Introduction

Preventing and managing hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV) infections is a serious public health issue worldwide. Worldwide, 240 million people are chronically infected with HBV, accounting for more than 620.000 deaths per year. 2.35% of the world population is chronically infected with HCV, approximately 160 million people worldwide (1,2). The estimated number of persons living with HIV in the world was approximately 36.9 million at the end of 2014 (3). The prevalence of HBV, HCV and HIV infections shows variations across different geographical areas in the world. Turkey is classified as a country of intermediate endemicity for HBV and HCV infections. According to the Turkish Ministry of Health, the first HIV case in Turkey was reported in 1985, and 11.109 HIV cases were reported until the end of March 2016 (4). A vaccine against hepatitis B has been available since 1982 (5), yet a systematic vaccination policy was not adopted at that time in Turkey. Since 1998, hepatitis B vaccination has been included in the national immunization program (6).

In several studies, it has been reported that psychiatric patients have an increased risk for hepatitis B, hepatitis C and HIV infections compared the general population (7,8). Comorbidity of schizophrenia and viral diseases incurs a worse prognosis for both conditions (9). Psychiatric symptoms may increase the risk of contracting blood-borne viral infections among people with severe mental illness including those with schizophrenia. Many patients with schizophrenia have high-risk sexual behavior and inadequate knowledge about protective measures or transmission or the risks of these diseases. To stay long periods in same-sex wards in hospitals may foster high-risk same-sex activity (10). In addition, due to the use of common shaving accessories in male patients may lead to parenteral transmission of these infections. These factors may increase the risk of transmission of blood-borne infections among psychiatric patients. Screening for and prevention of sexually-transmitted infections and blood-borne viruses are neglected in this population. Determining the frequency of HBV, HCV and HIV infections among patients with schizophrenia has a significant role in designing the strategies to control the disease. Data about the prevalence of these infections among patients with schizophrenia in Turkey could not be found in the literature. Therefore, this study was conducted to determine the frequency of HBV, HCV and HIV infections among patients with schizophrenia in Elazığ Mental Health Hospital, Turkey.

Materials and Methods

The mental health hospital is a state hospital with 488 beds in the Eastern Anatolia region of Turkey. The hospital serves 18 cities in Eastern and Southeastern Anatolia. Screening tests for HBV, HCV and HIV have been routinely performed in patients admitted to the psychiatry ward. This retrospective study included 489 patients with schizophrenia (409 males, 80 females) in Elazığ Mental Health Hospital in 2015. The study was approved by the Fırat University Ethics Committee.

Laboratory Examinations

Blood samples were analyzed in the central clinical laboratory of the hospital. HBsAg, anti-HBs, anti-HCV (GBC, Taiwan, R.O.C.) and anti-HIV (DIA.PRO, Milano, Italy) tests were performed using the Triturus system (Grifols, Parets del Valles, Spain) by the ELISA method. The positive and negative controls were included each run. Specimens with a cutoff index of <1 were considered as non-reactive; cutoff index ≥1 was considered as reactive for HBsAg, anti-HCV and anti-HIV tests. Samples with below 10 mlU/mL were considered as non-reactive, and values of above 10 mlU/mL were considered as reactive for anti-HBs. Initially reactive assays were repeated in duplicate.

Statistical Analysis

Statistical analyses were performed using SSPS 20 (SPSS Inc, Chicago, IL, USA). The chi-square test was used for categorical comparisons of nominal values in different groups. The Kruskal-Wallis test was used to compare parameters among the age groups. A p value of less than 0.05 was considered statistically significant.

Results

The mean age of 489 patients with schizophrenia was 42.46±11.29 years (range: 15-74 years).

As shown Table 1, 32 HBsAg-positive cases were reported, and the seroprevalence of HBsAg was determined as 6.5%. There was no significant difference in the frequency of HBsAg between genders. Additionally, no significant difference was found in the seroprevalence rate of HBsAg between age groups.

203 patients were detected to be anti-HBs-positive, and the seroprevalence rate was 41.5%. There was no significant difference in the seroprevalence rate of anti-HBs between genders. The highest seroprevalence was detected in the age group under 20 years (p<0.001) (Table1).

The seroprevalence rate of Anti-HCV was 0.2%. A 63-year-old male patient was detected to be anti-HCV-positive. In addition, anti-HIV was negative in all the patients.

Discussion

Psychiatric patients do not have awareness about risk factors facilitating transmission of blood-borne viruses, and protective measures against these infections. Several studies have indicated that patients with mental illnesses are at an increased risk for HBV, HCV and HIV infections. Although the prevalence of HBV, HCV and HIV in the general was found to be 4.9%, 1.8% and 0.32-0.42% respectively, it was 23.4%, 19.6% and 5.2-22.9% among individuals with severe mental illness. The prevalence of blood-borne viral infections in people with serious mental illness has been found to be higher than in the general population in the U.S.A (11). A meta-analysis of studies of the prevalence of HIV, HBV and HCV in people with severe mental illness published between 1980 and 2015 found that the prevalence of blood-borne viral infections in people with serious mental illness was consistently higher than in the general population in regions with a low prevalence of blood-borne viruses, such as the USA and Europe, and on par with the general population in regions with high general prevalence such as Africa for HIV and Southeast Asia for HBV and HCV (12). A study conducted in patients with chronic schizophrenia in Taiwan revealed that the seroprevalence of HBsAg and anti-HCV was 10.4% and 1.9%, respectively. The authors reported that this prevalence among patients with schizophrenia was not higher than in the general population in Taiwan (13).

The prevalence of HBV, HCV and HIV among 5.227 psychiatric patients in Elazığ Mental Health Hospital between 2011 and 2013 was reported in our previous study. According to this study, overall seroprevalence was 4.08% for HBsAg, 42.19% for anti-HBs and 0.69% for anti-HCV. HIV was not detected among the subjects of the study (14). In 2009, the seroprevalence of HBsAg, anti-HBs and anti-HCV in 1343 patients in a psychiatric hospital in the western part of Turkey was detected as 2.7%, 30.5% and 1.8%, respectively (15). The present study has demonstrated that the frequency of HBsAg, anti-HBs and anti-HCV among patients with schizophrenia was 6.5%, 41.5% and 0.2%, respectively. All the patients were anti-HIV-negative. The frequency of HBV infection among patients with schizophrenia was not higher than in the general population. Additionally, the prevalence of HCV and HIV in the general population in Turkey is already low. In our hospital, various preventive measures such as continuous surveillance, education of the psychiatric patients regarding transmission of blood-borne infections, and improving hospital conditions for patients are being taken.

The most dramatic decline in HBsAg positivity was observed among patients with schizophrenia under the age of 20 years. Anti-HBs positivity was detected in 80% of this group. In Turkey, hepatitis B vaccination was included in the national immunization program in 1998, and infants have been vaccinated with three doses. Adults in the risk groups are also vaccinated at their request (16,17).

This study has several limitations. The tests separating the active and chronic infection could not be analyzed. In addition, the test showing the evidence of previous HBV vaccination or past HBV infection in anti-HBs-positive patients could not be performed. Finally, it was a retrospective study, and risk factors associated with transmission of HBV and HCV in the patients could not be determined.

This study showed that the frequency of HBV, HCV and HIV infections among patients with schizophrenia was not higher than in the general population. Screening for blood-borne pathogens including HBV, HCV and HIV at the time of admission to the hospital is an important strategy to identify infected residents. Hepatitis B vaccination schedule should be extended to include all the community. Lastly, strategies targeting at risk reduction will be important to prevent further spread of blood-borne infections among psychiatric populations.

Ethics

Ethics Committee Approval: This retrospective study included 489 patients with schizophrenia (409 males, 80 females) in Elazığ Mental Health Hospital in 2015. The study was approved by the Fırat University Ethics Committee.

Peer-review: External and Internal peer-reviewed.