Original Research

Hepatitis B and C among chronic dialysis adults in central South Africa: A retrospective review

Lekgolane K. Sekwati, Joseph B. Sempa, Feziwe B. Bisiwe

Received: 24 June 2025; Accepted: 06 Oct. 2025; Published: 10 Dec. 2025

Copyright: © 2025. The Authors. Licensee: AOSIS.
This work is licensed under the Creative Commons Attribution 4.0 International (CC BY 4.0) license (https://creativecommons.org/licenses/by/4.0/).

Abstract

Background: Patients with chronic kidney disease (CKD), especially those on dialysis, have an increased risk of viral hepatitis B (HBV) and C (HCV) infection. The South African Renal Society recommends regular screening to ensure early detection, appropriate treatment and vaccination update for hepatitis B. Chronic kidney disease patients tend to have a poor immune response post-vaccination.

Objectives: The study investigated the prevalence of HBV and HCV, screening practices and immune response to HBV vaccination among patients on state-funded dialysis in the Free State province.

Method: Records of patients on chronic dialysis in 2021 were included in the study. Data were extracted from paper-archived and electronic medical and laboratory records.

Results: In total, 223 records were included. Over 90% of patients were screened for hepatitis B and C at baseline at all dialysis units, which decreased to 30% at some satellite units at follow-up screening. The seroprevalence for both HBV and HCV was 1.8%. Viral hepatitis B immunity was found in 78.4% of patients. Patients with a mean age of 45 years were more likely to have increased antibody titres. Human immunodeficiency virus seropositive patients were more likely to have lower antibody titres when repeated at 6 months. The vaccination rate was 74.5%. The vaccination non-response rate was 9.8% with no variable demonstrating a significant effect on vaccine response.

Conclusion: Both HVB and HCV prevalence were lower than described in similar settings with equal distribution between dialysis modalities. Screening was adequate at baseline but decreased at follow-up, resulting in non-identification of patients possibly needing re-vaccination.

Contribution: Missed opportunities are concerning and call for action to strengthen the outreach service to satellite dialysis units located in regional hospitals.

Keywords: viral hepatitis; hepatitis B; hepatitis C; chronic kidney disease; haemodialysis; peritoneal dialysis; vaccination immune response.

Introduction

Patients with chronic kidney disease (CKD), especially those with kidney failure on dialysis, have a higher risk than the general population of hepatitis B (HBV) and C (HCV) virus infection, leading to significant morbidity and mortality.¹ Patients with CKD have a compromised immune system. They are therefore more susceptible to infection because of suboptimal functioning of both the innate and adaptative immune system, resulting in impaired ability to clear primary viral infections. Further consequences include an increased incidence of hepatitis virus-associated malignancy and reduced vaccine response.^1,2

Moreover, haemodialysis (HD) entails a risk of cross-contamination for these bloodborne viruses. These patients often have anaemia as a complication of CKD and may require repeated blood and blood product transfusion, potentially exposing patients to contaminated blood products. The risk of transfusion-related transmission has to a large extent been mitigated by highly sensitive hepatitis B and C testing techniques and the introduction of recombinant erythropoietin, dramatically reducing the need for blood transfusions in patients with CKD.³ The judicious screening of blood donors for bloodborne infections has significantly reduced blood product-associated viral hepatitis infections.^3,4

Haemodialysis patients have a greater risk of contracting viral hepatitis than peritoneal dialysis (PD) patients because of potential exposure to residual blood via the extracorporeal circuit and cannulation needles.³ Furthermore, in low-resource settings, it is not always feasible to isolate machinery and equipment used for HBV- or HCV-positive HD patients from non-infectious patients.⁵

Patients with kidney failure on dialysis are among the high-risk individuals requiring regular viral hepatitis screening.⁶ The South African Renal Society recommends regular screening to ensure early detection, appropriate treatment and appropriate vaccination update for HBV.⁷ There is no vaccine available for HCV.

Vaccination against HBV is challenging in CKD because it has been identified as a risk factor for poor seroconversion after vaccination.⁸ Strategies employed to improve seroconversion rates after vaccination in the non-dialysis population have not been successful in patients on dialysis.^9,10 A systematic review reported that administration of additional vaccine doses or giving a higher dose is unsuccessful in the dialysis population.¹⁰ In addition, patients with CKD show a logarithmical decline of antibody titres over time, resulting in some patients losing immunity altogether.¹¹ Regular measurement of antibody titres allows identification of patients requiring a booster vaccination.

The World Health Organization (WHO) estimates that African countries account for 26% of the global burden of HBV and HCV disease.¹² In South Africa, the prevalence of HBV and HCV is potentially underestimated because of deficient surveillance data.⁶ This paucity in essential healthcare data is a shortfall because it implies that, potentially, people living with chronic HBV or HCV might be unaware of their status and could unknowingly transmit the infection. These people would benefit from treating these infections, preventing both transmission and complications. Identification of these individuals also promotes self-awareness, which should translate to improved health precautions such as safe sexual practices.

According to the national French registry, the prevalence of HBV and HCV in patients undergoing dialysis was low, ranging between 0.84% and 1.41%.¹³ A notably higher prevalence of 10.6% and 25.5% for HBV and HCV, respectively, was found in Pakistan.¹⁴ In sub-Saharan Africa, the prevalence of viral hepatitis is also high among dialysis patients. A systemic review and meta-analysis of 39 studies involving 13 African countries reported a pooled prevalence of 9.88% for HBV and 23.04% for HCV.¹⁵ However, in Botswana, a lower prevalence of 2.98% for HBV and 1.19% for HCV was reported.¹⁶

According to the 2022 South African Registry annual report on dialysis patients, the seropositive rate for HBV was 2.1% and for HCV 0.5%.¹⁷ These numbers may be influenced by underreporting. In the Eastern Cape province of South Africa, the prevalence of HBV in the dialysis population was 6.5%.¹⁸ A systematic review and meta-analysis including 634 articles that covered more than 390 000 dialysis patients, reported the estimated global prevalence of HCV in this population at 24.3%, with a significantly higher prevalence among patients on HD.¹⁹ In another meta-analysis evaluating 407 studies from 70 countries and representing approximately 1.3 million participants, the worldwide prevalence of HCV in dialysis patients was 21.0%, with the highest prevalence in low-income countries (48.5%). The prevalence in Africa was reported as 28.0%.²⁰

Knowledge of the prevalence of viral hepatitis in the South African dialysis population is poorly documented, which also holds true for the Free State province. This population group is especially vulnerable to viral hepatitis, more than the general population both in causality of CKD and as a complication of dialysis. Preventing viral hepatitis in this population is more challenging because of the unavailability of an HCV vaccine, as well as the difficulties outlined above with HBV vaccination in CKD patients. A study aiming to define the magnitude of the problem could add value to the knowledge of potential solutions to overcome these hurdles, especially in a low-resourced country.

The aim of the current study was to describe the prevalence of viral hepatitis in CKD adult patients on chronic dialysis, and their demographic and clinical characteristics. In addition, we investigated the screening practices at the various dialysis units in the Free State province public health sector and the HBV immune status of this population group. This information might be useful to bridge the current gaps in knowledge and promote action aimed at improving patient care and outcomes. In those with chronic viral hepatitis, measures would be taken to ensure that they were appropriately managed and vaccination programmes would be strengthened.

Research methods and design

Study design

This study was a retrospective, cross-sectional review of the medical records of dialysis patients in the Free State province public health sector in 1 year.

Study setting

The study was conducted at the Division of Nephrology, Department of Internal Medicine at the Universitas Academic Hospital in the Free State province of South Africa. All patients on state-funded chronic dialysis in the province are managed under the guidance of this tertiary unit. The patients on HD are distributed among various dialysis units situated at hospitals throughout the province, namely Universitas Academic Hospital (UAH) and Pelonomi Tertiary Hospital (PTH) in Bloemfontein Bongani Regional Hospital (BRHW) in Welkom Boitumelo Regional Hospital (BRHK) in Kroonstad, Dihlabeng Regional Hospital (DRH) in Bethlehem and Mofumahadi Manapo Mopeli Regional Hospital (MMMRH) in Phuthaditjhaba. However, these patients are all primarily under the care of the Nephrology Division at UAH. Figure 1 represents a map of the Free State province showing the location of the hospitals with dialysis units in the study.

FIGURE 1: Map of the Free State province showing the location of the public sector dialysis units in the study.

Participant selection

The register of all patients in the Chronic Kidney Replacement Programme during 2021 was used to identify records for inclusion in the study. Records of all patients > 18 years of age with CKD, who were on either HD or continuous ambulatory PD (CAPD), or switched between the modalities, were considered for inclusion. The records of all patients with CKD managed by kidney transplantation or conservative medical therapy were excluded.

Data sources and collection

Filed registers, paper-based medical records and the hospital software database Meditech^® were used to extract data pertaining to demographic variables, dialysis mode, how long the patient had been on dialysis and at which unit they received dialysis. Information on chronic diseases, vaccination data and whether immunosuppressive therapy was used, was also retrieved from the hospital records. The National Health Laboratory Service (NHLS) records system was used for extraction of data relating to hepatitis B and C serology and serum albumin levels.

The recruitment time frame for records for inclusion in the study was from January 2021 to December 2021. However, the timeframe for extraction of data itself was extended to include data that might fall outside of this range. For example, if the record belonged to a patient who started dialysis in October 2021 and only completed their hepatitis B vaccination in 2022, then this information was included in the study. Similarly, if the record belonged to a patient who was vaccinated during 2020, then these data were included in the study. Consequently, a time limitation for data extraction was set for the period 01 October 2020 to 30 June 2022.

Data were captured using REDCap software (REDCap Consortium; Nashville, TN, US [United States]) and transferred with de-identification to a Microsoft 365 Excel spreadsheet (Microsoft Corporation; Redmond, WA, US) for analysis.

The LIAISON^®XL assay (DiaSorin Inc.; Saluggia, Italy) was used for testing HBV and HCV antibodies. A HBV surface antibody titre of > 10 mIU/mL indicates immunity to HBV, whereas ≤ 10 mIU/mL is used as a threshold to administer HBV vaccine monthly for 3 months, and a fourth dose at 6 months. National guidelines⁶ recommend doubling the usual dose of 20 IU for the general population to 40 IU in the CKD population to improve the response. A successful response is defined as an anti-HBs antibody titre ≥ 10 mIU/mL measured 1–2 months after completion of the full primary vaccines series. Partial response refers to individuals who mounted a response that is lower expected titres. Vaccine non-responder refers to participants who failed to achieve ≥ 10 mIU/mL despite completing the recommended vaccine series.⁶

Data analysis

Data were analysed by the Department of Biostatistics, Faculty of Health Sciences, University of the Free State (UFS), using R version 4.3.0 (R Foundation for Statistical Computing; Vienna, Austria). Continuous variables were summarised using means with standard deviations for data that are approximately normally distributed and medians with the first and third quartiles for skewed data. Categorical variables were presented as frequencies and percentages. For group comparisons, the Kruskal–Wallis rank sum test was employed to compare continuous variables across more than two groups when the assumption of normality was not satisfied. The Wilcoxon rank sum test was used for pairwise comparisons between two groups. Associations between categorical variables were assessed using Pearson’s chi-squared test when expected cell counts were adequate, while Fisher’s exact test was applied for categorical comparisons with small, expected frequencies. All analyses were conducted using standard two-sided tests, with a significance threshold set at p < 0.05.

Ethical considerations

Ethics approval was granted by the Health Sciences Research Ethics Committee (HSREC) (ethics approval number UFS-HSD2022/0730/2607) of the UFS, the Free State Province Department of Health and the Department of Internal Medicine, School of Clinical Medicine, UFS on 11 June 2002. Patient information was anonymised and no identifying details were documented. Because data were collected from archived patient records, informed consent was not required as per guidelines of the institutional ethics committee.

Results

Demographic data

A total of 235 patients were identified for record review, with 223 included in the study. Of the 12 excluded records, 3 belonged to patients below 18 years, 6 records belonged to patients not in the chronic dialysis programme in 2021 and 3 records were excluded because of missing data.

The demographic characteristics of the study population are summarised in Table 1. The median age was 42 years (interquartile range [IQR]: 34; 50) and 52.5% (n = 117) of the patients were male. Of the 223 patients, 45.3% (n = 101) were CAPD patients and 37.7% (n = 84) were HD patients. In all, 38 (17.0%) patients had been transitioned between the two dialysis modalities during the study period. Patients who had been on dialysis for 6–48 months represented 48.9% (n = 109) of the sample, followed by 46.2% (n = 103) whose dialysis vintage exceeded 48 months. The UAH dialysis units constituted the majority (n = 146; 65.5%) of patients.

Hepatitis B and C screening practices

The screening practices for hepatitis B and C from the various HD centres are summarised in Table 2. Screening at baseline for hepatitis B surface antigen (HBsAg) was documented in 98.2% (n = 219) of the patients during the study period. Subsequent screening for HBsAg at 6 months decreased to 83.4% (n = 186).

Screening for antibodies against HBsAg (anti-HBs) at baseline was documented in 98.7% (n = 220) of the patients. Subsequent anti-HBs screening followed a pattern similar to HBsAg screening. Hepatitis C antibody (anti-HCV) screening was performed in 96.4% (n = 215) of the patients.

Hepatitis B surface antigen measurement

The seroprevalence of hepatitis B infection was 1.8%. The patients were equally divided between the HD and CAPD modality, were predominantly male (n = 3; 75.0%) and had a median age of 37 years (IQR 30;42). At baseline (Table 3), three of the patients tested negative for hepatitis B e antigen (HBeAg) and positive for e antibodies (anti-HBe). One patient had an equivocal HBeAg result, and the anti-HBe results were not documented. Hepatitis B viral load results were available for one patient, which measured below 2000 copies/mL.

At subsequent testing after 6 months (Table 4), the prevalence of HBsAg positivity remained at 1.8% (n = 4) with no new infections recorded. All four patients tested HBeAg negative and anti-HBe positive at 6 months. The hepatitis B viral load at 6 months was measured in only two patients, both being below 2000 copies/mL.

Hepatitis B surface antibody measurement

Anti-HBs seropositivity at baseline was 78.4%, indicating immunity. Higher antibody titres above 100 mIU/mL were observed in the older population with a mean age of 45 years (p = 0.007). There was no statistically significant difference in the antibody titres when stratified against other variables such as biological sex or dialysis mode and vintage.

All patients screened at baseline retained their antibody positivity when tested 6 months after baseline. The proportion of human immunodeficiency virus (HIV)-positive patients was higher in the group with anti-HBs titres less than 100 mIU/mL (p = 0.005). Human immunodeficiency virus positive patients demonstrated remarkable drop in their antibody titre over 6 months. There was no statistically significant difference in the 6 month repeat antibody titres when stratified against other variables such as biological sex or dialysis mode and vintage.

Hepatitis B vaccination outcomes

The seroconversion rate following vaccination was as follows: 68% full response, 21.9% partial response and 9.8% non-responders. No variable had a statistically significant impact (see Table 5) on whether patients mounted post-vaccination seroconversion or non-response. The non-responders were predominantly male with 50.0% being HIV-positive.

Hepatitis C screening

Only 1.8% (n = 4) of the patients in the study tested positive for anti-HCV. These patients had a median age of 51 years (IQR 43; 55), which was higher than the median age of the overall study population, and were predominantly female (n = 3; 75.0%). Three of the anti-HCV positive patients were on CAPD and had been on dialysis for more than 36 months. No HCV polymerase chain reaction (PCR) or genotyping laboratory data were available for any of the patients who were anti-HCV positive. Therefore, it could not be ascertained which hepatitis C genotype was prevalent in the study population. Furthermore, no patients tested positive for HBV and HCV co-infection.

Discussion

The seroprevalence for hepatitis B was 1.8%, below the national seroprevalence of 2.1% as described in the 2022 annual report of the South African Renal Registry. The hepatitis B seropositive participants were predominantly male who were younger and equally divided between the HD and PD modalities. All hepatitis B seropositive patients were HBeAg-negative and anti-HBe positive, with viral loads of less than 2000 copies/mL. No new infections were recorded during the study period. This could have been influenced by the selection bias created by the dialysis rationing policy applied in the Free State province public health sector, which only includes potentially transplantable patients on the dialysis programme, and excludes those with positive e antigen and complications of chronic HBV infection.²¹ Consequently, patients who would have been HBeAg-positive at the time of evaluation for dialysis, had likely not been started on dialysis in the public sector.

Approximately three quarters (74.4%) of patients in this study were HBsAb positive, implying immunity, which was higher than previously observed in a similar study.¹⁸ In the seropositive group at baseline testing, older patients (p = 0.007) had higher antibody titres at baseline screening. Human immunodeficiency virus-positive serology was associated with lower antibody titres at follow-up testing (p = 0.005). There was no difference according to dialysis mode and/or vintage and serum albumin. This was in contrast with previous observations that PD patients are at higher risk of losing their antibodies.²² The proportion of patients vulnerable to HBV infection was 24%, who should have been the target of vaccination efforts.

Fifty-five patients were anti-HBs negative at baseline screening, 41 were vaccinated, indicating a missed opportunity to vaccinate 14 patients. The vaccination failure rate was 9.8%. Unlike other studies,^10,18,23 biological sex was not associated with a statistically significant effect on-vaccination response. The efforts to improve vaccination response should include promoting access and availability of novel hepatitis B vaccines, which have been shown to be effective in vaccine non-responders and immune-suppressed individuals. The safety and efficacy of these novel vaccines has not been investigated in children and they are currently not licenced in South Africa.²⁴ As reported by others, dialysis vintage did not affect hepatitis B vaccination immune response. However, contrary to another study,⁹ the higher antibody titres in this study were not significantly observed in patients with higher serum albumin levels.

Immunosuppressive therapy use was low in the study and did not influence the maintenance of antibody titres or immune response to vaccination. In this cohort of patients who received the hepatitis vaccine, there was no difference observed in protective immunity according to how many doses a patient had received.

While screening at baseline for both HBV and HCV was performed in over 90% of patients at all the dialysis units across the province, the subsequent screening after 6 months dropped drastically to as low 30% and 50% in the smaller rural dialysis units. Poor adherence to screening guidelines is concerning as it poses a risk of missing vaccination opportunities and detection of new infections, with a possible risk of spread.

The findings of this study suggest that screening practices in the Free State province are comparable to South African Renal Society recommendations, but this is not standardised across all dialysis units. Attention should be given to standardising screening protocols, especially repeat testing of both HBsAg and HBsAb. In this study, older patients with a mean age of 45 years had higher antibody titres at the start of the study. This has not been observed in other studies. Patients with HIV seropositivity are at risk of losing their antibody protection against hepatitis B over time and require close monitoring to prevent missing the opportunity to revaccinate these patients.

Limitations of the study

Because of the retrospective nature of the study design, there were missing records and incomplete data. Furthermore, HCV infection could not be confirmed.

Conclusion

In the chronic dialysis population of the Free State province, South Africa, the prevalence of HBV was 1.8% compared to 2.1% in the South African Renal Registry of 2022.¹⁷ The prevalence of HCV was 1.8% compared to 0.5%.¹⁷ More than 90.0% of the patients were screened at least once a year, but subsequent screening decreased drastically, especially at the satellite dialysis units in the Free State province. Viral hepatitis B vaccination is a crucial public health tool to prevent the spread of the virus, but there are barriers to achieving post-vaccination seroconversion. Vaccination in this study was performed in 74.5% of the at-risk population. The study demonstrated that HIV seropositive patients are more likely to lose their hepatitis B immunity. There was no statistically significant variable that impacted post-vaccination response.

Acknowledgements

The authors acknowledge Dr. Daleen Struwig, medical writer/editor, Faculty of Health Sciences, University of Free State, for technical and editorial preparation of the manuscript. This article is based on research originally conducted as part of Lekgolane Kgotso Sekwati’s master’s dissertation titled ‘Hepatitis B and C among chronic dialysis adults in central South Africa: A retrospective review’, submitted to the Department of Internal Medicine, Faculty of Health Sciences, University of the Free State in 2025. The thesis was supervised by Feziwe Busiswa Bisiwe. The manuscript has since been revised and adapted for journal publication. The original dissertation is not available online. It has been uploaded to the UFS Electronic Theses and Dissertations but an embargo period was arranged to allow publication of articles derived from the research.

The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.

L.K.S. and F.B.B. conceptualised the study. L.K.S. developed the study protocol, collected the data and prepared the initial manuscript draft. J.B.S. performed the statistical analysis of data. F.B.B. was the study supervisor. All the authors approved the final version of the article.

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

The data that support the findings of this study are available from the corresponding author, F.B.B., upon reasonable request.

The views and opinions expressed in this article are those of the authors and are the product of professional research. The article does not necessarily reflect the official policy or position of any affiliated institution, funder, agency or that of the publisher. The authors are responsible for this article’s results, findings and content.

References