Frequency of Occult Hepatitis B Virus (HBV) in Chronic Hepatitis C Patients.

Occult HBV is defined as the presence of HBV DNA in the liver tissue and / or HBV DNA in blood of people with negative HBsAg by currently available assays. The objective of the study was to determine the prevalence of occult HBV in chronic HCV patients. It was a cross-sectional study of one year duration including patients coming to the outpatient department with a positive HCV RNA by PCR from May 2018 to May 2019. Blood samples were taken to test HBsAg. Those cases who were HBsAg negative were checked for HBV DNA using real time PCR. A total of 217 cases were included in the study. Mean age was 41.3 + 14.61 years. All 217 cases of chronic HCV infection, which were positive for HCV RNA by PCR, were found to be negative for both HBsAg and HBV DNA. No occult HBV was detected in cases of chronic HCV infection seeking treatment. Key Words: Occult, Hepatitis B, Chronic hepatitis C.

Comparison of dried blood spots with conventional blood sampling for diagnosis of hepatitis b & c through serological and molecular technique; a pilot study.

OBJECTIVE: To compare the sensitivity and specificity of dried blood spot with conventional blood sampling for serological and molecular testing of hepatitis B and C viruses. METHODS: The case-control study was conducted at the Pakistan Health Research Council Specialised Centre for Gastroenterology and Hepatology, Karachi, from May,2015 to April,2016 and comprised patients who were hepatitis B surface antigen-positive (group 1), anti-hepatitis C virus positive (group 2), hepatitis B virus deoxyribonucleic acid-positive (group 3), and hepatitis C virus ribonucleic acid-positive (group 4). A group of controls had healthy subjects negative for both hepatitis B and C viruses. Blood samples were collected using the conventional as well as the dried blood spot method using finger prick. Relevant tests were run for each subject using both the samples at baseline and after 3 and 6 months of storage. Receiver operative characteristic curve was plotted to determine the ideal cut-off points for dried blood spot testing and corresponding sensitivity and specificity. Data was analysed using SPSS 19. RESULTS: Of the 100 subjects, there were 20(20%) in each of the four patient groups and 20(20%) in the control group. Sensitivity of dried blood spot method was 95.2%, 95%, 80% and 70% for groups 2, 1, 4 and 3 respectively when tested within a week of sampling. Specificity was 100% for all the four groups. There was a significant correlation of the two methods for all the four parameters tested (p<0.01). CONCLUSIONS: Dried blood spot sampling correlated well with the conventional blood sampling method for serological and molecular testing.

Comparison of Rapid Anti-HCV Multi-sure Kit with Gold Standard ELISA.

OBJECTIVE: To compare the diagnostic yield of Multi-sure rapid HCV (hepatitis C virus) kit with ELISA. STUDY DESIGN: Comparative study. PLACE AND DURATION OF STUDY: Pakistan Health Research Council, specialised research center for gastroenterology and hepatology, from August 2016 to January 2017. METHODOLOGY: A modified rapid anti-HCV kit was compared with ELISA. This rapid kit is multi-parameter qualitative immune chromatographic kit for the in-vitro detection of antibodies to HCV in human blood. Patients who came to PHRC, were tested using anti-HCV ELISA, and their test was run simultaneously on multi-sure HCV rapid kit were included in the study. Each positive and negative sample was included in this study. SPSS software was adapted for data analysis. RESULTS: A total of 420 samples were collected. Among them, 255 (61%) were of male and 165 (39%) were of female patients. Mean age was 35 ± 14.33 years. All the samples run for anti-HCV on ELISA were also run on multi-sure rapid kit. It is evident that 22.4% were reactive on ELISA and 23.6% were reactive on rapid kit, while 75.5% were non-reactive on ELISA and 68.1% were non-reactive on rapid kit. Borderline positive results were seen in 2.1% on ELISA and 5.0% on rapid kit. Sensitivity of rapid kit was 87.2%, specificity 89.3% with 82.8% positive predictive value and 98.9% negative predictive value. CONCLUSION: Multi-sure kit showed significantly, less non-reactive and more borderline results as compared to ELISA. Comparison of multi-sure rapid kit with ELISA showed that core antibody can be used as an alternate marker for ELISA. Other non-structural proteins including NS3, NS4 and NS5 were found to be less significant. So, it is concluded that this rapid kit may not be recommended as an alternative of ELISA, except for places where ELISA is not available.

Infection control practices in blood banks of Pakistan.

BACKGROUND: Implementation of infection control standards in blood banks is important to prevent transmission of blood-borne infections such as HIV, hepatitis B and Hepatitis C. No study from Pakistan evaluated the infection control practices in the blood banks of Pakistan. AIMS: This study aimed to evaluate infection control practices with reference to safe blood supply, staff safety and waste disposal practices in blood banks of Karachi, Pakistan. METHODS: This was a cross-sectional study. Infection control practices of all blood banks working in Karachi were determined through a structured questionnaire followed by an educational intervention. Mean scores for overall infection control practices and specific practices regarding safe blood supply, staff safety and waste disposal were calculated and compared with different factors using statistical tools. RESULTS: Patient safety scores of 49 (92.5%) blood banks were within the satisfactory range but staff safety and waste disposal scores of only 26 (49.1%) and 4 (7.5%) blood banks were satisfactory. Significantly lower infection control (IC) scores were observed for stand-alone blood banks and those working in the absence of a haematologist (P-value < 0.001). Availability of written standard operating procedures (SOPs) and IC guidelines correlated positively (P-value < 0.001) with mean IC scores. CONCLUSIONS: Blood banks in Karachi lack implementation of IC standards particularly with reference to staff safety and waste management and disposal. Sindh blood transfusion authority (SBTA) should take measures to increase IC compliance within blood banks.

Report - Colonization rates and immune status of children against Streptococcus pneumoniae before the introduction of pneumococcal conjugate vaccine.

Pneumococcal infections contribute to high morbidity and mortality in Pakistan. Pneumococcal colonization rates and immune status of children before and after vaccination can serve as an important indicator to determine the success of immunization program. Aim of this study was to determine the pneumococcal colonization rate and immune status of children (<3-years) before the introduction of Pneumococcal immunization in EPI program. A cross sectional study of 3-months duration was conducted in collaboration with EPI Centre of NICH, Karachi. A total of 192 healthy children aged 3-months to 3-years were included in the study. Children with chronic or recurrent pulmonary disease were excluded. Demographic data and presence of any risks for pneumococcal colonization or immunity was recorded. Nasopharyngeal swabs were collected to determine the presence of S. pneumoniae and sensitivity pattern of the isolates. Blood samples were collected to determine immune status of these children. Sixty (31%) children were found to carry S. pneumoniae in their nasopharynx. Resistance to cotrimoxazole, erythromycin, chloramphenicol, penicillin and vancomycin was 100%, 30%, 25%, 22% and 0% respectively. Mean anti-PCP titre of children was 23.3mg/L. Mean anti-PCP titre in children who had previously suffered from RTI was significantly increased (p-value 0.039). This study may serve as baseline report for evaluating the success of pneumococcal immunization in future. A significant drop in nasopharyngeal colonization rates post vaccination would depict the success of pneumococcal immunization.

Use of the Health Belief Model for the Assessment of Public Knowledge and Household Preventive Practices in Karachi, Pakistan, a Dengue-Endemic City.

BACKGROUND: Prevention is most effective in reducing dengue infection risk, especially in endemic countries like Pakistan. Evaluation of public awareness and health beliefs regarding dengue fever (DF) is important for devising disease control strategies. This study assessed dengue knowledge, health beliefs, and preventive practices against DF in different socioeconomic groups of Karachi, Pakistan. METHODOLOGY: In this community-based cross-sectional study, 6 randomly selected towns were visited, 2 persons (man and woman) per household were interviewed using a structured questionnaire, and household practices were observed. Information regarding DF was shared through a printed pamphlet. Multivariate logistic regression analysis of variables associated with dengue knowledge and practices was conducted. PRINCIPAL FINDINGS: We interviewed 608 Karachi residents (mean age: 33.2 ± 13.35 years); 7.7%, 71.9%, and 20.4% had a high, middle, and low socioeconomic status, respectively. The mean knowledge score was 6.4 ± 2.10 out of 14. The mean preventive practices score was 9 ± 1.8 out of 17. Predictors of dengue knowledge were perceived threat (odds ratio [OR] = 1.802; 95% confidence interval [CI] = 1.19-2.71; p = 0.005), self-efficacy (OR = 2.910; 95% CI = 1.77-4.76; p = 0.000), and television as an information source (OR = 3.202; 95% CI = 1.97-5.17; p = 0.000). Predictors of dengue preventive practices were perceived threat (OR = 1.502; 95% CI = 1.02-2.19; p = 0.036), self-efficacy (OR = 1.982; 95% CI = 1.34-2.91; p = 0.000), and dengue knowledge (OR = 1.581; 95% CI = 1.05-2.37; p = 0.028). CONCLUSIONS: Public knowledge about DF is low in Karachi. Knowledge, threat perception, and self-efficacy are significant predictors of adequate dengue preventive practices. Prevention and control strategies should focus on raising awareness about dengue contraction risk and severity through television. Health messages should be designed to increase individual self-efficacy.

Sociodemographic factors associated with IgG and IgM seroprevalence for human cytomegalovirus infection in adult populations of Pakistan: a seroprevalence survey.

BACKGROUND: The seroprevalence of human cytomegalovirus (HCMV) infection ranges from 30 to 90 % in developed countries. Reliable estimates of HCMV seroprevalence are not available for Pakistan. This study determined the seroprevalence and sociodemographic factors associated with HCMV infection in adult populations of Karachi, Pakistan. METHODS: A seroprevalence survey was conducted on 1000 adults, including residents of two semi-urban communities, and visitors to a government and a private hospital. Questionnaire-based interviews were conducted. Sera were analysed for HCMV-specific IgG and IgM. Chi-square or Fisher's exact test was used for comparing sociodemographic variables against seropositivity of HCMV-IgG or IgM. Multiple logistic regression modeling was performed for IgG seroprevalence and adjusted odds ratios were computed. RESULTS: The seroprevalence of HCMV-IgG and IgM was 93.2 and 4.3 % respectively. 95.3 % of individuals who were IgM seropositive were also seropositive for IgG. Around 6 % (15/250) of women of childbearing age remained uninfected and were therefore susceptible to primary infection. HCMV-IgG seroprevalence was associated with being female (p = 0.001), increasing age (p = 0.002) and crowding index (p = 0.003) and also with lower levels of both education (p < 0.001) and income (p = 0.008). Seroprevalence also differed significantly by marital status (p = 0.008) and sampling location (p < 0.001). A logistic regression model for HCMV-IgG seroprevalence showed associations with being female (OR = 1.89; 95 % CI: 1.10-3.25), increasing age (OR = 3.95; 95 % CI: 1.79-8.71) and decreasing income (OR = 0.72; 95 % CI: 0.54-0.96). A strong association was observed between increased seroprevalence of HCMV-IgM and decreasing household size (p = 0.008). CONCLUSIONS: Seroprevalence of HCMV is very high in Pakistan, although 6 % of women of childbearing age remain at risk of primary infection. The IgM seropositivity observed in some individuals living in small household size (1-3 individuals) with persistent HCMV infection could have resulted from a recurrent HCMV infection. Future longitudinal research in pregnant women and neonates is required to study the trends in HCMV seroprevalence over time in Pakistan for the development of a potential HCMV prevention and vaccination programme.

Emerging trends of antimicrobial resistance in Helicobacter pylori isolates obtained from Pakistani patients: The need for consideration of amoxicillin and clarithromycin.

OBJECTIVE: To present antimicrobial susceptibility profile of helicobacter pylori isolated from gastric biopsies of dyspeptic patients. METHODS: The cross-sectional study was conducted from March 2008 to May 2013 at the Jinnah Postgraduate Medical Centre (JPMC), Karachi, and comprised patients with suspected peptic ulcer disease who underwent upper gastrointestinal endoscopy. Multiple gastric antral biopsies were taken. One sample was imbedded in the Campylobacter-like organism test, while other biopsies were processed for culture and confirmed on polymerase chain reaction. Isolates were subjected to antimicrobial susceptibility testing and minimum inhibitory concentrations of antimicrobial agents were estimated by Epsilometer test. SPSS 21 was used for statistical analysis. RESULTS: Of the 889 samples available, 254(28.6%) were positive after campylo-like organism test, of them, 92(36.2%) isolates were cultured. Susceptibility test showed 90(97.8%) resistance to metronidazole, 25(30.1%) ofloxacin, 6(16.2%) levofloxacin, 14(15.2%) furazolidone, 5(5.4%) clarithromycin, 4(4.3%) tetracycline and 2(2.2%) isolates showed resistance to amoxicillin. Resistance to more than one drug was observed in 37(40.2%) isolates. CONCLUSIONS: Low clarithromycin resistance was surprising since Pakistan is considered a hot bed of drug-resistant bacteria.

Is chlorhexidine-gluconate superior than Povidone-Iodine in preventing surgical site infections? A multicenter study.

OBJECTIVE: To compare the efficacy of povidone-iodine and chlorhexidine gluconate scrubs in preventing surgical site infections. METHODS: The randomised controlled clinical trial was conducted from May 2012 to April 2013 in two public-sector hospitals of Pakistan; one each in Karachi and Islamabad. Patients undergoing clean or clean contaminated surgeries were included and were randomly assigned to one of the two groups: group I comprised patients whose skin was preoperatively disinfected using 10% povidone-iodine, and in group II by 2% chlorhexidine gluconate in 70% alcohol. A predesigned proforma was filled for all patients to record demographic data, diagnosis, surgical procedure and antibiotic used. Patients in both groups were followed up for one month postoperatively to monitor any signs of surgical site infections. SPSS 16 was used for statistical analysis. RESULTS: Of the 388 patients from the two hospitals, 220(57%) were in group I and 168(43%) were in group II. Surgical site infection was observed in 22(10%) cases in group I and 12(7.1%) in group II (p=0.324). Pseudomonas aeruginosa (23.5%) was the predominant pathogen associated with surgical site infections followed by Staphylococcus aureus (17.6%). CONCLUSIONS: Chlorhexidine gluconate was associated with lower infection rates compared to povidone-iodine; but it was not statistically significant.

Clinical, laboratory and bacterial profile of Spontaneous Bacterial Peritonitis in Chronic Liver Disease patients.

OBJECTIVE: To determine the clinical and laboratory features, bacterial profile and antibiotic sensitivity pattern of Spontaneous Bacterial Peritonitis (SBP) in Chronic Liver Disease (CLD) patients presenting at a tertiary care hospital of Karachi. STUDY DESIGN: Cross-sectional study. PLACE AND DURATION OF STUDY: PMRC Centre for Gastroenterology and Hepatology and Jinnah Postgraduate Medical Centre, Karachi, from April 2010 to March 2012. METHODOLOGY: CLD patients with ascites were recruited from PMRC Centre for Gastroenterology and Hepatology and Jinnah Postgraduate Medical Centre, Karachi. Basic demographics, symptoms and clinical signs of patients were recorded. Patients with the history of antibiotic use within last 3 days or any intra-abdominal source of infection were excluded. Diagnostic paracentesis was done for ascitic fluid detailed report (D/R) and culture. Blood sample was collected for total leukocyte count, serum proteins and billirubin levels. RESULTS: Out of a total 152 CLD patients, 38 (25%) were diagnosed with SBP. Eight (24.2%) patients presented with classical SBP, 20 (52.6%) had culture negative neutrocytic ascites and 10 (26%) had bacterascites. Fever, abdominal tenderness and constipation were common in SBP patients. Ascitic fluid culture was positive in 19 (50%) patients. E. coli (65%) was the predominant pathogen followed by Enterococcus species (15%). Resistance was high against cephalosporins (78%) and fluoroquinolones (69.6%) and least against amikacin (13%) and meropenem (12%). CONCLUSION: Ascitic fluid D/R and culture together can lead to the accurate diagnosis of SBP and can guide for the right antibiotic choice as resistance to commonly prescribed antibiotic is common in such patients.

Innovative solution to sharp waste management in a tertiary care hospital in Karachi, Pakistan.

BACKGROUND: Prevalence of hepatitis B and C in Pakistan is 2.5% and 4.5%, respectively. Major cause of these infections is reuse of syringes. OBJECTIVE: To determine a cost-effective, innovative solution to prevent syringe reuse and break the transmission cycle of blood-borne infections. STUDY DESIGN, SETTINGS, AND DURATION: Analytical study in a tertiary care hospital, Jinnah Postgraduate Medical Centre, Karachi, Pakistan, July 2011 to June 2012. METHODS: Healthcare workers from 30 wards included in the study were trained on injection safety, use of needle remover and needle pit, and management of needlestick injuries. Each ward was provided with 2 needle-removing devices, and a pit was constructed for disposal of needles. Usage of the device in wards and pit use were monitored regularly. RESULTS: In 28 (93.3%) wards, sharp containers were accessible by public and were slack. Syringes were recapped using both hands in 27 (90%) cases; needlestick injury was reported by 30% of paramedics, while 25 (83.3%) of the interviewed staff had not received any formal training in injection safety. Vigilant monitoring and information sharing led to healthcare workers in 28 (96.5%) wards using the device. Needle containers were emptied in 27 (93.1%) wards, and needle pits were used in 26 (96.3%) wards. Needlestick injury was nil in follow-up. CONCLUSIONS: Needle removers permanently disable syringes. The needle pit served as a cost-effective, innovative method for disposal of needles. The intervention resulted in reducing the risk of needlestick injury.

Treatment of hepatitis B and C through national programme--an audit.

OBJECTIVES: To evaluate the response to treatment given on a large scale for hepatitis B and C through a nationwide programme. METHODS: Records of patients who received treatment of hepatitis B and C during past 2 years through the Prime Minister's programme for the Prevention and Control of Hepatitis Viral Infection was retrieved randomly from 12 sites after taking consent from the management and the site managers. Data confidentiality was ensured. All data was photocopied and brought to the Pakistan Medical Research Centre at the Jinnah Postgraduate Medical Centre, Karachi, where it was entered and analysed. The inclusion/exclusion criteria and the followup tests that were to be done before, during and after treatment were taken from the National programme manager so that actual data could be matched with the guidelines. Data was analysed through a specially developed programme. RESULTS: A total of 7752 patients received treatment at the 12 sites for hepatitis C. Adherence to inclusion/exclusion criteria or protocol was followed in 7572 (97.6%) patients. Out of 7572 patients, 3440 (45.4%) completed 6 months of interferon therapy, but the polymerase chain reaction test at the end of 6 months was available in 1686 (49%) cases. It was not detected at 6 months in 1133/1686 (67%) cases, while in 553 (33%) cases there was no response. Data for hepatitis B was collected from 8 sites. A total of 454 cases received treatment and 85 (18.72%) fulfilled the inclusion criteria. Treatment was completed by 9 (10.58%) cases, with 3 (3.52%) cases showing Hepatitis B 'e' antigen clearance and anti-HBe (antibody to hepatitis B 'e' antigen) production. CONCLUSION: Poor followup and inadequate documentation of serological/biochemical tests were the major drawbacks in both hepatitis B and C patients, resulting in wastage of huge human and financial resources without proper planning and accountability.

Active disease in chronic hepatitis C patients with normal alanine aminotransferase.

OBJECTIVE: To quantify liver damage using Metavir score, in chronic hepatitis C patients having normal alanine aminotransferase (ALT) to determine active disease requiring treatment. STUDY DESIGN: An analytical study. PLACE AND DURATION OF STUDY: Pakistan Medical Research Centre, JPMC, Karachi, from January 2007 - December 2010. METHODOLOGY: Patients suffering from hepatitis C with positive PCR, having persistently normal ALT on 3 separate occasions over a 6 months period and also having normal platelets and albumin were included in the study. After written consent, all patients underwent a liver biopsy and the degree of damage was assessed using Metavir scoring system. RESULTS: A total of 99 patients suffering from chronic HCV were included in the study. A majority of the patients (55.6%) were females. Using Metavir score, minimal fibrosis of ² 1 was seen in majority (78.8%) of the patients. Only 21.2% patients had fibrosis score ³ 2, with 16 (47.1%) of these also having inflammatory score ³ 2 (p < 0.001). The age of patients (mean 38.1 ± 10.2 years) had a significant association with the severity of liver damage (p < 0.001) as compared to younger age group (mean 33.1 + 9.8 years). CONCLUSION: A large proportion of patients with normal ALT have insignificant fibrosis indicating non active disease and thus questions the blanket use of interferon in all HCV RNA cases. It is strongly recommended that a liver biopsy should be done in all cases with normal ALT before deciding antiviral therapy.

Response to different conventional interferons in treatment of chronic hepatitis C.

BACKGROUND: Sustained virological response to interferon therapy is a great challenge for patients of chronic Hepatitis C. Over 20 brands of interferons are available in the local market with each claiming over 80% response and a wide variation in the cost thus creating confusion for treating physicians as to which drug should be selected. METHODS: Chronic Hepatitis C patients attending outpatients department of Pakistan Medical Research Centre JPMC from January 1998-December 2010 were evaluated. Complete blood count, liver function tests, serum proteins, HCV-RNA were done in all cases before starting therapy. Side effects were also noted. RESULTS: Total of 851 cases received interferon 3 MIU three times a week for 6 months. There were 638 (75%) males and 213 (25%) females, mean age was 36.1 +/- 10.4 years. All were HCV-RNA positive prior to treatment, at the end of 6 months 666 (78.3%) became negative while 185 (21.7%) were non-responders with positive HCV RNA. End of treatment response (ETR) showed 84.7% with Bioferon (Argentina), 83.8% Hebron (Cuba), 82.2% INF (Argentina), 82.1% Ceron (China), 81% Viteron (Korea), 80.7% Leveron (Argentina), 81.5% Hepaferon, 79.1% Anferon (China), 77.4% Intron (Belgium), 75% Green alpha (Korea), 74% Roferon (Switzerland), 67.3% Uniferon (Lithuania), and 68.4% with others. Post-treatment 211 cases were lost to follow-up. In remaining 358/640 (55.9%) negative for HCV-RNA, at six months follow up, whereas 98 (15.3%) relapsed. Sustained virological response (SVR) Ceron 68.2%, Hebron 66.3%, Bioferon 65.2%, Leveron 60.5%, Intron 60.3%, Viteron 57%, Anferon 53.3%, Green alpha, Roferon, Hepaferon, and others 50%, INF 48.5% and Uniferon 41.9%. Average cost of these interferons was Rs. 6,000/month, except Hepaferon 5,000/month, Roferon 10,600/month. CONCLUSIONS: ETR ranged from 74-84.7% and SVR 41.9% to 68.2% and > 60% SVR was observed with Ceron, Hebron, Bioferon, Leveron, Intron and were cost effective.

Changing trend of viral hepatitis--"A twenty one year report from Pakistan Medical Research Council Research Centre, Jinnah Postgraduate Medical Centre, Karachi".

OBJECTIVE: To determine the frequency and pattern of Hepatitis B and C over the past twenty one years, in a liver research unit of Karachi. METHODS: Retrospective analysis of the records of PMRC, Research Centre, Jinnah Postgraduate Medical Centre, Karachi, from 1987 to 2007 were reviewed. A special flow sheet was made where information of all patients with viral liver disease was entered. Patients having complete information of viral markers were included in the analysis. Cases with HBsAg, Anti HBc IgM positive and raised ALT were considered as acute Hepatitis B. HBs Ag/Anti HBc IgG positive were considered as chronic Hepatitis B. Delta antibody positive with or without HBsAg were considered as Delta Hepatitis. Anti HCV positive and raised ALT more than ten times for less than 6 months were considered as acute Hepatitis C, whereas Anti HCV and HCV-RNA positive with or without raised ALT for more than six months were considered as chronic Hepatitis C. Anti HEV IgM and Anti HAV IgM positive were considered as acute Hepatitis E and A respectively. RESULTS: A total of 5193 cases fulfilling all criteria of viral hepatitis were seen in the past 21 years. Of the total 3247 (62.5%) were males and 1946 (37.5%) females giving a male to female ratio of 1.7 : 1. Hepatitis C was the most common infection seen in 2896 cases (55.8%), followed by Hepatitis B in 1691 cases (32.6%). Seventy five percent cases of Hepatitis B were males and 25% females while 55% Hepatitis C cases were males and 45% females. Hepatitis B was seen a decade earlier in different age groups than hepatitis C. Overall, out of the total 5193 cases, 2294 (44.2%) were of chronic hepatitis, 1430 (27.5%) cirrhosis, 1083 (20.8%) carriers and 346 (6.7%) had acute hepatitis (hepatitis B; 214 (61.8%), hepatitis C; 21 (6.0%). While hepatitis B and hepatitis C both were present in 3 (1.3%). Hepatitis E was 70 (20.2%), hepatitis A 12 (3.5%) and all markers were negative in 26 (7.5%) cases). Forty cases (0.8%) were of Hepatocellular carcinoma. Year wise analysis of proportion of hepatitis B and C showed gradual decline of Hepatitis B and rise of Hepatitis C with a transition period between 1995 and 1996. CONCLUSIONS: Hepatitis C is the most common viral hepatitis, followed by hepatitis B, both are more common in males. Hepatitis B is seen a decade earlier than hepatitis C. Rising trend of hepatitis C and declining evidence of hepatitis B could be due to increased awareness and detection of hepatitis C and effective vaccination for hepatitis B in the country.

Determination of risk factors for hepatitis B and C in male patients suffering from chronic hepatitis.

BACKGROUND: Hepatitis B and C is common in Pakistan and various risk factors are attributable to its spread.One thousand and fifty consecutive male cases suffering from chronic liver disease (327 HBV and 723 HCV) were selected from the OPD of public sector hospital and a private clinic dealing exclusively with the liver patients. To compare the results 723 age and gender matched controls were selected from the blood transfusion services of the public sector hospital. A standard questionnaire was filled for all patients and controls which included the information on possible risk factors. FINDINGS: Family history of liver disease was significantly higher (43% and 34%) in HBV and HCV positive cases as compared to 5% in controls [odds ratio 15.6; 95% Confidence Interval CI: 10.1 - 24.1, 10.9; 95% Confidence Interval CI: 7.3 - 16.4] and same trend was seen for death due to liver disease in the family. Majority 74% hepatitis B positive cases had their shaves done at communal barbers but this practice was equally prevalent amongst controls (68%), thus negating it as a possible risk factor, but there is a significant risk with p < 0.05 associated with HCV in male that get their shave in barber. Very strong association of the disease was found with history of dental treatment (38% HCV 36% HBV and 21% controls) [Odd ratio 2.3; 95% CI: 1.8-3.0, Odd ratio 2.1; 95% CI: 1.5-2.8], surgery (23% HCV cases,14% HBV cases and 12% controls), history of blood transfusion was significantly higher in HCV (6%) as compared to controls (2.1%) [Odd ratio 2.9; 95% CI: 1.5-5.5]. History of taking injections for various ailments by the general practitioners (over 90% patients in both hepatitis B and C cases) was significantly higher as compared to 75% in controls [Odds ratio 3.8, 6.9; 95% CI: 2.4-6.1, 4.5-10.4] but hospitalization was not significant in HBV and HCV cases. CONCLUSION: Injections, surgery and dental treatment appear as major risk factors for the transmission of hepatitis B and C in the community. Massive health care awareness drives need to be done for both health care providers and the public to reduce this menace.

YMDD mutation in Pakistani patients. The comparison of Eastern response with the Western response.

Lamivudine exhibits potent antiviral activity in chronic hepatitis B. YMDD mutations in west is around 32% (5 years) but reports from East are scarce. To evaluate frequency of lamivudine resistance and compare the results with the West, a total of 100 chronic hepatitis B patients were given Lamivudine 100 mg before breakfast. Out of 81 patients (19 no follow up), (85%) males and (15%) females. Wild type were 69 (85%) and 12 (14.8%) pre-core mutants. At 1 year 25/69 wild type (36.2%) lost their HBeAg and 18 (26%) seroconverted. At 2 years 30 (43.4%) became HBeAg negative and 22(31.8%) had positive anti-HBe. At 3 years 33 (47.8%) became HBeAg negative and 25 (36.2%) sero-converted. Of 12 precore mutants 8 (66.6%) lost HBV DNA within 24 weeks of therapy. At 36 months 44.4% showed sero-conversion with a YMDD mutation rate of 6% which is in contrast to 32% reported from the West.

HCV exposure in spouses of the index cases.

OBJECTIVE: To study the exposure of HCV in the spouses of patients suffering from chronic hepatitis C virus infection attending the outpatients department of medical research center running a liver clinic. METHODS: Index patients were defined as patients suffering from hepatitis C related chronic liver disease. HCV infection was confirmed by a 3rd generation kit, chronic liver disease by raised alanine amino transferase for over 6 months. PCR was done in a selected group who could afford the test. Serum albumin, endoscopic confirmation of varices and ultrasonography were done to evaluate any evidence of decompensation. Spouses were checked for anti HCV and ALT, those found positive were considered as exposed. Those with negative HCV were defined as not exposed. RESULTS: A total of 153 index cases, 127 chronic liver disease compensated liver disease and 26 with cirrhosis (signs of decompensation) and their spouses entered the study, of whom 58 spouses were anti HCV positive (38%). Of 153 patients with chronic HCV infection, 127 patients had raised ALT and fulfilled the criteria of chronic liver disease (CLD). One hundred and three of 127 (81%) cases were PCR positive and 69 (67%) were candidates on interferon therapy. Of 26 cirrhotics 7 were PCR positive with advanced, disease. Out of 127 patients with CLD, 50 spouses were HCV positive, 21 of whom had raised ALT. Sixteen spouses (76%) were PCR positive. Spouses of 8 cirrhotic patients were found to be PCR positive. CONCLUSION: An overall HCV positivity of 38% in the spouses of index cases with 42% showing raised ALT indicates a high disease transmission. With a 5% exposure of the virus in general population, reasons for this high intra-spousal transmission needs to studied further.

Role of interferon anti body in predicting the response to interferon therapy in HCV patients.

OBJECTIVE: To see the frequency of formation of interferon antibodies in patients receiving alpha interferon and evaluate their role in treatment response. METHODS: Patients with chronic Hepatitis C receiving alpha interferon three times a week along with daily ribavarin in two gastroeneterolgy departments of public hospitals, running hepatology clinics were studied. Blood for interferon antibodies in most (71) cases was collected around 5th month of therapy, sera were stored and analyzed in batches. Sera of 134 patients was analyzed, of whom 44 were taking Interferon 2a and 90 were taking 2b. RESULTS: Of 134 cases, 17 showed the presence of antibodies in titers of over 50 units and 5 of these showed no response to interferon treatment (6%). Majority (78) of the cases had antibody levels of less than 20 followed by 39 cases whose levels ranged between 20-50 units. CONCLUSIONS: Interferon antibodies are formed in a small percentage of cases receiving interferon and that too are in such low titers that they are not hampering the treatment. Serial antibody levels may be done to see if they remain stationary or increase with the continuation of the therapy.

Esophageal motility disorders in diabetics with and without neuropathy.

OBJECTIVE: To detect the presence of esophageal motor disorders in diabetic patients, and to establish whether there is any difference between patients with and without neuropathy. METHODS: Fifty-six diabetic patients admitted at Department of Medicine at Ziauddin Medical University Hospital, Karachi were selected to observe if manometeric findings were different in diabetic patients with and without diabetic neuropathy. RESULTS: Poor glycemic control was observed amongst patients with diabetic neuropathy as compared to those without neuropathy. Double peaked peristalsis and failure of peristalsis was more common in patients with diabetic neuropathy as compared to those without neuropathy. High amplitude and broader wave peristalsis and hypertensive lower esophageal sphincter was found in patients without neuropathy. Aperistalsis and multiple peaked waves were equally prevalent in patients with and without neuropathy. CONCLUSION: Poor glycemic control was found in patients with diabetic neuropathy, double peaked and failed peristalsis was the most common manometric abnormality among them.