Hepatitis B virus infection among the informal waste pickers in Aden, Yemen

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M. Gubran, Hanan A. A. Mohammed, Salsabeel Abdulaziz Mohammed Al-yafeai, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8553750/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objectives This study aimed to determine the prevalence of and risk factors associated with hepatitis B virus infection (HBV) among informal waste pickers (IWPs) in Aden, Yemen. Methods a cross-sectional study was carried out among 151 IWPs. The collected blood samples were tested for the presence of HBsAg using the Cobas technique. Result The majority of IWPs were males, 144 (95.4%), with a total mean ± SD age of 29.14 ± 14.13 years. Only 0.7% (1/151) had HBV infection. The percentages for this case regarding the socio-demographic and other characteristics of IWPs were varied as in group over 39 years (2.7%), males (0.7%), married individuals (1.5%), those with illiterate education (2.2%), individuals living with their families (1.1%), those with low economic status (0.7%), and those dealing with mixed waste (0.9%). According to the distribution of infection in Aden districts, the percentage of HBV-positive case was 5.6% in Ash Shaikh Outhman. This low prevalence rate is making the determination of significant associations very difficult. Conclusion The prevalence of HBV among informal waste pickers in Aden, Yemen, was one of the lowest rates compared to global studies and almost the same as the rate in a population-based study in Yemen. The clustering of HBV infection was found in Ash Shaikh Outhman. Further studies are recommended to determine viral infections among informal waste pickers working at nighttime as well as immunization against HBV. Hepatitis B virus infection informal Waste Pickers waste recyclers Aden Yemen Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Hepatitis B virus (HBV) infection is one of the major health problems that may cause life-threatening hepatic complications include; hepatic fibrosis, cirrhosis, and carcinoma [ 1 ]. HBV has an icosahedral capsid that surrounds a double-stranded deoxyribonucleic acid (DNA) genome, hence the name of its family, Hepadnaviridae. The viral nucleocapsid is enclosed with a lipid envelope [ 2 , 3 ]. This virus may lead to chronic infection. The global prevalence of individuals living with chronic infection was over 296 million, while the annual new acute cases were estimated to be one and a half million people [ 4 ]. The acute infection may be characterized by fatigue, dark urine and yellowish eyes (jaundice), nausea, anorexia (loss of appetite), and discomfort or pain in the right upper abdomen [ 3 ]. This bloodborne virus can be transmitted through contact with contaminated blood or other body fluids and secretions. The contaminated needles and other sharps and shaving tools may also transmit infection [ 5 , 6 ]. It also may transmit through unprotected sex, especially with multiple partners, and vertically during childbirth (from infected mother to child) [ 5 ]. The informal waste pickers (IWPs) are a group of workers that manually collect, sort, and recover different types of reusables and recyclable waste materials, including plastics [ 1 ]. These IWPs are more susceptible to blood-borne viral infections because they are exposed to infectious sharp tools from either household or medical centers waste [ 7 , 8 ]. Poor education and awareness and lacking personal protective equipment (PPE) due to low economic status among IWPs, may increase the transmission of HBV infection [ 9 ]. In Pakistan, the recyclable material may be collected with about ninety thousand workers [ 10 ]. In Yemen the data about the prevalence of HBV infection among informal waste pickers, especially in the Aden governorate, was not identified. Meanwhile, two studies were conducted among formal waste handlers in Yemen: one among municipal waste collectors (MWCs) and the other among medical waste collectors, with prevalence rates of 5.0% and 9.17%, respectively [ 11 , 12 ]. Therefore, our study is considered the first study involving informal groups dealing with waste. It aimed to determine the prevalence of and risk factors associated with HBV infection among informal waste pickers in Aden, Yemen. Methodology Study area and design This analytical cross-sectional study was employed in Aden, Yemen, during the period from July 1 to December 15, 2025. In this observational study, the collection and analysis of data were at a single point in time where both the outcomes of the studied group and exposures were determined at the same time without any follow-up [ 13 ]. Sample size The calculation of sample size for informal waste pickers was based on the HBV rate from a study conducted among Egyptian informal solid waste handlers, in which the rate was 2% [Khalil et al., 2022]. By applying Stephen Thompson's equation: \(\:N=\frac{{\varvec{Z}}^{2}\varvec{P}(1-\varvec{P})}{{\varvec{d}}^{2}}\) , where N represents the sample size, Z is equal to 1.96 (at a 95% confidence level), P is the estimated prevalence (0.02), and d is the conventional maximum allowable error set at 5%. [ 14 ]. N \(\:=\frac{{\varvec{Z}}^{2}\varvec{P}(1-\varvec{P})}{{\varvec{d}}^{2}}=\frac{{(1.96)}^{2}\times\:2\varvec{\%}(1-2\varvec{\%})}{{\left(5\varvec{\%}\right)}^{2}}=\) 188 informal waste pickers. The sampling method that was applied to select 188 workers in different Aden districts was a stratified sampling technique; only 151 informal waste pickers ultimately participated because the activity of those waste pickers at daytime is lower than at nighttime, as well as the high mobility among them. The response rate of 80.3% (151/188) was acceptable for hard-to-reach populations such as informal waste pickers. Despite the reduced sample size, the non-responding workers were not replaced to maintain ethical compliance. Data collection The previously designed questionnaire was used as a data collection tool in a similar study from Brazil [ 15 ]. This questionnaire underwent some modifications by adding data regarding HBV transmission from other related studies [ 12 , 16 , 17 ]. The questionnaire included sociodemographic characteristics, duration of work for IWPs, sources/type of waste, and other information about previous exposure to blood transfusion, cupping, acupuncture, dental procedures, tattooing, catheterization, broken glasses, needle-stick and other sharp injuries, and splashes of body fluids. The clinical findings were also included in this questionnaire. Laboratory procedures Blood samples were withdrawn from those participants who agreed to take part in our study. The plain Vacutainer tubes were used to collect five mL of blood from each participant. The samples were immediately transported to the National Central Public Health Laboratories in the Aden government. The sera were separated from clotted blood using centrifugation, and the commercially available fully automated cobas® e 411 analyzer (Roche Diagnostics, Germany) was used to detect the hepatitis B surface antigen (HBsAg) in the separated sera. This system was selected due to its specificity and sensitivity, which reached more than 97%. Its principle is based on an electrochemiluminescence immunoassay (ECLIA) in which labeled specific hepatitis B surface antibodies (HBsAbs) are used to detect the presence of serum HBsAg [ 18 , 19 ]. Statistical analysis The data was entered into and analyzed by using SPSS (version 26). The mean and standard deviations (SD) were used to calculate the normally distributed age variable. Frequencies and percentages were calculated for all categorical variables using figures and tables. The statistical tests related to associations between the HBV infection and risk factors were not used because of the very low HBV positivity rate among one hundred and fifty-one IWPs. Results A total mean ± SD age was 29.14 ± 14.13 years, and the range of ages was 10 and 70 years. The majority of studied informal waste pickers were males, 144 (95.4%); unmarried, 86 (57%); had primary school education, 79 (52.3%); had low income, 151 (100%); and lived with their families, 88 (58.3%) (Table 1 ). Among 151 IWPs, only 0.7% (1/151) had HBV infection (Fig. 1 ). The prevalence of this case among age groups > 39 years was 2.7%; males, 0.7%; married, 1.5%; illiterate education, 2.2%; living with his family, 1.1%; dealing with mixed waste, 0.9%; and having a duration of work as a waste picker from 5 to 10 years, 2.3% (Figs. 2 to 4 ). All waste pickers had low income, and the percent of HBV was 0.7% (1/151). Regarding the distribution of infection in Aden districts, this HBV-positive case was in Ash Shaikh Outhman, with a percentage of 5.6% (Fig. 5 ). This case was exposure to broken glass and needle-stick exposure, with 0.8% each. The vaccination status was low, and the single positive case was unvaccinated (0.7%). The percent of nausea and jaundice as clinical findings in the positive case were 7.1% and 50%, respectively (Tables 2 and 3 ). Table 1 The general characteristics of informal waste pickers in Aden-Yemen Items Frequency Percentage % Age groups/years 39 37 24.5 Sex Male 144 95.4 Female 7 4.6 Marital status Unmarried 86 57.0 Married 65 43.0 Education level Illiterate 46 30.5 primary school 79 52.3 Secondary school 26 17.2 Income Low 151 100.0 Other 0 0.0 Accommodation Alone 63 41.7 Not alone 88 58.3 in Aden-Yemen Table 2 Association between risk factors and vaccination status and HBV infection among informal waste pickers in Aden, Yemen Risk Factor Category HBV Positive n (%) Blood transfusion Yes ( n = 7) 0 (0.0%) No ( n = 144) 1(0.8%) Cupping Yes ( n = 8) 0 (0.0%) No ( n = 143) 1(0.7%) Acupuncture Yes ( n = 1) 0 (0.0%) No ( n = 150) 1(0.7%) Dental procedures Yes ( n = 7) 0 (0.0%) No ( n = 144) 1(0.7%) Tattooing Yes ( n = 4) 0 (0.0%) No ( n = 147) 1(0.7%) Catheterization Yes ( n = 9) 0 (0.0%) No ( n = 142) 1(0.7%) Exposure to broken glass Yes ( n = 131) 1 (0.8%) No ( n = 20) 0 (0.0%) Splash of body fluid to the eye Yes ( n = 7) 0 (0.0%) No ( n = 144) 1(0.7%) Needle-stick exposure Yes ( n = 128) 1 (0.8%) No ( n = 23) 0 (0.0%) Exposure to other sharp items Yes ( n = 3) 0 (0.0%) No ( n = 148) 1(0.7%) Vaccination status Vaccinated ( n = 1) 0 (0.0%) Non-vaccinated ( n = 150) 1(0.7%) n = Total number of IWPS in each category Table 3 Hepatitis B virus infection and clinical findings among informal waste pickers in Aden, Yemen Clinical findings HBV Positive No % Fever Yes ( n = 8) 0 0.0 No ( n = 143) 1 0.7 Vomiting Yes ( n = 7) 0 0.0 No ( n = 144) 1 0.7 Nausea Yes ( n = 14) 1 7.1 No ( n = 137) 0 0.0 Anorexia Yes (n = 3) 0 0.0 No (n = 148) 1 0.7 Abdominal pain Yes (n = 3) 0 0.0 No (n = 148) 1 0.7 Jaundice Yes ( n = 2) 1 50.0 Yes ( n = 149) 0 0.0 n = Total number of IWPS in each category Discussion The current study is the first one providing insights into the prevalence of HBV infection among informal waste pickers in Yemen. It demonstrated one of the lowest prevalence HBV rates among informal waste pickers compared to almost all global studies. Our result agreed with that conducted among Brazilian waste pickers (0.69%) [ 20 ]. A study performed among Egyptian informal solid waste handlers showed that the HBV rate was 2% [ 21 ]. Several studies conducted among waste pickers in Latin America revealed varied rates, which ranged from 4.3 to 34.4% [ 15 , 22 , 23 , 24 ]. The rates of HBV infection among garbage and refugee scavengers in Pakistan were 12.9% and 18.8% [ 25 , 26 ]. Two studies conducted in Yemen revealed that 5.0% and 9.17% of MWCs and medical waste handlers had HBV seropositivity, respectively [ 11 , 12 ]. One of the most important factors related to our low prevalence is the time for collection of samples from those IWPs, which was daytime from 7am to 5pm, while the activity of most IWPs was at night. Other factors that may contribute to the variations in HBV rates include sample size, type of waste handling, and diagnostic techniques. Marinho et al. conducted one of the strongest studies among informal waste pickers, in which different techniques were used to screen the HBV markers, including HBsAg and antibodies against HBsAg (anti-HBs) and hepatitis B core antigen (HBcAg) using Enzyme - Linked Immunosorbent Assay ( ELISA), and the positive markers were confirmed by detection of HBV DNA genotypes and detection of occult infection using molecular techniques [ 15 ]. The difference in risky behaviors among different populations, such as tattoo and sex with multiple partners, may affect the rate of HBV infection [ 15 ]. Our rate was lower than HBV rates among the general Yemeni population because those previous studies conducted among individuals exposed to high risk, such as hemodialysis patients and members who had close intrafamilial contact with HBV-positive patients [ 6 , 16 , 17 , 27 , 28 , 29 ]. In the current data, the percent of HBV rate was high, 5.6%, in Ash Shaikh Outhman. Despite the single HBV-positive case, it was the first finding among waste pickers in Yemen. A study conducted among MWCs in Aden revealed that clustering of HBV was higher in the Khormaksar district because there is a main government and public hospital that is frequented by most residents of Aden and other governorates, resulting in aggregation of biomedical waste that is disposed of and segregated poorly [ 12 ]. Regarding sources of waste, our data disagreed with other studies [ 15 , 21 ]. Gubran et al. recorded that the rate was high among those MWCs who were handling biomedical waste [ 12 ]. Research from Ethiopia showed that medical waste handlers had a higher rate than nonmedical handlers (30). The risk for infectious viruses increased during handling of waste from clinical settings such as hospitals and clinics [ 31 ]. According to the duration of work as a waste picker, a different result than ours was reported in Brazil [ 15 ]. Low positivity rate in our data and low sample size may contribute to the discrepancy in results. A study among formal Yemeni MWCs recorded that those whose duration was over 10 years had the highest rate [ 12 ]. The exposure to contaminated waste and sharps for long durations without protective equipment increases the risk of viral infections [ 32 ]. The associated factors, such as the exposure to broken glass and needle-stick exposure in our study, may cause HBV infection among IWPs. A report from Brazil showed those exposed to waste sharps/needles, blood transfusions, and tattoo had the highest HBV rates [ 15 ]. Gubran et al. revealed that formal MWCs who were exposed to catheterization and needle-stick had significant associations with HBV infection [ 12 ]. In this study, the percentages of clinical findings, particularly nausea and jaundice, were 7.1% and 50%, respectively. There was no previous study among IWPs that agreed or disagreed with this result, so this was documented as the first finding in Yemen. A study from Yemen noticed significant associations between the HBV and most clinical findings of MWCs [ 12 ]. The study design, a cross-sectional one, which is one of the weakest studies because the causation is not established; the sample size; the daytime for sample collection; and the fact that the detection techniques of other viral markers were not done are major limitations in our study. All these limitations lead to the lack of significant associations due to low positivity cases and limit the use of multivariate analysis control for potential confounding factors. Conclusions The prevalence of HBV was one of the lowest rates among Yemeni informal waste pickers compared to global studies. It is also lower than almost all rates in population-based studies in the same country. The clustering of HBV infection was in Ash Shaikh Outhman. Further studies are recommended among IWPs using larger sample sizes, including those working during nighttime shifts, as well as testing of other infectious diseases. In addition, vaccination campaigns against HBV infection and targeted education programs should be implemented by public health authorities to raise awareness of infection risks among IWPs. Abbreviations HBV: Hepatitis B virus HBcAg : hepatitis B core antigen HBsAbs : hepatitis B surface antibodies HBsAg: hepatitis B surface antigen DNA: deoxyribonucleic acid ELISA: Enzyme - Linked Immunosorbent Assay IWPs: informal waste pickers ECLIA: Electrochemiluminescence immunoassay MWCs: municipal waste collectors SPSS: Statistical Package for the Social Sciences SD: standard deviations WHO: World Health Organization Declarations Acknowledgments The authors gratefully thank the informal waste workers who consented to participate in this study. They also thank the student's team for their contributions to data collection and the performance of laboratory test procedures. Ethics declarations Competing interests The authors declare that there is no conflict of interest Ethics approval and consent form Ethical approval: The ethical approval of this study was obtained from the Ethics Committee of the College of Medicine and Health Science at the University of Science and Technology; MEC No. (MEC/AD0134). Ethical approval was obtained in accordance with the standards outlined in the Helsinki Declaration. Written consent forms were obtained from all volunteer participants (both men and women) before any research procedure was performed. Funding The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. Availability of data and materials All data were presented in the manuscript; no further data are available, and they will be available from the corresponding author upon request. Authors' contributions ANMG analysis of data, supervision and revision, and final editing of the manuscript. 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SAGE Open Med 12:20503121241247685 Mussa S, Kasew D, Wondimeneh Y (2022) Seroprevalence of hepatitis B and C viruses and associated factors among medical waste handlers, northeast Ethiopia. Ethiop J Health Biomed Sci 12(2). https://doi.org/10.20372/ejhbs.v12i2.375 Squeri R, La Fauci V, Sindoni L, Cannavò G, Ventura Spagnolo E (2006) Study on hepatitis B and C serologic status among municipal solid waste workers in Messina, Italy. J Prev Med Hyg 47(3):110–113 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8553750","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":571625809,"identity":"622082d3-a7a5-47e1-95fc-bf0e90dda657","order_by":0,"name":"Ali N. M. 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Mohammed","lastName":"Ali","suffix":""},{"id":571625814,"identity":"23d7333c-a38b-4e14-a4ea-694c6b6625f2","order_by":5,"name":"Abdulhakeem Jmal Abdo Mohammed","email":"","orcid":"","institution":"Aden University","correspondingAuthor":false,"prefix":"","firstName":"Abdulhakeem","middleName":"Jmal Abdo","lastName":"Mohammed","suffix":""},{"id":571625815,"identity":"743a1595-edc1-4265-b300-970dab348bf1","order_by":6,"name":"Khadija Ali Haitham Saeed","email":"","orcid":"","institution":"Aden University","correspondingAuthor":false,"prefix":"","firstName":"Khadija","middleName":"Ali Haitham","lastName":"Saeed","suffix":""},{"id":571625816,"identity":"ad20ee37-0d93-430d-a6b5-f9c11d49bfeb","order_by":7,"name":"Nadia Abdulfatah Salem Hussein","email":"","orcid":"","institution":"Aden University","correspondingAuthor":false,"prefix":"","firstName":"Nadia","middleName":"Abdulfatah Salem","lastName":"Hussein","suffix":""},{"id":571625817,"identity":"b4d3b356-9b03-4ae5-9a97-1bbf8d6425c0","order_by":8,"name":"Nesma Hamza Abdullah Alnahdi","email":"","orcid":"","institution":"Aden University","correspondingAuthor":false,"prefix":"","firstName":"Nesma","middleName":"Hamza Abdullah","lastName":"Alnahdi","suffix":""},{"id":571625818,"identity":"3b31c31f-cbe3-4104-9e52-f1e16b63b93a","order_by":9,"name":"Sumaya Salem Ali Saleh","email":"","orcid":"","institution":"Aden University","correspondingAuthor":false,"prefix":"","firstName":"Sumaya","middleName":"Salem Ali","lastName":"Saleh","suffix":""}],"badges":[],"createdAt":"2026-01-08 16:39:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8553750/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8553750/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":100018097,"identity":"d2188c92-1e10-4fda-82cf-2d11c27ae1a6","added_by":"auto","created_at":"2026-01-12 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1","display":"","copyAsset":false,"role":"figure","size":16121,"visible":true,"origin":"","legend":"\u003cp\u003eThe prevalence of HBV infection among informal waste pickers in Aden-Yemen\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8553750/v1/875b46fd5186fda0437c56f6.png"},{"id":100361933,"identity":"1a2802d1-7b19-459e-a8ff-c57e7561e601","added_by":"auto","created_at":"2026-01-16 07:45:57","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":28719,"visible":true,"origin":"","legend":"\u003cp\u003eThe prevalence of HBV infection among informal waste pickers according to their age group and sex in Aden-Yemen\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8553750/v1/f336baa05c580d8a05e0d704.png"},{"id":100361503,"identity":"9737f560-5b25-4c0d-9da4-52f67cec06a9","added_by":"auto","created_at":"2026-01-16 07:45:14","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":30237,"visible":true,"origin":"","legend":"\u003cp\u003eThe prevalence of HBV infection among informal waste pickers according to their marital status, education level and accommodation in Aden-Yemen\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8553750/v1/0067aa307d8f5aa148357a74.png"},{"id":100362755,"identity":"9fafb102-6998-40ee-88cf-6de2306e935e","added_by":"auto","created_at":"2026-01-16 07:48:01","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":29836,"visible":true,"origin":"","legend":"\u003cp\u003eThe clustering of HBV infection among informal waste pickers according to source of waste and duration of work as waste picker in Aden-Yemen.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-8553750/v1/0f6ae1964a0209a44e254316.png"},{"id":100018107,"identity":"d684c8aa-cf57-4074-818b-19694566ef9e","added_by":"auto","created_at":"2026-01-12 07:13:43","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":32948,"visible":true,"origin":"","legend":"\u003cp\u003eClustering of HBV infection among informal waste pickers according to districts in Aden-Yemen.\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-8553750/v1/3fda361e52a9aeaa42c90a83.png"},{"id":100548131,"identity":"f51adce7-20c9-4f95-b53f-0798eb8ceb6a","added_by":"auto","created_at":"2026-01-19 08:17:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":901528,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8553750/v1/0349c108-a0f3-4b2e-86b1-ab85dbf10db1.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Hepatitis B virus infection among the informal waste pickers in Aden, Yemen","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHepatitis B virus (HBV) infection is one of the major health problems that may cause life-threatening hepatic complications include; hepatic fibrosis, cirrhosis, and carcinoma [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. HBV has an icosahedral capsid that surrounds a double-stranded deoxyribonucleic acid (DNA) genome, hence the name of its family, Hepadnaviridae. The viral nucleocapsid is enclosed with a lipid envelope [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. This virus may lead to chronic infection. The global prevalence of individuals living with chronic infection was over 296\u0026nbsp;million, while the annual new acute cases were estimated to be one and a half million people [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The acute infection may be characterized by fatigue, dark urine and yellowish eyes (jaundice), nausea, anorexia (loss of appetite), and discomfort or pain in the right upper abdomen [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis bloodborne virus can be transmitted through contact with contaminated blood or other body fluids and secretions. The contaminated needles and other sharps and shaving tools may also transmit infection [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. It also may transmit through unprotected sex, especially with multiple partners, and vertically during childbirth (from infected mother to child) [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The informal waste pickers (IWPs) are a group of workers that manually collect, sort, and recover different types of reusables and recyclable waste materials, including plastics [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThese IWPs are more susceptible to blood-borne viral infections because they are exposed to infectious sharp tools from either household or medical centers waste [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Poor education and awareness and lacking personal protective equipment (PPE) due to low economic status among IWPs, may increase the transmission of HBV infection [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn Pakistan, the recyclable material may be collected with about ninety thousand workers [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In Yemen the data about the prevalence of HBV infection among informal waste pickers, especially in the Aden governorate, was not identified. Meanwhile, two studies were conducted among formal waste handlers in Yemen: one among municipal waste collectors (MWCs) and the other among medical waste collectors, with prevalence rates of 5.0% and 9.17%, respectively [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTherefore, our study is considered the first study involving informal groups dealing with waste. It aimed to determine the prevalence of and risk factors associated with HBV infection among informal waste pickers in Aden, Yemen.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy area and design\u003c/h2\u003e \u003cp\u003eThis analytical cross-sectional study was employed in Aden, Yemen, during the period from July 1 to December 15, 2025. In this observational study, the collection and analysis of data were at a single point in time where both the outcomes of the studied group and exposures were determined at the same time without any follow-up [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSample size\u003c/h3\u003e\n\u003cp\u003eThe calculation of sample size for informal waste pickers was based on the HBV rate from a study conducted among Egyptian informal solid waste handlers, in which the rate was 2% [Khalil et al., 2022]. By applying Stephen Thompson's equation: \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:N=\\frac{{\\varvec{Z}}^{2}\\varvec{P}(1-\\varvec{P})}{{\\varvec{d}}^{2}}\\)\u003c/span\u003e\u003c/span\u003e, where \u003cem\u003eN\u003c/em\u003e represents the sample size, \u003cem\u003eZ\u003c/em\u003e is equal to 1.96 (at a 95% confidence level), \u003cem\u003eP\u003c/em\u003e is the estimated prevalence (0.02), and d is the conventional maximum allowable error set at 5%. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cb\u003eN\u003c/b\u003e \u003cspan class=\"InlineEquation\"\u003e \u003cspan class=\"mathinline\"\u003e\\(\\:=\\frac{{\\varvec{Z}}^{2}\\varvec{P}(1-\\varvec{P})}{{\\varvec{d}}^{2}}=\\frac{{(1.96)}^{2}\\times\\:2\\varvec{\\%}(1-2\\varvec{\\%})}{{\\left(5\\varvec{\\%}\\right)}^{2}}=\\)\u003c/span\u003e \u003c/span\u003e188 informal waste pickers.\u003c/p\u003e \u003cp\u003eThe sampling method that was applied to select 188 workers in different Aden districts was a stratified sampling technique; only 151 informal waste pickers ultimately participated because the activity of those waste pickers at daytime is lower than at nighttime, as well as the high mobility among them. The response rate of 80.3% (151/188) was acceptable for hard-to-reach populations such as informal waste pickers. Despite the reduced sample size, the non-responding workers were not replaced to maintain ethical compliance.\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eThe previously designed questionnaire was used as a data collection tool in a similar study from Brazil [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. This questionnaire underwent some modifications by adding data regarding HBV transmission from other related studies [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The questionnaire included sociodemographic characteristics, duration of work for IWPs, sources/type of waste, and other information about previous exposure to blood transfusion, cupping, acupuncture, dental procedures, tattooing, catheterization, broken glasses, needle-stick and other sharp injuries, and splashes of body fluids. The clinical findings were also included in this questionnaire.\u003c/p\u003e\n\u003ch3\u003eLaboratory procedures\u003c/h3\u003e\n\u003cp\u003e Blood samples were withdrawn from those participants who agreed to take part in our study. The plain Vacutainer tubes were used to collect five mL of blood from each participant. The samples were immediately transported to the National Central Public Health Laboratories in the Aden government. The sera were separated from clotted blood using centrifugation, and the commercially available fully automated cobas\u0026reg; e 411 analyzer (Roche Diagnostics, Germany) was used to detect the hepatitis B surface antigen (HBsAg) in the separated sera. This system was selected due to its specificity and sensitivity, which reached more than 97%. Its principle is based on an electrochemiluminescence immunoassay (ECLIA) in which labeled specific hepatitis B surface antibodies (HBsAbs) are used to detect the presence of serum HBsAg [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eThe data was entered into and analyzed by using SPSS (version 26). The mean and standard deviations (SD) were used to calculate the normally distributed age variable. Frequencies and percentages were calculated for all categorical variables using figures and tables. The statistical tests related to associations between the HBV infection and risk factors were not used because of the very low HBV positivity rate among one hundred and fifty-one IWPs.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD age was 29.14\u0026thinsp;\u0026plusmn;\u0026thinsp;14.13 years, and the range of ages was 10 and 70 years. The majority of studied informal waste pickers were males, 144 (95.4%); unmarried, 86 (57%); had primary school education, 79 (52.3%); had low income, 151 (100%); and lived with their families, 88 (58.3%) (Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Among 151 IWPs, only 0.7% (1/151) had HBV infection (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The prevalence of this case among age groups\u0026thinsp;\u0026gt;\u0026thinsp;39 years was 2.7%; males, 0.7%; married, 1.5%; illiterate education, 2.2%; living with his family, 1.1%; dealing with mixed waste, 0.9%; and having a duration of work as a waste picker from 5 to 10 years, 2.3% (Figs.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e to \u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). All waste pickers had low income, and the percent of HBV was 0.7% (1/151). Regarding the distribution of infection in Aden districts, this HBV-positive case was in Ash Shaikh Outhman, with a percentage of 5.6% (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis case was exposure to broken glass and needle-stick exposure, with 0.8% each. The vaccination status was low, and the single positive case was unvaccinated (0.7%). The percent of nausea and jaundice as clinical findings in the positive case were 7.1% and 50%, respectively (Tables \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe general characteristics of informal waste pickers in Aden-Yemen\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItems\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentage %\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eAge groups/years\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e19\u0026ndash;29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30\u0026ndash;39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e144\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMarital status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnmarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e57.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIlliterate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eprimary school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIncome\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e151\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAccommodation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003ein Aden-Yemen\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAssociation between risk factors and vaccination status and HBV infection among informal waste pickers in Aden, Yemen\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRisk Factor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHBV Positive\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eBlood transfusion\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes (\u003cb\u003en\u0026thinsp;=\u003c/b\u003e\u0026thinsp;7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo (\u003cb\u003en\u0026thinsp;=\u003c/b\u003e\u0026thinsp;144)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(0.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eCupping\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes (\u003cb\u003en\u0026thinsp;=\u003c/b\u003e\u0026thinsp;8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo (\u003cb\u003en\u0026thinsp;=\u003c/b\u003e\u0026thinsp;143)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(0.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eAcupuncture\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes (\u003cb\u003en\u0026thinsp;=\u003c/b\u003e\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo (\u003cb\u003en\u0026thinsp;=\u003c/b\u003e\u0026thinsp;150)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(0.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eDental procedures\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes (\u003cb\u003en\u0026thinsp;=\u003c/b\u003e\u0026thinsp;7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo (\u003cb\u003en\u0026thinsp;=\u003c/b\u003e\u0026thinsp;144)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(0.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eTattooing\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes (\u003cb\u003en\u0026thinsp;=\u003c/b\u003e\u0026thinsp;4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo (\u003cb\u003en\u0026thinsp;=\u003c/b\u003e\u0026thinsp;147)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(0.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eCatheterization\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes (\u003cb\u003en\u0026thinsp;=\u003c/b\u003e\u0026thinsp;9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo (\u003cb\u003en\u0026thinsp;=\u003c/b\u003e\u0026thinsp;142)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(0.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eExposure to broken glass\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes (\u003cb\u003en\u0026thinsp;=\u003c/b\u003e\u0026thinsp;131)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (0.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo (\u003cb\u003en\u0026thinsp;=\u003c/b\u003e\u0026thinsp;20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eSplash of body fluid to the eye\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes (\u003cb\u003en\u0026thinsp;=\u003c/b\u003e\u0026thinsp;7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo (\u003cb\u003en\u0026thinsp;=\u003c/b\u003e\u0026thinsp;144)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(0.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eNeedle-stick exposure\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes (\u003cb\u003en\u0026thinsp;=\u003c/b\u003e\u0026thinsp;128)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (0.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo (\u003cb\u003en\u0026thinsp;=\u003c/b\u003e\u0026thinsp;23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eExposure to other sharp items\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes (\u003cb\u003en\u0026thinsp;=\u003c/b\u003e\u0026thinsp;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo (\u003cb\u003en\u0026thinsp;=\u003c/b\u003e\u0026thinsp;148)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(0.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eVaccination status\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVaccinated (\u003cb\u003en\u0026thinsp;=\u003c/b\u003e\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon-vaccinated (\u003cb\u003en\u0026thinsp;=\u003c/b\u003e\u0026thinsp;150)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(0.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003en\u0026thinsp;=\u0026thinsp;Total number of IWPS in each category\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eHepatitis B virus infection and clinical findings among informal waste pickers in Aden, Yemen\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e \u003cp\u003eClinical findings\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eHBV Positive\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eFever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes (\u003cb\u003en\u0026thinsp;=\u003c/b\u003e\u0026thinsp;8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo (\u003cb\u003en\u0026thinsp;=\u003c/b\u003e\u0026thinsp;143)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVomiting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes (\u003cb\u003en\u0026thinsp;=\u003c/b\u003e\u0026thinsp;7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo (\u003cb\u003en\u0026thinsp;=\u003c/b\u003e\u0026thinsp;144)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eNausea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes (\u003cb\u003en\u0026thinsp;=\u003c/b\u003e\u0026thinsp;14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo (\u003cb\u003en\u0026thinsp;=\u003c/b\u003e\u0026thinsp;137)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAnorexia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes (n\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo (n\u0026thinsp;=\u0026thinsp;148)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAbdominal pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes (n\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo (n\u0026thinsp;=\u0026thinsp;148)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eJaundice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes (\u003cb\u003en\u0026thinsp;=\u003c/b\u003e\u0026thinsp;2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e50.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes (\u003cb\u003en\u0026thinsp;=\u003c/b\u003e\u0026thinsp;149)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;Total number of IWPS in each category\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe current study is the first one providing insights into the prevalence of HBV infection among informal waste pickers in Yemen. It demonstrated one of the lowest prevalence HBV rates among informal waste pickers compared to almost all global studies. Our result agreed with that conducted among Brazilian waste pickers (0.69%) [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. A study performed among Egyptian informal solid waste handlers showed that the HBV rate was 2% [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Several studies conducted among waste pickers in Latin America revealed varied rates, which ranged from 4.3 to 34.4% [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The rates of HBV infection among garbage and refugee scavengers in Pakistan were 12.9% and 18.8% [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Two studies conducted in Yemen revealed that 5.0% and 9.17% of MWCs and medical waste handlers had HBV seropositivity, respectively [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. One of the most important factors related to our low prevalence is the time for collection of samples from those IWPs, which was daytime from 7am to 5pm, while the activity of most IWPs was at night. Other factors that may contribute to the variations in HBV rates include sample size, type of waste handling, and diagnostic techniques. Marinho et al. conducted one of the strongest studies among informal waste pickers, in which different techniques were used to screen the HBV markers, including HBsAg and antibodies against HBsAg (anti-HBs) and hepatitis B core antigen (HBcAg) using Enzyme\u003cb\u003e-\u003c/b\u003eLinked Immunosorbent Assay \u003cb\u003e(\u003c/b\u003eELISA), and the positive markers were confirmed by detection of HBV DNA genotypes and detection of occult infection using molecular techniques [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The difference in risky behaviors among different populations, such as tattoo and sex with multiple partners, may affect the rate of HBV infection [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur rate was lower than HBV rates among the general Yemeni population because those previous studies conducted among individuals exposed to high risk, such as hemodialysis patients and members who had close intrafamilial contact with HBV-positive patients [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the current data, the percent of HBV rate was high, 5.6%, in Ash Shaikh Outhman. Despite the single HBV-positive case, it was the first finding among waste pickers in Yemen. A study conducted among MWCs in Aden revealed that clustering of HBV was higher in the Khormaksar district because there is a main government and public hospital that is frequented by most residents of Aden and other governorates, resulting in aggregation of biomedical waste that is disposed of and segregated poorly [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRegarding sources of waste, our data disagreed with other studies [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Gubran et al. recorded that the rate was high among those MWCs who were handling biomedical waste [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Research from Ethiopia showed that medical waste handlers had a higher rate than nonmedical handlers (30). The risk for infectious viruses increased during handling of waste from clinical settings such as hospitals and clinics [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAccording to the duration of work as a waste picker, a different result than ours was reported in Brazil [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Low positivity rate in our data and low sample size may contribute to the discrepancy in results. A study among formal Yemeni MWCs recorded that those whose duration was over 10 years had the highest rate [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The exposure to contaminated waste and sharps for long durations without protective equipment increases the risk of viral infections [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe associated factors, such as the exposure to broken glass and needle-stick exposure in our study, may cause HBV infection among IWPs. A report from Brazil showed those exposed to waste sharps/needles, blood transfusions, and tattoo had the highest HBV rates [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Gubran et al. revealed that formal MWCs who were exposed to catheterization and needle-stick had significant associations with HBV infection [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn this study, the percentages of clinical findings, particularly nausea and jaundice, were 7.1% and 50%, respectively. There was no previous study among IWPs that agreed or disagreed with this result, so this was documented as the first finding in Yemen. A study from Yemen noticed significant associations between the HBV and most clinical findings of MWCs [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe study design, a cross-sectional one, which is one of the weakest studies because the causation is not established; the sample size; the daytime for sample collection; and the fact that the detection techniques of other viral markers were not done are major limitations in our study. All these limitations lead to the lack of significant associations due to low positivity cases and limit the use of multivariate analysis control for potential confounding factors.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe prevalence of HBV was one of the lowest rates among Yemeni informal waste pickers compared to global studies. It is also lower than almost all rates in population-based studies in the same country. The clustering of HBV infection was in Ash Shaikh Outhman. Further studies are recommended among IWPs using larger sample sizes, including those working during nighttime shifts, as well as testing of other infectious diseases. In addition, vaccination campaigns against HBV infection and targeted education programs should be implemented by public health authorities to raise awareness of infection risks among IWPs.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eHBV:\u003c/em\u003e\u003c/strong\u003e\u0026nbsp; Hepatitis B virus\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eHBcAg\u003c/em\u003e\u003c/strong\u003e: hepatitis B core antigen\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eHBsAbs\u003c/em\u003e\u003c/strong\u003e: hepatitis B surface antibodies\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eHBsAg:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003ehepatitis B surface antigen\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eDNA:\u003c/em\u003e\u003c/strong\u003e deoxyribonucleic acid\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eELISA:\u003c/em\u003e\u003c/strong\u003e Enzyme\u003cstrong\u003e-\u003c/strong\u003eLinked\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eImmunosorbent\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eAssay\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eIWPs:\u003c/em\u003e\u003c/strong\u003e informal waste pickers\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eECLIA:\u003c/em\u003e\u003c/strong\u003e Electrochemiluminescence immunoassay\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eMWCs:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003emunicipal waste collectors\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSPSS:\u003c/em\u003e\u003c/strong\u003e Statistical Package for the Social Sciences\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSD:\u003c/em\u003e\u003c/strong\u003e standard deviations\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eWHO:\u003c/em\u003e\u003c/strong\u003e\u0026nbsp; World Health Organization\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors gratefully thank the informal waste workers who consented to participate in this study. They also thank the student\u0026apos;s team for their contributions to data collection and the performance of laboratory test procedures.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics declarations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that there is no conflict of interest\u003c/p\u003e\n\u003ch3\u003eEthics approval and consent form\u003c/h3\u003e\n\u003cp\u003eEthical approval: The ethical approval of this study was obtained from the Ethics Committee of the College of Medicine and Health Science at the University of Science and Technology; MEC No. (MEC/AD0134). Ethical approval was obtained in accordance with the standards outlined in the Helsinki Declaration. Written consent forms were obtained from all volunteer participants (both men and women) before any research procedure was performed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data were presented in the manuscript; no further data are available, and they will be available from the \u003cem\u003ecorresponding author\u0026nbsp;\u003c/em\u003eupon request. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eANMG analysis of data, supervision and revision, and final editing of the manuscript. 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J Prev Med Hyg 47(3):110\u0026ndash;113\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Hepatitis B virus infection, informal Waste Pickers, waste recyclers, Aden, Yemen","lastPublishedDoi":"10.21203/rs.3.rs-8553750/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8553750/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjectives\u003c/h2\u003e \u003cp\u003eThis study aimed to determine the prevalence of and risk factors associated with hepatitis B virus infection (HBV) among informal waste pickers (IWPs) in Aden, Yemen.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003ea cross-sectional study was carried out among 151 IWPs. The collected blood samples were tested for the presence of HBsAg using the Cobas technique.\u003c/p\u003e\u003ch2\u003eResult\u003c/h2\u003e \u003cp\u003eThe majority of IWPs were males, 144 (95.4%), with a total mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD age of 29.14\u0026thinsp;\u0026plusmn;\u0026thinsp;14.13 years. Only 0.7% (1/151) had HBV infection. The percentages for this case regarding the socio-demographic and other characteristics of IWPs were varied as in group over 39 years (2.7%), males (0.7%), married individuals (1.5%), those with illiterate education (2.2%), individuals living with their families (1.1%), those with low economic status (0.7%), and those dealing with mixed waste (0.9%). According to the distribution of infection in Aden districts, the percentage of HBV-positive case was 5.6% in Ash Shaikh Outhman. This low prevalence rate is making the determination of significant associations very difficult.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe prevalence of HBV among informal waste pickers in Aden, Yemen, was one of the lowest rates compared to global studies and almost the same as the rate in a population-based study in Yemen. The clustering of HBV infection was found in Ash Shaikh Outhman. Further studies are recommended to determine viral infections among informal waste pickers working at nighttime as well as immunization against HBV.\u003c/p\u003e","manuscriptTitle":"Hepatitis B virus infection among the informal waste pickers in Aden, Yemen","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-12 07:13:38","doi":"10.21203/rs.3.rs-8553750/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3394ed37-90cf-4f82-80c4-beda8858bc36","owner":[],"postedDate":"January 12th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-23T18:40:22+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-12 07:13:38","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8553750","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8553750","identity":"rs-8553750","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}