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Abstract
While the majority of worldwide hepatitis E viral (HEV) infections that occur in people are from contaminated water or food sources, there has also been a steadily rising number of reported cases of transfusion-transmitted HEV (TT-HEV) in blood donation recipients. For most, HEV infection is acute, self-limiting and asymptomatic. However, patients that are immunocompromised, especially transplant patients, are at much higher risk for developing chronic infections, which can progress to cirrhosis and liver failure, along with overall increased mortality. Because of the rising trend of HEV serological prevalence among the global population, and the fact that TT-HEV infection can cause serious clinical consequences among those patients most at need for blood donation, the need for screening for TT-HEV has been gaining in prominence as an important public health concern for both developing and developed countries. In the review, we summarise evidence for and notable cases of TT-HEV infections, the various aspects of HEV screening protocols and recent trends in the implementation of TT-HEV broad-based blood screening programmes.
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Dalton HR, Izopet J. Transmission and Epidemiology of Hepatitis E Virus Genotype 3 and 4 Infections. Cold Spring Harb Perspect Med 2018. [PMID: 29530946 DOI: 10.1101/cshperspect.a032144] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Following the introduction of robust serological and molecular tools, our understanding of the epidemiology of zoonotic hepatitis E virus (HEV) has improved considerably in recent years. Current thinking suggests that consumption of pork meat products is the key route of infection in humans, but it is certainly not the only one. Other routes of infection include environmental spread, contaminated water, and via the human blood supply. The epidemiology of HEV genotype (gt)3 and gt4 is complex, as there are several sources and routes of infection, and it is likely that these vary between and within countries and over time.
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Affiliation(s)
- Harry R Dalton
- Royal Cornwall Hospital, Truro TR1 3LJ, United Kingdom.,European Centre for Environment and Human Health, University of Exeter, Truro TR1 3LJ, United Kingdom
| | - Jacques Izopet
- Department of Virology, Hepatitis E Virus National Reference Centre, Toulouse University Hospital, 31059 Toulouse, France.,Toulouse-Purpan Centre for Pathophysiology, INSERM UMR1043/CNRS UMR 5282, CPTP, Toulouse University Paul Sabatier, 31024 Toulouse, France
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Izopet J. [HEV and transfusion-recipient risk]. ANNALES PHARMACEUTIQUES FRANÇAISES 2018; 76:89-96. [PMID: 29395014 DOI: 10.1016/j.pharma.2017.12.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 12/18/2017] [Indexed: 02/06/2023]
Abstract
HEV infections are mainly food- and water-borne but transfusion-transmission has occurred in both developing and developed countries. The infection is usually asymptomatic but it can lead to fulminant hepatitis in patients with underlying liver disease and pregnant women living in developing countries. It also causes chronic hepatitis E, with progressive fibrosis and cirrhosis, in approximately 60 % of immunocompromised patients infected with HEV genotype 3. Extra-hepatic manifestations such as neurological and renal manifestations have been reported. The risk of a transfusion-transmitted HEV infection is linked to the frequency of viremia in blood donors, the donor virus load and the volume of plasma in the final transfused blood component. Several developed countries have adopted measures to improve blood safety based on the epidemiology of HEV.
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Affiliation(s)
- J Izopet
- Laboratoire de virologie, centre national de référence virus des hépatites à transmission entérique (hépatites A et E), institut fédératif de biologie, CHU de Purpan, 330, avenue de Grande-Bretagne, TSA 40031, 31059 Toulouse, France; Inserm U1043/CNRS 5282, université Paul-Sabatier, centre de physiopathologie de Toulouse-Purpan, 31024 Toulouse cedex 03, France.
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Bura M, Michalak M, Łagiedo-Żelazowska M, Bukowska A, Bura A, Mozer-Lisewska I. HEV seroprevalence can significantly change after re-assessment. J Med Virol 2018; 90:783-785. [PMID: 29388686 DOI: 10.1002/jmv.25039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Accepted: 01/18/2018] [Indexed: 11/10/2022]
Affiliation(s)
- Maciej Bura
- Department of Infectious Diseases, Hepatology and Acquired Immunodeficiencies, Poznan University of Medical Sciences, Poznań, Poland
| | - Michał Michalak
- Department of Computer Science and Statistics, Poznan University of Medical Sciences, Poznań, Poland
| | | | | | - Aleksandra Bura
- Department of Infectious Diseases, Joseph Strus Multidisciplinary City Hospital in Poznan, Poznań, Poland
| | - Iwona Mozer-Lisewska
- Department of Infectious Diseases, Hepatology and Acquired Immunodeficiencies, Poznan University of Medical Sciences, Poznań, Poland
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Izopet J, Lhomme S, Chapuy-Regaud S, Mansuy JM, Kamar N, Abravanel F. HEV and transfusion-recipient risk. Transfus Clin Biol 2017; 24:176-181. [PMID: 28690036 DOI: 10.1016/j.tracli.2017.06.012] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 06/08/2017] [Indexed: 01/14/2023]
Abstract
HEV infections are mainly food- and water-borne but transfusion-transmission has occurred in both developing and developed countries. The infection is usually asymptomatic but it can lead to fulminant hepatitis in patients with underlying liver disease and pregnant women living in developing countries. It also causes chronic hepatitis E, with progressive fibrosis and cirrhosis, in approximately 60% of immunocompromised patients infected with HEV genotype 3. The risk of a transfusion-transmitted HEV infection is linked to the frequency of viremia in blood donors, the donor virus load and the volume of plasma in the final transfused blood component. Several developed countries have adopted measures to improve blood safety based on the epidemiology of HEV.
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Affiliation(s)
- J Izopet
- Department of virology, National reference center for hepatitis E virus, CHU Purpan, IFB, 330, avenue de Grande-Bretagne, TSA 40031, 31059 Toulouse, France; Inserm UMR 1043/CNRS UMR 5282, CPTP, center for pathophysiology of toulouse-Purpan, Toulouse university Paul-Sabatier, 31024 Toulouse, France.
| | - S Lhomme
- Department of virology, National reference center for hepatitis E virus, CHU Purpan, IFB, 330, avenue de Grande-Bretagne, TSA 40031, 31059 Toulouse, France; Inserm UMR 1043/CNRS UMR 5282, CPTP, center for pathophysiology of toulouse-Purpan, Toulouse university Paul-Sabatier, 31024 Toulouse, France
| | - S Chapuy-Regaud
- Department of virology, National reference center for hepatitis E virus, CHU Purpan, IFB, 330, avenue de Grande-Bretagne, TSA 40031, 31059 Toulouse, France; Inserm UMR 1043/CNRS UMR 5282, CPTP, center for pathophysiology of toulouse-Purpan, Toulouse university Paul-Sabatier, 31024 Toulouse, France
| | - J-M Mansuy
- Department of virology, National reference center for hepatitis E virus, CHU Purpan, IFB, 330, avenue de Grande-Bretagne, TSA 40031, 31059 Toulouse, France
| | - N Kamar
- Inserm UMR 1043/CNRS UMR 5282, CPTP, center for pathophysiology of toulouse-Purpan, Toulouse university Paul-Sabatier, 31024 Toulouse, France; Department of nephrology and organ transplantation, CHU Rangueil, 31059 Toulouse, France
| | - F Abravanel
- Department of virology, National reference center for hepatitis E virus, CHU Purpan, IFB, 330, avenue de Grande-Bretagne, TSA 40031, 31059 Toulouse, France; Inserm UMR 1043/CNRS UMR 5282, CPTP, center for pathophysiology of toulouse-Purpan, Toulouse university Paul-Sabatier, 31024 Toulouse, France
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Madden RG, Wallace S, Sonderup M, Korsman S, Chivese T, Gavine B, Edem A, Govender R, English N, Kaiyamo C, Lutchman O, van der Eijk AA, Pas SD, Webb GW, Palmer J, Goddard E, Wasserman S, Dalton HR, Spearman CW. Hepatitis E virus: Western Cape, South Africa. World J Gastroenterol 2016; 22:9853-9859. [PMID: 27956810 PMCID: PMC5124991 DOI: 10.3748/wjg.v22.i44.9853] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 10/19/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To conduct a prospective assessment of anti-hepatitis E virus (HEV) IgG seroprevalence in the Western Cape Province of South Africa in conjunction with evaluating risk factors for exposure.
METHODS Consenting participants attending clinics and wards of Groote Schuur, Red Cross Children’s Hospital and their affiliated teaching hospitals in Cape Town, South Africa, were sampled. Healthy adults attending blood donor clinics were also recruited. Patients with known liver disease were excluded and all major ethnic/race groups were included to broadly represent local demographics. Relevant demographic data was captured at the time of sampling using an interviewer-administered confidential questionnaire. Human immunodeficiency virus (HIV) status was self-disclosed. HEV IgG testing was performed using the Wantai® assay.
RESULTS HEV is endemic in the region with a seroprevalence of 27.9% (n = 324/1161) 95%CI: 25.3%-30.5% (21.9% when age-adjusted) with no significant differences between ethnic groups or HIV status. Seroprevalence in children is low but rapidly increases in early adulthood. With univariate analysis, age ≥ 30 years old, pork and bacon/ham consumption suggested risk. In the multivariate analysis, the highest risk factor for HEV IgG seropositivity (OR = 7.679, 95%CI: 5.38-10.96, P < 0.001) was being 30 years or older followed by pork consumption (OR = 2.052, 95%CI: 1.39-3.03, P < 0.001). A recent clinical case demonstrates that HEV genotype 3 may be currently circulating in the Western Cape.
CONCLUSION Hepatitis E seroprevalence was considerably higher than previously thought suggesting that hepatitis E warrants consideration in any patient presenting with an unexplained hepatitis in the Western Cape, irrespective of travel history, age or ethnicity.
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Hartl J, Otto B, Madden RG, Webb G, Woolson KL, Kriston L, Vettorazzi E, Lohse AW, Dalton HR, Pischke S. Hepatitis E Seroprevalence in Europe: A Meta-Analysis. Viruses 2016; 8:v8080211. [PMID: 27509518 PMCID: PMC4997573 DOI: 10.3390/v8080211] [Citation(s) in RCA: 160] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 07/12/2016] [Accepted: 07/25/2016] [Indexed: 02/06/2023] Open
Abstract
UNLABELLED There have been large numbers of studies on anti-HEV IgG seroprevalence in Europe, however, the results of these studies have produced high variability of seroprevalence rates, making interpretation increasingly problematic. Therefore, the aim of this study was to develop a clearer understanding of anti-HEV IgG seroprevalence in Europe and identify risk groups for HEV exposure by a meta-analysis of published studies. METHODS All European HEV-seroprevalence studies from 2003 to 2015 were reviewed. Data were stratified by assay, geographical location, and patient cohort (general population, patients with HIV, solid-organ transplant recipients, chronic liver disease patients, and individuals in contact with swine/wild animals). Data were pooled using a mixed-effects model. RESULTS Four hundred thirty-two studies were initially identified, of which 73 studies were included in the analysis. Seroprevalence estimates ranged from 0.6% to 52.5%, increased with age, but were unrelated to gender. General population seroprevalence varied depending on assays: Wantai (WT): 17%, Mikrogen (MG): 10%, MP-diagnostics (MP): 7%, DiaPro: 4%, Abbott 2%. The WT assay reported significantly higher seroprevalence rates across all cohorts (p < 0.001). Individuals in contact with swine/wild animals had significantly higher seroprevalence rates than the general population, irrespective of assay (p < 0.0001). There was no difference between any other cohorts. The highest seroprevalence was observed in France (WT: 32%, MP: 16%) the lowest in Italy (WT: 7.5%, MP 0.9%). Seroprevalence varied between and within countries. The observed heterogeneity was attributed to geographical region (23%), assay employed (23%) and study cohort (7%). CONCLUSION Seroprevalcence rates primarily depend on the seroassy that is used, followed by the geographical region and study cohort. Seroprevalence is higher in individuals exposed to swine and/or wild animals, and increases with age.
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Affiliation(s)
- Johannes Hartl
- First Medical Department, University Medical Center Hamburg-Eppendorf, University Hospital Hamburg Eppendorf (UKE), 20246, Hamburg, Germany.
| | - Benjamin Otto
- First Medical Department, University Medical Center Hamburg-Eppendorf, University Hospital Hamburg Eppendorf (UKE), 20246, Hamburg, Germany.
| | - Richie Guy Madden
- Royal Cornwall Hospital Trust and European Centre for Environment and Human Health, University of Exeter, Truro TR1 3HD, UK.
| | - Glynn Webb
- Royal Cornwall Hospital Trust and European Centre for Environment and Human Health, University of Exeter, Truro TR1 3HD, UK.
| | - Kathy Louise Woolson
- Royal Cornwall Hospital Trust and European Centre for Environment and Human Health, University of Exeter, Truro TR1 3HD, UK.
| | - Levente Kriston
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, 20246, Hamburg, Germany.
| | - Eik Vettorazzi
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, 20246, Hamburg, Germany.
| | - Ansgar W Lohse
- First Medical Department, University Medical Center Hamburg-Eppendorf, University Hospital Hamburg Eppendorf (UKE), 20246, Hamburg, Germany.
| | - Harry Richard Dalton
- Royal Cornwall Hospital Trust and European Centre for Environment and Human Health, University of Exeter, Truro TR1 3HD, UK.
| | - Sven Pischke
- First Medical Department, University Medical Center Hamburg-Eppendorf, University Hospital Hamburg Eppendorf (UKE), 20246, Hamburg, Germany.
- Royal Cornwall Hospital Trust and European Centre for Environment and Human Health, University of Exeter, Truro TR1 3HD, UK.
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Dalton HR, Kamar N, van Eijk JJJ, Mclean BN, Cintas P, Bendall RP, Jacobs BC. Hepatitis E virus and neurological injury. Nat Rev Neurol 2015; 12:77-85. [PMID: 26711839 DOI: 10.1038/nrneurol.2015.234] [Citation(s) in RCA: 159] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Hepatitis E is hyperendemic in many developing countries in Asia and Africa, and is caused by hepatitis E virus (HEV) genotypes 1 and 2, which are spread via the faecal-oral route by contaminated water. Recent data show that HEV infection is also endemic in developed countries. In such geographical settings, hepatitis E is caused by HEV genotypes 3 and 4, and is mainly a porcine zoonosis. In a minority of cases, HEV causes acute and chronic hepatitis, but infection is commonly asymptomatic or unrecognized. HEV infection is associated with a number of extrahepatic manifestations, including a range of neurological injuries. To date, 91 cases of HEV-associated neurological injury--most commonly, Guillain-Barré syndrome, neuralgic amyotrophy, and encephalitis/myelitis--have been reported. Here, we review the reported cases, discuss possible pathogenic mechanisms, and present our perspectives on future directions and research questions.
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Affiliation(s)
- Harry R Dalton
- Royal Cornwall Hospital, University of Exeter, Penventinnie Lane, Truro TR1 3LJ, UK.,European Centre for Environment &Human Health, University of Exeter, Penventinnie Lane, Truro TR1 3LJ, UK
| | - Nassim Kamar
- Departments of Nephrology and Organ Transplantation, CHU Rangueil, INSERM U1043, IFR-BMT, Université Paul Sabatier, 1 Avenue J. Poulhès, Toulouse Cedex 9, France
| | - Jeroen J J van Eijk
- Department of Neurology, Jeroen Bosch Ziekenhuis (JBZ), Henri Dunantstraat 1, 5223 GZ, 's-Hertogenbosch, Netherlands
| | - Brendan N Mclean
- Royal Cornwall Hospital, University of Exeter, Penventinnie Lane, Truro TR1 3LJ, UK
| | - Pascal Cintas
- Department of Neurology, Pierre Paul Riquet Hospital, CHU Purpan, Place du Dr Baylac, 31059 Toulouse, France
| | - Richard P Bendall
- Royal Cornwall Hospital, University of Exeter, Penventinnie Lane, Truro TR1 3LJ, UK.,European Centre for Environment &Human Health, University of Exeter, Penventinnie Lane, Truro TR1 3LJ, UK
| | - Bart C Jacobs
- Department of Neurology/Neuro-Immunology Erasmus MC, Erasmus MC, Afdeling Neurologie, Kamer EE 2287, Postbus 2040, 3000 CA Rotterdam, Netherlands
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Petrik J, Lozano M, Seed CR, Faddy HM, Keller AJ, Prado Scuracchio PS, Wendel S, Andonov A, Fearon M, Delage G, Zhang J, Shih JWK, Gallian P, Djoudi R, Tiberghien P, Izopet J, Dreier J, Vollmer T, Knabbe C, Aggarwal R, Goel A, Ciccaglione AR, Matsubayashi K, Satake M, Tadokoro K, Jeong SH, Zaaijer HL, Zhiburt E, Chay J, Teo D, Chua SS, Piron M, Sauleda S, Echevarría JM, Dalton H, Stramer SL. Hepatitis E. Vox Sang 2015. [PMID: 26198159 DOI: 10.1111/vox.12285] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Kmush BL, Labrique AB, Dalton HR, Ahmed ZB, Ticehurst JR, Heaney CD, Nelson KE, Zaman K. Two Generations of "Gold Standards": The Impact of a Decade in Hepatitis E Virus Testing Innovation on Population Seroprevalence. Am J Trop Med Hyg 2015; 93:714-717. [PMID: 26149865 PMCID: PMC4596587 DOI: 10.4269/ajtmh.15-0159] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 05/12/2015] [Indexed: 12/13/2022] Open
Abstract
Hepatitis E virus (HEV) is a global pathogen responsible for approximately 20 million infections every year in developing countries, yet remains under-recognized. In this population-based cohort study, 1,025 randomly selected participants were enrolled from Matlab, Bangladesh (2004-2005). All participants were tested for HEV antibodies and total immunoglobulin (Ig), using an in-house enzyme immunoassay developed by Walter Reed Army Institute of Research (WRAIR). In 2014, we retested the banked sera of 1,009 of those participants using the Wantai anti-HEV IgG enzyme-linked immunosorbent assay (ELISA). The WRAIR assay estimated the overall population seroprevalence as 26.6% (95% confidence interval [CI]: 24.0, 29.5), whereas the Wantai assay produced significantly higher estimated seroprevalence, 46.7% (95% CI: 43.5-49.8) (P < 0.001). However, the two tests give nearly identical findings in those 5 years and under (N = 94) with a 98% agreement between the tests. Retesting populations with modern assays is necessary to establish better population-level estimates of disease burden.
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Affiliation(s)
| | - Alain B. Labrique
- *Address correspondence to Alain B. Labrique, Department of International Health, Johns Hopkins Bloomberg School of Public Health, W5501, 615 North Wolfe Street, Baltimore, MD 21205. E-mail:
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Izopet J, Labrique AB, Basnyat B, Dalton HR, Kmush B, Heaney CD, Nelson KE, Ahmed ZB, Zaman K, Mansuy JM, Bendall R, Sauné K, Kamar N, Arjyal A, Karkey A, Dongol S, Prajapati KG, Adhikary D. Hepatitis E virus seroprevalence in three hyperendemic areas: Nepal, Bangladesh and southwest France. J Clin Virol 2015; 70:39-42. [PMID: 26305817 DOI: 10.1016/j.jcv.2015.06.103] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Revised: 06/24/2015] [Accepted: 06/27/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND Hepatitis E causes a significant burden of disease in developing countries and has recently been increasingly recognized in developed countries. Comparing population anti-hepatitis E virus (HEV) seroprevalence across populations has been difficult. OBJECTIVES The aim of this study was to compare the anti-HEV IgG seroprevalence in both adults and children in three hyper-endemic areas (Nepal, Bangladesh and southwest France) using a sensitive, commercial anti-HEV IgG assay. STUDY DESIGN Serum or plasma from adults and children in Nepal (n=498), Bangladesh (n=1,009) and Southwest France (n=1031) were tested for anti-HEV IgG using the Wantai assay. RESULTS After age-standardization, anti-HEV IgG seroprevalence was 47.1%, 49.8% and 34.0% in Nepal, Bangladesh and southwest France, respectively. There was no difference in seroprevalence by gender in any of the countries. A paucity of infections in children 1-10 years-old was consistently observed (less than 15%) at all 3 locations. CONCLUSIONS Surprisingly similar high rates of anti-HEV antibodies were detected using a common, sensitive assay. Despite differences in the epidemiology and circulating genotype of HEV in Nepal, Bangladesh and southwest France, this study found more similarities in population seroprevalence than expected.
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Affiliation(s)
- Jacques Izopet
- Université Toulouse III Paul Sabatier, Toulouse, France; Inserm, U1043, Toulouse, France; Hôpital Purpan, CHU de Toulouse, Toulouse, France
| | - Alain B Labrique
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Buddha Basnyat
- Oxford University Clinical Research Unit\Patan Hospital, Kathmandu, Nepal
| | - Harry R Dalton
- University of Exeter, Truro, Cornwall, UK; Royal Cornwall Hospital Trust, Truro, Cornwall, UK
| | - Brittany Kmush
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Kenrad E Nelson
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Zabed B Ahmed
- Child Health Research Foundation, Department of Microbiology, Dhaka Shishu Hospital, Dhaka, Bangladesh
| | | | | | - Richard Bendall
- University of Exeter, Truro, Cornwall, UK; Royal Cornwall Hospital Trust, Truro, Cornwall, UK
| | - Karine Sauné
- Université Toulouse III Paul Sabatier, Toulouse, France; Inserm, U1043, Toulouse, France; Hôpital Purpan, CHU de Toulouse, Toulouse, France
| | - Nassim Kamar
- Université Toulouse III Paul Sabatier, Toulouse, France; Inserm, U1043, Toulouse, France; Hôpital Rangueil, CHU de Toulouse, Toulouse, France
| | - Amit Arjyal
- Oxford University Clinical Research Unit\Patan Hospital, Kathmandu, Nepal
| | - Abhilasha Karkey
- Oxford University Clinical Research Unit\Patan Hospital, Kathmandu, Nepal
| | - Sabina Dongol
- Oxford University Clinical Research Unit\Patan Hospital, Kathmandu, Nepal
| | | | - Dinesh Adhikary
- Oxford University Clinical Research Unit\Patan Hospital, Kathmandu, Nepal
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