Serology based disease status of Pakistani population infected with hepatitis B virus. BMC Infect Dis. 2007;7:64. [PMID: 17597512 PMCID: PMC1913529 DOI: 10.1186/1471-2334-7-64]

Hepatitis B among University Population: Prevalence, Associated Risk Factors, Knowledge Assessment, and Treatment Management

Background: Very few studies have been reported on hepatitis B in the State of Azad Jammu and Kashmir, Pakistan, and none of them are specific to the prevalence and causes of hepatitis B spread among educational institutes. This study aimed to estimate the prevalence of hepatitis B infection and its associated risk factors among the University of AJ and K population. Methods: An observational, cross-sectional, and analytical study was conducted with 7015 students and employees. Hepatitis B was detected by rapid immunochromatographic tests (ICTs), enzyme-linked immunosorbent assay (ELISA), and real-time quantitative PCR. A questionnaire and interview method was used to assess the disease knowledge and associated risk factors with hepatitis B through Chi-square, Fisher’s exact test, and paired t-test. Results: Of the participants, 150 (2.13%) were found positive for the hepatitis B surface antigen (57.3% male and 42.7% female). Only 0.3% participants were found fully vaccinated against the hepatitis B virus. Among ethnic groups, the Syed tribe was found more prevalent for hepatitis B infection (40.6%), while use of contaminated mourning blades (95% CI: p = 0.0001) was found as an overlooked risk factor. Hepatitis preventive awareness sessions were found to be very significant (p = 0.0001). Conclusions: The study showed that an overlooked risk factor is playing a key role in the spread of HBV in a tribe living worldwide, which must be addressed globally to eradicate hepatitis B. In Pakistan, a country-wide annual HBV vaccination program should be launched to control hepatitis B.

Comparison of Biochemical Parameters in Patients with Hepatitis B, C, and Dual Hepatitis B and C in Northwest Pakistan

The leading causes of hepatitis are viral infections, Hepatitis B virus (HBV) and Hepatitis C virus (HCV). Millions of people have been infected with these deadly viral infections worldwide, and in Pakistan, every tenth person is infected with these viruses. Different populations respond with different rates to infectious diseases due to host genomic differences. To evaluate and compare the biochemical parameters in different types of hepatitis (Hepatitis B, C, and Co-infection) and different ethnic groups, a total of 200 pre-screened patients were recruited from District Headquarters Teaching Hospital Dera Ismail Khan and Tank. Blood samples (5ml) were taken from patients and were assayed for biochemical parameters, including four liver function tests (LFTs) and two renal function tests (RFTs). In 200 patients, the mean scores of Alanine transaminase (ALT) were 376±335, 315±265, and 478±519 IU/L in HBV, HCV, and co-infected patients, respectively. Moreover, the mean score of ALT was 31±7.2 IU/l in the normal control group. All other biochemical parameters demonstrated elevated levels in co-infection, HBV, and HCV, respectively, except total proteins. The RFTs showed a threshold or upper normal limit (UNL); nonetheless, when compared to normal control subjects, RFTs parameters were high in infected patients, as compared to normal control. Ethnicity wise comparison of parameters indicated that Pushtoon ethnic group indicated a high degree of severity of HBV infection and co-infection, as compared to Saraiki and Rajpoot ethnic groups, while Saraiki ethnic group showed a higher severity of HCV than both of Pushtoon and Rajpoot. Rajpoot ethnic group was least affected than both Pushtoon and Saraiki ethnic groups. Co-infected patients were more severely affected, as compared to HBV and HCV patients. The ethnicity-wise study provided evidence that different ethnic groups showed different degrees of severity. There may be some genetic background involved in hepatitis B and C viral infection due to which all three ethnic groups showed different degrees of severity. In gender-wise comparisons, male patients were more affected than female patients.

Thalassemia Patients from Baluchistan in Pakistan Are Infected with Multiple Hepatitis B or C Virus Strains

There are an estimated 2,000 children with β-thalassemia in the province Baluchistan of Pakistan. These children are at high risk of acquiring transfusion-transmitted infections (TTIs) due to their need of regular blood transfusions for survival. Therefore, we investigated the frequencies of TTIs among these multi-transfused patients in a region where the WHO guidelines for blood safety are not always followed. Sera from 400 children (mean age 7.7 ± 4.70 years) treated at two thalassemia centers in Baluchistan were investigated for TTIs. Eleven (2.8%) were hepatitis B surface antigen positive, and 72 (18.3%) had anti-hepatitis C virus (HCV), two of which were infected with both viruses. Only 22% of the children had been reached by the program for universal hepatitis B virus (HBV) vaccination which started in 2004. Half (51%) of the HCV infected had also been HBV infected. The HBV- and HCV-infected patients were older and had received more blood transfusions than the uninfected patients (P < 0.001). Molecular characterization of the viral strains revealed the presence of several genetically different strains in at least three HBV- and seven HCV-infected children. This is the first study to demonstrate infections with multiple HBV or HCV strains simultaneously infecting thalassemia patients. These may become the source for new emerging recombinant viruses of unknown virulence. The high prevalence of anti-HCV-positive children, and the presence of HBV infections among children who should have been vaccinated, highlights an urgent need for improvements of blood safety in this region of Pakistan.

Sensitivity and Specificity of Hepatitis B Virus Screening via Rapid Immunoassay Chromatographic Test

Introduction: In low-income and high hepatitis B and C virus burden countries like Pakistan, it is important to develop cheap yet efficient strategies in diagnosing as well as treating hepatitis. The aim of this study is to assess the sensitivity and specificity of serum hepatitis B surface antigen (HbsAg) via Rapid Immunoassay Chromatographic Test (RICT) for the screening of hepatitis B, compared to the gold standard laboratory-based method.

Methods: The study was conducted in the Hepatology Clinic of Civil Hospital, Sukkur. All records of the clinic from June 1, 2018, to December 31, 2018, were accessed for identification of the records in which hepatitis B screening via RICT and then confirmatory polymerase chair reaction (PCR) by gene amplification with forward and reverse primers was done.

Results: There were 151 samples in this study. There were 32 (94.1%) true-positive and three (5.8%) false-negative samples. There were two (2.5%) false-positive and 114 (97.4%) true-negative samples. The sensitivity of HbsAg detection via RICT for the screening of 1-1B V was 91.43%, specificity was 98.28% and the accuracy was 96.69%, compared to PCR.

Conclusion: The RICT method has high sensitivity and specificity. In low-income and high-hepatitis B virus-burden countries like Pakistan, it serves as a very efficient screening tool that is easy to use, cheaper in cost, and gives rapid and accurate results.

The Frequency and Risk Factors Identified for HBsAg and Anti-HCV in a Preoperative Screening of Patients Admitted in the Surgical Department at Al-Tibri Medical College Hospital

Objective

The aim of this study is to determine the frequency and risk factors for hepatitis B surface antigen (HBsAg) and anti-hepatitis C virus (Anti-HCV) in a preoperative screening of patients admitted at the surgical unit of Al-Tibri Medical College and Hospital and Lyari General Hospital, Karachi.

Materials and methods

This study was conducted at the surgical units of Al-Tibri Medical College Hospital and Lyari General Hospital, Karachi. This study was conducted for six months from 30th June 2017 to 31st December 2017. This observational study was performed using a non-probability convenient sampling technique. All patients who were undergoing elective and emergency surgical procedure were selected for the study and screened for HBsAg and anti-HCV by immunochromatographic test (ICT) method at the hospital laboratory. The risk factors identified as parenteral injections, past surgical procedure, blood transfusion, etc. along with demographic data as age, gender, and district residential status were recorded on a specially designed proforma. Data were analyzed using Statistical Package for the Social Sciences (SPSS) version 23. Descriptive statistics were applied, and the qualitative data were expressed as the mean and standard deviation.

Results

Among a total of 360 patients included in the study, 63 (21.38%) were found with anti-HCV positive, and 14 (3.88%) were HBsAg positive with none of the patients found to have co-infection. The male-to-female ratio was 2.3:1. The mean age of patients was 32.34±4.3 years. The age range affected commonly in the study population was 21-30 years, 24(31%). The commonest risk factor for transmission of viral infection was parenteral injection abuser 31(40.2%), followed by surgical procedure 13(18.1%), blood transfusion 10(12.9%), and barber shave 7(9.1%).

Conclusion

It was predicted in our study that hepatitis C was more common in patients screened preoperatively for surgery. However, the most frequent risk factor in these patients was parenteral abuse history. The preoperative screening is an important investigative tool for the identification of silent cases in the community for preventive measures adoption and treatment for silent carriers.  

Variability in the immunogenic preS region of Pakistani hepatitis B virus isolates

This paper reports the genetic variability of hepatitis B virus in Pakistan population. The worldwide prevalence of hepatitis B virus is estimated to be around 350 million that causes significant mortality especially in developing countries like Pakistan. In this study, genetic diversity of HBV was checked by using preS domain of HBV. About seventy-five samples were selected for study. Among these samples nine samples showed positive results after PCR and gel analysis. These nine samples were named SBS001-SBS008. After gel purification these samples were ligated in T/A cloning vector and transformed with E. coli DH5α. After successful cloning and positive restriction analysis these samples were subjected to DNA sequencing. Sequencing results showed that eight samples (SBS002-SBS008) have a deletion of 33 nucleotides at N-terminal that is characteristics of genotype D while SBS001 belongs to genotype C. Silent mutations and amino acid changes were also searched in this highly variable region of genome. Based upon this study it was concluded that genotype D is the most common genotype in Pakistan.

Molecular surveillance of HCV mono-infection and HCV-HBV co-infection in symptomatic population at Hyderabad, Pakistan

BACKGROUND

Pakistan is endemic to hepatitis B and C infections. Alarming rise in hepatitis C virus (HCV) infection has been noticed in some areas of Sindh with an increasing risk for co-infection frequency in this region.

OBJECTIVE

To estimate the burden of HBV/HCV infection in Hyderabad Pakistan.

METHODS

ELISA and Nucleic acid Amplification test were performed to detect viruses. SPSS and online calculator were used for statistical analysis.

RESULTS

From a total of 108 seropositive hepatitis patients, 36.1% (n=39) were found HCV RNA-positive. Non-significant differences were observed in the frequencies of HCV infection for both genders [OR=0.735, CI (95%) 0.307-1.761, p<0.05]. The percentage of HBV DNA detection among 108 HCV-seropositive cases was 17.9% (n=19). However, HCV-HBV co-infection in HCV-RNA positive cases was determined in 48.7% (n=19) cases with non-significant difference in both genders [OR=1.51, CI (95%) = 0.38 - 5.96, p< 0.05]. Analysis suggested weakly positive correlation between HCV mono-infection and HCV-HBV co-infection and age (r =0.184, and r =0.1231), respectively.

CONCLUSION

The study demonstrates a high prevalence of HBV co-infection among active hepatitis C patients of Hyderabad.

Epidemiological patterns and risk factors associated with hepatitis B virus in Pakistani population

Hepatitis B virus prevalence is increasing in Pakistani population. National level estimates regarding the prevalence are missing. People are unaware of the risk factors involved in HBV transmission. The objective of the study was to review the prevalence, genotypes, and risk factors associated with HBV transmission in Pakistani Population. Literature search was done by using keyword HBV prevalence, genotypes and risk factors from Pakistani population at Pubmed, PakMediNet and Google scholar. Six different studies showed that the percentage prevalence of HBV in general population was 4.61±0.73%, and 21 different studies showed the percentage prevalence of 2.33±0.46% in blood donors. High prevalence of 7.94±1.49% and 12.86±4.52% were observed in multi transfused and IDU populations. Six different studies showed that the major prevalent genotype was D. Awareness regarding various risk factors involved in-viral transmission was very low. Prevalence of HBV was very high in multitransfused populations due to non-implementations of international standards regarding blood transfusions. Barbers were unaware of the risk factors associated with their shops in viral transmission. Practices of unsterilized dental and surgical instruments and recycling of syringes were major factors in viral transmission. Massive awareness and vaccination programs are required to decrease the future burden of HBV from Pakistani population.

Hepatitis B genotypes and surface antigen mutants present in Pakistani blood donors

BACKGROUND

The prevalence of chronic Hepatitis B Virus (HBV) infection is 2-4% in the Pakistani population, defining Pakistan as an intermediate prevalence country. In this study, hepatitis B surface antigen (HBsAg) reactive blood donations were screened using a combination of serological and molecular methods to identify immune escape HBV mutant strains and to determine the HBV genotypes and subtypes present in Pakistan.

METHODS

Blood donations were collected at the Armed Forces Institute of Transfusion (AFIT) located in northern Pakistan and the Hussaini Blood Bank (HBB) located in the south. From 2009 to 2013 a total of 706,575 donations were screened with 2.04% (14,409) HBsAg reactive. A total of 2055 HBsAg reactive specimens, were collected and screened using a monoclonal antibody based research assay to identify immune escape mutants followed by PCR amplification and DNA sequencing to identify the mutation present. DNA sequences obtained from 192 specimens, including mutant candidates and wild type strains, were analyzed for escape mutations, genotype, and HBsAg subtype.

RESULTS

Mutations were identified in approximately 14% of HBsAg reactive donations. Mutations at HBsAg amino acid positions 143-145 are the most common (46%) with the mutation serine 143 to leucine the most frequently occurring change (28%). While regional differences were observed, the most prevalent HBV strains are subgenotypes of D with subgenotype D1/subtype ayw2 accounting for the majority of infections; 90.2% at AFIT and 52.5% at HBB.

CONCLUSIONS

The high frequency of immune escape HBV mutants in HBV infected Pakistani blood donors highlights the need for more studies into the prevalence of escape mutants. Differences between vaccinated and unvaccinated populations, the correlation of escape mutant frequency with genotype, and impact of escape mutations in different genotype backgrounds on the performance of commercially available HBsAg assays represent avenues for further investigation.

Awareness of hepatitis B and C among students of nonmedical universities in Karachi

Background

Pakistan is highly endemic with hepatitis B virus (HBV) and the incidence of HBV infection is rising steadily. The reasons may include poor public awareness about the transmission of HBV and HCV.

Objectives

To assess the awareness of HBV and HCV among students in nonmedical universities.

Methods

The study instrument was a structured 36 item questionnaire. After obtaining permission from the respective administrations, students were approached within their university campuses and were included by convenience sampling. The results were expressed as frequencies.

Results

Five hundred students from 5 different institutions participated in the survey, with 100 students representing each institute. Most students did not recognize the possible modes of infection of hepatitis B that include reuse of syringes (57.2%), blood transfusions (62.6%), and sexual contact (57.4%). However, most (67.8%) students correctly believe that there is a vaccination available for the prevention of HBV. Most students did not recognize the possible modes of infection of hepatitis C that include reuse of syringes (61.8%), use of intravenous drugs of addiction (71.4%), sexual contact (55.6%), and blood transfusions (55.2%) as possible modes of transmission. Most students (51.8%) incorrectly believed that there is a vaccination available for the prevention of HCV.

Conclusions

There is a prominent lack of awareness regarding the risk factors for HBV and HCV infection among the student community of nonmedical universities in Karachi, and an immediate need to conduct nationwide awareness programs to raise the awareness of HBV and HCV transmission in the Pakistani population exists.

Epidemiological, serological and molecular aspects of hepatitis B and C in children and teenagers of municipal daycare facilities schools and schools in the city of Santos

OBJECTIVE

To estimate the prevalence of the serological markers anti-HBc, HBsAg and anti-HBs of hepatitis B and anti-HCV of hepatitis C among children and teenagers enrolled at daycare facilities, kindergartens and municipal elementary education network in the city of Santos, São Paulo, Brazil.

METHODS

A cross-sectional study was carried out from June 28 to December 14, 2007, in which 4,680 finger-prick blood samples were collected from children and teenagers. A survey questionnaire was applied to their family members. The sample was dimensioned using the software Epi Info version 6 with expected frequency of 1%, acceptable error of 0.5% and confidence interval of 95%. The serological tests were performed using the ELISA technique. The molecular analysis was performed using the technique of polymerase chain reaction in House.

RESULTS

Age of the studied population ranged from 7 months to 18 years and 1 month. The general prevalence of anti-HBc reagent was 0.1%, HBsAg was 0.02% and anti-HCV was 0.02%.

CONCLUSIONS

In children, the general prevalence of serological markers for hepatitis B and C in the city of Santos was low when compared with literature data.

Viral Hepatitis in Pakistan: Past, Present, and Future

Viral hepatitis is a major cause of morbidity and mortality worldwide and a rising cause for concern in Asian countries. Weather it is blood borne or water/food borne hepatotropic virus, increasing burden is alarming for Asian countries. In this review we have evaluated the existing data to estimate the burden of viral hepatitis in populations of all age groups nationwide, along with an assessment of the risk factors and preventive and management strategies currently employed in Pakistan. The aim of our work is to consolidate and supplement the present knowledge regarding viral hepatitis in light of past and present trends and to provide future direction to the existing health policies.

How to cite this article

Butt AS, Sharif F. Viral Hepatitis in Pakistan: Past, Present, and Future. Euroasian J Hepato-Gastroenterol 2016;6(1):70-81.

Prevalence of hepatitis B virus in the Kurram Agency, Pakistan: A 5-year observational study in a war-affected region

BACKGROUND

Hepatitis B is an inflammatory liver illness caused by the hepatitis B virus. The exact magnitude and extent of the hepatitis B virus in Pakistan is still unknown, but at least 10 million people are estimated to be infected with chronic hepatitis B virus.

OBJECTIVES

The objective of this study was to determine the seroprevalence of hepatitis B surface antigen (HBsAg) in the war-affected area since 2009.

STUDY DESIGN

Observational study.

RESULTS

A total of 4922 healthy subjects were tested for the detection of HBsAg during 2009-2013, and 14.95% subjects were found to be reactive for HBsAg. The highest seroprevalence (26.0%) of HBsAg was found in those individuals who were less than 35 years of age. Male subjects were more affected (16.6%) than females. The seroprevalence of HBsAg was significantly associated with <35 years of age and male gender (P<0.005 for both). Moreover, an increasing trend over 5 years was observed, as 8.6% subjects were positive for HBsAg in 2009 and subsequently 10.4% in 2010, 14.6% in 2011, 18.9% in 2012, and 21.7% were reactive for HBsAg in 2013.

CONCLUSION

This study concluded that HBsAg was more prevalent in the war-affected region. The prevalence rate was increasing with time as the highest rate was found in 2013. Present observations will help to provide the background for awareness and bring the increasing levels of hepatitis B to the attention of health professionals and government authorities in order to increase the capacity of the health systems in such troubled areas.

Hepatitis B Virus Genotypes Distribution with HBsAg Positive in the North of Iran (Mazandaran) During 2011-2014

BACKGROUND

HBV infection is a major global health problem and ten genotypes (A to J) and multiples subtypes of HBV have been identified, and they show some distinct geographic distributions. The available data on HBV genotype in Iran are very heterogeneous and limited. Therefore in this study, we tried to identify the HBV genotypes by using polymerase chain reaction.

METHODS

In this cross-sectional study, HBV- positive serum samples of 122 patients with chronic hepatitis from 2011 to 2014 were studied. HBV-DNA was extracted from plasma samples using QIAamp(®) MiniElute(®) Virus Spin Kit (Qiagen). Plasma samples from HBsAg positive were confirmed the presence of HBV nucleic acid and determined the genotypes of HBV genome by PCR using the DNA PCR kit (Cinagene) with Taq-DNA polymerase enzyme and type of specific primers. All samples were examined in the virology laboratory of Sari Medical School.

RESULTS

The mean age of patients were 45 ± 25 (range, 20 to 70) year that 70 (57.37%) patients were male and 52 (42.62%) were female. The majority of HBV positive patients had a major surgery (44% patients) and then 32% patients followed by intra familial of hepatitis B virus infected and 11% of HBV positive patients had a history of blood transfusions. In this study, 91(74.59%) had genotype D, 7(5.73%) genotype B and 24(19.67%) genotype D and B.

CONCLUSION

This study indicates that the genotype D is the most frequent followed by the mixed genotypes D and B and genotype B in our region. Prevalence and incidence of HBV genotypes are with distributed among of areas and different genotypes may show different responses with antiviral therapy.

Prevalence and genotypes of hepatitis B virus infection in patients underwent coronary angiography and coronary artery bypass grafting in mazandaran heart center, sari, iran

BACKGROUND

Hepatitis B virus (HBV) infection is a major global health problem in the worldwide that associated with significant morbidity and mortality in cardiac surgery. The available data on HBV distribution and genotyping of HBV are very heterogeneous. Therefore in this study, we tried to indicate the prevalence of HBV infections in cardiac catheterization patients referred to health centers in the north of Iran and identified the HBV genotypes using polymerase chain reaction (PCR).

METHODS

In this cross-sectional study, we studied 2650 patients who underwent selective coronary artery angiography and coronary artery bypass grafting in Mazandaran heart center, Sari, Iran from 2011 to 2013. All serum samples were examined to detect HBsAg by ELISA test. HBV-DNA was extracted from HBsAg positive samples using Mini Elute Kit from Qiagen and determined the genotypes of HBV by PCR using the Master Mix kit with Taq-DNA polymerase enzyme and with type of specific primers. All samples were examined in the virology laboratory of Sari Medical School.

RESULTS

The mean age of patients was 59.7±10.9 (range, 20 to 81) year that 1590 (60%) patients were male and 1060 (40%) were female. Seventeen cases (0.08 %) were found with hepatitis B virus infection, and the highest rates of infection were reported among those aged 40-60 years old in this study. We found genotype D the predominant type in this study.

CONCLUSION

This study indicates that the prevalence of HBV endemicity in the north of Iran is low and genotype D is the only genotype in patients infected with HBV.

An analysis of the molecular evolution of hepatitis B viral genotypes A/B/D using a Bayesian evolutionary method

Background

Hepatitis B virus (HBV) infection is a major global health problem. The infectious virion contains an inner “core particle”, which is made of 180 or 240 copies of core protein, alternatively known as hepatitis B core antigen, or HBcAg which encloses the viral genome.

Method

In this study, we characterized HBV genotypes and used Bayesian analyses to estimate date of emergence of the most recent common ancestor (TMRCA) of three HBV genotypes, A, B, and D.

Results

We estimated that the rate of evolution of HBV core protein gene to be 1.127 (0.925–1.329, 95% HPD) substitutions per site per year. The TMRCA of HBV for genotypes A, B, D were 118 (54–194, 95% HPD) year, 184 (78–323, 95% HPD) year and 133 (65–230, 95% HPD) year, respectively. Demographic histories of the HBcAg gene showed that the relative genetic diversity had a sharp increase within the first 10 years of its emergence.

Conclusion

Using a bayesian evolutionary method to predict the outbreak trends of HBV through evolutionary trees of HBV, and provide theoretical foundations for clinical prevention and treatment of HBV.

Risk factors of hepatitis C infection among Egyptian blood donors

BACKGROUND

Surveillance of infectious disease markers in the blood donor population is important in recognizing trends in prevalence and incidence of transfusion related infections in asymptomatic volunteer blood donors.

SUBJECTS AND METHODS

It was a cross sectional study. Samples were collected from volunteer blood donors and questionnaire was designed to collect the risk factors data. The prevalence of hepatitis C antibodies among 1,000 apparently healthy blood donors were determined.

OBJECTIVE

To estimate the prevalence of virus C hepatic infection and to illustrate the various socio-economic, behavioural and medical factors related to infection with Hepatitis C (HCV) among apparently healthy individuals. It contributed to analysis of the particularities of Egyptian blood donors and helped to better understand the challenges and solutions of blood safety.

RESULTS

The prevalence of HCV was 16.8%. There was an association of positive anti-HCV test with socio-demographic, medical and behavioural risk factors.

CONCLUSION

This study provided comprehensive and reliable information on the possible risk factors affecting spread of Hepatitis C in the area.

A review of chronic hepatitis B epidemiology and management issues in selected countries in the Middle East

Experts from seven countries convened as a Specialist Panel for the Middle East to share information on practical issues relating to the epidemiology, diagnosis and management of chronic hepatitis B (CHB) infection. The Middle East is regarded as a region of high-to-intermediate epidemicity; however, infant vaccination programmes have successfully lowered the prevalence of hepatitis B infection in most countries to that of low-to-intermediate endemicity. Vaccine issues still to be addressed included improving coverage in some rural/poor communities, instituting hepatitis B vaccine at birth and providing vaccines for high-risk population groups. Hepatitis B infection in the Middle East primarily occurs as a result of perinatal infection, horizontal transmission between family members and transmission from injections. Blood transfusion services have broadly efficient screening programmes, but immunocompromised and haemodialysis patients are at risk. The cost of screening, monitoring and treating CHB influences practice in a number of Middle East countries, and there is a need for information on the most cost-effective options.

HBV vaccine efficacy and detection and genotyping of vaccineé asymptomatic breakthrough HBV infection in Egypt

AIM

To evaluate the impact of mass vaccination against the hepatitis B virus (HBV) in Egypt, and to search for vaccinee asymptomatic breakthrough HBV infection and its genotype.

METHODS

Seven hundred serum samples from vaccinated children and adults (aged 2-47 years) were used for quantitative and qualitative detection of HBsAb by ELISA. Three hundred and sixty serum samples representing undetectable or low or high HBsAb were screened for markers of active HBV infection (HBsAg, HBcAb (IgG) and HBeAb by ELISA, plus HBsAg by AxSYM) and HBV-DNA genotyping by nested multiplex PCR and by DNA sequencing.

RESULTS

It was found that 65% of children aged 2-4 years, and 20.5% aged 4-13 years, as well as 45% adults were good responders to HBV vaccination mounting protective level HBsAb. Poor responders were 28%, 59.5% and 34%, and non-responders were 7%, 20% and 21% respectively, in the three studied groups. Markers of asymptomatic HBV infections were HBsAg detected by ELISA in 2.5% vs 11.39% by AxSYM. Other markers were HBcAb (IgG) in 1.38%, HBeAb in 0.83%, and HBV-DNA in 7.8%. All had HBV genotype E infection.

CONCLUSION

It is concluded that HBV vaccine is efficient in controlling HBV infection among children and adults. The vaccine breakthrough infection was by HBV genotype E. A booster dose of vaccine is recommended, probably four years after initial vaccination.

The prevalence of HBV infection in the cohort of IDPs of war against terrorism in Malakand Division of Northern Pakistan

BACKGROUND

Hepatitis B is an important public health problem in the Pakistani population and is the major cause of chronic hepatitis, cirrhosis, fibrosis and hepatocellular carcinoma. High prevalence of HBV infections has been observed especially in areas of low economic status. In spite of effective immunization programs, no significant change has been observed in the epidemiology of HBV in the rural areas of Pakistan (~67.5% of the total population) mainly due to lack of interest from government authorities and poor hygienic measures. The current study was aimed at estimating the prevalence and risk factors associated with HBV infection within internally displaced persons (IDPs) due to war against terrorism in the Malakand Division of Northern Pakistan.

METHODS

Blood samples from 950 IDPs suspected with HBV infection (including both males and females) were collected and processed with commercial ELISA kits for HBsAg, Anti HBs, HBeAg, Anti HBe antibodies. The samples positive by ELISA were confirmed for HBV DNA by real-time PCR analysis.

RESULTS

The overall prevalence of HBV observed was 21.05% of which 78.5% were males and 21.5% were females. Most confirmed HBV patients belong to the Malakand and Dir (lower) district. High-risk of infection was found in the older subjects 29.13% (46-60 years), while a lower incidence (11.97%) was observed in children aged <15 years. Lack of awareness, socioecomic conditions, sexual activities and sharing of razor blades, syringes and tattooing needles were the most common risk factors of HBV infection observed during the cohort of patients.

CONCLUSION

The present study, revealed for the first time a high degree of prevalence of HBV infection in rural areas of Northern Pakistan. The noticed prevalence is gender- and age-dependent that might be due to their high exposures to the common risk factors. To avoid the transmission of HBV infection proper awareness about the possible risk factors and extension of immunization to the rural areas are recommended.

Transfusion transmitted infections in patients with hemophilia of Karachi, Pakistan

The aim of the study was to assess the prevalence of HCV, HBV, and HIV infections among the patients with hemophilia. Patients with Hemophilia A and B were evaluated who visited hospital for factor replacement therapy. The viral markers tested in these patients included anti-HCV-Ab, HBsAg, and anti-HIV-Ab. Seroprevalence was compared from 5717 exchange healthy blood donors for same markers. A total of 173 multitransfused male hemophiliacs showed prevalence of 51.4% for HCV, 1.73% for HBV, and nil for HIV. In blood donors seroprevalence was 1.9% for HCV, 1.81% for HBV, while no HIV-positive case was detected. Prevalence of anti-HCV-Ab was significantly high in patients with hemophilia than normal donors (P = .0005). This study showed that HCV infection was more frequently identified than HBV and HIV infections in multitransfused hemophiliacs. The frequency of hepatitis C among blood donors is also higher than that of hepatitis B which is showing downward trend.

Hepatitis B virus in Pakistan: a systematic review of prevalence, risk factors, awareness status and genotypes

In Pakistan, there are estimated 7-9 million carriers of hepatitis B virus (HBV) with a carrier rate of 3-5%. This article reviews the available literature about the prevalence, risk factors, awareness status and genotypes of the HBV in Pakistan by using key words; HBV prevalence, risk factors, awareness status and genotypes in Pakistani population in PubMed, PakMediNet, Directory of Open Access Journals (DOAJ) and Google Scholar. One hundred and six different studies published from 1998 to 2010 were included in this study. Weighted mean and standard deviation were determined for each population group. The percentage of hepatitis B virus infection in general population was 4.3318% ± 1.644%, healthy blood donors (3.93% ± 1.58%), military recruits (4.276% ± 1.646%), healthcare persons (3.25% ± 1.202%), pregnant women (5.872% ± 4.984), prisoners (5.75% ± 0.212%), surgical patients (7.397% ± 2.012%), patients with cirrhosis (28.87% ± 11.90%), patients with HCC (22% ± 2.645%), patients with hepatitis (15.896% ± 14.824%), patients with liver diseases (27.54% ± 6.385%), multiple transfused patients (6.223% ± 2.121%), opthalmic patients (3.89% ± 1.004%) and users of injectable drugs (14.95% ± 10.536%). Genotype D (63.71%) is the most prevalent genotype in Pakistani population. Mass vaccination and awareness programs should be initiated on urgent basis especially in populations with HBV infection rates of more than 5%.

Infectious immune status in an obstetric population of Pakistani immigrants in Norway

Aim: To investigate cytomegalovirus, rubella, varicella, toxoplasma, and hepatitis B immune status and factors associated with susceptibility for infections among Pakistani pregnant women in Norway. Methods: A total of 206 pregnant Pakistani women living in Norway participated in the evaluation. Blood samples were collected during pregnancy and tested for IgG antibodies against cytomegalovirus, rubella virus, varicella-zoster virus, Toxoplasma gondii, and hepatitis B (HB) virus. Results: All women had IgG antibodies against cytomegalovirus. Positivity for rubella IgG was 92%, 93% had varicella IgG antibodies, while 17% had toxoplasma IgG. Eleven per cent were anti-HBc positive, one of whom was HBsAg positive, which means that blood and cervix secretions are infectious with risk of virus transmission to the baby at the time of birth. Six women were only anti-HBc positive, they may have low-level HB infection, and risk of transmission cannot be excluded. Age younger than 25 years, having less than two children, and having lived less than 5 years in Norway were factors significantly associated with varicella-seronegative status, and thus susceptible for primary infection. Conclusions: To decrease the incidence of neonatal and maternal morbidity related to rubella, varicella, toxoplasma, and hepatitis B in our Pakistani immigrant population, we should intensify our rubella antenatal screening programme and focus upon rubella vaccination postpartum. We should offer varicella-seronegative women immunisation, advise toxoplasma-seronegative women to avoid visit to their home country during pregnancy, and give hepatitis B vaccine to all newborns regardless of maternal HBsAg status.

A study of genotypes, mutants and nucleotide sequence of hepatitis B virus in Pakistan: HBV genotypes in pakistan

BACKGROUND

Hepatitis B virus (HBV) genotypes and mutations are gaining importance in determining the clinical course of chronic liver disease.

OBJECTIVES

To determine and compare the distribution of HBV genotypes and genomic variations in Pakistan to other parts of the world.

PATIENTS AND METHODS

We conducted a prospective study at Aga Khan University Hospital from December 2006 to December 2008. HBV genotype was determined in 257 HBV DNA-positive patients. Patients were divided into two groups according to HBeAg positivity. Mutations in the pre-core and core promoter regions of HBV were determined in HBeAg-negative patients by line probe INNOLIPA assay.

RESULTS

The mean±SD age of patients was 28±5 years; there were 201 (78%) men. HBeAg was positive in 219 (85%) patients and negative in 38 (15%). HBeAg-positive patients were younger than HBeAg-negative patients (95% vs 21% in ≤30 years, p<0.001). HBV genotype D found in 247 (96.2 %) patients followed by a combined infection with HBV genotype B+D in 9 (3.3%) and 1 (0.5%) with genotype A. The mutations identified in 38 HBeAg-negative patients were T1762/A1764 in 21 (55.2%), PC mutant in 7 (18.4%), T1762/A1764/PC mutant in 2 (5%) and T1762/A1764/PC wild mutation in 1 (2%); no mutation identified in 7 (18.4%). Phylogenetic analysis did not show any significant differences between HBV genotype D isolated from Pakistan and those isolated from other parts of the world.

CONCLUSIONS

HBV genotype D is predominant in Pakistan, irrespective of HBeAg status. PC and BCP mutations were found in significant numbers of patients infected with genotype D. The HBV genotype D isolates from Pakistan are identical to the sequences isolated from other parts of the world.

Prediction on liver fibrosis using different APRI thresholds when patient age is a categorical marker in patients with chronic hepatitis B

BACKGROUND

Patient age as a predictive variable plays an important role in some indices and models. It was hypothesized that patient age might be a categorical marker.

METHODS

We collected the data of 623 CHB patients with liver biopsies. Two-hundred fifty-two patients could provide the duration of HBsAg-positive.

RESULTS

The positive correlation between duration of HBsAg-positive and patient age was statistically significant (r = 0.487, P < 0.001). When the cutoff value of patient age was 33.5 y, the best accuracy for liver fibrosis could be obtained. If we could use APRI threshold value of 0.11 for patients with age ≤ 35 and 0.18 for those > 35 y, we could correctly identify 110 CHB patients with insignificant fibrosis which were free of liver biopsy. For all CHB patients based on the APRI threshold of 0.11, 75 patients could be safely predicted as insignificant fibrosis.

CONCLUSIONS

Many more CHB patients with insignificant fibrosis could be free of liver biopsy when we used different APRI threshold values based on patient age, especially in patients with > 35 y. The study indicated that more attention should be paid to the influence of patient age on fibrosis.

Sexually transmitted infections among Pakistani pregnant women and their husbands in Norway

Aim

To assess frequency and determine the factors associated with Chlamydia trachomatis, herpes simplex virus type 2, and hepatitis B seropositivity among Pakistani pregnant women and their husbands in Norway.

Methods

All together 112 couples of Pakistani origin living in Norway participated in our study. Blood samples were tested for immunoglobulin G (IgG) antibodies against C. trachomatis, herpes simplex virus type 2, and hepatitis B.

Results

Pakistani women had significantly lower age, education level, and years of residence in Norway compared to their male partners. Among the men, 12% had positive chlamydial IgG antibodies in contrast to 1% of the women. These couples were discordant, meaning that the 13 wives of positive men were not infected with C. trachomatis, and the husband of one positive woman was not infected either. Four percent of women and 2% of men were positive for herpes simplex type 2. Only one couple was concordantly positive for herpes simplex type 2, the remaining four couples were discordant. Twelve percent of women and 21% of men were, or had been, infected with hepatitis B.

Conclusion

Sexually transmitted infections did not seem to be prevalent in Pakistani immigrant couples in Norway. However, it was striking that most couples were discordant. Pakistani immigrants should be offered hepatitis B vaccine.

Identification of the risk for liver fibrosis on CHB patients using an artificial neural network based on routine and serum markers

Background

Liver fibrosis progression is commonly found in patients with CHB. Liver biopsy is a gold standard for identifying the extent of liver fibrosis, but has many draw-backs. It is essential to construct a noninvasive model to predict the levels of risk for liver fibrosis. It would provide very useful information to help reduce the number of liver biopsies of CHB patients.

Methods

339 chronic hepatitis B patients with HBsAg-positive were investigated retrospectively, and divided at random into 2 subsets with twice as many patients in the training set as in the validation set; 116 additional patients were consequently enrolled in the study as the testing set. A three-layer artificial neural network was developed using a Bayesian learning algorithm. Sensitivity and ROC analysis were performed to explain the importance of input variables and the performance of the neural network.

Results

There were 329 patients without significant fibrosis and 126 with significant fibrosis in the study. All markers except gender, HB, ALP and TP were found to be statistically significant factors associated with significant fibrosis. The sensitivity analysis showed that the most important factors in the predictive model were age, AST, platelet, and GGT, and the influence on the output variable among coal miners were 22.3-24.6%. The AUROC in 3 sets was 0.883, 0.884, and 0.920. In the testing set, for a decision threshold of 0.33, sensitivity and negative predictive values were 100% and all CHB patients with significant fibrosis would be identified.

Conclusions

The artificial neural network model based on routine and serum markers would predict the risk for liver fibrosis with a high accuracy. 47.4% of CHB patients at a decision threshold of 0.33 would be free of liver biopsy and wouldn't be missed.

Global burden of aflatoxin-induced hepatocellular carcinoma: a risk assessment

BACKGROUND

Hepatocellular carcinoma (HCC), or liver cancer, is the third leading cause of cancer deaths worldwide, with prevalence 16-32 times higher in developing countries than in developed countries. Aflatoxin, a contaminant produced by the fungi Aspergillus flavus and Aspergillus parasiticus in maize and nuts, is a known human liver carcinogen.

OBJECTIVES

We sought to determine the global burden of HCC attributable to aflatoxin exposure.

METHODS

We conducted a quantitative cancer risk assessment, for which we collected global data on food-borne aflatoxin levels, consumption of aflatoxin-contaminated foods, and hepatitis B virus (HBV) prevalence. We calculated the cancer potency of aflatoxin for HBV-postive and HBV-negative individuals, as well as the uncertainty in all variables, to estimate the global burden of aflatoxin-related HCC.

RESULTS

Of the 550,000-600,000 new HCC cases worldwide each year, about 25,200-155,000 may be attributable to aflatoxin exposure. Most cases occur in sub-Saharan Africa, Southeast Asia, and China where populations suffer from both high HBV prevalence and largely uncontrolled aflatoxin exposure in food.

CONCLUSIONS

Aflatoxin may play a causative role in 4.6-28.2% of all global HCC cases.

Temporal trends in hepatitis B and C infection in family blood donors from interior Sindh, Pakistan

BACKGROUND

Hepatitis B (HBV) and C (HCV) infections are a serious global and national public health problem. Earlier studies have reported increasing rates of hepatitis infection in Pakistan, particularly in rural areas. Pakistan has no active surveillance program to monitor trends of these infections. The objective of this study was to verify this trend in blood donors from the rural Sindh area of the country.

METHODS

The study analysed the data of blood donors of interior Sindh who donated blood at JPMC blood bank from January 1, 2004 to September 15, 2007. HBsAg status was determined by using HBsAg Serodia kit and antibodies to HCV using the Detect HCV V.3 Kit. Samples repeatedly reactive for HBsAg or anti-HCV were considered positive for HBV or HCV infection respectively.

RESULTS

The overall seroprevalence of HBV infection among donors was 6.2 % (95% CI 5.5%-6.9%) and did not change significantly over the study period. Overall seroprevalence of HBV infection in literate blood donors was 5.7 %(95% CI 4.7%-6.8%). Prevalence decreased significantly in this group over the study period (p = 0.05). No other significant trends in seroprevalence of HBV infection were seen in the stratified analyses. The overall seroprevalence of HCV among donors was 7.5% (95% CI 6.8%-8.3%) and increased significantly over the study period from 7.2% (95% CI 5.8%-8.7%) in 2004 to 8.9% (95% CI 7.4%-10.6%) in 2007 (p = 0.02). Significant increase in seroprevalence was particularly seen in literate (p = 0.03), non-first time (p = 0.01) and Sindhi speaking (p = 0.01) donors.

CONCLUSION

Our study finds a steady increase in the prevalence of HCV infection in blood donors from interior Sindh between 2004 and 2007. On the contrary, decreasing prevalence of HBV was found, particularly in literate blood donors. There may be a need to have rural community-based epidemiological studies to identify the determinants of the spread of HCV infection and also those that are limiting the spread of HBV infection particularly in the literate blood donor population.