Introduction

Hepatitis C Virus (HCV) poses a significant global health threat, with an estimated 71 million people chronically infected worldwide. prominently impacting the liver and contributing to chronic liver diseases like cirrhosis and liver cancer. Although the acute phase of the infection is usually asymptomatic, potential symptoms may include fatigue, fever, nausea, and abdominal pain. Most HCV cases progress to chronic infections, potentially leading to severe liver damage. Despite the development of highly effective antiviral treatments that can effectively cure HCV, preventive measures such as safe injection practices and rigorous blood screening remain crucial in controlling its spread, particularly among high-risk populations (World Health Organization, n.d.)1. G Lim et al.,2 explored strategies to scale up hepatitis C screening and treatment in Pakistan, indicating that achieving World Health Organization (WHO) elimination targets by 2030 necessitates increased screening rates, improved referral processes, and regular re-engagement efforts, requiring a significant investment of approximately 9% of the annual health expenditure. Mahmood and Raja3 stated that Pakistan is grappling with a significant hepatitis C epidemic, affecting nearly 10 million individuals, most of whom are unaware due to the disease’s initial asymptomatic nature. Its transmission occurs primarily through infected blood exposure, often via shared contaminated needles, unscreened blood transfusions, or organ transplants. Unsafe medical practices and limited resources pose substantial challenges, necessitating a stronger focus on implementing effective preventive strategies to alleviate the disease burden. Seerat et al.,4 study assessed the seroprevalence of hepatitis B virus (HBV) and hepatitis C virus (HCV) infections among children in Lahore, Pakistan, revealing a higher incidence of HCV. Zaman et al.,5 focused on HCV incidence among waste collectors in Pakistan and found a 3.3% seroprevalence. The study conducted by Qamar et al.,6 in Tehsil Dagger District Buner, Pakistan, found a high seroprevalence of HCV un-typable variants. Various transmission routes were associated with different HCV isolates, including shaving at barber shops and intravenous drug use, emphasizing the need for anti-HCV therapy and infection monitoring. The study by Noreen et al.,7 in low socioeconomic communities of Islamabad indicated a 4% seroprevalence of hepatitis C. However, no significant associations were found with blood donation, drug abuse, or certain demographic factors. A study by Israr et al.,8 in Pakistan found a 2.1% of HCV among 375 pregnant women. They used chi-square analysis to determine the association between HCV infection and the risk factors. Ghias, et al.,9 used binary logistic regression model to identify the risk factors for HCV infection in Punjab, Pakistan, revealing that the history of blood transfusions, injections, oral and general surgery, and injections were related to HCV. In order to predict HCV status, they also contrasted logistic regression with artificial neural network models. Shafiq et al.,10 highlighted the urgency of addressing the high rates of hepatitis B and C globally, with household contact, dental work, surgery history, sexual contact, and transfusion history identified as major risk factors. Samo et al.,11 studied that both hepatitis B and C infections are significant public health concerns in Pakistan, with increasing seroprevalence attributed hospitalization, blood transfusion, needle injury, multiple sex partners, reused syringes, dental extraction, surgery, injectable drug abuse, and shaving at barbershops. Ullah et al.,12 revealed that individuals diagnosed with HCV in Pakistan generally hold pessimistic perspectives regarding their condition, expressing a lack of confidence in the effectiveness of treatment, especially among those who have undergone unsuccessful anti-HCV treatments. Saeed et al.,13 highlights Pakistan’s significant burden of Hepatitis B and C viruses, estimating 7–9 million with HBV and 10 million with HCV, emphasizing the lack of rural seroprevalence studies. Different population groups displayed varying seroprevalence rates. Saleem et al.,14 highlighted the significant seroprevalence of Hepatitis C (11.32%) in Pakistan among the general population, blood donors, and pregnant women, emphasizing risk factors like unsterilized needle use and blood transfusions. Russotto et al.,15 used interrupted time series approach to understand the consequences of the COVID-19 pandemic on viral hepatitis surveillance. They observed decrease in reported cases could be due to an increase in infection prevention control and containment measures put in place in a pandemic context. However, a delay in the initiation of epidemiological investigations was observed, which could lead to a further increase in incidence in the future. Khan et al.,16 conducted a study in the Swat region of Pakistan, revealing a high HCV incidence rate of 11.4%. The study highlights that young individual and those with a history of blood transfusions showed a higher infection rate.

In this study, our objectives were to determine the seroprevalence of Hepatitis C Virus (HCV), to identify and analyze the key risk factors associated with HCV transmission and to evaluate the relationship between identified risk factors and HCV seroprevalence in the Nowshera District, Khyber Pakhtunkhwa, Pakistan.

Materials and methods

This study employed a quantitative research design to investigate the seroprevalence of Hepatitis C Virus (HCV) and its associated risk factors in Nowshera District, Khyber Pakhtunkhwa, Pakistan. The data were collected at Qazi Hussain Medical Complex and District Headquarter (DHQ) Hospital Nowshera, covering the period from May 1, 2022, to June 30, 2023. Both hospitals are situated adjacent to the Kabul River, this area is prone to periodic flooding, which results in water contamination and the spread of various viral diseases, including HCV. The study was carried out in the pathology department, which serves both inpatients and outpatients.

Population sampling

All individuals aged 15 years and above, both male and female, presenting at the specified hospitals for medical care were considered eligible for inclusion in the study. A randomized sample of n = 606 patients, suspected cases of hepatitis as per clinical evaluation either referred for Hepatitis C screening by physicians or voluntarily participating in the study, was selected.

Questionnaire addressing risk factors associated with HCV infection were developed, both in Urdu and English version, based on globally recognized determinants, encompassing demographic, socio-economic, and pertinent medical and non-medical factors. Trained enumerators provided explanations of the study’s objectives and obtained written consent before blood sample collection. Face-to-face interviews were conducted, ensuring confidentiality especially for inquiries regarding history of incarceration and sexual activities.

Sera-diagnosis via ICT and ELISA

To conduct the anti-HCV antibodies test, approximately 5mL of blood was extracted from the radial vein of participants using a disposable syringe and stored in sterilized gel tubes. The serum was isolated following blood coagulation and preserved at -20 °C for future use. The sera were screened for anti-HCV antibodies using ICT technology from ACON® (ACON Laboratories Inc., San Diego, CA 92121, USA) and then employed second test by ELISA IgG by using Human Hepatitis C Virus IgG (HCV-IgG) Elisa Kit (EK711035) Gentaur Barcelona Spain, in accordance with the manufacturer’s instructions and read it through microplate ELISA reader for accuracy of the data and cross validation of the HCV diagnosis.

$$\:seroprevalence\:rate=\:\frac{Number\:of\:seropositive\:samples}{Number\:of\:total\:samples}*100$$

Ethics

The research was conducted at two educational hospitals in the respective regions, as the study involves humans, a bioethical approval (ref # 529/Oric/IRB) of the study was obtained from the Institutional Review Board of Qazi Hussain Medical Complex and from each participant of the study, a written informed consent form was taken following Helsinki’s Declaration 2013.

Statistical Analysis.

Statistical analysis of data obtained from routine HCV testing and risk factor assessment was performed using IBM SPSS Statistics version 27. Pearson’s χ2 and Fisher’s exact tests were utilized to examine the association between categorical variables, such as demographic characteristics and HCV seroprevalence. All P values were two-sided, and significance was considered if P < 0.05. Multivariable logistic regression analysis, adjusting for gender, marital status, education level, and assessed risk factors, was employed to identify independent predictors of HCV seroprevalence and to determine adjusted odds ratios (aORs) for the connections between reported risk factors and current or previous HCV infection.

Results and discussion

We recruited 606 patients according to our sampling plan on their consent and collected blood samples, which were screened for anti-HCV antibodies. The average age of these participant was 32 (32 ± 12) with minimum age of 15 years and maximum age of 71 years. Table 1 shows that, among the 606 blood samples, 73 were positive for HCV antibodies, which indicates a 12% seroprevalence of HCV in the District Nowshera, KP, Pakistan (Fig. 1). This is consistent with the findings of Ali, et al.,17 which reported seroprevalence rate among high-risk groups as 15.57% in Khyber Pakhtunkwha, Pakistan. 332 (54.8%) males and 274 (45.2%) females participated in the survey, among whom, 15.4% of males and 8.0% of females were seropositive HCV.

Fig. 1
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Seroseroprevalence of Hepatitis C virus infection among the studied population.

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Fig. 2
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HCV seroprevalence among income level groups.

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Table 1 Socio-demographic characteristics of study population by hepatitis C virus antibody status.
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⁎p < 0.05.

The seroprevalence of HCV is notably elevated in individuals aged 45–54, reaching 29.3%, and is similarly high among those aged 65 and above, at 28.6%. Conversely, the lowest seroprevalence is observed in participants younger than 25 years, at 6.8%. Of the surveyed population, 57 individuals (13.3%) who were unmarried tested positive for anti-HCV antibodies, whereas a lower seroprevalence of 9.0% (16) was observed among their married counterparts. A heightened seroprevalence of 12.8% (55) was observed in households with a residence of medium size families, that is 18–12 individuals. Furthermore, seroprevalence of HCV among uneducated individuals 17.2% (40) was observed. Economic standing undeniably influences the propensity for disease prevention, enabling a sanitary environment and access to preventative resources. Table 1 underscores a higher HCV seroprevalence among communities with diminished economic capacities, noting seroprevalence of 31.3% for monthly household incomes not exceeding PKR20,000 per month (Fig. 2). Detailed demographic characteristics and gender-specific seroprevalence rates are summarized in Table 1.

Fig. 3
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HCV Seroprevalence Across Education Levels.

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In Fig. 3, a bar chart depicts the relationship between HCV seroprevalence rates and educational attainment.

Table 2 Univariate analysis of reported risk factors for HCV infection among study population.
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⁎p < 0.05.

Fig. 4
figure 4

HCV seropositivity among subjects exposed to Accidental needle prick.

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Table 2 delineates various clinical risk determinants for HCV transmission. Notably, among Hospitalized, HCV seroprevalence was strikingly high at 19.6%, \(\:{\chi\:}^{2}\)(1, N = 606) = 11.57, p = 0.001), the risk of being infected with exposure to the hospitalized group is 2.09 times more than the counterpart group (RR = 2.09, 95% CI = 1.36, 3.21). This is lower than the HCV seroprevalenc in hospitalized group in Nawabshah, Sindh, Pakistan11. Among those undergoing multiple blood transfusions (at-least one times in the past two years), the HCV high at 21.2% (11 of 52). The chi-square analysis revealed a statistically significant association between blood transfusion and HCV infection, \(\:{\chi\:}^{2}\)(1, N = 606) = 4.53, p = 0.035), indicating that individuals who underwent blood transfusion had an increased risk of HCV (RR = 1.89, 95% CI = 1.06, 3.36). Dental interventions were associated with an HCV seroprevalence of 23.5%, \(\:{\chi\:}^{2}\)(1, N = 606) = 12.305, p = 0.001). This is higher than the 20% seroprevalence of HCV reported in District Peshawar, Pakistan10. Exposure to dental interventions increases the risk of HCV infection by 2.31 times, that is, (RR = 2.31, 95% CI = 1.46, 3.67). Seroprevalence of HCV among surgical patients was 27.8%, which was statistically significant \(\:{\chi\:}^{2}\)(1, N = 606) = 24.68, p = 0.001); individuals prone to surgery are nearly three times more likely to be infected with HCV, (RR = 2.98, 95% CI = 1.94, 4.58). Figure 4 showcases a pictorial presentation of accidental needle prick and HCV cases. The risk ratio of accidental needle prick (RR = 1.23) indicates a modestly increased risk of HCV infection in people exposed to needle prick at health facilities. Furthermore, experiencing tattoo procedures were associated with HCV seroprevalence rates of 14.3%. Concerning the subset frequently subjected to therapeutic injections, our data, as highlighted in Table 2, evidences escalated HCV seroprevalence rates in groups with frequently using injections within both five-years (18.4%), \(\:{\chi\:}^{2}\)(2, N = 606) = 33.39, p = 0.001) and 10-years’ timeframes (17.5%), \(\:{\chi\:}^{2}\)(2, N = 606) = 17.21, p = 0.001).

Table 3 Seroprevalence of HCV positive in association with life-style factors, Nowshera.
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The seroprevalence of Hepatitis C Virus (HCV) infection was examined in relation to various hygienic risk factors. Notably, the seroprevalence of HCV infection exhibited distinct patterns among individuals engaging in specific practices. Among those who regularly underwent facial shaving by barbers, the observed seroprevalence of HCV infection was notably high at 65.7% (23 of 35), the association between facial shaving at barber and HCV status is highly statistically significant \(\:{\chi\:}^{2}\)(2, N = 606) = 136.9, p < 0.001). A similar trend was observed among individuals who sought ear or/and nose piercing services, with a seroprevalence of 15.5%, \(\:{\chi\:}^{2}\)(1, N = 606) = 3.361, p = 0.067). Individuals who reported sharing razors at home exhibited a seroprevalence of 15.7%, which means that there is no statistical significance between the HCV status and sharing razor at home \(\:{\chi\:}^{2}\)(1, N = 606) = 1.9, p = 0.167) (Table 3). These observations suggest that HCV seroprevalence is notably higher in the context of barber-related practices compared to other hygiene-related factors.

Table 4 Model Summary.
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In the investigation of HCV infection outcomes, we applied a multiple logistic regression model featuring various groupings of demographic, clinical, and lifestyle covariates. The procedure involved stepwise forward selection, and the model chosen, at the ninth iteration, demonstrated the highest value of Cox & Snell R2 and Nagelkerke R2 followed by the lowest value of the Akaike Information Criterion (AIC), which was calculated as 265.06 (Table 4).

The noteworthy risk factors associated with HCV infection are listed in Table 5, which also provides their respective coefficients and key summary statistics of multivariable logistic regression, including slope coefficient, standard error, p-values, adjusted odds ratios (aOR), and confidence intervals for the aOR.

The aOR for workplace-related injuries was determined to be (aOR = 6.69, 95% CI = 3.2, 13.94). This signifies that keeping other factors constant, the likelihood of acquiring HCV infection due to workplace injuries only, is 6.69 times higher than for individuals who have safety measures at their workplace. Likewise, individuals who engage in facial shaving services provided by barbers exhibit an adjusted odds ratio (aOR = 40.6, 95% CI = 13.6, 121). Consequently, the risk of contracting HCV infection is fortified by 40.6 times for those who utilize barber services for shaving compared to those who do not.

Table 5 Multivariable logistic regression estimated odds ratio for risk factors and HCV infection.
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Table 5 also highlights the adjusted odds ratio (aOR = 8.6, [CI] 3.03–24.4) associated with a history of use of therapeutic injections frequently. History of HCV-infected family members contributes an aOR = 4.28. This finding indicates that the odds of acquiring HCV infection are 4.28 times greater for individuals living with HCV-infected family members compared to those without any HCV-infected family members. Similarly, other risk factors are interpreted in a comparable manner. Notably, the high-income level group showcases a reduced risk of HCV infection (aOR = 0.03, [C.I] 0.004–0.268), that is, the HCV infection is less likely (by 0.96 times). Specifically, with other covariates held constant, the odds ratio for income level 1 is 0.065, whereas for income level 4, it decreases to 0.03. The likelihood of acquiring HCV infection is 5.01 times higher among individuals who engage in ear and nose piercing practices, as indicated by the adjusted odds ratio. In the multivariable regression analysis, the following factors also showed significant associations with HCV infection: education level upto 16 years education degree ([aOR] 0.173, 95% [C.I] 0.047 − 0.643) which indicates 0.82 times less likely to acquire infection (Table 5).

Conclusion

In conclusion, our comprehensive analysis of HCV transmission modes and associated risk factors has highlighted the critical need for multifaceted interventions to combat this persistent public health challenge. Factors such as a history of family members infected with HCV, hospital admissions, surgical procedures, dental treatments, workplace injuries, frequent uses of therapeutic injections, local migration, and facial shaving by barbers all contribute significantly to the transmission of HCV.

The findings from this study underscore the urgency of implementing educational programs aimed at healthcare workers to ensure proper equipment sterilization and infection prevention. Furthermore, the general public must be made aware of the risks associated with non-sterilized and reused razors, particularly in barbershops, where facial shaving is a common practice.

When an active HCV infection is identified within a family unit, immediate preventive measures should be taken to prevent further transmission. This should be accompanied by a heightened focus on the risk factors associated with hospital admissions, surgical procedures, dental treatments, workplace injuries, therapeutic injections, local migration, and barber services in the context of HCV transmission.

By addressing these risk factors comprehensively, we can make significant progress in reducing the burden of HCV infection and improving public health. It is imperative that healthcare policies and public health initiatives are designed to encompass all these risk factors, ultimately contributing to a more effective and holistic approach in the fight against HCV transmission.

Limitations and future directions

While this study provides valuable insights into HCV transmission in the post-pandemic context: the emergence of the COVID-19 pandemic has markedly affected all the machinery of the healthcare systems and specifically laid countries off their track in their viral hepatitis elimination process; several limitations are acknowledged. Our study did not collect data prior to the pandemic, and there is no existing literature on pre-pandemic HCV transmission rates in our region. This limitation prevents direct comparisons and restricts our ability to analyze changes in transmission rates over time. Direct data from our region on how the preventive measures impacted transmission rates would provide a clearer picture. The findings of this study are specific to our region of study and may not be generalizable to other areas. Comparisons with studies from other countries, including Western nations, are included to provide context, but regional differences must be considered. Future research should aim to collect longitudinal data, including pre-pandemic and post-pandemic periods, to allow for more comprehensive analysis15. Investigations into the specific impacts of preventive measures within our region would provide deeper insights.