Community-based screening for hepatocellular carcinoma in elderly residents in a hepatitis B- and C-endemic area.

BACKGROUND AND AIM: The aim of the present study was to elucidate a reasonable model and the efficacy of hepatocellular carcinoma (HCC) screening on an elderly population. METHODS: Two-stage HCC screening was conducted in a hepatitis C virus (HCV)-endemic area. First, participants underwent blood tests for hepatitis B surface antigen (HBsAg), anti-HCV antibody, serum α-fetoprotein (AFP), aspartate aminotransferase, alanine aminotransferase, and platelet count. Patients who were abnormal for any of the six markers were enrolled for second-stage ultrasonography. Suspected cases were referred for confirmation. HCC cases were followed for 4 years. All patients were linked to national mortality and cancer register databases to identify newly-developed HCC, 30 months after screening. RESULTS: A total of 461 males and 541 females were screened for HCC, with 15.1% testing positive for HBsAg and 44.3% positive for anti-HCV. Among them, 619 (61.8%) met the criteria of ultrasonographic screening; 527 (85.1%) responded, and 16 confirmed HCC (male/female = 8/8, 68.8±8 years) cases were detected. All tumor diameters were less than 5 cm, and six were less than 2 cm. AFP and thrombocytopenia were two independent predictive factors of HCC. The overall survival rates of detected cases were 93.8% and 56.3% was 1 and 4 years, respectively. The only good prognostic predictor was "underwent curative treatment". Another seven non-HCC residents developed HCC after screening, and five of these were with either thrombocytopenia or AFP elevation. CONCLUSION: Under economical consideration, AFP and platelet count should be feasible screening markers of risk identification. Early detection and prompt treatment results in good prognosis in an aged population.

Acquirement and disappearance of HBsAg and anti-HCV in an aged population: a follow-up study in an endemic township.

BACKGROUND: HBsAg and anti-hepatitis C virus (anti-HCV) are stable markers and widely used. The seroconversion and seroclearance of HBsAg and anti-HCV are important for disease control and prognosis of diseases. AIMS: To investigate acquirement and disappearance of HBsAg and anti-HCV in an endemic area. METHODS: Seven years after a community screening, 1002 of 2909 residents of Tzukuan Township were recruited. HBsAg, anti-HCV and alanine transaminase (ALT) were checked in all who participated and hepatitis B virus (HBV) DNA, anti-HBs, anti-HBc, HCV RNA, anti-HDV and upper abdominal ultrasonography were studied in different groups. RESULTS: There were 461 male and 541 female residents with a mean age of 66.7 ± 8.6 years. No new HBsAg carrier was noted and the HBsAg clearance rate was 1.58% per year. One of the 17 cases with HBsAg clearance had positive HBV DNA, three had ALT elevation, two had cirrhosis and seven had anti-HBs seroconversion. Quantitative of HBsAg and HBV DNA were concordant and 78.1% subjects had low levels of titration. Anti-HBc alone contributed to 32.1% and was prominent in old age and the anti-HCV-positive group. The anti-HCV seroconversion rate was only 0.74% per year and household transmission was the only risk factor. Only 37.5% of cases with anti-HCV seroconversion had HCV viraemia and the anti-HCV seroreversion rate was 0.63% per year. The anti-HDV seroconversion rate was 0.72% per year and no subject showed anti-HDV clearance. CONCLUSIONS: Much higher rates of HBsAg seroclearance, anti-HCV seroreversion and anti-HBc alone were noted in this endemic area and no subject showed anti-HDV clearance.

Changing prevalence of anti-hepatitis A virus in adolescents in a rural township in Taiwan.

BACKGROUND: Hepatitis A virus (HAV) is transmitted through the oral-anal route. Areas of low prevalence of anti-HAV might have risks for a hepatitis A outbreak even under accidental infection as the source can spread easily. The prevalence of anti-HAV among children in Taipei is reported to be nearly 0%; however, the prevalence in rural areas remains undetermined. Our study aims to realize the prevalence change in a rural area. METHODS: We took blood samples for anti-HAV detection from the entire junior high school population in Taihsi Township of Yunlin County in Taiwan. Two cross-sectional studies were conducted in 1999 and 2006, with students born in the years 1984-1985 and 1993-1994 respectively. RESULTS: The prevalence of anti-HAV was 0.96% (2/209) among subjects born between 1984-1985, and 0.6% (1/168) in those born between 1993-1994. The HAV vaccine was not available for at the time of the earlier study, and it is suggested that this figure was caused by natural infection. The only anti- HAV-positive student in the later study had a history of HAV vaccination. CONCLUSIONS: The prevalence of anti-HAV has decreased to a very low level in recent years and is almost 0% in the generation born after 1984 in rural areas. Therefore, the possibility of an HAV outbreak should be noted. Furthermore, it is also necessary to offer correct information and suggestions concerning hepatitis A for tourists traveling abroad and reentering Taiwan.

Chronic hepatitis C increased the mortality rates of patients with hepatocellular carcinoma and diabetes mellitus in a triple hepatitis virus endemic community.

BACKGROUND: To elucidate the factors associated with mortality rates among older subjects with hepatocellular carcinoma (HCC) and diabetes mellitus (DM) in a triple hepatitis B virus (HBV), hepatitis C virus (HCV) and hepatitis delta virus (HDV) endemic community. METHODS: A total of 2,909 residents aged>or=45 years were screened for hepatitis B surface antigen (HBsAg), antibodies to HCV (anti-HCV) and alanine aminotransaminase (ALT) in 1997. Anti-HDV was detected in HBsAg-positive subjects. Those who expired from HCC and DM were identified from official mortality data sets (1997-2003). Survival was analyzed using the Kaplan-Meier survival curve with log-rank test and the Cox proportional hazard model. RESULTS: Forty-one patients died of HCC and 25 of DM during the study period. Multivariate analysis indicated that age>or=65 years (hazard ratio 3.4; 95% confidence interval 1.8-6.4), HBsAg (3.3; 1.7-6.7), anti-HCV (3.8; 1.7-8.5) and ALT>or=40 IU/L (3.7; 1.9-7.0) were independent predictors of HCC mortality, while age>or=65 years (4.8; 2.1-11.0) and anti-HCV (4.2; 1.7-10.6) were two independent predictors of DM mortality. There were synergistic effects of dual viral infections for HCC, but not for DM mortality. CONCLUSIONS: Old age and chronic HCV infection increase the risk of HCC and DM mortality. HBsAg and ALT levels are also risk factors for HCC mortality, but not DM. The synergistic effects of dual hepatitis viral infections are demonstrable and warrant further investigation.

Long-term efficacy of plasma-derived and recombinant hepatitis B vaccines in a rural township of Central Taiwan.

AIMS: To assess the differences of long-term efficacy between plasma-derived and recombinant hepatitis B virus (HBV) vaccines and the effectiveness of catch-up vaccination in adolescents with undetectable anti-HBs. METHODS: Before 1992, infants born in Taiwan were immunized using plasma-derived HB vaccine, and thereafter, by using recombinant HB vaccine. From the only junior middle school of a rural township in central-southern Taiwan, 1788 (93.7%) students from five cross-sectional screenings, grouping into three birth cohorts (Group I: born during 1984-1986, II: 1986-1992 and III: 1992-1995), were enrolled for checking HBsAg, anti-HBs and anti-HBc. Students with undetectable HBsAg and anti-HBs underwent a booster dose (2.5ug) of recombinant HB vaccine (Engerix-B; GlaxoSmithKline, Rixensart, Belgium) and had anti-HBs re-checked 3 weeks later. Individuals who had remained undetectable for anti-HBs completed the other two doses of HB vaccines at 1 and 6 months later. RESULTS: The prevalence of HBsAg (11.4, 5.4 and 1.2%), anti-HBs (64.5, 44.1 and 36.0%) and anti-HBc (29.5, 12.5 and 4.4%) decreased from Group I to III (P<0.001 for trends). After a booster dose, the positive rates of anti-HBs increased up to 80.5% (16% increase) in Group I, 81.0% (36.9% increase) in Group II, and 94.4% (58.4% increase) in Group III. The percentages of anamnestic response increased with a trend (P<0.001). A total of 110 non-responders completed 3 doses of catch-up HB vaccination, but 3 cases (2.7%) of Group II, evoked primary vaccination response. CONCLUSION: Recombinant vaccine showed predominant disappearance rate (62.7%) of anti-HBs 12-15 years after vaccination, but provided better anamnestic response after a booster dose. It also showed high success rate (97.3%) in catch-up vaccination in adolescents.

Changing aetiology of liver dysfunction in the new generation of a hepatitis B and C-endemic area: cross-sectional studies on adolescents born in the first 10 years after universal hepatitis B vaccination.

BACKGROUND/AIM: Geographical variation in viral hepatitis infection complicates various levels of liver diseases. This study elucidates the changing aetiology of alanine transaminase elevation (ALT levels >40 IU/L) in a previously hepatitis-endemic township. DESIGN/METHODS: Five cross-sectional screenings were performed on teenagers born from 1984 to 1993. We examined hepatitis B surface antigen (HBsAg), anti-hepatitis C virus (anti-HCV), ALT and body mass index, and additionally checked hepatitis B envelope antigen (HBeAg) for positive HBsAg and HCV RNA for positive anti-HCV. Teenagers with ALT elevation underwent an ultrasonography examination. RESULTS: This study enrolled 1788 (93.7%) of 1909 students, discovering individual prevalence of HBsAg (6.3%), anti-hepatitis B core (anti-HBc) (15.5%), anti-HCV (2.2%), overweight (22.4%), obesity (12.8%) and ALT >40 IU/L (3.7%). HBsAg and anti-HBc prevalence declined with trends, while obesity increased with trends (P<0.001). Among 66 ALT-elevated teenagers, prevalence percentages of risk factors were HBsAg (22.7%), anti-HCV (1.5%), obesity (45.5%), HBsAg with obesity (7.6%) and anti-HCV with obesity (3.0%). Additionally, obesity showed predominance (85.7%) among aetiologies of teenagers with fatty livers (60.9%). The independently associated factors of ALT elevation included being male (odds ratio, 2.18; 95% confidence interval, 1.21-3.93), HBsAg (4.25; 1.06-17.13), HBeAg (7.24; 1.64-31.9), HCV RNA (29.03; 5.8-145.29) and obesity (16.5; 8.79-30.98). CONCLUSION: In place of viral hepatitis, obesity is becoming the major aetiology of abnormal liver function among the young generation in a previously hepatitis-endemic area.

Identified cases of acute hepatitis C from computerized laboratory database: a hospital-based epidemiological and clinical study.

OBJECTIVE: Diagnosis of acute hepatitis C (AHC) relies on documented positive-seroconversion of antibody to hepatitis C virus (anti-HCV) that is infrequently encountered. To clarify the epidemiology and clinical course of AHC, we tried to find more AHC patients from a computerized laboratory database by using a supplemental criterion of rising anti-HCV titer. METHODS: All the computerized laboratory databases of anti-HCV and alanine aminotransferase (ALT) were reviewed. Candidates for AHC were identified by either anti-HCV positive seroconversion, rise of anti-HCV titer (signal to cut-off ratio (S/CO) ratio < 40 to > or = 40), or spontaneous HCV RNA clearance. AHC cases and their matched chronic hepatitis C controls were interviewed by a case-control study concerning risk factors. RESULTS: AHC was identified in 123 patients (68 men and 55 women; median age: 48.4+/-13.9 years), who had higher rates of recent surgery (p=0.037) and frequent injection therapy (p=0.036) compared to controls. Self-limited AHC was observed in 18 (19.1%, 95% confidence interval: 12.3-25.9%) of 94 AHC patients who had been followed for 6 months, with a higher bilirubin level (> or = 2 vs. < 2, p=0.007) compared to those evolved to chronic infection. CONCLUSIONS: Screening of a laboratory database for anti-HCV and ALT might uncover more AHC candidates to disclose the epidemiology and clinical course of AHC.