Seroprevalence of hepatitis B and C virus infections and risk factors in Turkey: a fieldwork TURHEP study

The usefulness of anti-HCV signal to cut-off ratio in predicting hepatitis C viremia and the effect of genotype differences on signal to cut-off ratio

OBJECTIVE

In the hepatitis C virus (HCV) diagnostic algorithm, an anti-HCV screening test is recommended first. In countries with low HCV prevalence, anti-HCV testing can often give false-positive results. This may lead to unnecessary retesting, increased costs, and psychological stress for patients.

METHODS

In this study, the most appropriate S/Co (signal-cutoff) value to predict HCV viremia in anti-HCV test(+) individuals was determined, and the effect of genotype differences was evaluated. Of the 96,515 anti-HCV tests performed between 2020 and 2023, 934 were reactive. A total of 332 retests and 65 patients without HCV-ribonucleic acid (RNA) analysis were excluded. Demographic data were calculated for 537 patients, and 130 patients were included in the study.

RESULTS

The average age of 537 patients was 55±18 years, and 57.1% were women. The anti-HCV positivity rate was 0.62% (602/96,515), and the actual anti-HCV positivity rate was 0.13% (130/96,515). Anti-HCV levels were higher in HCV-RNA(+) patients than in HCV-RNA-negative individuals (p<0.0001) (Table 1). Receiver operating characteristic curve analysis identified the optimal S/Co value to be 10.86 to identify true positive cases. Sensitivity was 96.1%, specificity was 61.2%, positive predictive value (PPV) was 44.2%, and negative predictive value (NPV) was 98% (Figure 2). A total of 107 (82.3%) of the patients were identified as GT1, and the most common subtype was GT1b (n=100).

CONCLUSION

If anti-HCV S/Co is ≥10.86, direct HCV RNA testing may be recommended; However, the possibility of false positivity should be considered in patients with a S/Co value below 10.86.

Correction: Păcurar et al. Hepatitis B in Pediatric Population: Observational Retrospective Study in Romania. Life 2024, 14, 348

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Retrospective analysis of serologic test requests in the diagnosis of viral hepatitis: Inappropriate test requests and cost

The rational laboratory use and implementation of test ordering procedures aim to reduce unnecessary test requests. This study aimed to determine the financial burden caused by inappropriate serological test requests for viral hepatitis and to investigate physicians' reasons for making unnecessary test requests. We performed a retrospective evaluation of inappropriate requests for hepatitis serology testing and the financial burden they caused at a tertiary care hospital over a 1-year period. The study found 2183 (3.84%) inappropriate test requests, costing $3309.00. Of these, 357 were same-day repeat requests and 1826 were requests not following diagnostic algorithms. In the logistic regression analysis of the factors affecting unnecessary test requests, a statistically significant difference was found between whether the unit was internal or surgical, whether the request came from inpatient services or outpatient clinics, and the professional titles (P < .05). Both types of inappropriate requests were more common among male physicians (P < .05). The highest rates of inappropriate test requesting were in physical therapy and rehabilitation, pediatrics, and adult emergency units. To identify the reasons behind unnecessary test requests, 135 physicians from 23 different departments participated in the survey. The main reasons for requesting tests were identified as protecting against malpractice and fears of misdiagnosis or overlooking a diagnosis. It has been observed that physicians often order tests routinely, without being fully familiar with standard test ordering procedures based on diagnostic algorithms, and lacking knowledge about rational laboratory use. The cost of tests is mostly unknown to clinicians. The study concludes that there are laboratory tests that incur much higher costs. When this assessment is applied to the entire laboratory, it becomes clear how significant a financial burden, unnecessary workload, and loss of time this situation can cause. Identifying the presence of unnecessary test requests is the first step in preventing them. Appropriate measures include highlighting these issues, providing necessary information, and offering in-service training.

Risk of hepatitis B virus reactivation in people with multiple sclerosis treated with ocrelizumab: an observational study from Turkey

BACKGROUND

The risk of hepatitis B virus (HBV) reactivation remains unclear in people with multiple sclerosis (MS) receiving ocrelizumab. We aimed to assess HBV seroprevalence and reactivation risk in MS patients on ocrelizumab and to evaluate the effectiveness of antiviral prophylaxis against HBV reactivation.

METHODS

In this single-center, cross-sectional study, 400 people with MS receiving ocrelizumab were screened for HBV at baseline and antiviral prophylaxis was implemented based on serological results. Patients were monitored for HBV reactivation, and outcomes were analyzed.

RESULTS

Among 56 (14%) patients who had serology compatible with occult or resolved HBV infection, 49 (85.7%) received antiviral prophylaxis regularly and had no HBV reactivation during the follow-up. Reactivation of HBV occurred in 2 out of 7 (28.6%) patients who did not receive antiviral prophylaxis and in one patient who did not adhere to the prophylaxis regimen. All patients with reactivation had anti-HBs levels below 100 mIU/mL and the median titer was significantly lower than the patients with no HBV reactivation (p = 0.034).

CONCLUSION

This study highlights a 14% anti-HBc positivity, indicating a potential risk for HBV reactivation in people with MS receiving ocrelizumab. This suggests the importance of vigilant monitoring and the implementation of prophylactic measures. Our recommendation emphasizes antiviral prophylaxis, particularly for patients with low anti-HBs, and a pre-emptive strategy for others.

Hepatitis delta virus infection in Turkey: A meta-analysis of prevalence

Objectives

Hepatitis delta virus (HDV) infection has been granted orphan disease status by the US Food and Drug Administration and the European Medicines Agency owing to its rarity and relatively limited research and treatment options. Turkey is considered an endemic country for the virus. We aimed to provide a current and updated country- and region-specific HDV infection prevalence.

Methods

In this meta-analysis, we searched databases, including MEDLINE, PUBMED, EMBASE, and UlakBim (Turkish Medical Index) published between January 1, 2006, and December 31, 2022. We included blood donor studies, outpatient clinic studies that comprised patients without cirrhosis, and inpatient clinical studies that comprised patients with cirrhosis. Turkey was divided into three regions: West, Central, and East Turkey.

Results

After a systematic assessment, 41 studies were included. Using a random-effects model, the estimated HDV prevalence among hepatitis B surface antigen-positive blood donors, outpatient clinic, and inpatient clinic patients were 3.37% (confidence interval [CI] 1.99-6.11), 5.05% (CI 4.00-6.23), and 29.06% (CI 10.45-51.79), respectively. The HDV prevalence among outpatient clinic patients in Western, Central, and Eastern regions were 3.38% (CI 2.47-4.44), 2.15% (CI 1.37-3.09), and 9.81% (CI 6.61-13.55), respectively.

Conclusions

East Turkey continues to have a high burden of HDV. Public health efforts, such as screening, should be targeted accordingly.

Adjusted estimate of the prevalence of hepatitis delta virus in 25 countries and territories

BACKGROUND & AIMS

Hepatitis delta virus (HDV) is a satellite RNA virus that requires the hepatitis B virus (HBV) for assembly and propagation. Individuals infected with HDV progress to advanced liver disease faster than HBV-monoinfected individuals. Recent studies have estimated the global prevalence of anti-HDV antibodies among the HBV-infected population to be 5-15%. This study aimed to better understand HDV prevalence at the population level in 25 countries/territories.

METHODS

We conducted a literature review to determine the prevalence of anti-HDV and HDV RNA in hepatitis B surface antigen (HBsAg)-positive individuals in 25 countries/territories. Virtual meetings were held with experts from each setting to discuss the findings and collect unpublished data. Data were weighted for patient segments and regional heterogeneity to estimate the prevalence in the HBV-infected population. The findings were then combined with The Polaris Observatory HBV data to estimate the anti-HDV and HDV RNA prevalence in each country/territory at the population level.

RESULTS

After adjusting for geographical distribution, disease stage and special populations, the anti-HDV prevalence among the HBsAg+ population changed from the literature estimate in 19 countries. The highest anti-HDV prevalence was 60.1% in Mongolia. Once adjusted for the size of the HBsAg+ population and HDV RNA positivity rate, China had the highest absolute number of HDV RNA+ cases.

CONCLUSIONS

We found substantially lower HDV prevalence than previously reported, as prior meta-analyses primarily focused on studies conducted in groups/regions that have a higher probability of HBV infection: tertiary care centers, specific risk groups or geographical regions. There is large uncertainty in HDV prevalence estimates. The implementation of reflex testing would improve estimates, while also allowing earlier linkage to care for HDV RNA+ individuals. The logistical and economic burden of reflex testing on the health system would be limited, as only HBsAg+ cases would be screened.

IMPACT AND IMPLICATIONS

There is a great deal of uncertainty surrounding the prevalence of hepatitis delta virus among people living with hepatitis B virus at the population level. In this study, we aimed to better understand the burden in 25 countries and territories, to refine techniques that can be used in future analyses. We found a lower prevalence in the majority of places studied than had been previously reported. These data can help inform policy makers on the need to screen people living with hepatitis B virus to find those coinfected with hepatitis delta virus and at high risk of progression, while also highlighting the pitfalls that other researchers have often fallen into.

The performance of hepatitis B surface antigen quantification as a noninvasive biomarker predicting liver injury and serum hepatitis B virus DNA level

OBJECTIVES

Chronic hepatitis B (CHB) is still a major public health problem worldwide. Recently, evidence indicating that serum hepatitis B surface antigen (HBsAg) quantification can be used for monitorization of hepatitis B virus (HBV) infection has been increased. In this study, we evaluated HBsAg levels during the natural course of CHB and identified correlations between HBsAg, HBV DNA levels and liver histopathology.

METHODS

From 6 August 2016 to 7 June 2017, naive patients, who are ≥18 years old, fulfilled the criteria for the diagnosis of CHB and had a liver biopsy within a year before or after admission, were included. HBsAg levels in serum samples were investigated by electrochemiluminescence immunoassay. Results were correlated with serum HBV DNA levels, histologic activity index (HAI) and fibrosis scores.

RESULTS

In this study 66 patients were included. There was a moderate and significant correlation between HBsAg levels and fibrosis scores (r = 0.386, P = 0.001), but no correlation with HAI. Serum HBsAg levels showed a positive, strong and significant (r = 0.740, P < 0.001) correlation with HBV DNA levels. In hepatitis B e antigen-negative patients, serum HBsAg levels were perfectly correlated with HBV DNA levels (r = 0.992, P < 0.001) and moderately correlated with fibrosis scores (r = 0.360, P = 0.006).

CONCLUSION

We found a positive correlation between serum HBsAg levels and the severity of fibrosis scores and serum HBV DNA levels. These findings suggest that serum HBsAg quantification might be a useful noninvasive diagnostic test for the prediction of fibrosis severity and HBV DNA level.

What Is the Real Epidemiology of Hepatitis D Virus and Why so Many Mixed Messages?

The disease burden of HDV is poorly understood. Our review identified multiple reasons: (1) HDV infection rates are overestimated in the general population due to limited sample sizes, sampling high-risk populations, and significant regional variations, (2) estimates are based on chronic HBV populations, but HBV burden itself is uncertain, (3) there is a lack of testing in at-risk populations, (4) prevalence testing is based on HDV antibody testing and not HDV RNA, which distinguishes between active infection versus prior exposure, (5) older studies used less reliable testing and (6) HBV vaccination programs have affected HDV prevalence, but is often not accounted for.

Hepatitis delta: Epidemiology to recent advances in therapeutic agents

Hepatitis D virus (HDV) was first described in 1977 and is dependent on the presence of hepatitis B surface antigen (HBsAg) for its entry into cells and on the human host for replication. Due to the envelopment with the hepatitis B virus (HBV) envelope, early phases of HDV entry resemble HBV infection. Unlike HBV, HDV activates innate immune responses. The global prevalence of HDV is estimated to be about 5% of HBsAg positive individuals. However, recent studies have described a wide range of prevalence between 12 to 72 million individuals. Infection can occur as super-infection or co-infection. The diagnosis of active HDV infection involves screening with anti HDV antibodies followed by quantitative PCR testing for HDV RNA in those who are HBsAg positive. The diagnostic studies have evolved over the years improving the validity and reliability of the tests performed. HDV infection is considered the most severe form of viral hepatitis and the HDV genotype may influence the disease course. There are eight major HDV genotypes with prevalence varying by geographic region. HDV treatment has been challenging as HDV strongly depends on the host cell for replication and provides few, if any viral targets. Better understanding of HDV virology has led to the development of several therapeutic agents currently being studied in different phase II and III clinical trials. There is increasing promise of effective therapies that will ameliorate the course of this devastating disease.

The changing epidemiology of delta hepatitis in Türkiye over three decades: A systematic review

Hepatitis D virus (HDV) infection represents the most serious form of chronic hepatitis. Turkey is among the countries with high HDV and intermediate hepatitis B virus prevalence. In Turkey, hepatitis B virus (HBV) vaccine series was included in the routine vaccination program in 1998. There have been regional differences in prevalence of HBV and HDV. Although a decline in HDV prevalence is estimated, there are uncertainties about the epidemic patterns of it. HDV prevalence was studied in varying groups and geographic regions. In this study, we aimed to analyse hepatitis D epidemiology in all groups and geographic regions in recent 35 years. During the study period of 35 years, 111 publications were noted. The analysis was done on the basis of three periods: 1999 and before (Period 1), 2000-2009 (Period 2), and 2010 and after (Period 3). The groups studied included inactive carrier state, chronic hepatitis B, all HBsAg-positive individuals and special groups. Among inactive HBV carriers, HDV prevalence did not change significantly over three decades. Among patients with chronic hepatitis, studies reported decreasing (from Period 1 to Period 2) and then increasing (from Period 2 to period 3) HDV prevalence. The studies including all HBsAg-positive patients reported decreasing (from Period 1 to Period 2) and then increasing (from Period 2 to period 3) HDV prevalence. Cumulative data of these 3 groups were taken to reveal HDV prevalence in HBV-infected patients, and it showed decreasing (from Period 1 to Period 2) and then increasing (from Period 2 to period 3) HDV prevalence. Cumulative data of these 3 groups analysed according to the geographic regions of the country showed that Eastern and Southeastern Anatolia regions still have a high burden of HDV. The study showed that although HDV prevalence decreased from 8.3% in Period 1 to 4.8% in Period 2, it tended to increase 5.5% in Period 3. HDV infection is still a healthcare problem in Turkey.

Change in Rates of HBsAg and Anti-HBs in Şırnak 20 Years After Introduction of Hepatitis B Vaccine into Routine Infant Immunization Program

Objectives

This study aimed to monitor the change in the rate of hepatitis B infections in Şırnak, a province in south-eastern Turkey, and to determine the rate of immunization for hepatitis B in this region after the national immunization program covered hepatitis B.

Materials and Methods

This retrospective study included patients born in 1998 or after and applied to different outpatient clinics in the province between April 2017 and June 2018. Patients in this study were screened for HBsAg and anti-HBs for various reasons. We analyzed confirmed HBsAg and anti-HBs positive results according to gender, age, and vertical transmission. Anti-HBs-positive patients were divided into four groups according to their ages, and the groups were compared.

Results

Out of 2713 patients, 1530 (56.4%) were male, and the mean age was 12.77 (0-20). Four patients (0.14%) were HBsAg positive, and the anti-HBs positivity rate was 61.22%. The difference was statistically significant when the anti-HBs positivity rate was compared between the age groups (p<0.001). The highest anti-HBs positivity rate was found in the 0 to 5 age group.

Conclusion

There has been a significant decrease in hepatitis B virus infection rates after introducing the hepatitis B vaccine into routine infant immunization programs. The widespread introduction of hepatitis B vaccination should be targeted in Turkey, considering its geographical and sociocultural diversity.

Silent HDV epidemics culminates in high levels of liver cirrhosis in endemic region despite 20 years of HBV vaccination

The hepatitis delta virus (HDV) is believed to be a vanishing infection in countries with successful hepatitis B virus (HBV) vaccination programs. We assessed the current status of HDV infection in Tuva, a region of the Russia that has been highly endemic for HBV. The proportion of HDV-infected patients among HBsAg-positive patients in the regional registry in 2020 was 32.7% (786/2401). An analysis of the medical records of 514 HDV patients demonstrated that 37.5% (193/514) had liver cirrhosis at the first doctor's visit, and 7.4% of patients lived in families where another family member had HDV. All HDV patients were infected with genotype HDV-1, 94.5% had HBV genotype D, and 5.5% had genotype A. A serosurvey conducted among 1170 healthy volunteers showed that the average detection rate of HBsAg with anti-HDV was 1.0% (95% CI: 0.57-1.81%). No anti-HDV positive samples were detected in participants aged under 30 years. The HBsAg/anti-HDV positivity rate peaked at 7.4% in patients aged 50-59 years, which was significantly higher than in a similar age cohort surveyed in 2008 (1.6%, p < .0001). A Bayesian analysis showed that HDV circulation in Tuva resulted from two waves of introduction, the first in the 1810s (95% HPD: 1741-1834) from Central Asia, and the second in the 1960s (95% HPD: 1953-1979) from Russia. HBV has a much longer history of circulation in Tuva with the MRCA for the predominant genotype HBV-D dated to 972 (95% HPD: 535-1253) for subtype D1, 1274 (95% HPD: 936-1384) for D2, and 1173 (95% HPD: 1005-1618) for D3. A SkyGrid reconstruction of population dynamics showed an increase in the intensity of HDV spread in recent decades. This situation shows the need for HDV screening and prevention measures among people living with HBV.

HCV Genotype Distribution Among People Who Inject Drug in Turkey: Findings from Multicenter and Cross-Sectional Study

Background

Hepatitis C virus (HCV) infection is very common in people who inject drugs (PWID). Studies about the prevalence and genotype distribution of the HCV among PWID are very crucial for developing strategies to manage HCV infection. This study's objective is to map the distribution of HCV genotypes among PWID from various regions of Turkey.

Method

This prospective, multicenter, cross-sectional study involved 197 PWID who tested positive for anti-HCV antibodies from 4 different addiction treatment facilities in Turkey. Interviews were done with people who had anti-HCV antibodies, and blood samples were taken to check the HCV RNA viremia load and genotyping.

Results

This study was conducted on 197 individuals with a mean age of 30.3 ± 8.6 years. 9.1% (136/197 patients) had a detectable HCV-RNA viral load. Genotype 3 was the most commonly observed genotype by 44.1%, followed by genotype 1a by 41.9%, genotype 2 by 5.1%, genotype 4 by 4.4%, and genotype 1b by 4.4%. Whereas genotype 3 was dominant with 44.4% at the central Anatolia region of Turkey, the frequencies of genotypes 1a and 3, which were predominantly detected in the south and northwest regions of Turkey, were very close to each other.

Conclusion

Although genotype 3 is the predominant genotype in the PWID population in Turkey, the prevalence of HCV genotype varied across the country. To eliminate HCV infection in the PWID, treatment and screening strategies that differ by genotype are essentially required. Especially identification of genotypes will be useful in developing individualized treatments and determining national prevention strategies.

Impact of COVID-19 fear on Hepatitis C management

Background/Aim: Hepatitis C virus (HCV) infection, a major cause of cirrhosis worldwide, is the most common cause of cirrhosis and hepatocellular carcinoma in Turkey. Today, HCV infection can be treated effectively and safely using direct-acting antiviral drugs, and therefore, the World Health Organization has announced elimination targets by 2030. During the pandemic, many social and personal restrictions were applied for fear of increasing the prevalence of coronavirus disease 2019 (COVID-19) infection. Here we investigate the effects of these restrictions on managing HCV infection in internal medicine departments that deal with both infections. Methods: Patients who applied to the internal medicine departments of our hospital and tested for anti-HCV between 11 March 2020 and 09 April 2022, which was the time interval when official restrictions were applied in Turkey during the COVID-19 pandemic, were included in the study. Patients who were not tested for anti-HCV were excluded from the study. The study was planned as a retrospective cohort study, and patients’ files tested for anti-HCV were scanned. Anti-HCV positivity, HCV RNA PCR testing, and treatment status in HCV RNA-positive patients were evaluated. Results: During the official pandemic period when social restrictions were applied, anti-HCV positivity was revealed in 400 (1.9%) of 21,501 patients for whom anti-HCV tests were performed in internal medicine departments. HCV RNA was not tested in 64 of 400 patients with positive anti-HCV test (16%), and 83 (24.7%) of 336 patients tested for HCV RNA were found to be positive. It was determined that 17 (20.5%) of the HCV RNA-positive patients did not receive antiviral treatment. Conclusion: In studies conducted in Turkey in the pre-pandemic period, it was determined that HCV RNA was not tested in approximately half of the anti-HCV-positive patients, while this rate was found to be only 16% during the pandemic period. This can be explained by the fact that patients infected with the COVID-19 virus were mostly followed-up by internal medicine clinics, where the awareness of viral hepatitis was high. It was determined that 20.5% of the patients with positive HCV RNA PCR tests remained untreated. This finding suggested that the social and personal restrictions applied during the pandemic led to patient follow-up and treatment disruptions.

The Effects of the COVID-19 Pandemic on Clinical and Laboratory Follow-up of Patients Diagnosed With Chronic Hepatitis B: A Multicenter, Prospective, Observational Study

Background: Chronic hepatitis B (CHB) patients who are under the treatment of antiviral agents should be monitored in routine control visits. However, during the COVID-19 pandemic, the visits were interrupted. Objectives: This study aimed to investigate whether these patients were affected regarding clinical, laboratory, and treatment outcomes. Methods: This prospective study consisted of CHB patients aged > 18 who were applied to 3 tertiary centers between 14 February and 30 March 2022. The patients were selected from the ones who regularly applied to outpatient clinics and under the treatment of antiviral agents before the pandemic. The demographic and laboratory values, including serologic, biochemistry, and molecular results, were compared between the 2 groups who came and did not come to control visits. Results: A total number of 220 patients were included. More than half (n = 142, 64.5%) were female. The median age was 44 years (19 - 73). A hundred and forty-two (64.5%) patients did not come to control visits during the pandemic. The most common reason was anxiety about COVID-19. The tenofovir treatment was replaced with entecavir (ETV) due to osteopenia and with alafenamide due to osteopenia and/or renal failure. The previous agents were re-started in 27 (79.5%) patients who discontinued the treatment. Conclusions: The COVID-19 pandemic negatively impacted the follow-up of CHB patients. In this regard, 15.5% of patients stopped their treatments. The patients who stopped their follow-ups and continued tenofovir disoproxil fumarate (TDF) had proteinuria and decreases in bone mineral density (BMD) and estimated glomerular filtration rate (eGFR) levels.

Assessment of HCV-RNA test results and access rates to antiviral treatment in patients with anti-HCV positivity-a 10-year analysis

BACKGROUND

Currently, hepatitis C virus (HCV) infection can be cured by direct-acting antivirals (DAAs). In this study, we aimed to find the rate of viremia among patients with a positive anti-HCV test and the rate of antiviral treatment given to viremic patients. We also aimed to reach patients with anti-HCV positivity but not tested for HCV-RNA, and patients, who were diagnosed with HCV-RNA positivity but received no treatment.

METHODS

In this study, individuals tested for anti-HCV in Tokat Gaziosmanpaşa University Research and Application Hospital in the period between January 2010 and January 2020 were reviewed retrospectively. Anti-HCV positive patients, who were not tested for HCV-RNA, and HCV-RNA positive patients, who did not receive treatment, were called for a follow-up visit in the outpatient clinic.

RESULTS

: The prevalences of anti-HCV positivity and viremia among patients were 2.24% and 0.67%, respectively. A HCV-RNA test was ordered in 71.7% of the anti-HCV positive patients. Antiviral treatment was not given to 44.4% of the viremic patients. Of the patients, who were called for a follow-up visit in the outpatient clinic, 3.9% attended the visit. Of these patients, 0.8% were HCV-RNA positive and 0.7% received treatment.

DISCUSSION

Although the rate of HCV-RNA testing was relatively high in patients with anti-HCV positivity, almost half of them did not receive treatment. We could reach only one-third of the patients, who were called for a follow-up visit, and only a few patients received treatment. Individuals with anti-HCV positivity should be referred to a specialist without delay and HCV-RNA testing should be performed immediately to achieve HCV elimination targets. The likelihood of difficulties in reaching patients later should be considered.

Evaluation of the safety and antiviral efficacy of the tenofovir alafenamide fumarate molecule in immunosuppressed patients

Aim: Patients with chronic or prior hepatitis B virus (HBV) infection may experience HBV reactivation during immunosuppressive therapy. The objective of this study was to evaluate the safety and antiviral efficacy of tenofovir alafenamide fumarate (TAF) for prophylaxis of HBV reactivation in patients on immunosuppressive therapy. Material and Method: This study included patients who were started on immunosuppressive treatment due to hematologic/solid malignancy, autoimmune disease, or inflammatory disease and were treated with TAF for at least six months due to HBsAg and/or total anti-HBc positivity at Karadeniz Technical University Farabi Hospital between January 2018 and February 2021. Electronic medical records were retrospectively reviewed and the adverse event profile was analyzed. Results: Of the 94 patients enrolled in the study, 70.2% (n=66) were male. The mean age of the patients was 60.37±14.56 years. The reasons for initiation of immunosuppressive drug treatment were hematologic malignancies in 48.9% (n=46), solid tumors in 27.7% (n=26), and other causes (autoimmune/inflammatory) in 23.4% (n=22). There was no statistically significant difference in creatinine, phosphorus, glucose, and LDL profile between baseline and 6-12 months of TAF treatment (p=0.861, p=0.136, p=0.323, p=0.304, respectively). All patients in whom HBV DNA was detectable at baseline became negative at the last follow-up visit. None of the patients developed HBV reactivation and there was no need to discontinue antiviral/immunosuppressive treatment due to side effects. Conclusion: TAF is a safe and effective short-term option to prevent HBV reactivation in patients receiving immunosuppressive therapy.

Isparta İlinde Aile Hekimlerinin Yaptığı Evlilik Öncesi Taramaların Sonuçlarının İncelenmesi: Retrospektif Çalışma

Aim: Family physicians, who are the primary providers of health care also perform a premarital examination, which is included in preventive services and required to ensure the continuation of healthy generations. This study was conducted to raise awareness and assess the current situation by analyzing the results of premarital examinations in the province of Isparta. Material and Method: This is a retrospective, epidemiological, analytical study. The data of 16.181 people who applied to family health centers in Isparta provinces and districts for any reason between the years 2017-2020, were analyzed retrospectively. Results: As a result of retrospective examination and analysis of premarital examination data of 16.181 people between 2017 and 2020, the average age was 29.70±8.70, VDRL-RDR was found in 0.2% of the individuals, TPHA in 0.1%, HBsAg in 0.9%, Anti-HBcIgM in 0.03%, Anti-HCV in 0.4%, and Anti-HIV positivity was not detected. Anemia was found in 3.5% of the individuals, and thalassemia carrier was found in 2.2%. Conclusion: Examinations in the family in the province of Isparta will also be completed in close proximity to family physicians, and premarital examination will be performed. In the training, detailed information was given about emphasizing the repetition of premarital examination by physicians.

Predictors of eligibility for reimbursement of antiviral treatment in HBe-Ag negative chronic hepatitis B patients with high ALT levels

Background/Aim: A liver biopsy is required for the reimbursement of antiviral therapy in Hepatitis B e-antigen (HBe-Ag) negative chronic hepatitis B patients. Liver biopsy is an invasive procedure with potential complications, such as bleeding, pain, pneumothorax, and even death. The study aimed to evaluate simple and non-invasive parameters that may help predict histological criteria that would be eligible for antiviral treatment reimbursement. Methods: HBeAg-negative chronic hepatitis B patients with alanine transaminase (ALT) levels > upper normal limit (40 IU/L) and HBV DNA viral load > 2000 IU/ml who underwent liver biopsy were enrolled in this retrospective cohort study. ALT, aspartate aminotransferase (AST), alpha-fetoprotein (AFP) values, hepatitis B virus (HBV) DNA levels, platelet count, and hepato-steatosis grade based on ultrasonography were used to predict the eligibility for antiviral therapy reimbursement. Eligibility for reimbursement of antiviral treatment regarding histological criteria defined by National Social Security Institution is based on the hepatitis activity index (HAI) score ≥ 6 and/or fibrosis score ≥ 2 according to Ishak’s scoring system. Results: One hundred and fifteen patients were included in the study; 79 patients (68.7%) were male. The mean age of patients was 46.51 (11.39). Sixty-two patients (53.9%) had a fibrosis score ≥ 2, and 80 (69.6%) patients had an HAI score ≥ 6. Ninety-two (80%) of the patients fulfilled histological criteria for antiviral treatment reimbursement. Multivariate analysis revealed that age and platelet count were independent predictors of eligibility for antiviral treatment reimbursement. The platelet count cut-off point was 198 x 109 /L for predicting eligibility for antiviral treatment reimbursement. Conclusion: Most patients (92/115, 80%) with high ALT and DNA viral load were eligible for antiviral treatment reimbursement. Platelet count and age may be used as simple non-invasive parameters for predicting the eligibility for antiviral treatment reimbursement in terms of histological findings.

Evaluation of HBsAg Seroclearance in Patients with Hepatitis B

Objective

Hepatitis B surface antigen (HBsAg) seroclearance/seroconversion is regarded as an indicator of the ultimate immune control of hepatitis B virus (HBV) infections. HBsAg loss is the most important endpoint, as it shows deep suppression of HBV replication and viral protein expression. This study was aimed to retrospectively evaluate the HBsAg seroclearance/seroconversion status in patients with acute or chronic hepatitis B (CHB) diagnosis.

Materials and methods

Patients diagnosed with acute or CHB at the Harran University Faculty of Medicine Department of Gastroenterology between January 2012 and December 2020 were included in this study. This study was designed as a retrospective historical cohort. Experimental analysis of the data was done with the help of the SPSS version 22.0 package program.

Results

Of 1,053 patients with positive HBsAg, 854 patients with sufficient data in their files were included in this study. There were 494 (57.8%) males and 360 (42.2%) females; the mean age was 42.71 ± 14.31 (range 18-88). The mean duration of illness was 86.13 ± 72.92 months. In the 9-year follow-up of 854 patients, 65 (7.9%) of the last HBsAg test were negative and seroclearance had developed. The last anti-HBs test was positive in 49 (75.4%) of 65 patients who developed seroclearance, and it was found that seroconversion had developed. Twenty-seven of 30 (90%) of the patients who developed seroclearance had liver transplantation. Sixteen of 19 (84.2%) of them had acute hepatitis B, 14 of 477 (2.9%) were hepatitis carriers, 5 of 201 (2.5%) had e-negative CHB, 2 of 36 (5.6%) had cirrhosis, and 1 of 43 (2.3%) of them were delta hepatitis who developed seroclearance disease; none of the 38 e-positive CHB patients developed seroclearance.

Conclusion

In the 9-year follow-up of patients who were positive for HBsAg at their first admission, approximately one-tenth (7.9%) developed seroclearance, and two-thirds also developed seroconversion. After liver transplantation and acute hepatitis B, almost all patients developed seroclearance, whereas, in approximately 3% of carriers (e-negative CHB and cirrhotic patients) seroclearance developed.

How to cite this article

Taşkın MC, Uyanikoglu A, Cindoglu C. Evaluation of HBsAg Seroclearance in Patients with Hepatitis B. Euroasian J Hepato-Gastroenterol 2022;12(2):65-68.

Assessment of Hepatitis B, Hepatitis C and Human Immunodeficiency Virus Screening Results Performed Before Elective Eye Surgery

Objective: Although preoperative screening for Hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) infections in patients is a controversial issue in terms of cost-effectiveness and patient privacy, this practice is commonly carried on by surgical branches. The goals of this study were to evaluate the prevalence of preoperative HBV surface antigen (HBsAg), anti-HCV and anti-HIV antibodies, as well as whether seropositive patients were referred to the infectious diseases outpatient clinic. Methods: In this study, blood samples from 884 patients who underwent elective eye surgery at Tokat Gaziosmanpasa University Medical Faculty Hospital between August 2019 and April 2021 were researched for HBsAg, anti-HCV and anti-HIV positivity and seroprevalences were determined. It was also determined whether patients with seropositivity from the hospital automation system had previously been diagnosed and if newly diagnosed patients applied to the infectious diseases outpatient clinic in the subsequent period. Results: The study comprised a total of 884 patients. Males comprised 457 (51.7%) of all patients, with a mean age of 63.21± 16.05. In 29/839 (3.3%) of the patients, HBsAg was positive. Anti-HCV positivity was found in 21/872 (2.4%) people. Anti-HIV positivity was not detected in any of the patients. Conclusion: It would be a more accurate and effective approach to increase compliance with standard hygiene and protection measures rather than requesting routine pre-operative testing for HBV, HCV and HIV. If these tests reveal seropositivity, the patient should be informed of the disease and referred to an infectious disease specialist.

Molecular Epidemiological Characteristics and Risk Factors for Acquiring HBV Among Li Ethnic in Baisha County, Hainan Island-Subgenotype D3 Was First Discovered in China

The residents of Baisha, a county of Hainan Island, mainly composed of Li ethnic population and relatively closed living environment with its unique geographical location. Our previous study showed that Li ethnic population of Baisha is an endemic center for hepatitis C virus, with significantly higher rates than in other parts of China. However, the epidemiology of HBV in this region remains unclear. Therefore, we conducted a comprehensive epidemiological survey of HBV in Baisha County, including 1,682 Li ethnic residents. The total seropositive rate for HBsAg was 10.2% and was higher than other parts of China. HBV-positive status was associated with the 20–40-year-old group (OR = 1.27, 95%CI 1.04–1.39, P < 0.01) and alcohol consumption (OR = 2.17, 95%CI 1.58–2.99, P < 0.01). Phylogenetic analysis showed that HBV subgenotype D3 was predominant in Baisha County which was first discovered in China, followed by C5, C1, B2, and undetermined subgenotypes which were significantly different from other geographical distribution of main genotypes in China. The most recent common ancestor (tMRCA) of the HBV genotype C in the Li ethnic of Baisha County was 1846 (95%CI: 1739–1932), and Baisha-C5 was earlier than Baisha-C1 and Baisha-C2. Most Baisha-D3 sequences were concentrated in one bundle and unrelated to those D3 genome sequences elsewhere in the world. According to the phylogenetic tree, D3 was introduced into Baisha County in 1884 (95%CI: 1816–1993) and became a local endemic virus. In conclusion, HBV infection in the Li ethnic group is characterized by a high prevalence rate in 20–40-year-old individuals and a unique genotype distribution which were significantly different from other geographical distribution of main genotypes in China, and subgenotype D3 was first discovered in China.

Hepatitis B Vaccination in Children With Ongoing Cancer Treatment: A Safety and Efficacy Study of Super-Accelerated Vaccination Scheme

OBJECTIVE

Children with cancer have an increased risk for hepatitis B virus (HBV) infections due to chemotherapy-induced secondary immunodeficiency and frequent blood transfusions. The aim of this study is to evaluate the efficacy and safety of hepatitis B vaccination during the intensive induction chemotherapy in children with cancer found to be seronegative for hepatitis B on admission.

MATERIALS AND METHODS

Children newly diagnosed with cancer were evaluated for the presence of hepatitis B surface antigen (HBsAg) and antibody on admission. The children negative for both were included in the study. A super-accelerated vaccination scheme (3 booster doses at days 1-5, 8-12, and 28-33) was administered to these seronegative children concurrently with induction chemotherapy. Antibody response was checked 4-8 weeks after the last vaccination and 6 months after the end of the treatment.

RESULTS

Eleven out of 122 children were seronegative for hepatitis B on admission (9%). Acute lymphoblastic leukemia, lymphoma, and solid tumors were diagnosed in 5, 4, and 2 children, respectively. Complete seroconversion was achieved in 4-8 weeks after the last vaccination with high titers of anti-HBs antibody, and all patients remained antibody-positive until 6 months after the completion of chemotherapy.

CONCLUSION

The risk of transfusion-related infections increases with a number of transfused products and donor exposures, and it is more significant for immunosuppressed children with hematologic and oncologic malignancies. Hepatitis B vaccination could safely be applied with brisk and sustained responses in this vulnerable population, based on the local epidemiological data.

Comparison of Tenofovir Alafenamide and Entecavir Therapy in Patients with Chronic Hepatitis B Initially Treated with Tenofovir Disoproxil: A Retrospective Observational Survey

Background: In chronic hepatitis B patients with or exposed to the risk of osteoporosis or renal dysfunction, switching from tenofovir disoproxil fumarate (TDF) to tenofovir alafenamide fumarate (TAF) or entecavir (ETV) may be the right choice. Objectives: This study aimed to present real-life data in terms of the efficacy and safety of a TAF/ETV treatment change while receiving TDF. Methods: This retrospective study was conducted on 344 adult patients from 10 centers. The data of patients who had changed to ETV (n = 107) and TAF (n = 237) while receiving TDF were analyzed. The data collected at 0 and 6 months of treatment were analyzed. The virological response was assessed based on undetected hepatitis B virus (HBV) DNA. Serum alanine aminotransferase (ALT) values were used to evaluate the biochemical response. For renal function, serum creatinine and phosphorus, as well as estimated glomerular filtration rate (eGFR), were recorded. Moreover, lumbar spine and hip T-scores along with the serum lipid profile were evaluated. Results: The mean age of patients was 41.14 ± 13.46 years, and 224 (65.1%) of the participants were male. The treatment arms were not significantly different in terms of demographic characteristics, comorbid diseases, infection duration, family history of HBV infection, blood platelet count, serum biomarkers, such as ALT, phosphorus, creatinine, total bilirubin, albumin, lipid profile, and HBV DNA levels at the beginning. No statistically significant difference was found between the proportion of undetectable HBV DNA of the two treatment groups after 6 months (P = 0.221). The ALT normalization in the ETV and TAF groups at the sixth month compared to the baseline levels was not significantly different (P = 0.853, P = 0.330, respectively). There was no statistically significant difference between the two treatment arms regarding changes in eGFR, creatinine, phosphorus, hip, and spine T-scores from baseline to 6 months (P = 0.296, P = 0.78, P = 0.141, P = 0.832, P = 0.947, respectively). In those who switched to TAF or ETV, low-density lipoproteins cholesterol were observed to be significantly higher after 6 months compared to baseline values (P = 0.002, P = 0.049, respectively). The TC increased significantly in the TAF group (P = 0.035). Conclusions: Our study showed that switching to ETV and TAF sustained the viral suppression and biochemical response achieved by TDF therapy. The treatment switch to TAF of ETV can control renal dysfunction and reduce bone mineral density caused by TDF.

Screening of Hepatitis A and B Seropositivity among Turkish Healthcare Providers Admitted to Occupational Health Services

This study aimed to determine the protection rates against hepatitis A virus (HAV) and hepatitis B virus (HBV), among healthcare providers (HCPs). The occupational health service data of Gaziosmanpaşa Training and Research Hospital between January 2020 and December 2020 were evaluated for this retrospective observational study. Of the 1,722 participants aged 34.40 ± 9.16 years, 48.6% (n = 861) were male, and 55.0% (n = 975) were doctors and nurses. The anti-HBs seropositivity rate was 87.5% (n = 1,501). None of the participants had anti-HCV antibodies. Twelve participants were HBsAg positive. A level of anti-HBs titer ≥10 mIU/mL was maintained in 66.7% of the HCPs vaccinated in childhood, while 71.3% (n = 1,263) of the participants had anti-HAV IgG. HAV vaccination needs were higher in the doctor and nurse groups than in the other groups (60.5% and 39.5%, respectively, p = 0.003). HBV protection was higher among HCPs in polyclinics/wards and surgery/intensive care units than in those working in the emergency department (odds ratio (OR): 2.099, 95% confidence interval (CI) = 1.285-3.429; OR: 1.592, 95% CI = 1.037-2.443, respectively). HAV protection was higher in HCPs aged 31-50 years and over 50 years than in those aged 18-30 years (OR: 2.046, 95% CI = 1.647-2.541; OR: 3.615, 95% CI = 2.164-6.037, respectively). In this study, one out of every two HCPs aged 18-30 years admitted to the occupational health control services had not yet received the HAV vaccine. The low levels of HBV protection among HCPs in the emergency department highlight the need for occupational health screening and HBV vaccination for HCPs working in emergency services in hospitals.

Evaluation of Seroprevalence of Hepatitis B Virus and Hepatitis C Virus in Reference Center Hospital in Turkey's Southeast Anatolia Among Patients Referred for Major or Minimally Invasive Surgery: Last Decade Experience in a Previously High Prevalence Area

Background: There is a high worldwide prevalence of chronic Hepatitis B Virus (HBV) and Hepatitis C Virus (HCV) infections, among the significant causes of liver-related morbidity and mortality. Objectives: We aimed to determine the prevalence of HBV and HCV in a referral center hospital in Southeast Anatolia among patients that applied for major or minimally invasive surgery. Methods: In a tertiary referral state hospital for general purposes, patients undergoing surgical procedures and serologic examinations for HBV and HCV were included in the study between January 2011 and September 2020. Results: In the general population, hepatitis B surface antigen (HBsAg) and anti-HBs were examined in 220,724 patients, and anti-HCV was examined in 186,017 patients. The mean age was 42.3 ± 20.2 years with a 51.8% male distribution. The frequency of positive HBsAg and anti-HCV in all patients was 9.4 and 0.9%, respectively. On the other hand, the frequency of positive HBsAg and anti-HCV was 4.2 and 0.7%, respectively, among patients admitted for a surgical procedure. The mean age was 46.1 ± 21.1 years with a slightly male predominance (54 vs. 46%). In this group, the frequency of positive HBsAg was higher in males (5.1%) while the lowest was in the 1 - 10 age range (0.4%) and the highest in the 41 - 50 age range (5.7%). Between 2011 and 2019, the prevalence of HBsAg positivity decreased from 6.4 to 4.0%, while anti-HCV positivity was similar in both genders, and its frequency increased with age. Conclusions: Between 2011 and 2020, the overall prevalence of HBV and HCV decreased in the Southeast Anatolia Region of Turkey.

Analysis of 23 Years of Cornea Donor Data From an Eye Bank in Turkey

OBJECTIVES

We evaluated 23 years of data for cornea donors at the Istanbul Faculty of Medicine Lions Eye Bank.

MATERIALS AND METHODS

Annual statistics of corneal donors between 1996 and 2019 were reviewed retrospectively. Records for 2008 and previous years were compared with records for 2009 and years thereafter,to assess donor demographics and reasons for discard of corneas.

RESULTS

A total of 3849 corneas were obtained from 2018 donors during a 23-year period. Of these, 26 donors (11.2%) were registered, whereas 1792 (88.8%) did not register any decision for donation. There were 210 (5.46%) corneas discarded for positive serology and 291 (7.56%) for unsuitable tissue morphology, and 3348 (86.98%) corneas were determined to be suitable for transplant. For the cause of death in 2009 and subsequent years, the incidence of trauma was lower (P = .001) compared with the years previous to 2009, whereas incidence of cardiac pathology (P = .014) was higher. The number of donors older than 50 years was higher for 2009 and years thereafter, compared with data from earlier years (P = .024). The rate of discarded corneas for unsuitable tissue morphology (P = .004) and total discarded corneas (P = .027) decreased in 2009 and years thereafter. The rate of discarded corneas for HIV was higher after for 2009 and years thereafter (P = .047), whereas the rate of discarded corneas for syphilis was significantly higher for 2015 and years thereafter (P = .001).

CONCLUSIONS

This study evaluated the most extensive eye bank data in Turkey and found that advances in lamellar surgery techniques and improvements in specular microscopic facilities have expanded the pool for cornealtransplants to include tissues from older donors. Moreover, the incidence rates for HIVpositive and syphilis-positive serology tests in discarded corneas have increased over time.

Healthcare students' vaccination status, knowledge, and protective behaviors regarding hepatitis B: a cross-sectional study in Turkey

AIM

We aimed to determine the vaccination status, knowledge, and protective behaviors of healthcare students related to hepatitis B and to examine the related factors.

METHOD

This cross-sectional study was conducted in seven universities from seven geographical regions of Turkey. The study group included 5451 healthcare students. Data were collected with a questionnaire including items on sociodemographic characteristics, vaccination status, knowledge and protective behaviors related to hepatitis B. Data were analyzed with Pearson's chi-square and logistic regression analyses.

RESULTS

86.0% of the students had hepatitis B vaccine while 7.6% did not. Vaccination was higher in nursing and midwifery students (aOR = 1.87, CI 95%: 1.26-2.77; aOR = 3.87, CI 95%: 2.14-7.02, respectively). Vaccination was 1.28 times higher in females (CI 95% 1.03-1.60). The ≥23 age group had 1.79 times higher vaccination rate than those in the ≤19 (CI 95%: 1.26-2.53). Vaccination was higher in students whose family's economic status is middle and high (aOR = 1.53, CI 95%: 1.07-2.19; aOR = 1.47, CI 95%: 1.03-2.19, respectively). Vaccination was higher in those living in towns and cities during childhood (aOR = 1.36, CI 95%: 1.06-1.74; aOR = 1.79, CI 95%: 1.34-2.38, respectively). Females had more knowledge of hepatitis B and protective behaviors. Both knowledge and protective behavior scores of vaccinated participants were significantly higher (p < .05).

CONCLUSION

We found that the vaccination rate in healthcare students was high, but lower than the country's targets. The students were sensitive about the protective behaviors from hepatitis B infection and had sufficient knowledge of HBV contamination.

Severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) /Hepatitis B virus (HBV) Co-infected Patients: A case series and review of the literature

OBJECTIVE

We aimed to determine whether severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)/hepatitis B virus (HBV) coinfection affects liver function and the outcome of the disease.

METHODS

One hundred fifty-six laboratories confirmed SARS-CoV-2 positive patients were followed up between 1 July and 31 December 2020 and analysed retrospectively. Continuous variables were compared with the independent samples t-test. Categorical variables were compared using the Pearson's chi-square or Fisher's exact test. A P value of less than .05 was considered statistically significant.

RESULTS

The age range of the cohort was from 40 to 78 and 73 (46.8%) of 156 patients were male. There was no significant difference in age and gender distribution between 20 patients (12.8%) with SARS-CoV-2/HBV coinfection and 136 patients without HBV infection (87.2%) (P > .05). Liver function tests were higher in the SARS-CoV-2/HBV coinfected patient group but were not statistically significant. The levels of creatine kinase (CK) were significantly higher in coronavirus disease 2019 (COVID-19) patients without HBV infection compared with the SARS-CoV-2/HBV coinfected patient group (P = .0047). Severe/critical illness was less common in the SARS-CoV-2/HBV coinfected patient group, and no deaths were observed.

CONCLUSIONS

SARS-CoV-2/HBV coinfection did not change the severity and outcome of COVID-19. However, the patients with SARS-CoV-2/HBV coinfection should be closely monitored for liver complications.

Prevalence of HBsAg seropositivity during pregnancy and evaluation of vaccination programs: A multicenter study in Turkey

OBJECTIVE

Hepatitis B virus (HBV) infection remains a global public health problem. Among its modes of transmission, vertical transmission from mother to child during pregnancy is exceedingly important. This study investigated seropositivity for hepatitis B surface antigen (HBsAg) among pregnant women aged 16-49 years and their pregnancy outcomes in several health institutions (university and state hospitals, family health centers) from seven cities in Turkey.

METHODS

An Excel form was sent to the sites participating in the study, and the total number of pregnant women who were tested for HBsAg between 2010 and 2017, HBsAg positivity rates, and the ages of HBsAg-positive pregnant women was collected retrospectively. Serum samples were obtained from 204,865 pregnant women from four regions between 2010 and 2017, including 107,463 from Black Sea, 2306 from Marmara, 48,339 from East Anatolia, and 46,757 from Aegean. HBsAg levels were determined on automated devices using chemiluminescence.

RESULTS

In the study, the data of 204,865 pregnant women from seven different provinces (Afyonkarahisar, Erzurum, Istanbul, Izmir, Manisa, Mus, and Rize) in different geographical regions were accessed, and HBsAg positivity was found in 2343 pregnant women (1.14%). The highest HBsAg seroprevalence was found in women who were older 26-40 years/1977-1991 birth year range on average. In the data of the present study, the number of pregnant women with HBsAg positivity among pregnant women born after the initiation of the national vaccination program and catch-up vaccination program is only 124 and constitutes 5.3% of all HBsAg-positive pregnant women.

CONCLUSION

In this study, it has been found that HBsAg positivity in pregnant women has been decreasing in Turkey and that it is significantly lower, especially in those born after the initiation of the national vaccination program. Continuation of national neonatal HBV vaccination with high compliance is very important.

Lack of awareness of Hepatitis B screening and vaccination in high-risk groups

Background/aim

Hepatitis B virus (HBV) vaccination rates are insufficient in high-risk patients worldwide. This study aimed to investigate the screening, immunization, and vaccination rates in three high-risk groups for HBV infection: allogeneic hematopoietic stem cell transplantation (AHSCT), renal transplantation (RT), and chronic hepatitis C (CHC) groups.

Materials and methods

The serological data of consecutive patients between 2014 and 2019 were reviewed using the hospital database.

Results

The HBV screening rates were 100.0%, 90.4%, and 82.4% in the AHSCT, CHC, and RT groups, respectively (p = 0.003). The immunization rates against HBV through either previous exposure or vaccination were 79.5%, 71.7%, and 46.5% in the AHSCT, RT, and CHC groups, respectively (p < 0.001). The HBV vaccination rate was significantly low in the CHC group (71.5%, 69.0%, 34.6% in the AHSCT, RT, and CHC groups, respectively, p < 0.001). If patients lost their immunity due to immunosuppressive therapy were accounted, the vaccination rates increased to 95.2% in the AHSCT group and 72.9% in the RT group. The rate of annual screening for HBV status was 97.9% in the AHSCT group, but it was only 23.9% in the RT group.

Conclusion

HBV screening and vaccination rates were significantly lower in the RT and CHC groups than in the AHSCT group.

The changing context of hepatitis D

The global epidemiology of hepatitis D is changing with the widespread implementation of vaccination against hepatitis B. In high-income countries that achieved optimal control of HBV, the epidemiology of hepatitis D is dual, consisting of an ageing cohort of domestic patients with advanced liver fibrosis who represent the end stage of the natural history of HDV, and of a younger generation of immigrants from endemic countries who account for the majority of new infections. As observed in Europe in the 1980s, the distinctive clinical characteristic of chronic hepatitis D in endemic countries is the accelerated progression to cirrhosis and hepatocellular carcinoma. Despite some recent progress, the therapeutic management of HDV remains unsatisfactory, as most patients are not cured of HDV with currently available medicines. This review article describes the current epidemiology and clinical features of chronic hepatitis D, based on the literature published in the last 10 years.

Hepatitis B vaccination response of treatment-naive patients with juvenile idiopathic arthritis

To evaluate the vaccine response of treatment-naive juvenile idiopathic arthritis (JIA) patients who were fully vaccinated against Hepatitis B Virus (HBV) and then compare their antibody status with healthy controls. In this multicenter study, initial visit hepatitis B surface antigen (HbsAg) and anti-hepatitis B surface antibody (anti-Hbs) titers of 262 treatment-naive JIA patients who were followed up regularly between May 2015 and October 2019 were evaluated retrospectively from patients' medical records and compared with 276 healthy peers. Both HbsAg and anti-Hbs antibody titers were tested by the ELISA technique. Anti-HBs titers ≥ 10 IU/L were considered as reactive indicating seroprotection against HBV. In the JIA group, seropositivity rate was 59.1% while 72.9% of the control group were immune against HBV (p = 0.002). The median titer for anti-Hbs was 14 (range: 0-1000) IU/L in the patient group and 43.3 (range: 0-1000) IU/L in the control group (p = 0.01). Neither JIA patients nor healthy controls were positive for HbsAg. Patients with JIA vaccinated according to the national vaccination schedule were evaluated at their first visit in pediatric rheumatology outpatient clinics for anti-Hbs presence and it was found that they have lesser seroprotectivity than their age and sex-matched routinely vaccinated, healthy peers. So, to complete missing vaccines and booster vaccine doses, assessing the immune status of the patients at the time of diagnosis against HBV should be in the check-list of physicians dealing with pediatric rheumatic diseases.

Physician awareness of hepatitis C virus among different departments

Aim of the study

To determine the anti-hepatitis C virus (HCV) positivity in our region and to evaluate physician awareness of HCV among different inpatient and outpatient departments in a tertiary reference center in Turkey.

Material and methods

This retrospective study was conducted between January 2017 and January 2020. The patients tested for anti-HCV for any reason were enrolled from the data of all patients admitted to our hospital, which is the reference center of the region.

Results

A total of 121,492 anti-HCV assays were screened from the computerized database. Total number of patients with a positive anti-HCV result was 891 (0.81%). HCV RNA was positive in 147 (16.5%) of 891 patients and negative in 389 (43.7%) patients. Unfortunately HCV RNA was not tested in 355 (39.8%) patients. The percentages of the untested patients regarding the departments were 65.38% (n = 85/130) in medical inpatient clinics, 61.02% (n = 72/118) in surgical clinics, 16.67% (n = 88/528) medical outpatient departments, 96.8% (n = 91/94) in surgical outpatient departments, and 90.5% (n = 19/21) in the emergency department.

Conclusions

The prevalence of anti-HCV positivity was found to be 0.81% and was stable in Turkey. However, the level of physician awareness for HCV was unsatisfactory, and differed between departments. Because HCV is commonly asymptomatic, positive patients should not be overlooked and adequate treatment should be administered. Awareness of physicians should be increased to prevent delays in the diagnosis of hepatitis C and to reduce the number of untreated patients.

Real-world efficacy and safety of Ledipasvir + Sofosbuvir and Ombitasvir/Paritaprevir/Ritonavir ± Dasabuvir combination therapies for chronic hepatitis C: A Turkish experience

BACKGROUND/AIMS

This study aimed to evaluate the real-life efficacy and tolerability of direct-acting antiviral treatments for patients with chronic hepatitis C (CHC) with/without cirrhosis in the Turkish population.

MATERIAL AND METHODS

A total of 4,352 patients with CHC from 36 different institutions in Turkey were enrolled. They received ledipasvir (LDV) and sofosbuvir (SOF)±ribavirin (RBV) orombitasvir/paritaprevir/ritonavir±dasabuvir (PrOD)±RBV for 12 or 24 weeks. Sustained virologic response (SVR) rates, factors affecting SVR, safety profile, and hepatocellular cancer (HCC) occurrence were analyzed.

RESULTS

SVR12 was achieved in 92.8% of the patients (4,040/4,352) according to intention-to-treat and in 98.3% of the patients (4,040/4,108) according to per-protocol analysis. The SVR12 rates were similar between the treatment regimens (97.2%-100%) and genotypes (95.6%-100%). Patients achieving SVR showed a significant decrease in the mean serum alanine transaminase (ALT) levels (50.90±54.60 U/L to 17.00±14.50 U/L) and model for end-stage liver disease (MELD) scores (7.51±4.54 to 7.32±3.40) (p<0.05). Of the patients, 2 were diagnosed with HCC during the treatment and 14 were diagnosed with HCC 37.0±16.0 weeks post-treatment. Higher initial MELD score (odds ratio [OR]: 1.92, 95% confidence interval [CI]: 1.22-2.38; p=0.023]), higher hepatitis C virus (HCV) RNA levels (OR: 1.44, 95% CI: 1.31-2.28; p=0.038), and higher serum ALT levels (OR: 1.38, 95% CI: 1.21-1.83; p=0.042) were associated with poor SVR12. The most common adverse events were fatigue (12.6%), pruritis (7.3%), increased serum ALT (4.7%) and bilirubin (3.8%) levels, and anemia (3.1%).

CONCLUSION

LDV/SOF or PrOD±RBV were effective and tolerable treatments for patients with CHC and with or without advanced liver disease before and after liver transplantation. Although HCV eradication improves the liver function, there is a risk of developing HCC.

Social stigmatization in Turkish patients with chronic hepatitis B and C

BACKGROUND AND AIM

Viral hepatitis is the most important cause of chronic hepatitis worldwide. Stigmatization is defined as a feeling of rejection and isolation of patients by society due to illness. There are no studies on chronic viral hepatitis in the literature in English, which has its own religious and socio-cultural structure. In our study, we aimed to investigate the presence of social stigmatism and psychosocial effects on patients with different stages of chronic viral hepatitis B and C.

METHODS

Forty-five patients with chronic hepatitis C and 114 patients with chronic hepatitis B were enrolled in the study. Berger's scale was used for stigmatization, composed of 40 four-point Likert items that have four subscales: personalized stigma, disclosure, negative self-image, and public attitude. Stigma score ranges between one and four. Stigma is accepted as present if the overall score is above two.

RESULTS

Overall the mean stigma scores were 1.97±0.58 and 2.14±0.57 for chronic hepatitis B and C, respectively. There was stigma in 47.4% of the patients with chronic hepatitis B, and 60% of the patients with chronic hepatitis C. Being male was the risk factor on overall stigma, disclosure and public attitude in chronic hepatitis C. Living in an urban setting was the risk factor on negative self-image in chronic hepatitis C and on personalized stigma and disclosure in chronic hepatitis B.

CONCLUSIONS

To the best of our knowledge, this is the first study that provides qualitative information about chronic hepatitis-related stigma. Stigmatization is a major problem in Turkey and worldwide. We believe that increasing the knowledge of the patients and society by teaching about the transmission routes of the disease and focusing on vaccination studies will prevent stigmatization.

Early detection of chronic hepatitis B and risk factor assessment in Turkish migrants, Middle Limburg, Belgium

Background

Turkey is an intermediate hepatitis B virus (HBV) endemic country. However, prevalence among Turkish migrants in Belgium is unknown, especially in those born in Belgium with a foreign-born parent, i.e. second-generation migrants (SGM).

Aims

To evaluate the prevalence of HBV infection and associated risk factors in Turkish first-generation migrants (FGM), i.e. foreign-born, and SGM.

Methods

Between September 2017 and May 2019, free outreach testing for hepatitis B surface antigen (HBsAg), hepatitis B core antibodies (anti-HBc), and antibodies against HBsAg was offered to Turkish migrants in Middle-Limburg, Belgium. Face-to-face questionnaire assessed HBV risk factors. HBsAg positive patients were referred and followed up. Turkish SGM were stratified into birth cohort born before and after 1987, since those born after 1987 should be covered by the universal infant vaccination program.

Results

A total of 1,081/1,113 (97.1%) Turkish did go for HBV testing. Twenty-six (2.4%) were HBsAg positive; 11/26 were unaware of their status and 10/11 were successfully referred. HBsAg prevalence was 3.0% in FGM and 1.5% in SGM, p = .070. Only one out of seven HBsAg positive SGM was born after 1987. In the multiple generalized estimating equations model, the most important risk factors for anti-HBc positivity were male gender (p = .021), older age (p < .001), FGM (p < .001), low educational level of the mother (p = .003), HBV infected mother (p = .008), HBV infected siblings (p = .002), HBV infected other family member (p = .004), gynaecological examination in Turkey or unsafe male circumcision (p = .032) and dental treatment in Turkey (p = .049).

Conclusion

Outreach testing was well-accepted and referral to specialist care was generally successful. National HBV screening should be implemented in the Turkish FGM population and might be considered in SGM not covered by primary prevention strategies.

Hepatitis A, B and C seropositivity among first-year healthcare students in western Turkey: a seroprevalence study

Background

The risk of viral hepatitis among healthcare students (HCSs) is greater than that among the general population. Therefore, this study was conducted to investigate the seroprevalence of the hepatitis A virus (HAV), hepatitis B virus (HBV) and hepatitis C virus (HCV) among first-year HCSs at a university in Turkey and as a secondary objective, to determine the factors associated with HAV and HBV seropositivity.

Methods

This cross-sectional study was performed in first-year HCSs in Izmir, western Turkey. Data were collected using a self-administered questionnaire including items on sociodemographic characteristics, medical history, and hygiene. A total of 650 HCSs were tested for the HAV, HBV and HCV markers. Categorical variables were compared using the chi-square test. The association between independent variables and anti-HAV seropositivity and anti-HBs seropositivity was assessed by multinomial logistic regression analysis.

Results

The overall frequency of total anti-HAV seropositivity was 34.9%. HBsAg, total anti-HBc and anti-HBs seropositivity were found in 0.3, 1.2 and 93.7% of samples, respectively. All of the HCSs were negative for anti-HCV. Total anti-HAV seropositivity was found to be 1.73 times higher in those ≥21 years old, and it was 1.61 times higher in those who perceived their economic status to be average and 2.75 times higher in those who perceived their economic status to be low. Total anti-HAV seropositivity was found to be 4.37 times higher in those who lived in provinces with intermediate human development index levels. Total anti-HBs seropositivity was found to be 2.48 times higher in those ≤20 years old, and it was 2.13 times higher in those who perceived their economic status to be average.

Conclusions

Approximately two out of three HCSs were susceptible to HAV infection. Since HCSs are at high risk for HAV infection, they should be vaccinated before medical clerkships begin. Our results indicate that there is a high prevalence of anti-HBs seropositivity among HCSs. This result may be largely attributed to the implementation of a successful vaccination program in Turkey since 1998.

A Systematic Review of the Current Hepatitis B Viral Infection and Hepatocellular Carcinoma Situation in Mediterranean Countries

Viral hepatitis B is a global public health problem affecting nearly two billion subjects; 3.3% of whom are from the WHO (World Health Organization) Eastern Mediterranean Region (EMRO). It induces both acute and chronic hepatic disorders with subsequent liver cirrhosis and hepatocellular carcinoma (HCC) in a considerable percentage of patients based on the age of exposure. In this review, hepatitis B virus (HBV) and HCC prevalence, distribution and prevalence of different genotypes, and male/female infection frequencies in relation to the vaccination status in the Mediterranean countries were reported. Study Design. This systematic review describes the prevalence of hepatitis B infection, genotype distribution of hepatitis B virus, and prevalence and incidence of hepatocellular carcinoma in Mediterranean countries belonging to three different continents: Southern Europe (Spain, France, Italy, Croatia, and Greece), North Africa (Morocco, Algeria, Tunisia, Libya, and Egypt), and the Near East region (Syria, Lebanon, Turkey, Israel, and Palestine). We tried to collect new data from electronic databases: PubMed, ScienceDirect, ResearchGate, Google Scholar, and public health reports between 1980 and 2019. For each publication, we recorded reference, publication year, study characteristics (date, locations, sample size, and study population), and participant characteristics (population group, year, age, and sex). No language limitation was imposed, and articles or reports from non-peer-reviewed sources were not considered for this analysis. The main keywords were HBV prevalence, hepatitis B infection, HBV genotype, and HCC. Inclusion and Exclusion Criteria. Healthy population-based studies included the following sample populations: (i) voluntary blood donors, (ii) pregnant women, (iii) community studies, (iv) hemodialysis patients, (v) hospitalized patients, (vi) healthcare workers, (vii) sex workers, (viii) drug abusers, and (ix) prisoners. We excluded studies from the following special groups who were assumed to be at a special high risk: patients from sexually transmitted disease clinics and thalassemia clinics and professional or paid blood donors.

Can family physicians have a role in eradication of hepatitis c infection?

BACKGROUND/AIMS

Hepatitis C Virus (HCV) infection is an important global public health problem. The application of screening programs is important for the elimination of HCV in addition to DAA therapies. The aim of this study was to measure the knowledge, attitudes and behaviours of family physicians, who are important in screening programs for the diagnosis, natural history, and treatment of HCV infection.

MATERIALS AND METHODS

This cross-sectional study aimed to measure the knowledge levels in respect of HCV screening, diagnosis, natural history and treatment, of family physicians working nationwide in Turkey, through a survey.

RESULTS

The most common reason to perform an anti-HCV test stated by 70.9% (n:420) of the participants was the mandatory screening program before marriage. Of the participants included in the study, 29.6% (n=175) had encountered anti-HCV test positivity at least once within the last year, and of these, 15.4% (n=27) had no knowledge of whether the patient went to a higher level center for further diagnosis, while 58.9% (n=103) did not know the disease stage. In response to questions about current drug options for hepatitis C infection, 14.5% were aware of DAA and 34.8% of participitant reported interferon+ ribavirin.

CONCLUSION

Family physicians have gaps in their knowledge of the screening, natural history and treatment of HCV infection. The results of this study show that HCV training plans for family physicians should cover all aspects of the infection, and emphasize the necessity for the establishment of guideline-based screening recommendations.