Occult HBV Infection among a Cohort of Nigerian Adults

Objective: To determine markers of HBV infection and detect the presence of its occult infection in serum of a cohort of adult Nigerians. Methodology: The study involved 28 adult Nigerians with viral hepatitis (Group 1) and 28 apparently healthy adult Nigerians as controls (Group 2). Their sera were assayed for HBsAg; HBeAg; anti-HBe; anti-HBc; anti-HBs; and anti-HCV; while HBV DNA was determined in 15 patients with chronic hepatitis. Significance of differences between the patients and control subjects was assessed using Chi-square test at a 95confidence level. Results: Sero-detection of HBsAg; HBeAg; anti-HBe and anti-HBc was higher among the patients compared to the controls. HBV infection was diagnosed by HBsAg (89) and a duo of HBsAg and anti-HBc (100) among the patients. Similarly; eleven and four types of different patterns of HBV markers were observed among the respective groups. Anti-HBe (9.5); anti-HBc (14.3); and anti-HBs (9.5) were detected among all the subjects who were sero-negative for HBsAg. HBV DNA was also detected in 86.7of the 15 patients with chronic hepatitis; while occult HBV infection was observed in 7.2of the patients and none (0) of the controls; p 0.05. Furthermore; HCV infection occurred among subjects with all the different patterns of HBV markers; except those with occult HBV infection and natural immunity to HBV. Conclusion: This study shows that occult HBV infection is present among Nigerian adults and determination of HBsAg; anti-HBc; anti-HBe; and HBV DNA will assist in its detection

Hepatitis B and C in doctors and dentists in Nigeria.

We surveyed a random sample (n = 75) of doctors and dentists at University College Hospital, Ibadan, Nigeria. They were offered anonymous testing for hepatitis B surface antigen (HBsAg), hepatitis Be antigen (HBeAG), antibodies to hepatitis B core antigen (anti-HBc) and to hepatitis C virus (anti-HCV), by enzyme immunoassay. The results suggest a high prevalence of hepatitis B virus (HBV) with a high potential of transmissibility, as well as a high prevalence of HCV infection. The majority of the doctors and dentists use universal precaution for protection against viral hepatitis on < 50% of the occasions when they carry out procedures on their patients. Infection with HBV was associated with type of specialty (surgeons, dentists) and lack of HBV vaccination (p < 0.05). After logistic regression, these factors were independently associated with HBV infection (p < 0.05). Sixty (80%) had not received prior HBV vaccination. Unvaccinated personnel were more likely to be surgeons, dentists, < 37 years of age, and have fewer years of professional activity (p < 0.05). After logistic regression, only fewer years of professional activity remained independently associated with lack of vaccination (p < 0.05). To reduce the occupational exposure of HBV, universal precautions must be rigorously adhered to when the doctors and dentists carry out procedures on their patients, and all health-care workers should be vaccinated with HBV vaccine and the HCV vaccine, when it becomes available.

Prevalence and epidemiological characteristics of hepatitis B and C infections among doctors and dentists in Nigeria.

A random sample of seventy five doctors and dentists at the University College Hospital, Ibadan, Nigeria, was surveyed. They were offered anonymous testing for hepatitis B surface antigen (HBsAg), hepatitis B e antigen (HBeAg), antibodies to hepatitis B core antigen (anti-HBc) and to hepatitis C virus (anti-HCV) by enzyme immunoassay. The results suggest a high prevalence of hepatitis B virus (HBV) with a high potential of transmissibility, as well as a high prevalence of HCV infection. Most of the doctors and dentists use universal precaution for protection against viral hepatitis less than 50% of the occasions when they carry out procedures on their patients. Infection with HBV was associated with type of specialty (surgeons and dentists) and lack of HBV vaccination (p < 0.05). After logistic regression, these factors were independently associated with HBV infection (p < 0.05). Sixty (80%) of these health care workers had not received prior HBV vaccination. The unvaccinated personnel were more likely to be surgeons, dentists, less than 37 years of age and have fewer years of professional activity (p < 0.05). After logistic regression, only the fewer years of professional activity remained independently associated with lack of vaccination (p < 0.05). We conclude that to reduce the occupational exposure of HBV, universal precautions must be rigorously adhered to when doctors and dentists carry out procedures on their patients. It is necessary that these health care workers are vaccinated with HBV vaccine and the currently anticipated HCV vaccination, if not immune. No recent study exists that exclusively addresses this problem in health care workers in tropical Africa.

Discriminant analysis of biochemical parameters in liver disease.

Discriminant function analysis has been used to investigate the relative value of six biochemical parameters (plasma ferritin, C-reactive-protein, bilirubin, alkaline phosphatase, glutamic oxaloacetic acid transaminase and albumin) in the diagnosis of liver disease. This was done among four groups totalling 70 subjects including healthy controls and patients with acute viral hepatitis, liver cirrhosis and primary hepatocellular carcinoma. Albumin had most value in distinguishing between groups, followed cumulatively by ferritin, alkaline phosphatase, C-reactive protein, bilirubin and glutamic oxaloacetic acid transaminase. However, if data on albumin, alkaline phosphatase, bilirubin and glutamic oxaloacetic acid transaminase had already been routinely collected, there would be no advantage in collecting data on ferritin and C-reactive protein. Any four of the six parameters would be of about equal value in distinguishing between diagnostic groups. When the data on all six biochemical parameters was combined in an optimum way, about 66% of all individuals could be correctly assigned to one of the four groups using biochemical markers alone. While the control subjects and patients with acute viral hepatitis formed a relatively well defined, tight cluster (apart from two patients with acute viral hepatitis), patients with liver cirrhosis and primary hepatocellular carcinoma were almost indistinguishable, using these biochemical parameters. If the latter two groups were pooled, then about 86% of subjects could be correctly classified.

Hepatitis B and C virus and hepatocellular carcinoma.

Antibody to hepatitis C virus (anti-HCV) was detected in 18.7% of patients with hepatocellular carcinoma (HCC) and in 10.9% of controls (P < 0.001). The corresponding prevalences of hepatitis B surface antigen (HBsAg) were 59.3% and 50.0% (P < 0.001). Using patients with non-hepatic disease as controls, stepwise logistic regression analysis indicated that both anti-HCV (odds ratio 6.88%; 95% confidence interval [CI] 1.63-9.77) and HBsAg (odds ratio 6.46; 95% CI 1.68-18.13) were independent risk factors for HCC. Calculation of the incremental odds ratio indicated no interaction between hepatitis B virus (HBV) and HCV. Blood transfusion was a significant risk factor for acquiring HCV infection with odds ratios of 5.48 (95% CI 1.07-29.0) and 2.86 (95% CI 1.31-22.72) for HCC cases and controls, respectively. The mean age of HCC cases with HBsAg and anti-HCV was lower than that of HCC patients with anti-HCV alone (P < 0.01). It is concluded that there is a high rate of HBV infection, and a low rate of HCV infection, among Nigerian patients with HCC. However, HBV and HCV are independent risk factors for the development of HCC, with HBV having an effect more rapidly. Screening of blood products for transfusion might minimize the risk of HCV transmission.

Doctors at risk of hepatitis B and HIV infection from patients in Nigeria.

The aim of this study was to assess the degree of residents' concern about acquiring hepatitis B virus (HBV) and human immunodeficiency virus (HIV) infection from their patients at the University College Hospital, Ibadan, Nigeria. We surveyed 149 resident doctors. The response was 89%. Nine per cent of the resident doctors reported percutaneous exposures to needles contaminated with blood of patients infected with HBV or HIV. Eighty per cent of the residents experienced moderate to major concern about contracting these viral infections from their patients. The majority of the doctors (54-64%) indicated that they should be allowed to decide for themselves whether to treat the infected patients. A substantial proportion of them (46-49%) believed that refusing to take care of the patient was not unethical. About 86-96% of the doctors believed that the hospital as well as the Residency Training Programme administrators were not concerned about the risk of acquiring the viruses from their patients. In general, the results demonstrate a major degree of concern about acquiring HBV and HIV infections among resident doctors. Moreover, there is a need for the hospital and Residency Training Programme administrators to formally address these concerns so as to motivate well and reassure these doctors. No such study exists that exclusively address this important and topical subject in doctors in tropical Africa.

PIP: In Ibadan, Nigeria, 149 resident physicians completed a questionnaire revolving around their degree of exposure to hepatitis B virus (HBV) or HIV-infected patients, their concern about acquiring these infections, and the effect of this concern on their caring for patients and on the health policies of the University College Hospital. 9% had been stuck by a needle contaminated with the blood of an HBV- or HIV-infected patient. The 12 residents reporting a needle stick had 21 needle-stick exposures altogether. 54% of the residents used universal precautions while performing procedures no more than 50% of the time. 61-67% estimated their risk of acquiring these infections as no greater than 1/10,000, which compares to the estimate found in the literature. Yet 80% had moderate to high concern about acquiring HBV or HIV infection from their patients. 32-34% of residents reported that their concerns about acquiring these infections would not adversely affect patient care. 60-77% of residents would continue to care for patients with HBV or HIV infection if given a choice. 54-64% believed that they should be allowed to decide themselves whether to provide care to infected patients. About 50% did not consider it unethical to refuse to care for infected patients. 86-96% thought that the hospital and the residency training program administrators did not worry about the risk of acquiring HBV or HIV infection from their patients. These findings show that resident physicians are greatly concerned about acquiring HBV and HIV infections. They also indicate a need for the hospital and training program administrators to formally handle these concerns in order to motivate and reassure the residents.

Natural history of liver cirrhosis in 116 Nigerians.

One hundred and sixteen cirrhotic patients were prospectively studied over a ten year period. Hepatitis B surface antigen was positive in 70% of tested patients. The cirrhotic liver was mainly macronodular and primary hepatocellullar carcinoma was associated with 63% of the patients. Half of the patients were critically ill with high incidences of ascites, jaundice and encephalopathy. Cirrhotic patients had significantly lower body temperature onycholysis and hyperpigmented palmo-plantar macular areas. The mean survival time was three years from onset of the initial symptoms to death. Patients with concomitant liver cancer were usually dead within six months after onset of the illness. Gender did not substantially affect the course of the disease. The major causes of death were tumour development (63%), gastrointestinal bleeding (40%), haemoperitoneum (28%) and hepatic failure (25%).

Self-reported incidence of accidental exposures to patients' blood and body fluids by resident doctors in Nigeria.

An anonymous survey of 149 resident doctors was conducted to estimate the extent of accidental exposures to blood and body fluids of patients over a one-year period. There was a total of 1142 exposures. Ninety-three percent of respondents reported one or more exposure incident(s). Analysis of events and procedures leading to accidental exposures revealed that recapping needles was involved in 17%, suturing accounted for 14%, setting up intravenous lines 11%, cuts with scalpel 9% and phlebotomy 9%. Surgical residents had a threefold greater risk of exposure compared with medicine residents. No trend was found for accidental exposures by level of residency training. Seventy-four percent of the residents used universal precautions 50% or less of the time. Only half of the doctors could recall formal instruction on correct course of action after exposure and 5% of them had as undergraduates hepatitis B vaccine prior to the commencement of venepuncture duties. All but one of the residents' exposures were not reported to the Staff Medical Services Department. The doctor who reported was neither tested for hepatitis B virus or human immunodeficiency virus nor was he properly treated. Only 5 (4.6%) of the contaminating patients were evaluated serologically for their status of these viruses. These data emphasize the need for increased efforts toward improved early and continuing education, prevention and correct management of accidental exposures to blood or body fluids of patients by resident doctors in Nigeria. No recent study exists that exclusively addresses this problem in doctors in tropical Africa.

Frequency of defaecation and stool consistency in Nigerian students.

To provide a context in which to interpret reports of bowel dysfunction, it is important to know bowel patterns of the general population. We asked 600 apparently healthy students at the Medical School of the University of Ibadan, Nigeria, to complete a questionnaire. Their diet consists mainly of foods derived from tubers and legumes such as yam, cassava and beans. The majority of our students defaecated between three times per day and three times per week. Subjects with one bowel movement per day were in the minority. There were no marked differences in bowel frequencies between sexes or nationalities. Most defaecations occurred in the early morning, in women earlier than in men. There was no relation between bowel frequency and stool consistency. Approximately 20% of subjects took laxatives regularly. More often than not, laxatives were taken for reasons unrelated to bowel habit, indicating the need for a health education programme to warn against self-medication and indiscriminate use of laxatives in the population. Our results are compared to reported findings in surveys of other populations.

A study of irritable bowel syndrome diagnosed by Manning criteria in an African population.

Symptoms of irritable bowel syndrome (IBS) using the Manning Criteria were sought by a questionnaire administered to 400 (male-female ratio 3:1) apparently healthy medical students. With a response rate of 84%, 230 (65.5%) reported more than six episodes of abdominal pain in the preceding year (1992-1993). Contrary to expectation, 100 (43.5%) reported symptoms consistent with the diagnosis of IBS. The one-year period prevalence of the syndrome was 30% overall, with prevalence figures of 24% for males and 48% for females (P < 0.01). There was no difference in the type of diet (mainly high-fiber diets) consumed by subjects with and without IBS. About two thirds of the subjects with IBS had sought medical advice during the study period; the consultation behavior was influenced by factors such as the presence of other symptoms. This is the first detailed evidence in a random sample of an African population showing symptoms consistent with a diagnosis of IBS to be very common. It casts doubt on the assumption generated by other workers that IBS is rare among native Africans.

The geographical distribution of physicians in Oyo State, Nigeria.

The distribution of physicians in the different States of Nigeria is unknown. Recently, data about physicians and their practice location in Oyo State became available. The overall physician:population ratio was 1:7,858, with a ratio of 1:3,877 in Ibadan local government areas and 1:27,439 in other local government areas in the state (z = 9.32, p < 0.001). Similarly, specialists are more likely to locate in Ibadan local government areas. With increasing supply of physicians, this pattern of distribution may possibly persist and widen the differences in the availability of physicians between the Ibadan and other local government areas in the state. Our findings have important implications for policy review by the government to plan the future supply of physician manpower and alleviate physician maldistribution.

Cutaneous manifestations of liver cirrhosis in an African (negroid) population.

Sixty negroid patients with liver cirrhosis were examined for their cutaneous features at the University College Hospital, Ibadan, Nigeria. When compared with age and sex matched controls, the cirrhotic patients had significantly lower body temperature, onycholysis and hyperpigmented palmo-plantar macular areas (p < 0.05). Until now, these features have not been previously associated with liver cirrhosis. Other cutaneous signs such as sparse silky hair, female public hair pattern, digital clubbing, leuconychia, ankle oedema and corneal jaundice are found more commonly in cirrhotic patients (p < 0.05) and have been previously documented. All these features in a middle-aged man with hepatomegaly may be of added distinctive value particularly in many rural centres in tropical countries where facilities for definitive histological diagnosis are frequently lacking. The relevance of some of these cutaneous features in the light of the pattern described in Caucasians is also discussed.

Serum alphafoetoprotein, hepatitis B virus infection and primary hepatocellular carcinoma in Nigerians.

Serum alphafoetoprotein and hepatitis B antigen were estimated by radioimmuno-assay and haemagglutination methods respectively in 42 Nigerian adults comprising 14 subjects in each of three groups, viz, controls, liver cirrhosis and primary hepatocellular carcinoma. At an abnormal concentration of serum alphafoetoprotein greater than 200 micrograms/L, a correct diagnosis of primary liver cancer was made in 64.3% of the patients at a specificity of 100%. However, no correlation was found between serum concentrations of alphafoeto-protein and status of hepatitis B surface antigen in the patients with primary liver cancer. It may be concluded that serum alphafoeto-protein is useful in the diagnosis of primary hepatocellular carcinoma in Nigerians and secretion of the onco-foetal protein by neoplastic hepatocytes is unlikely to be influenced by hepatitis B virus infection.

Clinical feminisation and sex hormone concentrations in Nigerian men with cirrhosis with and without hepatocellular carcinoma.

The study explored the incidence of clinical feminisation and the sex hormone levels of 18 Nigerian patients with liver cirrhosis (LC) alone and 18 patients with LC and hepatocellular carcinoma (HCC). The incidence (11%) of clinical feminisation in Nigerian patients was lower than values reported from other countries and there was no association between feminising signs and the sex hormone levels of the patients. Plasma oestradiol and sex hormone-binding globulin (SHBG) levels were significantly higher and testosterone lower in patients with liver diseases than in 18 age-matched normal controls. Serum concentrations of oestradiol were also found to be significantly higher in patients with LC alone than in those with LC and HCC. A possible promotive role for oestrogens in the development of HCC from the cirrhotic liver is discussed.

Cardiovascular systemic invasion by hepatocellular carcinoma: incidence and pattern in a west African population.

To determine the frequency of cardiovascular systemic invasion by hepatocellular carcinoma (HCC). Eighty-one Nigerian patients who had autopsy examinations were studied. Of these, 36 (44%) had tumour thrombi within the cardiovascular system (CVS) or metastases to the heart itself. Compared with the patients without CVS invasion, no clinicopathologic findings distinguished these two groups from each other. Furthermore, CVS invasion did not worsen the generally bad prognosis of these patients with liver cancer. It is concluded that CVS invasion is frequent and difficult to diagnose by clinical examination. Patients who are selected to undergo hepatic resection must be assessed by imaging techniques to exclude CVS invasion. However, it is unlikely that frequent and routine imaging procedures will affect the generally bad prognosis of the majority of the patients.

Sickness absenteeism among employees of a teaching hospital in Saudi Arabia.

The sickness absence records of workers at the King Khalid University Hospital over a period of two years (1990-1991) were analysed to identify the category of workers at high risks. The records of each staff who went on 'sick-off' are available at the Employee Health Clinic of the hospital. There were 861 workers with sickness absence records during the period of study and 86% are expatriates on contract. The prevalence of sickness absence is higher among contract workers than non-contract workers about 16% and 9% respectively. The sex ratio was 1:2 in favour of females among contract employees but 1.2:1 in the male's favour for the Saudis. The observed sex differential in the rate of sickness absence in each occupational group is statistically significant (P < 0.01). Females have more spells of sickness than males and the duration of sickness absence is significantly higher in females. However, the average spell of sickness which is generally low is not different between contract and non-contract workers although slightly higher in the former. There was no significant occupational effect on the spells and duration of sickness absence. Respiratory infections and diseases of the digestive and musculoskeletal systems are the major diseases causing sickness absence. The implications of these findings are discussed in the paper. But for a good monitoring of sickness absence records, a health record surveillance card for each employee is recommended.

A prospective study of the morbidity pattern of patients seen at a university primary care clinic.

Information on the morbidity pattern of patients seen at a primary care clinic is sparse or not available for most countries in the Middle East including Saudi Arabia. A prospective study of all new patients at the primary care clinic of King Khalid University Hospital (KKUH), Riyadh, Saudi Arabia was therefore carried out over a period of one year (1991G to 1992G). An analysis of the morbidity pattern of 9,441 new patients seen over this period is hereby reported. There is a male prepondence overall and more than 70% of the patients were below 40 years of age. III-defined illnesses, diseases of the skin, genitourinary, digestive, musculoskeletal and respiratory diseases accounted for more than 70% of the patients. About one-third of the patients, mainly those with diseases of the skin and genitourinary systems, were referred for specialist care. It is conceivable that the commonly observed pattern of diseases in this study may change over a period of time either due to the interventions adopted by the primary care clinics or as part of social development or as a cumulative effect of both. The primary physician has to be aware of such a change by periodically analyzing the available morbidity pattern.

Soluble immune complexes and immunoglobulin (IgG, IgA and IgM) levels in Nigerians with primary liver cell carcinoma.

Circulating soluble immune complexes and serum immunoglobulins (G,A and M) levels were determined in patients with primary liver cell carcinoma (PLCC) and healthy subjects by the polyethylene glycol precipitation and single radial immunodiffusion methods respectively. A considerably higher proportion of the patients than the controls had elevated levels of soluble immune complexes, IgG and IgM were significantly higher in the patients than the controls, that of IgA was lower. Correlation studies showed association between serum concentration of IgG, IgA and IgM and the levels of circulating soluble immume complexes. Several factors may influence our findings of elevated concentrations of soluble immune complexes and serum immunoglobulins G and M as well as the positive correlations between these indices. It could be as a result of increased rate of production and release of antigen from the tumour; enhanced interaction of antibody with membrane antigens at the tumour cell surface which promoted release of immune complexes or/and decreased rate of elimination of the complexes from the body of phagocytosis. That antibodies are required for the formation of immune complexes may explain our observation of increased levels of IgG and IgM.