, HCV, and syphilis) and dividing this number by the total number of blood donors screened during the study period. Logistic regression was employed to examine the significance of potential risk factors in relation to TTIs. Odds ratios with their respective 95% confidence intervals (CI) and P-values were computed. A significance level of 0.05 was utilized in the analysis.

 

Ethical considerations

 

The authorization to undertake this research was granted by RCBT Karongi, as substantiated by a reference letter (Ref: No. 025/RBC/BIOS/BTD/RCBT Karongi/2020). Given the nature of our study, which relied on secondary data, obtaining explicit consent forms from the participants was not required. However, we duly recognized and honored the initial consent given by participants at the time of primary data collection, which had included the potential for the data's use in further research studies. We also ensured the confidentiality of all data involved in our research. To uphold anonymity, we refrained from using any identifiable personal information such as participants' names during the analysis. Additionally, to safeguard the data and further protect privacy, all data was securely stored in password-encrypted computer systems.

 

 

Blood donors´ profile

 

Table 1 presents the characteristics of blood donors at RCBT Karongi from 2015 to 2019. A total of 36,708 individuals donated blood during this period, with 57.5% being males. The median age of blood donors was 24, ranging from 18 to 65 years, and the age group of 18-25 years accounted for 56.9% of donors. Approximately half (50.4%) of the blood donors had the "O" blood group, and new donors constituted 64.8% of the total. The majority of donors (53.8%) originated from schools, and 86.7% were singles. Notably, a significant proportion of donors came from the Nyamasheke district (28.6%), while the Ngororero district contributed the fewest donors (2%). Among the donor categories, students had the highest donation rate, accounting for 75.2% of the donors.

 

Prevalence of HIV, HBV, HCV, and Syphilis among blood donors

 

Between 2015 and 2019 at RCBT Karongi, the overall prevalence of transfusion-transmissible infections (TTIs) was 2.1%. However, the specific prevalence rates for HBV, HCV, HIV, and Syphilis were 1.3%, 0.4%, 0.06%, and 0.34%, respectively (Table 2). Notably, there was a significant decreasing trend in HBV prevalence (P-Value = 0.018) over the study period. In contrast, the prevalence of HIV and Syphilis remained relatively stable from 2015 to 2019. HCV exhibited a decline in 2016, followed by an increase in 2017, and then remained relatively constant from 2018 to 2019(Figure 1).

 

Table 3 demonstrates that the highest occurrence of Hepatitis B Virus (HBV) was found in males, exhibiting a rate of 1.6%, and in the age group of 26-35 years with an infection rate of 1.8%. Evaluating the frequency of donations, new blood donors were identified to have a significant prevalence of HBV infections at 1.9%. Urban blood donors were more frequently infected with HBV, having a 2.1% rate, as compared to their rural counterparts. Among all districts, Rusizi reported the highest HBV infection rate at 2.6%. The incidence of HBV was notably high among married blood donors and donors from military and police camp, with rates of 1.7% and 16.8% respectively.

 

The prevalence of HCV was found high among males with 0.5% and the age group of 56-65 years showed a high prevalence of 1.8% compared to other age groups. Based on donor regularity, a high proportion in HCV was found among new blood donors wit 5.9%, those who lived in urban areas with 0.85%, and those who came from the Karongi district with 3.8%.

 

The proportion of HIV was found high among females with 0.07%, the age group of 56-65 years with 0.25%, new blood donors with 0.096%, urban blood donors with 0.18%, those who came from the Ngororero district with 0.14%, married blood donors with 0.13% and among informal employed blood donors with 0.1%.

 

The current study found that a high proportion of Syphilis was among males with 0.45%, age group of 36-45 years with 0.69%, new blood donors with 0.40%, urban blood donors with 0.51% those who came from Rusizi district with 0.45%, married blood donors with 0.70%, and among police and army with 1.2%.

 

Risk factors of TTIs infections

 

The bivariate analysis revealed a significant correlation between Hepatitis B Virus (HBV) incidence in blood donors and several factors: gender, age, donation frequency, location of residence, district, marital status, and occupation. The findings suggested that male donors had higher exposure than females, with an Odds Ratio (OR) of 1.8 and a 95% Confidence Interval (CI) of 1.5-2.2. Age groups 26-35 years (OR: 1.8, 95% CI: 1.5-2.3) and 36-45 years (OR: 1.7, 95% CI: 1.3-2.3) also exhibited higher association with HBV compared to the 18-25 years age group. New donors (OR: 11.9, 95% CI: 7.6-18.4) were more susceptible to HBV than recurring donors. Blood donors from Rusizi District showed a higher likelihood of HBV (OR: 2.9, 95% CI: 2.2-3.8) compared to donors from other districts. Donors residing in rural areas (OR: 1.3, 95% CI: 1.0-1.6), urban locations (OR: 2.1, 95% CI: 1.6-2.6), and military and police camps (OR: 1.6, 95% CI: 1.1-2.6) all demonstrated an elevated risk of HBV infections when compared to donors originating from schools. Additionally, donors who were married (OR: 1.4, 95% CI: 1.1-1.8), informally employed (OR: 1.4, 95% CI: 1.1-1.8), and self-employed (OR: 2.1, 95% CI: 1.2-3.7) were found to be more prone to HBV.In relation to Hepatitis C Virus (HCV), significant associations were found with gender, age, donation frequency, type of residence, district of residence, and marital status. Male donors (OR: 1.7, 95% CI: 1.2-2.4) and those within the age brackets of 26-35 years (OR: 1.7, 95% CI: 1.2-2.5), 36-45 years (OR: 2.2, 95% CI: 1.4-3.5), 46-55 years (OR: 2.6, 95% CI: 1.4-4.8), and 56-65 years (OR: 6.2, 95% CI: 2.8-13.6) demonstrated a higher risk of HCV. New donors (OR: 4.3, 95% CI: 2.6-7.0) and those living in the districts of Rusizi (OR: 3.5, 95% CI: 1.9-6.2), Nyamasheke (OR: 3.1, 95% CI: 1.7-5.3), and Karongi (OR: 2.1, 95% CI: 1.1-3.7) were also associated with an increased likelihood of HCV infections. Blood donors residing in urban areas had higher exposure to HCV (OR: 2.5, 95% CI: 1.7-3.8) when compared to donors from schools. Moreover, married blood donors (OR: 1.6, 95% CI: 1.1-2.3) were found to be more prone to HCV relative to their single counterparts.

 

Bivariate analysis indicated that HIV prevalence among blood donors was linked with age, donor frequency, and type of residence. Those in the age group of 36-45 years (OR: 3.0, 95% CI: 1.1-8.5), new donors (OR: 12.4, 95% CI: 1.6-92.5), and those residing in urban areas (OR: 6.1, 95% CI: 2.1-17.1) showed a higher propensity for HIV infections.As for Syphilis, bivariate analysis associated its prevalence among blood donors with gender, age, donation frequency, type of residence, district of residence, marital status, and occupation. Males (OR: 1.9, 95% CI: 1.2-2.9), age groups of 26-35 years (OR: 2.3, 95% CI: 1.5-3.5), 36-45 years (OR: 3.5, 95% CI: 2.2-5.6), and new blood donors (OR: 1.9, 95% CI: 1.2-2.9) had a higher risk. Moreover, donors living in the districts of Rusizi (OR: 2.0, 95% CI: 1.2-3.3) and Rutsiro (OR: 1.7, 95% CI: 1.0-2.9) showed increased susceptibility to Syphilis. Risk of Syphilis was also greater in donors living in rural (OR: 3.2, 95% CI: 1.9-5.5), urban (OR: 3.2, 95% CI: 1.9-5.5) areas and military & police camps (OR: 7.6, 95% CI: 4.1-14.1), and among married donors (OR: 2.5, 95% CI: 1.7-3.7). Those in informal employment (OR: 2.8, 95% CI: 1.8-4.3), the police or army (OR: 5.1, 95% CI: 2.8-8.9), and self-employed individuals (OR: 3.9, 95% CI: 1.5-9.9) were found to have an increased risk for Syphilis.In the multivariate analysis (Table 4), HBV showed a significant correlation with male gender (AOR: 1.7, 95% CI: 1.3-2.1), age group of 26-35 years (AOR: 1.2, 95% CI: 1.1-1.9), new donors (AOR: 13.2, 95% CI: 8.4-20.6), donors living in Rusizi District (AOR: 2.5, 95% CI: 1.9-3.3), and those who were married (OR: 1.7, 95% CI: 1.2-2.4).HCV had a significant correlation with being male (AOR: 1.5, 95% CI: 1.1-2.1), and various age groups such as 26-35 years (AOR: 1.6, 95% CI: 1.1-2.4), 36-45 years (AOR: 2.0, 95% CI: 1.1-3.5), 46-55 years (AOR: 2.4, 95% CI: 1.2-4.8), and 56-65 years (AOR: 5.8, 95% CI: 2.4-14.0). HCV was also notably correlated with new blood donors (AOR: 4.7, 95% CI: 2.8-7.8), and residents of the districts of Rusizi (AOR: 2.9, 95% CI: 1.6-5.3), Nyamasheke (AOR: 3.9, 95% CI: 2.1-7.0), and Karongi (AOR: 2.6, 95% CI: 1.4-4.8).There was a significant link between HIV infection and being a new blood donor (AOR: 12.1, 95% CI: 1.6-91.0), as well as being a blood donor who lives in urban areas (AOR: 4.1, 95% CI: 1.2-13.5).Syphilis had key associations with being male (AOR: 1.9, 95% CI: 1.2-2.9), being a first-time blood donor (AOR: 2.3, 95% CI: 1.4-3.6), and living in both rural (AOR: 2.2, 95% CI: 1.2-3.8) and urban areas (AOR: 2.2, 95% CI: 1.2-4.2).

 

 

Blood transfusion services in Rwanda have strived to improve the quality of blood since 2011. However, the Western province has been reporting a high rate of the major TTIs in the general population. Therefore, the identification and trends evaluation of the proportion and the risk factors associated with TTIs in the Western province has been a valuable index on assessing the existing intervention strategies for fighting TTIs among blood donors. Hence, this study aimed to determine TTIs prevalence and explore associated risk factors among blood donors at Karongi Regional Centre for Blood Transfusion from 2015 to 2019.

 

Findings showed a significantly decreasing trend of HBV proportion and a slightly decrease in HCV proportion while the proportion of HIV and Syphilis among blood donors remained slightly constant from 2015 to 2019. This may be explained by vaccination campaigns among people at risk for HBV and HCV testing campaigns that targeted suspected individuals in Rwanda. These campaigns may have lowered the prevalence of HBV and HCV [14, 15]. However, low prevalence of syphilis might be associated with the lower prevalence of HIV proving success of the national HIV control program and surveillance systems [16, 17]. In addition, since 2014 blood service in Rwanda started the accreditation process which may be resulted in strengthening blood donors selection and qualification process, which has led to the decline of TTIs prevalence among blood donors [22].

 

In this study, the HBV, HCV, and Syphilis infections were was significantly associated with male blood donors. This was similar to the finding of a study conducted in Jijiga Blood Bank, Eastern Ethiopia [23]. The higher risk for males to counteract TTIs can be related to being more involved in sexual intercourse, fights, and conflicts that might lead to blood contacts [12, 14].

 

The current analysis revealed that the risk of HBV and HCV increases with age. This association is consistent with what was found in studies conducted in the National Blood Transfusion Service of Eritrea and Western China [12,24]. HBV and HCV infection were increasing by age among blood donors and this might be due to duration of exposure to the virus and also to the fact that people in these age groups are more sexual active than young people [25]. According to blood donor´s regularity, in RCBT Karongi, new blood donors were found to be significantly related with all TTIs (HBV, HCV, HIV, and Syphilis) . This association was similarly found in studies conducted in Shiyan-Central China [26], Eritrea [12], Bahir Dar district blood bank, northwest Ethiopia [9]. These findings of this study support the hypothesis that first-time blood donors represent a high-risk group for transfusion-transmissible infections (TTIs). This could be due to the fact that repeat donors undergo screening during their initial donation, resulting in individuals with TTIs or a higher risk of acquiring TTIs not returning for subsequent donations [27].

 

HIV and Syphilis were found to be significantly associated with urban areas among blood donors. This reflects the situation existing in Rwanda where urban areas present a high prevalence of HIV [17]. However, in a study conducted in Rwanda in 2016 in the general population, the prevalence of Syphilis was not significantly associated with urban areas [16]. But it was hypothesized that the prevalence of syphilis would be significantly higher in urban residences in different studies and surveys conducted [28,29].

 

The districts bordering neighbouring countries to Rwanda constituted a high risk for HBV and HCV. In line with this, Rusizi, Karongi, and Nyamasheke District bordered with Democratic Republic of Congo (DRC). Moreover, Rusizi districts bordered Burundi. Located at the borders, these districts are marked by high across borders migration and business movements, factors that might lead to having more vagabonding sexual intercourses.

 

Married blood donors were also found to be significantly risk factor for HBV among blood donors in RCBT Karongi. This was similar to the study conducted in five Chinese blood centres [30]. Though, this might be linked to sexual behaviour, possibly behaviour like traditional scarification or low vaccination rate among the married population [14].

 

The strength of the current study relies on the larger sample size, wider coverage of socio-demographic characteristics, and the long study duration (5 years). However, this was a retrospective cross-sectional study, we were not able to provide information regarding further behavioural and sexual risk factors and cause-effect relationship to TTIs among blood donors such as a history of traditional operations, history of invasive procedures, history of multiple sexual partners, history of having unprotected sex, etc. In addition, our study indeed focused on HIV, Hepatitis B and C, and Syphilis because these are the infections that the World Health Organization (WHO) mandates screening for in all blood donations. It is critical to note that these diseases are also the primary TTIs of significance in Rwanda, hence our focus on these in our study. We, however, limited our scope to the four aforementioned infections due to their significant public health impact and the current national screening recommendations in Rwanda [13]. We recognize this as a limitation of our study and other potential TTIs could be explored further in future research.

 

 

The findings of this study hold significant implications for public health and blood safety. Our analysis demonstrated a notable overall TTIs prevalence in the blood donor population, with several key demographic and regional factors contributing to the risk. Particularly, new blood donors, certain age groups, and urban dwellers exhibited higher infection rates. Distinct trends in HIV, HBV, HCV, and Syphilis infections were also observed. These findings emphasize the need for refined donor screening and selection strategies, as well as targeted health education programs, to enhance the safety of blood supply. Moreover, continuous monitoring of TTIs trends using sensitive testing methods is critical for effective disease control. Our results underscore the urgency of these measures in the studied region and potentially serve as a reference for similar settings worldwide.

 

 

The authors declare no competing interests.

Funding

AFENET through UR/School of Public Health, funded this study.

 

 

ON analysed the data, drafted, and finalised the manuscript. EM advised on data analysis and structure of the manuscript and reviewed the manuscrpt. HDU, FN and TM contributed to drafting the manuscript, FB and JO assisted in the analysis. All authors have read and agreed to the publisheable version of the manuscript.

 

 

We would like to express our gratitude to the Blood Transfusion Division (BTD) for granting us permission to use their data, and to the University of Rwanda/School of Public Health (UR/SPH) for their support. We also thank the African Field Epidemiology Network (AFENET) for providing funding for this study.

 

 

Table 1: Socio-demographic characteristics of blood donors

Table 2: Prevalence of HIV, HBV, HCV, and Syphilis among blood donors in RCBT Karongi from 2015 to 2019

Table 3: Proportion and risk factors associated with TTIs among blood donors in RCBT Karongi (2015-2019) (Bivariate analysis)

Table 4: Risk factors associated with TTIs among blood donors in RCBT Karongi (2015-2019) (Multivariate analysis)

Figure 1: Trends of HIV, HBV, HCV, and Syphilis among blood donors in RCBT Karongi from 2015 to 2019

 

 

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