Mojgan Mamani ( Department of Infectious Diseases )
Seyyed Hamid Hashemi ( Department of Infectious Diseases )
Amin Niayesh ( Department of Psychiatry )
Ali Ghaleiha ( Department of Dental Pathology )
Mehrdada Hajilooei ( Department of Dental Pathology, Hamedan University of Medical Sciences, Hamedan, Iran. )
Objective: To study on the frequency of hepatitis B and C infections in chronic psychiatric patients in Day Night Patient Care Centres in Hamedan in 2006-2007.
Methods: This is a cross sectional study done on 170 patients with chronic mental disorders admitted in patient care institutions of Hamedan in 2006-2007. Positive tests for HCV-Ab were confirmed by RIBBA test.
Results: Of 170 patients, 56% were males and 44% were females, (age range 15-71 years). Hepatitis B and C infection was found only in males, with Hepatitis B in 1.8% patients. All of Hepatitis B cases two thirds of Hepatitis C cases were institutionalized in one of the centers.
Conclusions: Overall frequency of Hepatitis B and C infections in chronic psychiatric patients in care centers is more than the general population and centralization of these cases in one center causes transmission of infection if the standard precautions are not observed.
People with severe mental illness represent approximately 2.6% of the US population.1 Criteria for severe mental illness include presence of a major mental illness, chronicity, and pervasive impairment of function.2-5 Such impairments are most often present in schizophrenia spectrum disorders (e.g., schizophrenia, schizoaffective disorder), bipolar disorder, and major depression, which together represent the preponderance of severe mental illness.6
Along with their psychiatric impairment, persons with severe mental illness are at an increased risk for several co morbid conditions as substance use disorder.7 They are also likely to be overrepresented in high-risk categories for infection, not only for HIV but also other pathogens with similar routes of transmission, as hepatitis B virus (HBV) and hepatitis C virus (HCV) In general, people with severe mental illness appear to have increased rates of sexually transmitted diseases (STDs) they are likely to engage in high-risk behaviours such as using injection drugs, having multiple sexual partners and high-risk partners, infrequently using condoms, engaging in same-sex sexual activity, trading sex for money or drugs, and engaging in sex while using psychoactive substances.8-10
These risk factors, along with poverty, a characteristic of people with severe mental illness, raises the concern that this population is also at elevated risk for HBV and HCV infection.
Intensive search has shown no published data on the prevalence of HBV and HCV in people with severe mental illness in Iran.
The aim of this study was to estimate the frequency of hepatitis B and C virus in chronic psychotic patients in Hamadan in 2007.
Patients and Methods
In a descriptive study with permission from Welfare Organization of Hamedan Province, blood smears of all patients in every care centers (170 patients) were taken (5cc). Then serum smears were carried to laboratory for studying and HBs Ag and HCV Ab tests were done in ELIZA. In HCV Ab positive patients RIBBA test was done for confirmation.
This survey was done on 170 chronic psychiatric patients. Of the total 95 (56%) were males and 75 (44%) were females with majority 41 (36%) being between 36-45 years age.
Schizophrenia was the most prevalent disease in 84 (49%) patients and 7 (4%) had behaviour disorders.
Marital status showed that 110 (65%) patients were single and 35 (19%) were divorced.
Of 170 patients 2 (1.2%) had Hepatitis B Infection and 3 (1.8%) had Hepatitis C Infection. All of patients with Hepatitis B Infection and 2/3 of Hepatitis C infected patients were in one of the
Hepatitis B patients were in age group of 36-45 years and Hepatitis C patients were all more than 55 years age. All of the HB patients had the history of addiction and tattoo and half of them had a history of living in prisons. Among patients with HC, one had a prison history, another had undergone a major operation and one patient had unknown risk factors. All patients with HBV were married while 2 with HCV were single and one was divorced.
In the present study 2 patients were infected with HBV and 3 with HCV.
In Freudenreich's study in an outpatient Clinic in US, prevalence of HCV was 8.2%(11), while in Japan, 9.1% Schizophrenic patients were infected with HCV; this figure was considerably high when compared to blood donors.12
Reports indicate that patients with mental illnesses have a high prevalence of HBV infection13-16and the prevalence of this infection in psychiatric patients varies substantially in different countries. In Brazil 22.4% psychiatric patients were positive for HBV infection,17 in Spain it was 81.3%, in Northern Ireland 4.5%,(18,19) in USA 23.4%,20 and in Taiwan it was 18.1% in institutionalized psychiatric patients.21 A study from Singapore showed 12.7% psychiatric patients to be positive for HBsAg, 63.4% HBV surface antibody (HBsAb), and 69% HBV core antibody.22
In Mexico 7.1% patients in a psychiatric hospital were positive for HBV and this was higher when compared with blood donors.23
In another study in Portugal, 1.6% of psychiatric Patients were positive for HBAg.24
The small prevalence of HBV and HCV in the present study, when compared with other studies is presumably due to lower prevalence of Hepatitis in Iran. General prevalence of HBV and HCV in one centers was probably due to shortfalls in observing standard precautions in patient care centers.
In the present study all HBV and HCV infections were seen in males, which is similar to Saeed Saleh's study in Amman 71.5% of HCV infections were reported in males.25
In Taiwan, prevalence of Hepatitis B and C was more in males.13 Reasons for more infections in males could be restricting female psychiatric patients.
All HB infections were in age group of 36-45 years and about HC, all patients were more than 55 years old. In a Mexican study on chronic psychiatric patients, aging was presented as a risk factor for Hepatitis B infection.23 In another survey which was done between 1989 and 1992 in an Italian psychiatric hospital, prevalence and incidence of HBV, HCV and HIV were studied in patients and staffs of hospital. No case of HIV was founded. Prevalence of HBV and HCV in psychiatric patients was respectively 0.99% and 0.24%, and this number was more than blood donor group.28
Chronic psychiatric patients in Day Night care centers with consideration of type of their psychiatric illness and shortage of knowledge about the risks of infectious diseases and not observing standard precautions are prone to Hepatitis infection. Tattoo, addiction, prison history and history of major operation were introduced as risk factors for Hepatitis B infection that are also mentioned in other articles. With considering specific condition of our patients and this reality that some of the patients had no reliable source for getting the information, we can not definitely talk about probable risk factors.
Overall frequency of Hepatitis B and C infections in chronic psychiatric patients in care centers is more than general population. Centralization of most Hepatitis B and C infections in one center can implicate transmission of this infection among chronic psychiatric patients due to not observing standard precautions.
1.Manderscheid RW, Sonnenschein MA. Mental Health, United States, 1996.Washington,DC: US Dept of Health and Human Services 1996.
2.Schinnar A, Rothbard A, Kanter R, Jung Y. An empirical literature review of definitions of severe and persistent mental illness. Am J Psychiatry 1990; 147: 1602-8.
3.Announcement of Community Support System Strategy Development and Implementation. Rockville, Md: National Institute of Mental Health; 1994.
4.Goldman HH, Gattozzi AA, Taube CA. Defining and counting the chronically mentally ill. Hosp Community Psychiatry 1981; 32: 21-7.
5.Goldman HH. Epidemiology. In: Talbott JA, ed. The Chronic Mental Patient: Five Years Later. Orlando, Fla: Grune & Stratton 1984; pp 15-31.
6.Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington DC: American Psychiatric Association 1994.
7.Regier DA, Farmer ME, Rae DS, Locke BZ, Keith SJ, Judd LL, et al. Comorbidity of mental disorders with alcohol and other drug abuse. JAMA 1990; 264: 2511-8.
8.Carey MP, Carey KB, Kalichman SC. Risk for human immunodeficiency virus (HIV) infection among persons with severe mental illnesses. Clin Psychol Rev 1997; 17: 271-91.
9.McKinnon K. Sexual and drug risk behavior. In: Cournos F, Balakar N, eds. AIDS and PeopleWith Severe Mental Illness: A Handbook for Mental Health Professionals. New Haven, Conn: Yale University Press 1996; pp 17-56.
10.Kalichman SC, Kelly JA, Johnson JR, Bulto M. Factors associated with risk for HIV infection among chronic mentally ill adults. Am J Psychiatry 1994; 151: 221-7.
11.Freudenreich O, Gandhi RT, Walsh JP, Henderson DC, Goff DC. Hepatitis C in Schizopherenia: Screening Experience in a Community-Dwelling Clozapine Cohort. Psychomatics 2007; 48: 405-11.
12.Nakamura Y, Koh M, Miyoshi E, Ida O, Morikawa M, Tokuyama A, et al. High prevalence of Hepatitis C virus infection among the inpatients of schizopherenia and psychoactive substance abuse in Japan. Prog Neuro Psychopharmacol Biol Psychiat 2004; 28: 591-7.
13.Feng CS., prevalence of hepatitis B in an adult psychiatric hospital. J Am Geriatr Soc 1982; 30: 326-8.
14.Franson TR, Ksobiech LJ, Simonsen HW. Prevalence of hepatitis B carriers in a mental health in-patient facility: implications for employee screening and vaccination. Psychiatr Hosp 1986; 17: 81-3.
15.Gmelin K, Doerr HW, Middelhoff H, von Ehrlich B, Sann G, Theilmann G, et al. Hepatitis markers in a psychiatric institution. Dev Biol Stand 1983; 54: 545-8.
16.Prats F, Porta Serra M, Yazbeck H, Herrera R, Gasso JM. The prevalence of serological markers for the human immunodeficiency virus and the hepatitis B virus in a psychiatric hospital. Gac Sanit 1990; 4: 179-83.
17.de Souza MM, Barbosa MA, Borges AM, Daher RR, Martins RM, Cardoso DD. Seroprevalence of hepatitis B virus infection in patients with mental problems. Rev Bras Psiquiatr 2004; 26: 35-8.
18.Asensio F, Bayas JM, Bertran MJ, Asenjo MA. Prevalence of hepatitis B infection in long-stay mentally handicapped adults. Eur J Epidemiol 2000; 16: 725-9.
19.Kee F, McGinnity M, Marriott C, Calvert GJ, Shanks OE, O'Neill H, et al. Hepatitis B screening in a northern Irish mental handicap institution: relevance to hepatitis B vaccination. J Hosp Infect 1989; 14: 227-32.
20.Rosenberg SD, Goodman LA, Osher FC, Swartz MS, Essock SM, Butterfield MI, et al. Prevalence of HIV, hepatitis B, and hepatitis C in people with severe mental illness. Am J Public Health 2001; 91: 31-7.
21.Chang TT, Lin H, Yen YS, Wu HL. Hepatitis B and hepatitis C among institutionalized psychiatric patients in Taiwan. J Med Virol 1993; 40: 170-3.
22.Tey BH, Oon CJ, Kua EH, Kueh YK, Wong YW, Chin JH. Prevalence of hepatitis B markers in psychiatric in-patients in Singapore: a pilot study. Ann Acad Med Singapore 1987; 16: 608-11.
23.Esquivel CA. Hepatitis B virus infection among inpatients of a psychiatric hospital of Mexico. Clean Pract Epidemol Ment Health 2005; 1: 10.
24.Cournos F, McKinnon K, Jumaian N. Schizophrenia and Comorbid Human Immunodeficiency Virus or Hepatitis C Virus, Juin Psychiatry 2005; 66: 24-33.
25.Said WM, Saleh R, Jumaian N. Prevalence of Hepatitis B Virus Among Chronic Schizophrenia Patients. East Mediterr Health J 2001; 7: 562-30.
26.Di Nardo V,Petrosillo N, Ippolito G, Bonaventura ME, Puro V, Chiaretti B, et al. Prevalence and incidence of hepatitis B virus, hepatitis C virus, and human immunodeficiency virus among personnel and patients of a psychiatric hospital. Eur J Epidemiol 1995; 11: 239-42.