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PLOS Glob Public Health
PLOS Glob Public Health
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PLOS Global Public Health
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Public Library of Science San Francisco, CA USA

10.1371/journal.pgph.0002447
PGPH-D-23-01433
Research Article
Medicine and health sciences
Medical conditions
Infectious diseases
Viral diseases
Hepatitis
Hepatitis B
Medicine and health sciences
Gastroenterology and hepatology
Liver diseases
Infectious hepatitis
Hepatitis B
Medicine and Health Sciences
Gastroenterology and Hepatology
Liver Diseases
Liver Disease and Pregnancy
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Pathology and laboratory medicine
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Biology and life sciences
Organisms
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Medicine and Health Sciences
Women's Health
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Medicine and Health Sciences
Women's Health
Obstetrics and Gynecology
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People and Places
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Africa
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Women's Health
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Antenatal Care
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Epidemiology
Medical Risk Factors
Medicine and Health Sciences
Health Care
Health Care Facilities
Correlates of Hepatitis B infection in pregnant women attending antenatal clinics in Wa Municipality, Ghana
Determinants of increasing maternal viral Hepatitis B infection in Wa Municipality, Ghana
Awiah Emmanuel Anebakwo Conceptualization Formal analysis Funding acquisition Methodology Resources Writing – original draft 1
https://orcid.org/0000-0002-5580-4909
Aabalekuu Simon Investigation Methodology Resources Writing – original draft 2 *
https://orcid.org/0000-0003-2791-0103
Dun-Dery Frederick Formal analysis Methodology Resources Supervision Writing – review & editing 3
https://orcid.org/0000-0002-5551-5031
Dun-Dery Elvis Junior Conceptualization Methodology Resources Writing – review & editing 4
https://orcid.org/0000-0002-2703-8856
Bayor Fidelis Data curation Resources Writing – review & editing 5
https://orcid.org/0000-0003-0167-5512
Adokiya Martin Nyaaba Methodology Resources Supervision Writing – review & editing 6
Bessing Barnabas Formal analysis Supervision Writing – original draft Writing – review & editing 7
1 Wa Municipal Health Administration, Upper West Region, Wa, Ghana
2 Department of Public Health, Regional Health Directorate, Upper West Region, Wa, Ghana
3 Department of Paediatrics, Cumming School of Medicine, University of Calgary, Alberta, Canada
4 Department of Public Health, Purdue University, West Lafayette, IN, United States of America
5 Department of Anaesthesiology, Lawra Municipal Hospital, Ghana Health Service, Wa, Ghana
6 Department of Epidemiology and Biostatistics, School of Public Health, University for Development Studies, Tamale, Ghana
7 World Health Organization, Ghana Country Office, Accra, Ghana
Atulomah Nnodimele Onuigbo Editor
Babcock University, NIGERIA
The authors have declared that no competing interests exist.

* E-mail: aabalekuusimon78@gmail.com
10 9 2024
2024
4 9 e000244714 8 2023
13 8 2024
© 2024 Awiah et al
2024
Awiah et al
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Despite the availability of an effective vaccine against viral hepatitis B infection, it remains prevalent, highly transmissible especially through mother-to-child, life-threatening, and a major public health challenge. A positive Hepatitis B e-Antigen (HBeAg) mother has a 90% risk of transmitting the virus to the unborn child in the perinatal period. This study sought to determine the prevalence and risk of Hepatitis B infection among pregnant women in the Wa Municipality of Ghana. A cross-sectional study employing systematic random sampling was conducted among 183 consented pregnant women who went for antenatal care in nine health facilities in the Wa Municipality. A structured validated questionnaire was used to collect information about socio-demographic and obstetric characteristics, awareness of Hepatitis B Virus (HBV) transmission and its prevention. Blood samples (3.0 mls) were collected from each participant to test for HBV serum markers using a Wondfo One Step HBV rapid immunochromatographic assay (Catalog number W003) for the Hepatitis B surface antigen (HBsAg). We conducted descriptive statistics including the prevalence and used multivariable logistic regression to determine the risk of Hepatitis B among study participants. Data was analysed using Stata/SE 15. About 20.2% of the 183 pregnant women screened tested positive for HBsAg. Generally, compared with younger pregnant women, older (> = 25) pregnant women were >9 times less likely to test positive for both chronic Hepatitis B core antibody (HBcAb) and (HBeAg) Hepatitis B infections. However, pregnant women in polygamous relationship were more likely to test positive for both (HBcAb) and (HBsAg and HBeAg) Hepatitis B infections compared with those in monogamous relationship. In a multivariable analysis, pregnant women in a polygamous relationships were about 5 times more likely to test positive for HBsAg (AOR = 4.61, 95% CI: 2.06–9.89) and HBcAb (AOR = 4.89, 95% CI:1.52–6.81) and HBeAg (AOR = 4.62, 95% CI:1.21–6.39) compared with those in a monogamous relationship. This study highlights a high HBsAg prevalence among pregnant women with those in polygamous relationship and younger age more likely to test positive. Facility and community-based health services should emphasize the need for regular screening, education, and vaccination of pregnant women, especially those at high risk, to prevent mother-to-child transmission of viral hepatitis B.

The authors received no specific funding for this work. Data AvailabilityAll the relevant data regarding this work are presented in the paper.
Data Availability

All the relevant data regarding this work are presented in the paper.
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pmcIntroduction

Despite the availability of a highly effective vaccine against viral hepatitis B virus (HBV) infection, the disease has become more prevalent, life-threatening, and a tremendous public health challenge, especially in sub-Saharan Africa (5%) including Ghana, even though it is twice as much (10%) in Asia [1]. According to estimates, about 8% of Ghana’s population has chronic Hepatitis B surface antigen (HBsAg) in 2020 [2, 3] with 6% among pregnant women [4]. Mother-to-Child transmission during delivery is one of the major routes of infection among children, resulting in the chronicity of the diseases with heightened risks of developing liver complications such as cirrhosis, hepatocellular carcinoma, and liver failure [5, 6]. In contrast, sexual contact is one of the transmission routes for HBV infection amongst high-risk adults in areas of low endemicity [7]. About 87%-90% of patients infected with HBV may either develop immunity or become chronic carriers, especially among those infected at infancy [8], leading to the risk of developing liver cirrhosis or liver cancer [9]. The most effective way to prevent HBV transmission to newborns is to identify HBV-positive pregnant women and timely initiation of approved interventions such as immunoglobin [10]. Thus, screening asymptomatic people is an important instrument in disease detection, prompt diagnosis, and intervention, particularly at an early stage [11]. To prevent mother-to-child transmission, a child born to a positive HBsAg mother should receive the Hepatitis B vaccine and the Hepatitis B immune globulin within 12 hours of birth, which provides over 95% protection against HBV infection [1, 12].

Women, especially of younger reproductive maternal age [13, 14], with chronic HBV infection remain a major source of the continued spread of the virus. As such, young maternal age is a high-risk factor for contracting HBV, aside from polygamous marital relationship [15–17], among other factors. Therefore, pregnant women need screening to detect the virus in prenatal care to enable early intervention [18].

Even though there have been studies in Ghana covering various aspects of hepatitis B among pregnant women, the evidence about the prevalence remains limited in the Upper West Region (UWR) of Ghana. A recent rural-urban study documented a low knowledge level of mother-to-child transmission among pregnant women in two districts of the UWR [19]. In 2020, a systematic review of the HBV prevalence in the Ghanaian population further emphasized the poor documentation of HBV-prevalence data across the country [20] and the lack of it in the UWR in particular [21]. Thus, this study explored the prevalence and associated factors of HBV among pregnant women in the Wa Municipality, Ghana to bridge this gap in the dearth of prevalence data.

Materials and method

Study design and setting

A facility-based cross-sectional study was conducted among pregnant women. A questionnaire was administered to gather key demographic data and awareness on transmission and prevention of the HBV infection in the municipality. The study was carried out in Wa Municipality, the capital town of the UWR of Ghana.

Selection of antenatal care (ANC) health facilities

Nine public health facilities in the town of Wa offer prenatal care services, namely the UWR hospital, Wa municipal hospital, Wa urban health centre, Charia health centre, Kambali health centre, Charingu health centre, Bamahu health centre, Busa health centre, and Kpongu health center.

Study participants and sampling

The study sample comprised pregnant women who attended antenatal care (ANC) in the Wa municipality from June 1–30, 2018. Considering the prevalence of 13.1% HBV infection among pregnant women in the country [22], the original sample size estimated was 175 based on the formula (n = Z2pq/d2) as suggested by Cochrane in 1977 [23]. However, after adjusting for a non-response rate of 5%, the estimated sample size increased to approximately 184 participants. Consecutive sampling was used for the selection of pregnant women attending the ANC. Pregnant women who met the inclusion criteria (attended antenatal services from June 1–30, 2018) were recruited to achieve the desired sample size. The proportion of study participants selected from each health facility was determined by the total number of the average registered ANC clients relative to each facility in the previous two months. The process was repeated every ANC day till the sample size was met. The regional hospital was purposively selected due to its central location and the fact that a substantial proportion of pregnant women in the municipality accessed antenatal care services from there. Pregnant women who had emergency conditions such as pre-eclampsia and eclampsia requiring urgent medical attention at the time were excluded from the study.

Data collection

A structured questionnaire was used to collect the data. We collected data on respondents’ socio-demographic characteristics, obstetric and gynaecological variables, and their awareness of mother-to-child transmission and prevention of HBV infection. We also collected three millilitres (3mls) of blood samples through venipuncture into ethylenediaminetetraacetic acid (EDTA) tube to measure the seroprevalence of HBsAg. The laboratory technologist cleaned the site with an alcohol swab before collecting three 3mls of blood for testing. We used a Wondfo One Step HBV rapid immunochromatographic assay (catalog number W003) for Hepatitis B envelop antibody (HBsAg), HBeAg, and Hepatitis B Core Antibody (HBcAb), HBeAb, and HBsAb because it is not automated and does not require any additional instrument. The Wondfo One Step rapid diagnostic test kit has relatively comparably high sensitivity (≥ 98%) and specificity (≥96%) [24] ratings as other rapid diagnostic test kits. The venous blood samples were stored under the recommended standard cold chain temperature range of 2°C to 8°C and transported in a vaccine carrier to Care Diagnostic Laboratory (CDL), a private laboratory in the study area. CDL is the best laboratory to produce faster and quality serum analysis results in the study area. All samples were analysed within 8 hours after collection.

Potential risks

This study had minimal risk of pain associated with the venipuncture procedure.

Laboratory procedure and sample analysis

Before testing, the test kit and specimen were kept at room temperature (10°C-30°C). We opened the pouch at the notch to remove the cassette and placed it on a clean, flat surface. We labelled the cassette with the specimen identification number to be tested. We pipetted and filled the plastic dropper with the specimen. Holding the dropper vertically, we dispensed 1 drop of the specimen (about 40–50 μL for whole blood, 30–45 μL for serum/plasma) into the sample pad, ensuring no air bubbles. Then added one (1) drop (about 35–50 μL) of sample diluent and read the results in 15 minutes, even though some positive results were visible within a minimum of one (1) minute. We performed all the tests following the manufacturer’s instructions with adequate controls.

Reading and interpretation of results according to Medscape

Results of HBV serologic markers were reported qualitatively:

Positive (+) test results: (1) For HBsAg, HBsAb, HBeAg; the test was considered positive if a rose-pink band appeared and was visible in the control region and within the appropriate test region and (2) For HBeAb and HBcAb; the test was considered positive if a rose-pink band was visible only in the control region, and no colour band appeared in the appropriate test region.

Negative (-) test results: (1) For HBsAg, HBsAb, and HBeAg; the test was negative if a rose-pink band was visible only in the control region. No color band appears in the appropriate test region and (2) For HBeAb and HBcAb; the test was negative if the rose-pink band was visible in the control and appropriate test regions.

Invalid test results: the test was invalid if no visible band appeared or if there was a visible band only in the test region but not in the control region.

Ethical considerations and consent

We obtained ethical approval from the Ghana Health Service Ethics Review Committee (GHSERC-029/01/18). We explained the study protocol, including potential risks/benefits of participation, to pregnant women in English and the local languages before their consented enrolment. Written informed consent was obtained from eligible women while verbal consent was obtained from participants who neither spoke nor understood the English language. In the case of the few minors, the research assistants contacted the parent or guarantor listed in the participant’s ANC records via phone call to seek their verbal consent after the study protocol was explained to them. Questionnaires were assigned unique serial numbers without participants names or other personally identifiable information. We ensured that the serial numbers corresponded to the unique ID numbers on the sample collection containers to avoid the possibility of misclassification of samples and/test results. As the research information is purely for academic purposes, we encrypted soft copies whilst hard copies were stored under lock and key.

Data analysis

After data collection, one participant withdrew her consent to participate. Thus, a total of 183 participants were included in the analysis. Descriptive statistics on socio-demographic, hepatitis B prevalence, and awareness variables were presented as frequencies, proportions and means using tables. A Chi-square Test was used to determine if there was a significant relationship between the covariates and our outcome variables. To evaluate associations with Hepatitis B serological markers, we used logistic regressions to obtain Odds Ratio (OR) along with 95% confidence intervals (CI). To identify the factors that remained independently associated with the Hepatitis B serological markers (our outcomes), we fitted a single multivariable logistics regression model that, at the onset, included all covariates and potential confounders for which a Wald test of their estimated coefficient yielded p<0.05 in the univariable logistics analyses. This resulted in estimation of Adjusted Odds Ratio (AOR) with 95% CI. The model goodness of fit was assessed based on low Akaike Information Criterion (AIC), and Hosmer-Lemeshow test. Stata/SE 15 was used for all analyses.

Results

Socio-demographic characteristics of participants

The average (mean) age of participants was 32 years. The majority (60.1%) of the study participants were between 25–34 years of age, married (92.1%), self-employed (43.2%), had a tertiary level of formal education (34.4%), and acknowledged Islam as their religion (73.2%) as shown in Table 1.

10.1371/journal.pgph.0002447.t001 Table 1 Socio-demographic characteristics of pregnant women in Wa Municipality.

Variable	Measurement	
Age group (in years)	Frequency	Percentage (%)	
 15–24	49	26.8	
 25–34	110	60.1	
 ≥35	24	13.1	
Marital Status			
 Not married	13	7.1	
 Married	170	92.9	
Occupation			
 Civil servant	43	23.5	
 Unemployed	35	19.1	
 Self-employed	79	43.2	
 Student	26	14.2	
Level of education			
 No formal education	28	15.3	
 Primary	18	9.9	
 Junior High	41	22.4	
 Senior High/Vocational training	33	18.0	
 Tertiary	63	34.4	
Parity			
 Primiparous (1)	62	33.9	
 Multiparous (2–4)	95	51.9	
 Multiparous (>4)	26	14.2	
Stage of pregnancy (Gestation)			
 First trimester	28	15.3	
 Second trimester	72	39.3	
 Third trimester	79	43.2	
Religious affiliation			
 Islam	134	73.2	
 Christianity	49	26.8	
 Traditionalist/Traditionalist	0	0	
Area of residence			
 Urban	112	61.2	
 Rural	71	38.8	

Prevalence of Hepatitis B serological markers

Fig 1 shows the distribution of Hepatitis B markers among pregnant women attending ANC. Out of the 183 sera examined, 20.2%, 7.1% and 18.6% of the pregnant women tested positive for HBsAg, HBeAg, and HBcA, respectively.

10.1371/journal.pgph.0002447.g001 Fig 1 The prevalence of Hepatitis B biomarkers amongst study participants.

Awareness of Hepatitis B virus transmission and prevention

In this study, majority (89.1%) of the 183 pregnant women surveyed demonstrated awareness of HBV transmission indicating a high level of knowledge regarding this health concern. More than half (57.0%) of the respondents knew that HBV could be transmitted through unprotected sex, kissing (55.7%), and transfusion of infected blood and blood products (51.4%). In addition, 71.0% indicated that HBV could be cured (see Table 2).

10.1371/journal.pgph.0002447.t002 Table 2 Awareness of Hepatitis B among pregnant women in the Wa Municipality.

Awareness questions	Response frequency N (%)	
Yes	No	Do not know	
Ever heard of Hepatitis B	163 (89.1)	20 (10.9)	0(0.0)	
Hepatitis B can be transmitted through unsterilized needles, blades, and other sharp materials	65 (35.5)	118(64.5)	0(0.0)	
Hepatitis B can be transmitted by infected blood and blood products	94 (51.4)	89 (48.6)	0(0.0)	
Hepatitis B can be transmitted through kissing	102 (55.7)	81 (44.3)	0(0.0)	
Hepatitis B can affect any person	138 (75.4)	35 (19.1)	10 (5.5)	
Hepatitis B can be prevented by vaccination	146 (79.8)	30 (16.4)	7(3.8)	
Hepatitis B is transmitted through unsafe sex	104 (56.8)	79 (43.2)	0(0.0)	
Hepatitis B can be cured	129 (70.5)	49 (26.8)	5(2.7)	
Hepatitis B can be transmitted from an infected mother to an unborn child	40 (21.9)	143(78.1)	0(0.0)	

Factors associated with hepatitis B virus serological markers

From Table 3, we did not find a statistically significant relationship between occupation, marital status, gravida, gestation, educational level, residence, history of blood transfusion, body piercing, tattooing and family history of HBV infection and our outcomes (HBsAg, HBcAb, HBsAb, and HBeAb). However, there was a significant test of trend amongst age group for HBeAg (p = 0.01) and marital type for HBsAg (p = 0.01), HBcAb (p = 0.01) and HBeAb (p = 0.04).

10.1371/journal.pgph.0002447.t003 Table 3 Chi-square test of association between participants’ socio-demographic characteristics and their HBsAg, HBeAg, and HBcAb status.

Variable	HBsAg	HBeAg	HBcAb	HBsAb	HBeAb	
(%)	p-value	(%)	p-value	(%)	p-value	(%)	p-value	(%)	p-value	
Age		
 15–24	32.4	0.26	53.9	0.01	32.3	0.20	33.3	0.99	31.6	0.77	
 25–34	48.8	23.1	57.5	66.6	57.9	
 ≥35	18.9	23.1	20.6	0.0	10.6	
Occupation		
 Civil servant	10.8	0.19	7.7	0.43	8.8	0.10	33.3	0.47	10.5	0.11	
 Unemployed	21.6	23.1	20.6	33.3	15.8	
 Self-employed	48.7	61.5	50.0	0.0	42.1	
 Student	18.9	7.7	20.6	33.3	31.6	
Marital Status		
 Single	13.5	0.09	23.1	0.06	14.7	0.07	0.0	0.89	5.3	0.88	
 Married	86.5	76.9	85.3	100	94.7	
Gravida		
 Primigravida	35.1	0.59	38.5	0.81	35.3	0.80	33.3	0.91	31.6	0.92	
 Multigravida (2–4 children)	46.0	46.2	44.1	66.7	57.9	
 Multigravida (>4 children)	18.9	15.4	20.6	0.0	10.5	
Gestation		
 1st trimester	16.2	0.52	23.1	0.12	14.7	0.74	33.3	0.46	26.3	0.48	
 2nd trimester	48.7	61.5	47.1	66.7	31.6	
 3rd trimester	35.1	15.4	38.2	0.0	42.1	
Education level		
 None	21.6	0.69	15.4	0.38	20.6	0.80	0.0	0.66	10.5	0.71	
 Primary	10.8	15.4	11.8	0.0	15.8	
 JHS	24.3	38.5	23.5	33.3	21.0	
 SHS/Vocational	13.5	15.4	14.7	0.0	10.5	
 Tertiary	29.7	15.4	29.4	66.7	42.1	
Tribal marks	48.7	0.27	53.9	1.00	47.1	0.25	33.3	0.41	42.1	0.17	
Blood transfusion	16.2	0.51	7.7	1.00	17.7	0.48	33.3	0.51	10.5	0.77	
Tattoo	13.5	0.79	15.4	0.67	11.8	1.00	0.0	0.51	5.3	0.31	
Multiple piercing	43.2	0.85	53.9	0.39	47.1	0.56	66.7	0.37	42.1	0.96	
Family history	7.7	0.47	7.7	0.47	17.7	0.82	-	-	-	-	
Residence		
 Urban	56.8	0.57	69.2	0.77	58.8	0.85	-		-		
 Rural	43.2	30.8	41.2	-	-	
Marital type		
 Polygamy	51.4	0.01	46.2	0.04	41.2	0.01	33.3	0.82	41.2	0.05	
 Monogamy	37.8	45.2	47.1	66.7	58.2	
Immunized against HBsAg (Yes only)	13.5	0.09	23.1	1.00	11.8	0.07	33.3	0.92	10.5	0.23	
Statistically significant at P<0.05

In our univariate analyses (Table 4), occupation, marital status, gravida, gestation, educational level, residence, history of blood transfusion, body piercing, tattooing and family history of Hepatitis B, residence are not significantly associated with a positive test for HBsAg, HBcAb, HBsAb, and HBeAb. However, age and marital type are significantly associated with a positive test for HBsAg, HBeAg, and HBcAb. For instance, pregnant women aged 25–34 (AOR = 0.61, 95% CI:0.27–0.89) and ≥35 (AOR = 0.59, 95% CI:0.39–0.68) years were less likely to test positive for HBeAg compared with pregnant women age between 15–24 years.

10.1371/journal.pgph.0002447.t004 Table 4 Univariable logistic regression of covariates with Hepatitis B markers among pregnant women attending antenatal care in Wa Municipality.

Variable	HBsAg	HBeAg	HBcAb	HBsAb	HBeAb	
COR (95% CI)	COR (95% CI)	COR (95% CI)	COR (95% CI)	COR (95% CI)	
Age		
 15–24	Ref (1.00)	Ref (1.00)	Ref (1.00)	Ref (1.00)	Ref (1.00)	
 25–34	1.03 (0.06–5.39)	0.61 (0.27–0.89)	0.48 (0.08–0.90)	1.08 (0.41–1.79)	1.08 (0.24–2.27)	
 ≥35	1.05 (0.62–5.71)	0.59 (0.39–0.68)	0.42 (0.03–0.68)	1.06 (0.12–1.64)	1.09 (0.40–2.80)	
Occupation		
 Civil servant	Ref (1.00)	Ref (1.00)	Ref (1.00)	Ref (1.00)	Ref (1.00)	
 Unemployed	1.14 (0.98–1.31)	0.85 (0.44–1.65)	0.71 (0.33–1.53)	1.10 (0.93–1.29)	0.98 (0.72–1.34)	
 Self-employed	1.07 (0.87–1.32)	0.86 (0.48–1.56)	0.68 (0.41–1.13)	0.56 (0.24–1.28)	1.01 (0.66–1.56)	
 Student	0.79 (0.60–1.04)	0.65 (0.35–1.19)	1.03 (0.82–1.30)	0.50 (0.22–1.09)	1.04 (0.87–1.25)	
Marital Status		
 Single	Ref (1.00)	Ref (1.00)	Ref (1.00)	Ref (1.00)	Ref (1.00)	
 Married	1.01 (0.91–1.13)	0.93 (0.78–1.11)	1.09 (0.56–2.12)	0.75 (0.46–1.22)	0.91 (0.86–1.19)	
Gravida		
 Primigravida	Ref (1.00)	Ref (1.00)	Ref (1.00)	Ref (1.00)	Ref (1.00)	
 Multigravida (2–4 children)	0.93 (0.78–1.11)	1.05 (0.70–1.56)	1.25 (0.66–2.36)	0.91 (0.73–1.12)	0.98 (0.96–1.00)	
 Multigravida (>4 children)	1.16 (0.74–1.82)	1.01 (0.52–1.95)	1.19 (0.98–1.45)	1.00 (0.91–1.10)	0.93 (0.85–1.01)	
Gestation		
 1st trimester	Ref (1.00)	Ref (1.00)	Ref (1.00)	Ref (1.00)	Ref (1.00)	
 2nd trimester	0.91 (0.77–1.10)	1.09 (0.56–2.12)	1.07 (0.87–1.32)	0.91 (0.86–1.19)	1.03 (0.82–1.30)	
 3rd trimester	1.01 (0.91–1.13)	0.93 (0.78–1.11)	1.01 (0.66–1.56)	0.75 (0.46–1.22)	1.07 (0.98–1.17)	
Education level		
 None	Ref (1.00)	Ref (1.00)	Ref (1.00)	Ref (1.00)	Ref (1.00)	
 Primary	1.11 (0.71–1.69)	1.32 (0.62–2.80)	1.01 (0.91–1.12)	0.96 (0.63–1.47)	1.68 (0.75–3.77)	
 JHS	0.94 (0.77–1.10)	0.95 (0.56–1.34)	1.02 (0.86–1.22)	1.35 (0.85–2.16)	0.54 (0.15–1.95)	
 SHS/Vocational	0.51 (0.13–1.92)	1.10 (0.92–1.31)	0.79 (0.39–1.59)	1.41 (0.79–2.51)	0.47 (0.12–1.77)	
 Tertiary	1.07 (0.98–1.17)	1.74 (0.49–2.01)	1.39 (0.15–1.67)	1.51 (0.04–2.18)	1.14 (0.03–1.26)	
Tribal marks	1.16 (0.05–1.28)	1.19 (0.08–1.30)	0.49 (0.37–1.65)	0.66 (0.05–1.88)	1.09 (0.85–1.96)	
Blood transfusion	0.16 (0.94–1.98)	0.97 (0.96–1.98)	0.88 (0.82–1.95)	1.04 (0.01–1.07)	1.04 (0.07–1.07)	
Tattoo	1.02 (0.01–1.03)	1.00 (0.99–1.01)	0.99 (0.96–1.01)	0.97 (0.91–1.03)	0.93 (0.83–1.03)	
Multiple piercing	0.87 (0.79–1.96)	1.06 (0.97–1.16)	0.91 (0.01–1.92)	1.00 (0.99–1.01)	1.01 (0.99–1.01)	
Family history	1.04 (0.09–1.07)	1.01 (0.98–1.05)	0.95 (0.03–1.97)	0.09 (0.05–1.97)	1.04 (0.96–1.13)	
Residence		
 Urban	Ref (1.00)	Ref (1.00)	Ref (1.00)	Ref (1.00)	Ref (1.00)	
 Rural	1.09 (0.70–1.68)	0.91 (0.77–1.10)	1.11 (0.92–1.33)	1.01 (0.85–1.20)	1.01 (0.91–1.13)	
Marital type		
 Polygamy	Ref (1.00)	Ref (1.00)	Ref (1.00)	Ref (1.00)	Ref (1.00)	
 Monogamy	2.61 (1.27–4.04)	2.57 (1.42–5.74)	2.85 (1.41–6.79)	1.89 (0.27–2.82)	2.74 (0.61–4.62)	
Immunized against HBsAg (Yes only)	1.46 (0.22–1.75)	1.48 (0.25–1.75)	1.75 (0.51–2.02)	1.70 (0.46–1.96)	1.51 (0.96–2.36)	
COR: crude odds ratio, Data in bold are P<0.05

From Table 5, our multivariable logistic regression analyses found that pregnant women aged 25–34 (AOR = 0.21, 95% CI:0.01–0.78) and ≥35 (AOR = 0.24, 95% CI:0.05–0.62) years were less likely to test positive for HBeAg compared with pregnant women age between 15–24 years. This was similar with HBcAb were women age between 25–34 (AOR = 0.42, 95% CI: 0.09–0.80) and ≥35 (AOR = 0.31, 95% CI:0.06–0.45) were less likely to test positive compared with pregnant women age between 15–24 years.

10.1371/journal.pgph.0002447.t005 Table 5 Multivariable logistic regression of selected covariates with Hepatitis B markers among pregnant women attending antenatal care in Wa Municipality.

Variable	HBsAg	HBcAb	HBeAg	
AOR (95% CI)	AOR (95% CI)	AOR (95% CI)	
Age group	
 15–24	Ref (1.00)	Ref (1.00)	Ref (1.00)	
 25–34	0.89 (0.01–1.78)	0.42 (0.09–0.80)	0.21 (0.01–0.78)	
 ≥35	0.91 (0.12–1.6)	0.31 (0.06–0.45)	0.24 (0.05–0.62)	
Marital type	
 Monogamy	Ref (1.00)	Ref (1.00)	Ref (1.00)	
 Polygamy	4.61 (2.06–9.89)	4.89 (1.52–6.81)	4.62 (1.21–6.39)	
AOR: Adjusted Odds Ratio; CI: Confidence Interval; data in bold are P<0.05

On the contrary, pregnant women in the polygamous relationship were 5 times more likely to test positive for HBsAg (AOR = 4.61, 95% CI: 2.06–9.89), HBcAb (AOR = 4.89, 95% CI:1.52–6.81), and HBeAg (AOR = 4.62, 95% CI: 1.21–6.39) compared to pregnant women in monogamous relationship.

Discussion

Prevalence and associated factors of hepatitis B virus serological markers

The study assessed the current prevalence of HBV and its associated factors among pregnant women in the Wa Municipality of Ghana. Our study reveals a 20.2% one-point seroprevalence of HBV infections among pregnant women. This prevalence is three times higher than the national prevalence [3] as well as other studies that reported between 9.7% and 16.7% HBsAg prevalence among pregnant women in Ghana and Cameroon [3, 6, 25]. Differences in study designs, variations in general HBsAg prevalence, varied laboratory test methods of sera, and vaccination uptake rates across the local study populations could explain the variations in observed prevalence between our study and previous research in Cameroon and Ghana [3, 6].

Our results further revealed that similar to many related studies, younger pregnant women (15–34 years), more than half (56.8%) of those in the urban area, and most of the formally educated pregnant women were positive for HBsAg compared to their rural counterparts[10, 25, 26], [27, 28]. The high HBsAg prevalence recorded among the younger pregnant mothers in this study complements the results of a related study in Germany, where persons below 30 years were 2.4% more likely to be HBsAg-positive [13], but contradicts findings of no infection among pregnant women in the Ho municipality of Ghana[20].

However, even though the HBsAg-positivity is much more prevalent among the young, formally educated, and urban pregnant women in this study, only less than one-tenth of them were seropositive for HBeAg. The low HBeAg is significant for clinical practice as it suggests that despite the high HBsAg prevalence rate, most infections were inactive and may not be virulent. Contrary to findings of a statistically significant association between low formal education and high HBsAg-positivity in Brazil [29], the high HBsAg-positivity among formally educated in this study is likely only quantitative because this study has a higher proportion of formally educated respondents. The observed difference in seroprevalence could also be due to the type of testing equipment, the reagent and assay used for testing, or the endpoints considered in the respective studies. The highest HBsAg-positivity among the age group 15–24 years in this study also confirms findings of similar studies in Island and Taiwan [30, 31]. The findings on age group and HBeAg-positive were statistically significant and comparable to a study in Cameroon [32].

Regarding the vaccination rate against Hepatitis B, only about a third of pregnant women in this study were vaccinated before the screening, and about a tenth of the vaccinated tested positive for HBsAg without any statistical significance. Contrary to this finding, results from a similar study in Madagascar found no HBsAg-positive women even though the women had no history of Hepatitis B vaccination [2]. The type, method of storage of the vaccine, and the influence of the accuracy of the HBsAg test before vaccination could account for the different outcomes.

We also found that polygamous pregnant women were about five times more likely to be HBsAg-positive than those in monogamous marital relationships. This result confirms the findings of other studies conducted in Ethiopia, Kenya, and Nigeria [26, 32–34]. Generally, the known risk factors for HBV infection—blood transfusion, tribal marks, multi-piercings, and tattooing did not show any statistically significant association with HBsAg-positivity in this study. This finding confirms the results of a similar study in Ethiopia [34], but contradicts previous studies in Cameroon [35–37]. The observation of no association between HBV infection and the measured characteristics in our study compared to the Cameroonian studies could be due to varied HBV prevalence in the respective general populations, including variations in cultural and behavioural norms across the two study areas.

Awareness of mother-to-child transmission of Hepatitis B and its prevention

Comparable to findings of similar studies [6, 32], over three-quarters of the pregnant women in the current research knew that HBV could be transmitted through risky lifestyles such as unprotected sexual intercourse [6, 32]. However, most pregnant women in this study did not know the possibility of mother-to-child transmission. This finding is contrary to a similar Chinese study where most pregnant women knew that their babies were highly susceptible to infection from their infected mothers, even in vitro, but did not know about transmission risks via unprotected sexual intercourse [38]. Compared to the Chinese study, this difference could be due to insufficient opportunities for health education on the Hepatitis B virus among the respondents in the current study.

Limitations

This study was conducted in only four of the nine public health facilities in the Wa municipality due to resource constraints. As such the findings reported here could be different and generalizability should be applied with caution. We also acknowledge the detectability of HBsAg in our sample could be influenced by both the assay’s sensitivity and the stage of the HBV infection. Early and very late stages of the disease might result in levels of HBsAg that are difficult to detect, and this variability is a critical consideration for interpreting test results accurately, and therefore the real-life applicability of our findings.

Additionally, we acknowledge that the study did not comprehensively explore all known relevant factors with the likelihood of influencing the natural history of HBV infectivity based on the dynamics of epidemiological principles, the public health principles of prevention and control and the framework of the modifiable risk factors of the population of interest. Therefore, the results presented here should be contextually interpreted and applied when needed.

Conclusion

One in five of the pregnant women in the study area were HBsAg-positive. The findings of this study highlight the need for routine screening and vaccination of pregnant women, particularly those at high risk, to prevent the transmission of hepatitis B viral infection to their offspring. Facility and community-based antenatal health education should also focus on increasing maternal knowledge of the mother-to-child transmission route of HBV.

10.1371/journal.pgph.0002447.r001
Decision Letter 0
Atulomah Nnodimele Onuigbo Academic Editor
© 2024 Nnodimele Onuigbo Atulomah
2024
Nnodimele Onuigbo Atulomah
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Submission Version0
10 Oct 2023

PGPH-D-23-01433

Hepatitis B viral infection and associated factors among pregnant women attending antenatal care in Wa Municipality, Ghana.

PLOS Global Public Health

Dear Mr. Aabalekuu,

Thank you for submitting your manuscript to PLOS Global Public Health. After careful consideration, we feel that it has merit but does not fully meet PLOS Global Public Health’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

EDITOR: 

The authors are kindly encouraged to consider all the recommendations made by the reviewers for revision,

Attention has been called on the development of the variables, statistical analysis, and how the data is reflected in the discussion of findings,

The abstract needs revision, particularly, the omissions in the reporting of the data related to the odds ration statistic and the corresponding 95% confidence intervals.

Please submit your revised manuscript by 28 October 2023. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at globalpubhealth@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pgph/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

We look forward to receiving your revised manuscript.

Kind regards,

Nnodimele Onuigbo Atulomah, PhD

Academic Editor

PLOS Global Public Health

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Additional Editor Comments (if provided):

Two reviewers assessed the manuscript thoroughly and made their observations and recommendation. I agree with these observations as well. Considering how important the subject of the study is, especially with regards of providing better understanding of the dynamics involved with the problem phenomenon, I am requesting the authors to consider every recommendations made and revise as suggested.

Kindly address the issues raised about the theoretical basis of the study, the statistical analysis conducted. I am worried about the application of certain statistical analysis such as logistic regression which is the preferred tool for appropriately expressing the predictive value of the predictor variables. This has been inappropriately used in this study. Tidy the statistical analysis.

I would recommend this article: https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-022-14723-3

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Does this manuscript meet PLOS Global Public Health’s publication criteria? Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe methodologically and ethically rigorous research with conclusions that are appropriately drawn based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: No

**********

3. Have the authors made all data underlying the findings in their manuscript fully available (please refer to the Data Availability Statement at the start of the manuscript PDF file)?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception. The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: No

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS Global Public Health does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Congratulations to the authors on this amazing work directed towards tackling the lingering mother-to-child transmission of HBV infection in Sub-Saharan Africa. However, I have a few comments that may be helpful in fine-tuning your article.

1. Overall, there are some typos that need to be checked and corrected in the entire text. For instance, "highly transmissible" in the third line of the abstract should be followed by a comma before the word "especially".

2. The statement "A prospective systematic random cross-sectional study was conducted" in the methods section of the abstract appears to be vague. Is it a prospective systematic random study in terms of the design or the sampling approach?

It will be lucidly comprehended if it is rephrased as follows: A prospective cross-sectional study was conducted among 183 systematically and randomly selected pregnant women. Alternatively, it could be rephrased in a more canonical way by saying that "a prospective cross-sectional study employing systematic random sampling was conducted among 183 pregnant women attending..."

3. In the results section of the abstract, did you mean to say "being in a polygamous marital affair or relationship compared to monogamy?". If yes, kindly correct the current statement as it states "being in a polygamous marital compared to monogamy".

4. Is it the virus that is transmitted vertically (i.e., materno-foetally) or the surface antigen? Kindly recheck and probably correct the last statement in the conclusion section of the abstract.

5. If the statement "...especially in sub-Saharan Africa (5%) including Ghana, even though it is twice as much (10%) in Asia" is referring to HBV infection burden (i.e., prevalence), then you should attribute the figures to the regional prevalence of HBV across SSA and Asia, respectively, instead of inserting the figures without indicating what they describe.

6. There seems to be a conflicting sampling technique reported to have been used for participants' selection. At first, it was stated that a systematic random sampling approach was employed, and then again, consecutive sampling. If a systematic random sampling technique was used, was there a sampling frame? And what was the fixed sampling interval that followed the random start, if any (which wasn't mentioned, of course)? However, if it is consecutive sampling, then the statement on systematic random sampling should be corrected.

7. Regarding the sample size estimation, kindly include or reference the value of the proportion of the population attribute (i.e., p in the Cochran formula) that yielded a sample size of 183, if the confidence interval is at 95% and the margin of error is 5%. Did you in any way factor in the non-response proportion in the final sample size employed?

8. There is no statement or empirical evidence about the sensitivity and specificity of the employed Wondfo Rapid One-Step HBsAg test kit. This is very important for the validity of this study and for future studies that would want to leverage the same methods.

9. Since you do not report having a reference scale for the assessment of HBV-specific knowledge, it will be better if you do not use the terms "assessment" and "knowledge," as written in the data collection section of the methodology: "assessment of their knowledge of mother-to-child transmission and prevention of HBV." Hence, the word "awareness" should be uniformly used since it is obvious that you sought to capture their awareness of some characteristic features of the infection, such as transmission and prevention.

Furthermore, the awareness variable was only reported descriptively using frequency and proportions. Yet, in the methods section of the abstract, it was claimed that the variable was assessed using an awareness summary score. Where is the summary or the weighted aggregate score computed for the variable and the reference scale for the assessment? Therefore, the appropriate word or words should be used in place of "assessment".

10. Kindly rephrase the first statement under the "Data Analysis" section so that charts and tables will not appear as forms of descriptive statistics. They are both for data presentation.

-Which type of Chi-square test did you employ?

-What was the basis for the selection of just two variables for the multi-variable logistic model?

11. How did you ensure confidentiality regarding the participants' HBV test results and other data captured? Kindly include this in the ethical consideration section.

12. I think it is appropriate to express the last category of the respondents age as ≥35 (i.e., 35 years and above), instead of (35+)−44 in table 1. Because if the oldest respondents were aged 44 years and you wanted it to reflect in the age categorization, then you could have expressed the last age group as 35–44, similar to other categories.

-In the heading of Table 4, do you mean multiple/multivariable logistic regression instead of "multi-logistic regression"? Please check.

13. Check and correct the typos in this statement in the discussion section:"However, as recorded elsewhere, there was no significant association between respondents’ age group and their HB HBsAg-positivity status in this study, unlike reported elsewhere [21]".

14. "More than half of the pregnant women in the study area were HBsAg-positive". Really? Is 20.2% (i.e., HBsAg-positive results) more than half? Kindly correct the statement.

15. Any study limitations?

Reviewer #2: TITLE: The title would be better rendered as "Factors associated with Hepatitis B viral infection among pregnant women attending antenatal care in Wa Municipality, Ghana".

A. OBSERVATIONS: These are presented below;

Abstract: The objective of the study in line 4 of the abstract would greatly benefit from a revision and it is suggested that it should read thus; "This study sought to determine factors associated with the prevalence of Hepatitis B infection among pregnant women in Wa Municipality of Ghana."

The methods section of the abstract should read thus; "A cross-sectional survey study design was conducted among 183 consenting pregnant women in nine antenatal care facilities in Wa Municipality. A structured validated questionnaire was used to collect information about socio-demographic and obstetric characteristics, awareness of HBV transmission and its prevention scores. Blood samples (3.0 mls) were collected from each participant to test for HBV serum markers using a Wondfo One Step HBV rapid immunochromatographic assay (Catalog number W003) for the Hepatitis B surface antigen (HBsAg) profile. Data was analyzed using Stata/SE 15. Descriptive statistics were used for the socio-demographic, prevalence, and awareness variables. Chi-square and Fisher´s Exact Test were performed to determine the association between the variables.

The result section appear flawed considering that values of the 95% confidence intervals reported In lines 3-6 are inappropriately stated without the sample statistic and actually reflect not directly association but prediction computed from binary logistic regression analysis which is not mentioned as one of the statistical tools used. In actual fact, relationships are best expressed with regression analysis and the corresponding predictive values of the explanatory variables computed with binary logistic regression. These analysis are inadequate.

INTRODUCTION: The major revisions are needed for the introduction for observed typographical issues and lack of adequate conceptualization of modifiable risk factors of the at-risk population and their personal-level disposition that puts them at risk of an infection such as perception of the risks and consequences of an infection which includes transmitting the virus to their infants, attitudinal disposition towards preventing becoming infected and that prevention is far better than cure. These are salient factors to be considered in such a study. Throughout the introduction, the study did not address likely sources of associated modifiable and non-modifiable risk factors for HBV infection. In addressing these, how do you intend to establish scientific basis for these risk factors and demonstrate association as indicated by the title of the study? The contents of the study are basically what constitute risk factors for infection. No conceptual and theoretical framework or structured questions raised for the study to answer. Since these were not considered before planning the study protocol, it would mean going back to the drawing board and fresh data collection.

Methodology:

There is no evidence to suggest that the study design is a prospective study design because data collection does not resemble such hence it is recommended to stay with "facility-based cross-sectional survey design…".

Kindly be informed that Cochrane does not have a sample size computational formula, but this study is merely citing "sample size formula used in a study conducted by Cochrane in 1977" Kindly state this to reflect as expressed above which is the preferred syntax. Variables in the study appears not to be informed by any structured theoretical framework to confer validity to the instrument for data collection. The observed inclusion of knowledge in the study as a factor.

Data analysis is insufficient because only a few variables have been considered. Data analysis is inadequate and lack rigor such study deserves.

Discussions:

The discussion demonstrates clearly that the study was mainly laboratory study and was unable to uncover adequately the associated factors involved with observed prevalence of HBV infection among participants in the study. While knowledge was identified as a factor in the infection dynamics related to personal-level disposition of the at-risk population, this is not sufficient. The lack of adequately exploring fully important factors can be seen from the inability of the study to conceptualize the likely dynamics of infectivity within the epidemiological principles of the natural history of HBV infectivity, the public health principles of prevention and control and the theoretical framework of the modifiable risk factors of the population of interest. Therefore, a lot of factors have not been considered in this study. This makes the study weak and unable to provide proof of concept in regard to the objective of the study. With the conclusion stating that "More than half of the pregnant women in the study area were HBsAg-positive…" and that "Facility and community-based antenatal health education should also focus on increasing maternal knowledge of the mother-to-child transmission route of HBV" would not solve the problem because awareness alone is not sufficient to trigger the necessary caution and infection-prevention decision necessary to establish behaviour that translates to prevention of infection and transmission of the virus. The conclusion raises more questions than answers. It is not enough to test the population to determine the level of infection within the community but what may be responsible for this situation.

**********

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Reviewer #1: Yes: Ismail Bamidele Afolabi

Reviewer #2: Yes: Dr Bola Christie Atulomah

**********

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While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

10.1371/journal.pgph.0002447.r002
Author response to Decision Letter 0
Submission Version1
25 Apr 2024

Attachment Submitted filename: Response to Reviewers_PGPH-D-23-01433.docx

10.1371/journal.pgph.0002447.r003
Decision Letter 1
Atulomah Nnodimele Onuigbo Academic Editor
© 2024 Nnodimele Onuigbo Atulomah
2024
Nnodimele Onuigbo Atulomah
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Submission Version1
1 May 2024

PGPH-D-23-01433R1

Factors associated with Hepatitis B viral infection among pregnant women attending antenatal care in Wa Municipality, Ghana.

PLOS Global Public Health

Dear Mr. Aabalekuu,

Thank you for submitting your manuscript to PLOS Global Public Health. After careful consideration, we feel that it has merit but does not fully meet PLOS Global Public Health’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

==============================

Kindly consider the recommendations made for revision of aspects of the manuscript likely to have escaped your revision:

The presentation of the study design in both abstract and main manuscript. Kindly consider the explanations given for the suggested revision,

The statistical analysis conducted and how the results have been presented and the rationale for revision,

Importantly, the conclusions made which appears to give the impression of a cause-effect relationship for data analysis that infer predictive value.

==============================

Please submit your revised manuscript by May 31 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at globalpubhealth@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pgph/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

We look forward to receiving your revised manuscript.

Kind regards,

Nnodimele Onuigbo Atulomah, PhD

Academic Editor

PLOS Global Public Health

Journal Requirements:

1. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments (if provided):

This is an important study that needs to be published to provide the understanding the authors of this study desire to share. The authors' concerns are well justified. However, there are certain minor but very important syntax issues to be resolved and straightened out to make the argument in the manuscript credible. Some were pointed out in the first round of the manuscript review but were not attended to. Please attend to these observed issues.

1. The title has been revised as recommended.

2. Abstract: The recommendation made by one of the reviewers to modify the methods section to read: "A cross-sectional survey study design was conducted among 183 consenting pregnant women in nine antenatal care facilities in Wa Municipality. A structured validated questionnaire was used to collect information about socio-demographic and obstetric characteristics, awareness of HBV transmission and its prevention scores. Blood samples (3.0 mL) were collected from each participant to test for HBV serum markers using a Wondfo One Step HBV rapid immunochromatographic assay (Catalog number W003) for the Hepatitis B surface antigen (HBsAg) profile. Data was analyzed using Stata/SE 15. Descriptive statistics were used for the socio-demographic, prevalence, and awareness variables. Chi-square and Fisher´s Exact Test were performed to determine the association between the variables.” was partially implemented. There remain the issue of the study design not attended to. The error of a “prospective” cross-sectional design is in error. This raises the question of What qualifies this study protocol to be considered a prospective study? Were data collected repeatedly throughout the period of the study for every participant?

The flaws appearing in the result presented in the abstract was pointed out in the first round of the review process but it appeared that no action was taken to revise the flawed observations.

There is gross misapplications of 95%CI for p-values throughout the results presented. Kindly note the data in line 34-35: “…monogamy (95%CI [.01-.03], p<0.01)…” appear to have missed the sample statistic that should have been placed before the 95%CI.

The conclusion in lines 39 - 40. do not emerge from the data. What the data suggest is that “...a high HBsAg prevalence, is likely involved with the type of marital relationship and young age.” rather than influenced because the data analysis was more of comparing the likelihood of an outcome of risk. This well expressed in line 36 - 38. The logistic regression is most appropriate in establishing predictive value when comparing explanatory variables likely to predict an outcome than its current misuse for association. To establish and characterize the nature of association would be best to apply multiple regression.

Kindly read through the manuscript for typographical errors and correct them.

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Reviewers' comments:

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

10.1371/journal.pgph.0002447.r004
Author response to Decision Letter 1
Submission Version2
30 Jul 2024

Attachment Submitted filename: Response to Reviewers_PGPH-D-23-01433R1.docx

10.1371/journal.pgph.0002447.r005
Decision Letter 2
Atulomah Nnodimele Onuigbo Academic Editor
© 2024 Nnodimele Onuigbo Atulomah
2024
Nnodimele Onuigbo Atulomah
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Submission Version2
14 Aug 2024

Correlates of Hepatitis B Infection in Pregnant Women Attending Antenatal Clinics in Wa Municipality, Ghana.

PGPH-D-23-01433R2

Dear Mr Aabalekuu,

We are pleased to inform you that your manuscript 'Correlates of Hepatitis B Infection in Pregnant Women Attending Antenatal Clinics in Wa Municipality, Ghana.' has been provisionally accepted for publication in PLOS Global Public Health.

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