The burden of hepatitis C virus infection in Punjab, India: A population-based serosurvey

Introduction

Hepatitis C virus (HCV) infection prevalence is believed to be elevated in Punjab, India; however, state-wide prevalence data are not available. An understanding of HCV prevalence, risk factors and genotype distribution can be used to plan control measures in Punjab.

Methods

A cross-sectional, state-wide, population-based serosurvey using a multi-stage stratified cluster sampling design was conducted October 2013 to April 2014. Children aged ≥5 years and adults were eligible to participate. Demographic and risk behavior data were collected, and serologic specimens were obtained and tested for anti-HCV antibody, HCV Ribonucleic acid (RNA) on anti-HCV positive samples, and HCV genotype. Prevalence estimates and adjusted odds ratios for risk factors were calculated from weighted data and stratified by urban/rural residence.

Results

5,543 individuals participated in the study with an overall weighted anti-HCV prevalence of 3.6% (95% Confidence Interval [CI]: 3.0%–4.2%) and chronic infection (HCV Ribonucleic acid test positive) of 2.6% (95% CI: 2.0%–3.1%). Anti-HCV was associated with being male (adjusted odds ratio 1.52; 95% CI: 1.08–2.14), living in a rural area (adjusted odds ratio 2.53; 95% CI: 1.62–3.95) and was most strongly associated with those aged 40–49 (adjusted odds ratio 40–49 vs. 19–29-year-olds 3.41; 95% CI: 1.90–6.11). Anti-HCV prevalence increased with each blood transfusion received (adjusted odds ratio 1.36; 95% CI: 1.10–1.68) and decreased with increasing education, (adjusted odds ratio 0.37 for graduate-level vs. primary school/no education; 95% CI: 0.16–0.82). Genotype 3 (58%) was most common among infected individuals.

Discussion

The study findings, including the overall prevalence of chronic HCV infection, associated risk factors and demographic characteristics, and genotype distribution can guide prevention and control efforts, including treatment provision. In addition to high-risk populations, efforts targeting rural areas and adults aged ≥40 would be the most effective for identifying infected individuals.

Evidence of allelic heterogeneity for associations between the NOD2/CARD15 gene and ulcerative colitis among North Indians

BACKGROUND

Three common disease susceptibility variants in the NOD2 gene are associated with inflammatory bowel disease in Caucasians, but not in Asians. Aim To screen for NOD2 variants and examine susceptibility for inflammatory bowel disease in North Indians.

METHODS

A case-control study was carried out in Punjab, India. Confirmed cases of ulcerative colitis and Crohn's disease and healthy controls matched for age (+/-10 years) and ethnicity were studied. Besides genotyping the three disease susceptibility variants (SNP8, SNP12 and SNP13), all 12 exons were resequenced to determine other potential single nucleotide polymorphisms.

RESULTS

Two hundred and ninety-eight ulcerative colitis, 25 Crohn's disease and 262 controls were investigated. Median age (range) at diagnosis was 39 (7-78) years for ulcerative colitis and 40 (32-58) years for Crohn's disease. All three disease susceptibility variants were either monomorphic or rare in the population. Sequencing (n = 30) revealed two single nucleotide polymorphisms: SNP5 (268 Pro/Ser) and rs2067085 (178 Ser/Ser). The frequency of SNP5 was higher among ulcerative colitis (17% vs. 12% in controls, P = 0.016) and Crohn's disease cases (20% vs. 12%, P = 0.28). SNP5 carriers had elevated risks for ulcerative colitis (OR = 1.72, 95% CI = 1.17-2.52, P = 0.005).

CONCLUSIONS

The absence of known inflammatory bowel disease susceptibility variants and potential associations between SNP5 and ulcerative colitis in North Indians suggests the presence of allelic heterogeneity for ulcerative colitis susceptibility.

Incidence and prevalence of ulcerative colitis in Punjab, North India

INTRODUCTION

Ulcerative colitis occurs worldwide. It is considered common in most of Europe and North America and uncommon in most of the developing Asian countries. The incidence/prevalence of ulcerative colitis varies not only according to geographical region but also with race and ethnicity. There are no reported data from India on the incidence of the disease and its prevalence.

MATERIAL AND METHODS

A house to house survey was conducted by questionnaire, formulated to enquire about symptoms that are suggestive of ulcerative colitis. Those with prolonged diarrhoea with or without rectal bleeding were considered as suspected cases. These suspected cases were subjected to video sigmoidoscopy/colonoscopy and rectal biopsy. In addition, patients already diagnosed and receiving treatment for ulcerative colitis, encountered during the survey, were reviewed. Resurvey of the same areas was conducted after a one year interval to detect new cases. Using direct methods, standardised rates were calculated using world standard population weights 22, 18, 16, 12, 12, 9, 7, 3, and 1 for each 10 year age group. Standardised rates were also obtained separately for males, females, and combined populations, using the Punjab state 1991 population census data. Rates were also estimated according to UK 2000 population data. Ninety five per cent confidence intervals (95% CI) of prevalence and incidence rates of ulcerative colitis were estimated under the assumption that the distribution of cases followed a Poisson probability model.

RESULTS

A total population of 51 910 were screened from January to March 1999. We identified 147 suspected cases and of these 23 were finally established as ulcerative colitis cases, giving a crude prevalence rate of 44.3 per 100 000 inhabitants (95% CI 29.4-66.6). A second visit to the same areas after one year identified 10 suspected cases in a population of 49 834. Of these, three were confirmed as "definite" ulcerative colitis giving a crude incidence rate of 6.02 cases per 100 000 inhabitants (95% CI 1.2-17.6).

CONCLUSIONS

This is the first population based study from India reporting on the incidence and prevalence of ulcerative colitis. The disease frequency is not much less than that reported from Europe and North America.

Hepatitis C--knowledge & practices among the family physicians

BACKGROUND

Hepatitis C virus (HCV) is an important cause of end stage chronic liver disease worldwide. There is plethora of informations on hepatitis C virus in the recent hepatology related periodicals. However, family physicians to whom such patients initially present, should be aware of various aspects of hepatitis C virus infection. Therefore, the present study evaluated the information on hepatitis C virus known to practicing family physician in the state of Punjab.

MATERIAL & METHODS

Nine hundred thirty six family physicians were randomly selected from 7 districts of Punjab and were mailed a questionnaire designed to test their knowledge on HCV, its transmission, clinical presentation, complications and treatment. In addition, questions were asked to assess commonly employed mode of therapy for short duration illnesses and the practice of reusing syringes/needles. All question had unequivocal answer. The questionnaire reply was anonymous.

RESULTS

Only 28% (n = 262) doctors returned the questionnaire. The response to different sections of questionnaire was variable. Seventy six percent doctors (n = 176) were aware that HCV is parenterally transmitted. 18% (n = 41) doctors were still reusing needles and syringes. Fifty eight percent (n = 134) doctors considered hepatitis C as a common cause of acute viral hepatitis. Only 72% (n = 166) of doctors knew about the relevant tests for diagnosis of hepatitis C.

CONCLUSIONS

Despite having knowledge about parenteral route of transmission of HCV infection, a sizeable proportion of family physicians in the Punjab state continues to reuse needles and syringes. Information on the virology, clinical presentation, diagnostic tests and management approaches were lacking among a substantial proportion of family physician. Therefore, awareness about HCV need to be increased among the practicing physicians.

Chronic hepatitis C--treatment results in northern India

BACKGROUND

There have been major innovations in the treatment of chronic hepatitis C in the last decade. The course of the disease is variable and host, viral and environmental factors can influence the disease course and response to various treatment protocols. Data on the therapeutic response among north Indian patients with chronic hepatitis 'C' is limited. Therefore, we analysed our results of treatment among patients with chronic hepatitis C.

MATERIAL & METHODS

A total of 55 patients with chronic hepatitis C were treated. Forty nine patients completed treatment with either interferon alpha 2b alone (n = 12) or combination of interferon alpha 2b and ribavarin (n = 37). All the patients were seropositive for anti HCV and, HCV RNA. All of them had elevated ALT and histological features of chronic hepatitis. Response to treatment was evaluated as end treatment response (ETR) i.e. HCV RNA not detected at end of treatment and sustained response (SR) i.e. HCV RNA not detected six months after completing the treatment. Adverse effects were also recorded.

RESULTS

Overall, ETR was documented among in 69% of the patients and SR in 45% patients. Sustained response rate was higher with combination therapy as compared to interferon alone i.e. (51% vs 25%). Sustained response with induction dosing was 57%. Treatment had to be stopped in 3 patients due to major side effects like psychiatric disorders (2) and hypotension (1) and 3 patients were lost to follow up during the course of therapy.

CONCLUSION

Sustained virological response with combination therapy is better than with interferon alone. Induction dosing improves the sustained virological response further. Major side effects with the antiviral drugs necessitating drug withdrawal is infrequent.

Methylprednisolone acetate versus oral prednisolone in moderately active ulcerative colitis

BACKGROUND

Patients with active ulcerative colitis are treated with corticosteroids. We compared the efficacy and safety of intramuscular depot preparation of methylprednisolone acetate with oral prednisolone in the treatment of moderately active ulcerative colitis.

DESIGN

Open labeled, randomized, prospective, four-month study.

METHODS

40 patients with moderately active ulcerative colitis (activity index 150-220) were randomized into two groups. Group A (n=21) received methylprednisolone acetate (80 mg intramuscularly once weekly for 6 weeks). Group B (n=19) received oral prednisolone (40 mg/day) in a 'tailing-off' regimen. In addition, patients in both the groups received sulfasalazine. Patients were followed up at 1, 2, 3, 4, 8, 12 and 16 weeks. The primary measure of therapeutic response was activity index. An index of <150 was considered as clinical remission. Secondary efficacy was assessed by subjective evaluation of acceptability of treatment by the patient.

RESULTS

After one week of treatment, the decrease in mean activity index was significantly more with oral prednisolone (p<0.05), and five 5 patients (23.8%) in Group A and 12 (63.2%) in Group B were in clinical remission (p<0.05). However, after 2 weeks and beyond, the mean activity index and the number of patients with clinical remission were comparable in the two treatment groups.

CONCLUSIONS

Methylprednisolone acetate as a depot preparation and oral prednisolone are equally effective in inducing remission in patients with moderately active ulcerative colitis. Though symptomatic improvement is quicker with oral prednisolone, the remission rate with the two drugs was similar after 2 weeks of treatment.

Coexistence of celiac disease and ulcerative colitis

Coexistence of celiac disease and ulcerative colitis has been reported from Western countries. We report two patients, a 30-year old man and a 16-year old boy, who presented initially with features of celiac disease and later developed ulcerative colitis.

Multiple mucosal bridges in the oesophagus after sclerotherapy for varices

An oesophageal mucosal bridge can occur due to acquired causes and also due to congenital anomalies. A patient with mucosal bridge of the distal oesophagus following sclerotherapy with absolute alcohol is reported.

Intrapulmonary vascular dilatation in portal hypertension due to cirrhosis of liver

BACKGROUND

Intrapulmonary vascular dilatation in patients with portal hypertension due to chronic liver disease has been reported mainly from Western countries.

METHODS

Fifty in-patients with portal hypertension due to cirrhosis of the liver were subjected to contrast-enhanced two-dimensional echocardiography in order to detect the presence of intrapulmonary vascular dilatation. Their arterial blood oxygen saturation was measured. The patients, including 37 men, were aged mean 43.5 years; 30 had alcoholic cirrhosis and 20 postnecrotic cirrhosis. Twelve patients were in Child-Pugh, class B and 38 in class C.

RESULTS

None of the 50 patients was cyanosed or had clubbing. Their mean pO2 was 83.2 mmHg. None had evidence of intrapulmonary vascular dilatations.

CONCLUSION

Intrapulmonary vascular dilatation was not observed in our patients with liver cirrhosis. However, the sensitivity of contrast-enhanced echocardiography for this purpose needs to be reviewed.

Self-reported disease awareness--a questionnaire survey of ulcerative colitis patients

OBJECTIVE

To evaluate patient knowledge about ulcerative colitis and relate this to their socio-demographic characteristics.

METHODS

145 patients with ulcerative colitis were given a two-sectioned awareness questionnaire in a language they understood. The first section, which tested disease awareness, consisted of 16 items. Awareness was classified as very low (< or = 4 correct answers), low (5-8), medium (9-12) and high (13-16). The second section contained 11 questions pertaining to general opinions and views about the disease.

RESULTS

Nine (6.2%) participants had very low level of awareness, 107 (73.8%) low level, 29 (20%) medium, and none high disease awareness. Only disease duration influenced disease awareness significantly. Age, sex, marital status, occupation and education level had no relation to the level of awareness. A majority of patients resorted to use of alternative medicines during their disease course; however, with increasing awareness the use of other types of therapy was reduced. Drug compliance had significant association with disease awareness.

CONCLUSIONS

Our patients with ulcerative colitis had poor disease awareness. Since awareness affected treatment compliance, the study emphasizes the need for better education of the patients and their family about the disease.

Cronkhite Canada syndrome

Cronkhite Canada syndrome is an acquired non-familial syndrome characterised by diffuse gastrointestinal polyposis with alopecia nail dystrophy and hyperpigmentation. There is chronic diarrhoea and protein losing enteropathy. The etiology of this syndrome remains obscure. The rarity of the case prompts this case report.

Spider angiomas in the gastrointestinal tract

Spider angiomas are cutaneous manifestations of endocrine imbalances in cirrhosis. We describe unusual cases of massive bleed from spider angiomas in the oral cavity and colon in association with cirrhosis of liver.

Negative ion density fronts during ignition and extinction of plasmas in electronegative gases

Negative ion density fronts have been shown to occur in electronegative steady-state plasmas with hot electrons. In this Letter, we report theoretical and numerical results on the spatiotemporal evolution of negative ion density fronts during plasma ignition and extinction (afterglow). During plasma ignition, the negative ion fronts are analogous to hydrodynamic shocks. This is not the case during plasma extinction where, although negative ions diffuse freely in the plasma core, the negative ion front propagates towards the chamber walls with a nearly constant velocity.

Role of azathioprine in severe ulcerative colitis: one-year, placebo-controlled, randomized trial

OBJECTIVE

To investigate the efficacy of azathioprine in treating patients with severe ulcerative colitis.

DESIGN

One-year, randomized, placebo-controlled trial.

SUBJECTS

83 patients with severe ulcerative colitis were enrolled. Fifty patients who relapsed within two months on corticosteroid withdrawal were randomized into two groups. The azathioprine group received oral sulfasalazine (6-8 g/day), oral prednisolone (1 mg/Kg/day) and oral azathioprine (2 mg/Kg/day). The placebo group received oral sulfasalazine (6-8 g/day), oral prednisolone (1 mg/Kg/day) and placebo. Corticosteroids were tapered over 12-16 weeks.

RESULTS

Five patients (2 in azathioprine group, 3 in placebo group) dropped out of the study. Three patients in the azathioprine group had side effects. The number of patients going into complete remission and partial remission was not significantly different in the two groups. The proportion of relapses in the azathioprine group was lower than in the placebo group (p < 0.05).

CONCLUSIONS

In patients with ulcerative colitis, azathioprine had no effect in achieving remission, when given in combination with prednisolone; however, it lowers the proportion of relapses. Side effects like pancreatitis and hepatitis are mild and respond promptly to drug withdrawal.

Non-traumatic rhabdomyolysis with acute renal failure

A clinical profile of non-traumatic rhabdomyolysis with acute renal failure is presented. Myoglobinuric renal failure is treatable and hence a high index of suspicion is warranted in the etiologies discussed.

Hepatitis A and acute pancreatitis

Acute pancreatitis in association with acute viral hepatitis A in uncommon. We present the case of a young girl with acute pancreatitis complicating acute viral hepatitis A. The finding of IgM anti-HAV and exclusion of a vast array of other etiologies implicates hepatitis A the cause.

Hereditary pancreatitis

Hereditary pancreatitis is a rare cause of chronic pancreatitis and has been mainly reported in western literature. It is inherited in an autosomal dominant manner. In this report, we present our data on two affected members in a family from Punjab, North India.

High seroprevalence of hepatitis C virus and dual infection (hepatitis B and C virus) in non-alcoholic chronic liver disease in north India

BACKGROUND

There are conflicting reports on the prevalence of hepatitis B and C virus (HBV and HCV) mediated chronic liver disease (CLD) in India.

AIM

To study the prevalence of HBV and HCV associated in CLD in north India.

MATERIAL AND METHODS

Eighty five patients (66 males, 19 females; age range 16-70 years) with unequivocal CLD were analysed. CLD patients with nonviral aetiologies were excluded. All sera were tested for anti-HCV by EIA (third generation), HBsAg, IgM and IgG anti-HBc, HBeAg/Anti-HBe by EIA (Abbott Diagnostics, IL). Positive anti-HCV results were confirmed by RIBA-II assay.

RESULTS

Sixteen (18.8%), 22 (25.9%) and 21 (24.7%) patients had HBV, HCV and HBV + HCV infection, respectively. Twenty six (30.6%) CLD patients had no viral markers.

CONCLUSION

HCV is emerging as an important cause of CLD in India. Dual infection (HBV + HCV) is seen in 25% patients. Dual infection influences the prognosis and response rates to interferon therapy.

Chronic hepatitis--changing trends

The clinical expressions, courses and consequences of hepatitis caused by different viruses (A,B,C,D,E,G) are different. Diagnosis of hepatitis is incomplete unless its etiology is specified and for chronic hepatitis, the etiology is apparent in almost all cases when autoimmune and metabolic diseases are also included. Hence, the classification based only on histology is not adequate and emphasis should also be on the etiology. The prognostic indices governing a response to interferon therapy in patients with chronic viral hepatitis have advanced with the knowledge of role played by viral genotypes, serum ferritin, hepatic iron concentration, viral quantification, and severity of histology. There have been recent changes in the definition and classification of autoimmune hepatitis as well as there is availability of newer immunosuppressive agents with encouraging results.