Transmission of Hepatitis C between Spouses An Epidemiological

Med. J. Cairo Univ., Vol. 82, No. 1, June: 297-308, 2014
www.medicaljournalofcairouniversity.net
Transmission of Hepatitis C between Spouses
An Epidemiological Study at National Liver Institute Hospital
WESAM S. MORAD, M.D. 1 ; MOHAMED K. EL-SOBKY, M.D.2 ; GAAFAR M. ABDEL-RASOUL, M.D. 2 ;
EMAN A. REWISHA, M.D. 3 ; OLFAT M. HENDY, M.D. 4 and MANAL A. EL-BATANONY, M.D. 2
The Departments of Community Medicine, National Liver Institute 1 , Faculty of Medicine 2 , Hepatology 3 and Clinical Pathology4,
National Liver Institute, Menoufiya University
Abstract
single subtype, 4a, which responds less successfully
to interferon therapy than other subtypes [6-8] .
Background/Aims: In Egypt, relatively higher rates of
sexual transmission have been reported and reflect the higher
background prevalence in this country. In rural Egypt, sexual
transmission between monogamous spouses ranged between 3
and 34%.
It was said that Egypt has one of the highest HCV
prevalence rates in the world. About one in every 10
persons has the virus. It is widely believed that mass
therapy of Egypt’s rural population against schistosomiasis (bilharziasis) in the 1960s and 1970s,
which did not follow rigorous hygiene standards,
are responsible for the current rates of hepatitis C.
Bilharziasis, a water-borne disease, and was at one
time endemic in Egypt. Also he blames the high
HCV rates on bad hygiene habits, the population’s
ignorance of the virus and lack of a vaccine against
the virus. Also it can come from children playing
with scissors, teenage boys borrowing someone’s
razor to shave or even a toothbrush. These persons
don’t have any manifestations, they don’t feel anything, and it is often discovered by accident [9] .
Methods: This is a cross sectional hospital based study
evaluated the non-sexual and sexual risk factors of HCV infection transmission from male and female index cases to their
spouses. This study documented previously uncertained lifestyle risk factors for HCV transmission between spouses, confirmed the high prevalence of HCV infection (17% to 26%) in
Egypt which is higher than other parts of the world, and provided evidence of sexual transmission of HCV (30).
Results: HCV transmission from wife to husband including sexual relationship occurred in 46% of cases while from
husband to wife was 25% and 35.5% overall HCV transmission
between spouses. Sexual intercourse of positive HCV female
more than 4 times per month is 66 times risky to transmit HCV
infection to her husband.
Conclusion: This study emphasize that transmission between spouses significantly occur due to sexual contact but we
can’t ignore the significant role of non sexual risk factors of
HCV transmission among married couples.
In Egypt, relatively higher rates of sexual transmission have been reported and reflect the higher
background prevalence in this country. In rural egypt, sexual transmission between monogamous spouses ranged between 3 and 34% (95% CI 0-49) [10] .
Key Words: Spouses – Sexual transmission – Hepatitis C virus
– Obstetric risk factors – Cross-sectional studies
– Roc curve.
Taken together, although some cases of acute
HCV have been related to sexual transmission, the
degree to which sexual transmission of HCV occurs is controversial because sexual transmission is
difficult to confirm given that partners might have
other risk factors for HCV transmission such as
Intravenous drugs users. Phylogenetic analysis to
identify genetic relatedness of HCV viral isolates in
partners is required to confirm sexual transmission.
All studies on the sexual transmission of hepatitis C
are limited by the potential of the confounding variable of IDU or shared items such as razors and other
Introduction
EGYPT has possibly the highest HCV prevalence
in the world; 10-20% of the general population are
infected and HCV is the leading cause of HCC and
chronic liver disease in the country [1-5] . Approximately 90% of Egyptian HCV isolates belong to a
Correspondence to: Dr. Wesam S. Morad,
E-mail: [email protected]
297
300
items among sexual partners. Large studies directed
at evaluating HCV infected persons with multiple
sexual partners are needed for accurate estimates of
sexual transmission [11] .
In a study among spouses in Egypt, it was estimated that wife to husband transmission was 34%
and 10% for Anti HCV positive wives with and
without detectable HCV RNA respectively. The
probability of husband to wife transmission was
estimated to be 3% and 0% for Anti HCV positive
husband with and without detectable HCV RNA respectively. Overall, 6% were estimated to have contracted HCV from their spouse [10] .
Early studies found the rate of HCV positivity in
partners increased with the longer duration of marriage, suggesting risk of sexual transmission correlated with frequency of contact [12] .
However, subsequent studies adjusting for age
did not find a consistent relationship between the
duration of the sexual relationship and HCV positivity in partners [13] .
Some other studies indicate that sexual transmission from men to women is more efficient than
transmission from women to men. Since HCV is
spread through blood, the risk of sexual transmission may be higher when a woman is having her
menstrual period [14] .
HIV co-infection is associated with higher rates
of anti-HCV in persons engaged in higher-risk sexual practices, Additionally, in studies of STD clinic attendees and men having sex with men, other
STDs (herpes simplex virus, Trichomonas, gonorrhea) and sexual practices that may traumatize the
mucosa (e.g., anal receptive sex) are more frequent
in anti-HCV positive than anti-HCV negative individuals’. Suggesting these factors increase the sexual transmission of HCV [15,16] .
Many people are very worried about getting
or giving hepatitis C to others that they live with.
However, it would be very hard to give or get HCV
unless there is direct blood to-blood contact. Things
like razors, toothbrushes, nail clippers and other personal hygiene items can spread HCV, but it is very
difficult to do so. For example, in order for someone
to get HCV from a tooth brush there would have to
be blood from someone who has HCV on the toothbrush then someone would have to take that same
toothbrush and brush their teeth. Next there would
have to be an open cut or wound in the mouth for
the HCV infected blood to get into the bloodstream.
The bottom line is that this just doesn’t happen very
Transmission of Hepatitis C between Spouses
easily. In fact, there has never been a proven case of
this happening [14] .
In order to eliminate other possible risk factors
for hepatitis C that could measure the link between
sexual intercourse and HCV transmission, John
interviewed each spouse about risk factors other
than sexual intercourse. Each spouse also underwent an antibody test for HCV, when antibodies
specific to HCV are detected, it tells the doctor that
the patient has the viral infection [17] .
We know that blood-borne viruses can be transmitted through certain types of sexual activity. HCV
has rarely been detected in semen and vaginal fluids. However, most studies suggest that the virus
is not often found in these body fluids, or that it is
present in very low amounts and the virus particles
may be non-infectious [14] .
Some people feel more secure knowing that they
are doing everything; they can prevent sexual transmission of HCV. Safer sex practices can also help
to prevent the spread of hepatitis A and B, HIV, and
other STDs. A decision to use safe sex methods depends on the nature of the sexual relationship [18] .
To reduce the risk of HCV transmission during
oral sex or deep kissing, practice regular good oral
hygiene-healthy teeth and gums may be the best
defense against the spread of diseases through the
mouth. Many experts recommend that people avoid
brushing or flossing their teeth right before or after oral sex or deep kissing, since these can cause
bleeding gums and tiny abrasions [14] .
Prevention messages for persons with sexual
practices:
Persons who are at risk for sexually transmitted
diseases should be advised:
That the surest way to prevent the spread of human
immunodeficiency virus infection and other sexually transmitted diseases is to have sex with only
one uninfected partner or not to have sex at all.
-
-
-
To use latex condoms correctly and every time to
protect themselves and their partners from diseases spread through sexual activity.
To get vaccinated against hepatitis B, and if appropriate, hepatitis A [19] .
While sexual transmission of HCV remains somewhat controversial, most studies indicate that transmission through sexual activity is uncommon,
and most experts believe the risk of sexual transmission is low. According to Maryl and National
Institutes of Health, people in stable, monogamous
Wesam S. Morad, et al.
relationships do not need to change their current sexual practices, although they should discuss safer
sex options if either partner is concerned about sexual transmission. People with multiple sex partners
should practice safer sex, in particular the use of latex condoms [14] .
Material and Methods
Study population:
On April 1, 2007 till September 30 2008, there
were 200 HCV patients (110 females and 110 males)
at NLI hospital, Prior to the interview 20 HCV patients (10 females and 10 males) (pilot study sample) were interviewed and tested for the efficiency
of data collection forms, to detect deficiencies and
remodeling them, Estimating the time needed to
collect the required data and Exploring the obstacles found to know the appropriate methods to deal
with them, leaving 200 HCV eligible patients for
the study all were approached and asked to participate in the study provided informed consent. The
study protocol was approved by the Medical Ethics
Review Board of the Faculty of Medicine at the Menoufiya University.
Participants were interviewed by the same interviewer using a questionnaire comprising demographic, life-style variables, medical history, non
sexual risk factors, and sexual history. The demographic variables included age, residence, education and occupation. Medical variables included a
history of blood transfusions or donations, hospital
admission, surgery, invasive hospital procedures
(venous or urinary catheterization and liver biopsy)
and endoscopy, bilharsiasis history, chronic diseases
history, wound sutures, skin tattoo, teath treatment
or extraction, ear piercing, circumcision, abortion
or caesarean section, delivery method, person and
site and HCV family member at home. Life-style
factors, including injection drug use, common teath
brush, common face and hand towels, sharing shaving blades and/or nail cutters, skin tattoo and using
condom during sexual intercourse. Sexual history
included age at marriage, marital duration, sexual
relationship length, history of sexually transmitted
diseases sexual activity were also requested. Conforming with ethics requirements, patients were
not obligated to answer every question on the questionnaire. Consequently, there were some missing responses, especially for “sensitive” life-style
questions, although this represented no more than
8 percent for any one variable. Also high costs of
investigations needed for each couple especially
HCV RNA PCR and Hepatitis B markers to exclude
hepatitis viruses other than hepatitis “C” virus as a
301
cause of hepatitis was one of the obstacles faced
at the study.
Laboratory methodology:
Serum specimens from both hepatitis “C” patients and either their spouses, all cases were screened
using a third generation ELISA using kit from Biocheme. Immunosystem Inc. It qualitatively determined the presence of antibodies to four recombinant HCV proteins in serum, serum Hbs Ag done
by a test based on enzyme linked immunosorbant
assay (ELIZA) by kit from Sorine Biomedica Co.
and Serum from for both index male and female
patients HCV infection was confirmed by detection
of circulating HCV-RNA using qualitative reverse
transcription-polymerase chain reaction technique
(PCR) by Amplicor hepatitis C virus (HCV) from
Roche. It is a direct DNA probe test that utilizes a
nucleic acid amplification technology called polymerase chain reaction (PCR) and nucleic acid hybridization for the detection of HCV-RNA in human
serum and plasma.
Statistical analysis:
Statistical analyses were performed using SPSS
(SPSS, Inc., Chicago, Illinois), Epilnfo (CDC,
Atlanta, Georgia), and LogXact (Cytel Software
Corporation, Cambridge, Massachusetts). Associations between index male and female HCV status and dichotomous variables were assessed with
the chi-square statistic. Chi-square for linear trend
was used for associations between categorical variables and HCV status. When the expected number
in any cell was less than five, a two-tailed Fisher’s
exact test was used. When comparing two-sample
means, Student’s t-test was used for normally distributed variables, while non-parametric Mann
Whitney test was done for non-normally distributed variables. Odds ratio (OR) was used to calculate the risk of exposure long with 95% confidence interval and both were done to measure the
strength of association. Roc curve (Receiver operating characteristic curve) was to determine cut
levels of both marital duration and average number
of sexual intercourse per month where at this level
there were the best sensitivity and specificity and
above these levels there were risk of HCV transmission. The validity of the model was measured
by means of the concordance© statistic (equivalent to the area under the Roc curve). A model with
a c value above 0.7 was considered useful while a
c value between 0.8 and 0.9 indicated excellent diagnostic accuracy. The percentage of transmission
of HCV infection from index males and females to
their spouses was estimated.
302
Transmission of Hepatitis C between Spouses
ROC Curve of sexual intercourse numbers of
husbands of index females
1.0
Results
0.8
Sensitivity
Sexual intercourse numbers above 5 of husbands of index females is more risky to acquire
HCV infection from their wives with a sensitivity
and specificity of (76.1&71.2%) respectively and
AUC of 0.78 (Table 1). Husbands of HCV positive
wives with sexual intercourse numbers more than 5
times per month is 12 times risky to acquire HCV
infection than others (93.0 vs 7.0% OR, 11.75; 95%
CI, 4.1-34.4) (Table 2).
0.6
0.4
0.2
0.0
0.2
0.0
0.4
0.6
Specificity - 1
Fig. (1)
1.0
0.8
Table (1): Sensitivity, specificity and accuracy of sexual intercourse numbers.
Studied variables
.Sexual intercourse no
Cut level 5 times/month
Sensitivity
Specificity
AUC
Accuracy
SE
CI
76.1%
71.2%
0.78
78.6%
0.05
**(0.87 – 0.68)
Highly significant ** .
Table (2): Significant Sexual risk factors differences among male spouses of index females regarding HCV transmission
Total
No. of patients
Sexual risk factors
Sexual intercourse no
times/month 5≥
times/month 5>
51
49
Anti HCV positive
male spouses
%
.no
93.0
7.0
37
9
or
CI 95%
11.75
** (34.4 – 4.1)
Highly significant **.
It was found that the mean age of Anti HCV
positive male spouses was (51.8±9.7), 93.5% endoscopic instrumentation, 87% usage of face and
hand towels in common, 82.6% of past history of
teeth treatment or extraction. 58.7% of past history
of bilharsiasis mean age at marriage was (25.8±5.2)
and mean sexual intercourse length of (23.4±10.4)
(Table 3).
Table (3): Non significant demographical, non-sexual and sexual risk factors among male spouses of index females
.regarding HCV transmission
Total
No. of patients
risk factors
Anti HCV positive male
spouses
No.
p
value
%
–
X±SD
Demographical RF
age in years:
0.14 **
51.8±9.7
Education:
Illiterate up to basic education
Secondary education and above
59
41
26
20
21.7
78.3
0.6
Occupation:
Specialized work
non specialized work
51
49
21
25
45.7
54.3
0.32
Common teeth brush:
yes
10
6
13.0
0.51 *
Common face and hand towels:
yes
82
40
87.0
0.23
Sharing shaving blades and/or nail cutters:
yes
63
31
67.4
0.4
Goza and cigarette smoking:
yes
70
34
73.9
0.43
Wesam S. Morad, et al.
303
Table (3): Count.
Non Sexual RF
Anti HCV positive male
spouses
Total
No. of patients
risk factors
No.
%
p
value
Previous operations:
yes
45
22
74.8
0.6
Hospital admission:
yes
50
26
65.5
0.23
Endoscopy:
yes
89
43
93.5
0.19
I.V. injections:
yes
13
6
13.0
0.99
Mosquito, fleas and tics bites:
yes
34
15
32.6
0.96
Chronic diseases:
yes
41
21
45.7
0.38
Bilharsiasis:
yes
55
27
58.7
0.49
Wound sutures:
yes
32
17
37.0
0.33
Skin tattoo:
yes
8
4
8.7
* 1.0
Teeth treatment or extraction:
yes
74
38
82.6
0.07
Blood transfusion:
yes
8
5
11.1
*0.46
Blood donation:
yes
35
16
34.8
0.97
HCV infected member at home:
yes
9
4
8.7
* 1.0
Using condom during intercourse:
yes
1
0
0.0
* 1.0
Sexual RF
_
X±SD
Age at marriage in years:
46
marital duration:
46
23.5±9.8
Sexual relationship length:
46
23.4±10.4
** 0.47
*** 0.52
25.8±5.2
* Yates corrected.
** t-test.
*** mann whitney test.
ROC Curve of sexual intercourse numbers among
wives of index males
1.0
0.8
Sensitivity
Sexual intercourse numbers above 4 of index
husbands is more risky to transmit HCV infection to wives with a sensitivity and specificity of
(100.0 and 76.4%) respectively and AUC of 0.96
(Table 4). Husbands of HCV positive wives with
sexual intercourse numbers more than 4 times per
month is 66 times risky to transmit HCV infection
than others (96.0 vs 26.7% OR, 66; 95% CI, 8.461396.4) (Table 5).
0.6
0.4
0.2
0.0
0.0
Fig. (2)
0.2
0.4
0.6
Specificity - 1
0.8
1.0
304
Transmission of Hepatitis C between Spouses
Table (4): Sensitivity, specificity and accuracy of sexual intercourse numbers per month.
Studied variables
Sensitivity
Specificity
AUC
Accuracy
SE
CI
100.0%
76.4%
0.96
96.0%
0.02
** (0.99–0.92)
Sexual intercourse No.
Cut level 4 times/month
Table (5): Significant demographical, non-sexual and sexual risk factors among female spouses of index males regarding
HCV transmission
Demographical RF
risk factors
Total No. of
patients
.no
%
or
CI
%95
Occupation:
2.67
* (7.94–0.9)
20.0
6
* (35.3–1.11)
11
44.0
2.9
* (8.48–1.1)
73
14
56.0
75
23
92.0
5.09
* (34.1–1.03)
≥4 times/month
44
24
96.0
66
≥4 times/month
56
1
4.0
Working
25
10
40.0
Housewife
75
15
60.0
8
5
By midwives
27
By others
Blood transfusion:
yes
Non Sexual RF
Anti HCV positive
female spouses
Ear piercing:
Sharing shaving blades and/or nail cutters:
Sexual RF
yes
*Yates corrected.
Sexual intercourse number:
* Significant.
** (1396.4–8.46)
** Highly significant
It was found that the mean age of Anti HCV positive male spouses was (37.5±9.5), 100% circumcision, 92% past history of IV injections, 88.0% usage
of face and hand towels in common, 92.0% of past
history of teeth treatment or extraction. 64% of past
history of bilharsiasis, mean age at marriage was
(20.2±6.1) and mean sexual intercourse length of
(16.9±10.2) (Table 6).
Table (6): Non-significant demographical, non-sexual, obstetric and sexual risk factors among female spouses of index males regarding HCV transmission.
Anti HCV positive
female spouses
Total
No. of patients
risk factors
No.
%
p
value
Demographical RF
X±SD
:Age in years
37.5±9.5
25
**0.19
Education:
Illiterate up to basic education
Secondary education and above
42
58
12
13
48.0
52.0
0.48
Common teeth brush:
yes
8
3
12.0
* 0.4
Common face and hand towels:
yes
93
22
88.0
*0.36
Wesam S. Morad, et al.
305
Table (6): Count.
Non Sexual RF
risk factors
Obestatric RF
Anti HCV positive
female spouses
Total
No. of patients
No.
%
p
value
Previous operations:
yes
52
14
56.0
0.64
Hospital admission:
yes
68
19
76.0
0.32
Endoscopy:
yes
9
3
12.0
* 0.16
I.V. injections:
yes
95
23
92.0
* 0.59
Mosquito, fleas and tics bites:
yes
81
19
76.0
* 0.56
Chronic diseases:
yes
32
11
44.0
0.14
Bilharsiasis:
yes
77
16
64.0
0.07
Wound sutures:
yes
37
10
40.0
0.72
Circumcision:
yes
97
25
100.0
* 0.57
Teeth treatment or extraction:
yes
85
23
92.0
* 0.5
Blood donation:
yes
3
2
8.0
* 0.15
HCV infected member at home:
yes
11
5
20.0
* 0.14
Method of delivery:
normal labor:
Caesarean section
94
6
23
2
89.3
10.7
*0.63
Who delivery the mother?:
Doctor
midwives
78
22
16
9
42.3
57.7
0.05
Delivery site:
At home
At hospital
47
53
14
11
57.7
42.3
0.29
abortion:
yes
43
11
42.3
0.91
Sexual RF
–
X±SD
*Yates corrected.
Age at marriage in years:
marital duration:
Sexual relationship length:
** t-test.
225
25
25
*** mann whitney test
20.2±6.1
18.2±10.3
16.9±10.2
*** 0.5
*** 0 . 19
*** 0.16
306
Transmission of Hepatitis C between Spouses
It was found that High to very high PCR viremia
is 17 and 30 times risky for HCV transmission from
index wives and index husbands to their spouses respectively (63.0 vs 36.9% OR, 16.7; 95% CI, 5.1-
59.1) and (92.0 vs 8.0% OR, 29.6; 95% CI, 5.91199.7) of index wives and husbands respectively
(Table 7).
.Table (7): PCR viremia among index males and females regarding HCV transmission
Total
No. of patients
PCR viremia
Anti HCV positive
index cases
No.
%
or
CI 95%
Index females:
High to very high viremia
mild to moderate viremia
34
66
29
17
63.1
36.9
16.7
** (59.1–5.1)
Index males:
High to very high viremia
mild to moderate viremia
44
56
23
2
92.0
8.0
29.6
** (199.7–5.91)
**Highly significant.
- (Mild viremia (600-250.000 IU).
- (High viremia (2.500.000-5.000.000 IU)
- (Moderate viremia (250.000-2.500.000 IU).
- (Very high viremia (>5.000.000 IU).
- (NLI-PCR department).
frequency of HCV transmission was 46.0%
from Anti HCV positive wives to their husbands
and 25.0% from Anti HCV positive husbands to
their wives (Fig. 3).
Percentage
frequency of HCV transmission between spouses
50
45
40
35
30
25
20
15
10
5
0
46
25
Husband to Wife
transmission
Wife to husband
transmission
Fig. (3): frequency of HCV transmission in both index
males and index females
Discussion
This study was conducted to provide representative data for NLI, as well as to supply data for HCV
transmission risk factors between spouses. HCV infection is a natural problem in Egypt; its prevalence
rate is from 17% to 26% [20] which is higher than
other parts of the world. It was 3% worldwide. In
addition, the proportionate morbidity rate of HCV
disease in NLI during the period of the study was
80%. There are many risk factors known which facilitate HCV transmission. In this work, we found
that the risk of contracting HCV among index female and index male patients was significantly as-
sociated with Demographic, non-sexual, sexual risk
factors. In this study HCV, transmission from wife
to husband including sexual relationship occurred
in 46% of cases while from husband to wife was
25%.
In a previous study among spouses in Egypt, it
was estimated that wife to husband transmission
was 34% and 10% for Anti HCV positive wives
with and without detectable HCV RNA respectively. The probability of husband to wife transmission was estimated to be 3% and 0% for Anti HCV
positive husband with and without detectable HCV
RNA respectively [10] .
Study risk factors for HCV transmission among
spouses:
The only seen association that carries a significant risk was due to no of sexual intercourse /
month in both female and male spouses and in addition non-sexual factors including occupation, blood
transfusion, circumcision, ear piercing and sharing
shaving blades in male spouses. This non-sexual
risk factors operating among male spouses may in
part be related to exposure particularly to female including trauma during labor.
In this study mean age of HCV positive spouses
of index females or male were [(37.5±9.2 yrs) or
(51.8±9.7 yrs)] higher than that of HCV negative
ones [(49.2±1 1.1 yrs) or (35.4±9.2 yrs)] respectively though the difference was not significant any how
this could be explained that older age results into
increase marital duration so increasing incidence of
HCV transmission. In similar study the mean age
was higher for HCV-positive spouses (57.7 vs 49.6
yr) than for HCV negative spouses ( p-value <0.01)
Wesam S. Morad, et al.
[21] . Regarding Nicotine smoking (Cigarette and
Goza) although the difference was non-significant
but higher percent was found in HCV positive husbands of index female (73.9%) thus, we can’t ignore
nicotine consumption role as a risk factor in HCV
infection. This could be explained in part that sharing Goza might result into increasing risk of HCV
infection especially in cases of diseased HCV cases
with bleeding gums. In similar study, it was found
that nicotine consumption was also higher (41.0%)
in husbands of index female [22] .
History of sharing shaving blades and/or nail
clippers showed no significant difference in HCV
infected husbands of index female versus HCV negative ones (67.4 vs 59.2%) but again higher percent
was found in HCV positive than HCV negative ones
on the other hand it showed significant difference
(p-value <0.05) in HCV infected wives of index
males versus HCV negative ones (92.0 vs 69.3%
OR, 5.09; 95% CI, 1.03–34.1) respectively. It is
possible that, dry blood on shaving blades or nail
cutters might be a source of HCV infection when
shared with others. In similar study it was found that
(87.5%) were sharing nail clippers and (58.3%) of
them were sharing manicure cutters [23] .
Although using teeth brush in common didn’t
show association between significant HCV transmission among spouses but still carry a higher percent among HCV positive spouses compared with
their negative ones. This could be explained by
brush contamination from bleeding gums of HCV
index cases. Terrault, [24] stated that differences between risk groups although in some cases was not
significant yet it may reflect different rates of exposure to non-sexual sources of HCV, such as sharing
nail clippers, manicure cutters or toothbrushes.
In this research endoscopy wasn’t a significant
factor among HCV positive index spouses versus
HCV negative ones, this reflect different rates of
exposure to non-sexual sources of HCV as a higher
percent was found in HCV positive spouses (93.5
vs. 85.2% and 12.0 vs. 8.0%). In similar work done,
Centers for Disease Control and Prevention reported that Patient to patient transmission of HCV occurred via endoscopy [25] .
Past history of IV injections were found equal
(13.0%) between HCV positive husbands of index
females versus their HCV negative ones, while higher percent was found in HCV negative wives of
index male versus their HCV positive ones (75.8%
vs. 92.0%). This again can reflect difference in exposure rate between female and male spouses. In
similar study it showed that the percentage of couples sharing glass syringes was significantly higher
307
among those with both partners infected (65.6% vs
12.9%; OR=12.9; 95% CI=5.4–31.4) [21] .
History of Bilharziasis had no significant difference in positive HCV spouses compared with
their negative ones although still more recorded by
positive HCV female spouses compared with their
HCV negative ones and high in HCV negative male
spouses compared with their HCV positive ones
(58.7 vs. 51.9% and 81.3 vs. 64.0%) respectively.
In other study, it was reported that Egypt has the
highest HCV prevalence worldwide and the use of
parenteral antishistosomal therapy has been implicated in this high rate of infection [26] .
Past history of blood transfusion was still more
recorded by positive HCV infected spouses (20.0%)
in females (11.1%) in males compared with HCV
negative ones but the difference was not significant
in male spouses of index females while, it was carried 6 times more risk in HCV transmission in female spouses of index males than those with negative history respectively. It might be explained that
blood transfusion via inadequate sterilized equipments in street campaigns was a risk factor of HCV
transmission. In similar study it was reported that
(37.5%) of positive HCV spouses gave past history
of blood transfusion [23] .
In this study, it was found that no significant difference (p-value >0.05) was found regarding practicing unprotected sex (sex without condoms) among
HCV positive husbands of index females compared
with their negative ones (100% vs. 98.2%). This reflects monogamous relationships between spouses
which, carry less violence or through vaginal candiasis risk for HCV transmission while sex with
more than one partner carries high risk of HCV infection if not well protected. In agreement with that
was found (96.0%) of husbands of positive spouses
were conducted unprotected sexual intercourse [13] .
In agreement with other authors average duration of marriage in this study was longer among
HCV positive spouses of index females and males
compared with their HCV negative ones (23.5±9.8
vs. 21.9±13.3 and 18.2±10.3 yrs vs. 14.8±8.3 yrs)
respectively. This could be explained by that, marriage usually includes a sexual relationship, but also
other kinds of body contact and exposure to other
risk factors (i.e. sharing the same personal tools
such as toothbrushes, razors and others) may increase risk of HCV transmission between spouses.
Homology analysis on HCV nucleotide sequence is
important in study of sexual transmission of HCV,
but we did not perform homology analysis in this
study because of cost burden so it was not easy to
308
explain the increased rate of HCV infection in couples married for a longer time.
In similar study average duration of marriage was (1521±506.7) & (1532.4±670.2) weeks
(p>0.05) [27] .
In other study, it was found that spouses of antiHCV positive patients were more likely to be infected with HCV than other family members and the infection rate increased with duration of marriage. In
particular, a significant difference was found in the
prevalence of positive anti-HCV between spouses
married for more than 15 years and those married
for a shorter time [28] .
On the contrary, another study done showed that
there is no prevalence of HCV infection between
sexual partners married for 13 years or more. This
discrepancy might be due to differences in studied
samples or due to differences in sexual behavior or
non-sexual risky exposure [29] .
Although average length of sexual relationship
of HCV positive female and male spouses was longer than that of their HCV negative ones (23.4±10.4
vs. 21.6±11.8 and 16.9±10.2 yrs vs. 14.3±7.9 yrs)
respectively but still not a significant risk factor for
HCV transmission.
In this study, it was found that higher percent of
positive HCV female and male spouses gave history
of sexual intercourse more than 4 up to 5 times per
month than HCV negative ones and that they were
more risky to had HCV infection than those practicing sex in fewer times (93.0% vs 7.0%; p-value
<0.01; OR, 11.75; 95% CI, 4.14-34.4 and 96.4% vs
25.9%; p-value <0.01; OR, 77.32; 95% CI, 10.11619) respectively. All couples denied practicing
anal intercourse or sex during menstruation.
In similar study it was reported that The mean
length of sexual relationship was 21.4 years in
which 94.0% of couples were sexually active and
6.0% didn’t and the average rate of sexual intercourse was 1.6 times per week (6.4 times per month)
as estimated for the whole period of partnership [13] .
In other study, the risk of sexual transmission
of hepatitis C virus infection was evaluated among
895 monogamous heterosexual partners of HCV
chronically infected individuals were followed for
10 years in a long-term prospective study. It was
found that the average weekly rate of sexual intercourse was 1.8 [30] .
A highly significant association ( p-value <0.0 1)
was found between PCR viremia degrees in index
females or males and transmission of HCV to their
Transmission of Hepatitis C between Spouses
spouses. Index females and males with high up to
very high viremia transmit HCV infection (63.1
and 92.0%) to their spouses respectively while
those with low up to moderate viremia (36.9 and
8.0%) respectively. In addition, those index female
and male cases with high viremia had greater risk
in transmission of HCV infection to their spouses
than those with lower viremia (OR, 16.7; 95% CI,
5.1–59.1 and OR, 29.6; 95% CI, 5.91–199.7) respectively.
On the other hand no significant association
was found between HCV positive index females
and males versus their HCV negative ones ( p-value >0.05), regarding the rest of risk factors; age,
Education, occupation, common teeth brush, use
of common hand and face towels, sharing shaving blades and/or nail cutters, Cigarette and Goza
smoking, past history of previous operations, hospital admission, endoscopy, mosquito, fleas and tics
bites, chronic diseases history, bilharsiasis, wound
sutures, ear piercing, blood donation, I.V. injections,
teeth treatment or extraction, presence of HCV infected family member at home, using condom at
intercourse, sexual diseases, methods of delivery,
delivery site, who deliver mother, abortion, place of
beard shaving, age at marriage, marital duration and
length of sexual relationship. Although in HCV positive spouses higher percent was found regarding
positive HCV cases versus lower percent in HCV
negative ones thus these risk factors though not
playing seen role in transmission between spouses
yet we can’t exclude completely their role in HCV
transmission among them.
In this study it was found that overall percentage
of HCV transmission between spouses was (35.5%)
where (46.0%) transmission from wife to husband
and (25.0%) from husband to wife.
In a study among spouses in Egypt, it was estimated that wife to husband transmission was 34%
and 10% for Anti HCV positive wives with and
without detectable HCV RNA respectively. The
probability of husband to wife transmission was
estimated to be 3% and 0% for Anti HCV positive
husband with and without detectable HCV RNA respectively [13] .
These later percentage is much lower than that
detected in this study where the overall HCV transmission was (35.5%) this difference in the overall
HCV transmission can be due to the change in the
prevalence of HCV in Egypt possibly increasing by
time also the finding that (80-90%) of female and
male spouses were practicing sex more than 3-4
times/month may increase the likelihood of transmission between spouses. Moreover the significant
Wesam S. Morad, et al.
309
association between degree of viremia among male
and female index groups and the percent of spouses
infected by HCV and the significant relationship
between no of sexual intercourse and percentage
of transmission of HCV infection among spouses,
emphasize that transmission between spouses significantly occur due to sexual contact but we can’t
ignore the significant role of non sexual risk factors
of HCV transmission among married couples such
as type of occupation, sharing clippers or nail cutters and blood transfusion.
Acknowledgments:
This study was supported by cooperation of all
patients and their spouses who responded to my
questionnaire and supplied me with the needed data
that were included in this work.
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