Chronic diarrhoea: a prospective study in Thai patients at Chulalongkorn University Hospital, Bangkok

Fifty-five Thai patients with chronic diarrhoea were prospectively studied to find out the underlying causes. The aetiology was identified in 38.2%, uncertain in 29.1%, and unknown in 32.7% of the patients. In the group with a definitive aetiologic diagnosis, parasitic and infective causes were commoner than non-infective causes. Amoebiasis and giardiasis were more frequent than expected, such that empirical therapeutic trial with an antiprotozoal may be justified if initial routine investigations fail to uncover the cause of the diarrhoea. No significant clinical features were noted between the infective and the non-infective groups. Overall, repeated stool microscopy using the concentration technique was the most useful single investigation in approaching the chronic diarrhoea problem.     

Current prevalence of hepatitis B,A and C in a healthy Spanish population. A seroepidemiological study

Summary A seroepidemiological study was carried out in order to determine the prevalence of markers of viral hepatitis infection in employees of five health-care companies and their cohabiting family members. Each participating family unit was required to fill out a questionnaire, in which, among other data, the employee was requested to indicate his or her job category. Markers of hepatitis B infection (anti-HBs, anti-HBc or HBsAg) were observed in 11.7% (58/497) of all subjects. When employees and family members were analysed according to the employee's job category, significant differences were found between staff (3%) and administrative personnel (13.3%; p<0.01) or factory workers (16.9%; p<0.01). Of 489 individuals tested for the presence of anti-HAV and anti- HCV, 59.1% and 0.6% respectively, were positive. There was a correlation between the prevalence of anti-HAV and age; a large proportion of the subjects under the age of 30 years had no evidence of prior HAV infection.

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Prävalenz der Hepatitis B, A und C in einer gesunden spanischen Bevölkerungsgruppe. Aktuelle seroepidemiologische Studie

Zusammenfassung Um die Prävalenz von Virus-Hepatitis-Markern zu ermitteln, wurde eine seroepidemiologische Studie durchgeführt, in die Beschäftigte von fünf pharmazeutischen Firmen und Familienmitglieder der Wohngemeinschaft aufgenommen wurden. Fragebogen, die alle teilnehmenden Familien auszufüllen hatten, enthielten unter anderem Daten zur Berufsbezeichnung. 58 von 497 untersuchten Seren (11,7%) wiesen Marker einer Hepatitis B Virus-Infektion auf (anti-HBs, anti-HBc oder HBsAg). Nach Berufskategorie aufgeschlüsselt, fanden sich zwischen Beschäftigten und Familienmitgliedern signifikante Unterschiede: Personen, die zum Staff gehörten, waren in 3% der Fälle positiv, Verwaltungspersonal in 13,3% (p<0,01), Fabrikarbeiter in 16,9% (p<0,01). Von den 489 auf anti- HAV getesteten Personen waren 59,1 % positiv, anti-HCV-Antikörper wiesen in derselben Gruppe 0,6% der Getesteten auf. Die Prävalenz von anti-HAV zeigte eine Altersabhängigkeit; ein großer Anteil der unter 30jährigen hatte keine Marker für eine durchgemachte HAV-Infektion.

     

Natural fluctuations of hepatitis C viral load in a homogeneous patient population: a prospective study

The aim of this study was to determine the variation in hepatitis C viral load over an extended period of patient follow up. Serum samples were collected from 49 female individuals who were identified as having been infected from the same source of hepatitis C-contaminated anti-D immunoglobulin during the period from 1977 (May) to 1978 (November). All patients attended the hepatitis C clinic at Cork University Hospital, Cork, Ireland. The study group was homogeneous with respect to gender, hepatitis C virus (HCV) genotype (1b), and duration of infection. None of the patients had received antiviral therapy at the time of completion of study. Viral load quantifications were assessed using the Roche Monitor (F. Hoffmann-La Roche, Ltd., Basel, Switzerland) assay. The mean age of the study group at time of infection was 30.3 years (SD +/- 6.1) with a range from 18.5 to 43 years. The mean time of follow-up was 4. 1 years (SD +/- 1.0) with a range from 1.2 to 5 years. The mean rate of change of viral load per year was 0.23 log(10) viral copies per mL serum for the study group (SD +/- 0.19) with a range of -0.18 to 0.78 that was significantly different from zero, P < 10(-10). The rate of change of viral load per year was negatively correlated with viral load at first determination, r = -.35, P =.01. Age at infection did not correlate with the slope of change of viral load, P =.10. In conclusion, most women infected with HCV 1b will have an increase in viral load over time but a few patients who acquire infection early in adult life will show a decrease in viral load.     

Survival in patients with HIV infection and viral hepatitis B or C: a cohort study

AIM: To assess survival in patients with HIV and viral hepatitis co-infection. METHODS: A prospective university clinic cohort of 472 patients with HIV infection who were followed for 8343 patient-months. The outcome measures were the survival from HIV or liver disease assessed by the Kaplan-Meier method. Multivariable analysis using a Cox regression model identified variables associated with mortality. RESULTS: Patients were divided into four subgroups: HIV/hepatitis B virus (HBV) (n = 72), HIV/hepatitis C virus (HCV) (n = 256), multiple hepatitides (n = 18) and HIV alone (n = 126). One hundred and thirty-four patients (28.4%) died during follow-up. Liver mortality was noted in 55 patients, representing 12% of the cohort and 41% of the total mortality. Survival curves were similar in patients with HIV alone and those with any viral hepatitis co-infection. Liver deaths were more common in patients with multiple hepatitides (28%) HIV/HBV (15%), HIV/HCV co-infection (13%) versus HIV alone (6%). Liver mortality was comparable in HIV/HBV as in HIV/HCV co-infected patients and was not associated with gender, ethnicity, age, or mode of infection. HIV deaths were similar in patients co-infected with viral hepatitis compared with those with HIV alone. In patients with viral hepatitis co-infection, initial CD4 cell count > 200 x 10(6) cells/l and use of highly active antiretroviral therapy (HAART) were associated with significantly reduced liver mortality. CONCLUSIONS: Patients with HIV and viral hepatitis had greater liver mortality than patients with HIV alone, but had comparable HIV mortality. Co-infection with hepatitis B is associated with hepatic outcomes similar to hepatitis C. Control of immunosuppression with HAART and CD4 counts > 200 x 10(6) cells/l are associated with better hepatic outcomes and should be the first priority in patients with HIV and viral hepatitis.     

A multicenter study of viral hepatitis in a United States hemophilic population

Hemophilia A and B patients seen at nine US regional treatment centers were tested for serologic markers of hepatitis B virus (HBV), hepatitis C virus (HCV), and hepatitis delta virus (HDV) during 1987 and 1988. Because human immunodeficiency virus (HIV) infection, a potentially confounding variable, was present in 53% of the group, the population was divided by HIV status for analysis purposes. In the HIV-positive group (N = 382), less than 1% had not been infected with HBV, HCV, or HDV, whereas 75% had evidence of infection with HBV and 98% with HCV. HBsAg, a marker of active HBV infection, was present in 12% of subjects; 96% of these were HCV positive. Anti-HDV was detected in 35 subjects (9.1%); all were anti-HBc positive. Ten of the 35 (29%) also were positive for IgM anti-HDV, indicating current infection. All 10 were HBsAg positive and 7 of the 9 tested were HDV RNA positive. Severe/moderate hemophilia B patients were more likely to have experienced an HBV infection and to be anti-HDV positive than were similar hemophilia A patients (22% v 8%, P < .05). In the HIV-negative group (N = 345), the subjects were younger and had less severe hemophilia than the HIV-positive patients. No evidence of HBV, HCV, or HDV infection was found in 18%, whereas 33% had experienced HBV infection and 79% were anti-HCV positive. Within this group, 4% were HBsAg positive. All 13 subjects with anti-HDV (4% of the HIV-negative group) also possessed anti-HBc. One (7.7%) was IgM anti-HDV positive and the serum from another contained HDV RNA. Both of these individuals were HBsAg positive. As in the HIV-positive group, severe/moderate hemophilia B patients were more likely to be HBV and HDV positive than were hemophilia A patients (9% v 3%, P < .05). A prevalence study of viral hepatitis in a large US hemophilic population showed that active infection with HCV is common, occurring in 89% of all study patients regardless of HIV status. Evidence of active HBV infection was found in 8%; 19% of these were actively infected with HDV. HDV was more common in hemophilia B patients after controlling for disease severity.     

HLA-A, B, C and DR antigens in chronic hepatitis B viral infection

To study the role of genetic factors in hepatitis B virus (HBV)-related liver diseases, HLA typing with 47 specificities of HLA-A, B, C and DR loci using Terasaki's 2-stage microlymphocytotoxicity method was performed in 253 normal subjects and 305 patients with various HBV-related liver diseases, including 95 healthy carries of HBV, 30 with chronic persistent hepatitis (CPH), 74 with chronic active hepatitis (CAH), 51 with liver cirrhosis and 55 with hepatocellular carcinoma (HCC). The frequency of HLA-B17 was significantly higher in patients with HCC than in healthy carriers (27.3% vs 4.2%, Pc less than 0.01). A similar situation was noted for HLA-DR3 in a comparison of patients with CAH and healthy carriers (37% vs 10%, Pc less than 0.05). Comparisons among various groups involving other specificities were statistically nonsignificant. It is concluded that genetic predisposition to the development of CAH, as well as HCC is present in HBsAg carriers, and further clarification of underlying mechanisms is needed.     

Acute viral hepatitis B with bridging necrosis: a follow-up study

ABSTRACT— Forty patients with bridging necrosis (BN) on biopsies taken during the course of acute viral hepatitis B were included in a prospective study to assess the prognostic significance of this lesion. Of the 22 patients with complete clinical, biochemical and histological follow-up (histological follow-up 5–33 months), only two failed to eliminate HBs- and HBe-antigen in serum, a finding paralleled by transition to chronic active hepatitis and by the persistence of focal HBc- and HBs-antigen expression in liver tissue. Nineteen of 22 patients showed complete histological healing; one developed inactive cirrhosis. It is concluded that, in the setting of acute viral hepatitis B, the histological lesion of BN is of no particular prognostic significance, and that transition to chronic liver disease is much less frequent than has been assumed from previous studies of etiologically heterogeneous patient populations. Markers of poor prognosis are the failure of serological elimination of HBs- and HBe-antigen and the persistence of spotty expression of HBc- and HBs-antigen on immunofluorescence histology.     

广州市自然人群病毒性肝炎血清流行病学研究

目的了解广州市自然人群病毒性肝炎的血清流行病学特征。方法采取分层多级整群系统随机抽样方法抽取研究对象,对其作流行病学个案调查,并应用酶联免疫吸附试验（ELISA法）检测病毒性肝炎各感染标志物。结果广州市自然人群HAV、HBV、HCV、HDV、HEV、HGV感染率分别为74．47％、64．10％、0．65％、0．13％、1．69％和0．65％;HAV、HBV和HEV的感染率在老城区、新城区和郊市区中的差异有高度显著性意义（P〈0．01）,而HCV、HDV和HGV的差异无显著性意义（P〉0．05）;HBV感染率在男女之间差异有高度显著性意义（P〈0．01）,HCV感染率在男女之间差异有显著性意义（P〈0．05）,而HAV、HDV、HEV和HGV的感染率则无性别差异（P〉0．05）;HAV、HBV、HCV、HDV、HEV、HGV最低感染年龄分别为2岁、2岁、20岁、31岁、5岁和13岁,最高感染年龄分别为90岁、86岁、46岁、67岁、74岁和71岁;HAV、HBV和HEV感染率均与年龄呈正相关（P〈0,01、P〈0,01和P〈0．05）。结论广州市自然人群各型病毒性肝炎感染具有不同的流行病学特征,其中HAV和HBV的感染率较高,HCV、HDV、HEV和HGV的感染水平则较低。     

Acute viral hepatitis A and C: report of a case]

We present a case of acute hepatitis by simultaneous A and C virus infection. The coinfection was suspected due to the high levels of transaminases lasting more than 9 months after onset of the illness. During the early stages of the illness, the patient had IgM antibodies to hepatitis A virus. Serological tests for hepatitis B and C viruses, cytomegalovirus and Epstein-Bar virus were negative. Due to the persistently high transaminase levels, we repeated the serology, detecting positive results for hepatitis C antibody, while hepatitis B serology remained negative as well that for all other virus tested. With these findings, we believe that a patient with hepatitis A of long duration, requires additional serological examinations to determine the possibility of coinfection by another virus.     

Prevalence of hepatitis B and C virus infection among working women in Bangkok.

A small-scale seroepidemiological survey on hepatitis B and C virus infection was conducted in the vicinity of Bangkok, Thailand, in 1998. Adult women working in a health sciences institution were invited to participate in the study, and 52 subjects (19 to 57 years of age) volunteered to offer peripheral blood. They were non-smoking and non-habitually drinking, and about two thirds of the subjects were married. The sera from the blood samples were assayed for HBsAg, anti-HBs, anti-HBc, and anti-HCV positivities. The serum assay showed that none of the subjects was positive to HBsAg or anti-HCV, but a half of the subjects (50%) were either positive to anti-HBs, to anti-HBc or to the both, thus having experienced HBV infection in the past. The prevalence of the positivities was significantly higher among those at 35-57 years of age than those younger than 35 years. Comparison of the present findings with the results reported in literature suggested that the risk of HBV infection should have been higher than that of HCV infection, that the observed positivity of HBV infection was probably lower than ever reported, and that anti-HCV positivity should be the lowest.     

Hepatitis B and hepatitis C viruses: a review of viral genomes,viral induced host immune responses,genotypic distributions and worldwide epidemiology

Hepatitis B and hepatitis C viruses (HCV) are frequently propagating blood borne pathogens in global community. Viral hepatitis is primarily associated with severe health complications, such as liver cirrhosis, hepatocellular carcinoma, hepatic fibrosis and steatosis. A literature review was conducted on hepatitis B virus (HBV), HBV genome, genotypic distribution and global epidemiology of HBV, HCV, HCV genome, HCV and host immune responses, HCV genotypic distribution and global epidemiology. The valued information was subjected for review. HBV has strict tissue tropism to liver. The virus infecting hepatocytes produces large amount of hepatitis B surface antigen particles which lack the DNA. It has capability to integrate into host genome. It has been found that genotype C is most emerging genotype associated with more severe liver diseases (cirrhosis). The approximate prevalence rate of genotype C is 27.7% which represents a major threat to future generations. Approximately 8% of population is chronic carrier of HBV in developing countries. The chronic carrier rate of HBV is 2%-7% in Middle East, Eastern and Southern Europe, South America and Japan. Among HCV infected individuals, 15% usually have natural tendency to overcome acute viral infection, where as 85% of individuals were unable to control HCV infection. The internal ribosomal entry site contains highly conserved structures important for binding and appropriate positioning of viral genome inside the host cell. HCV infects only in 1%-10% of hepatocytes, but production of tumor necrosis factor alpha (from CD8+ cells) and interferon-gamma cause destruction of both infected cells and non-infected surrounding cells. Almost 11 genotypes and above 100 subtypes of HCV exists worldwide with different geographical distribution. Many efforts are still needed to minimize global burden of these infections. For the complete eradication of HBV (just like small pox and polio) via vaccination strategies, sincere efforts would be required from government and nongovernmental organizations.     

Evidence-based medicine tratment of chronic viral hepatitis B and C

Worldwide, viral hepatitis is the most common cause of jaundice, chronic liver disease, cirrhosis and hepatocellular carcinoma. Although mayor advances have been made in the field of treatment and prevention, there is not a totally satisfactory treatment for each of both diseases. They account for a high percentage of the etiology of viral hepatitis and have a tendency towards chronicity and developing cirrhosis, resulting in a tremendous waste of medical resources. On the other hand, their treatments are long-term ones and the drugs, which are employed, are expensive. Thus, it is necessary to make an evidence-based medicine approach in this particular kind of illness to obtain the best benefit/cost ratio. In this current review, we analyzed the different drugs and therapeutic schedules, which are used in the chronic viral hepatitis B and C, and as well as their obtained response.     

Prevention of viral hepatitis (B and C) reassessed

As hepatitis B and C viruses share modes of transmission, their combined occurrence is not uncommon, particularly in areas where both viruses are endemic and in individuals at high-risk of parenteral infection. Both viral hepatitis infections form an important global public health problem, responsible for over half a billion chronic infections worldwide.Their distinctive characteristics impact upon their epidemiology and transmission, and the success of the different prevention strategies.For several decades safe and effective vaccines have been available to prevent HBV infection. Universal vaccination is the cornerstone of global HBV control. Despite major success, vaccine uptake is hampered, and increasing efforts are required to eliminate acute and chronic hepatitis B. Unlike hepatitis C and HIV, HBV has not captured sufficient attention from policymakers, advocacy groups or the general public: a major challenge for the future.Although progress has been made in the development of an HCV vaccine, short-term successes are not expected. Even without a vaccine, successes can be reported in the field of hepatitis C due to e.g. implementation of universal precaution measures in health-care settings, screening of blood and blood products, and identification and counselling of infected people. Despite significant efforts, HCV transmission in injecting drug users is increasing.

• despite the availability and widespread use of effective hepatitis B vaccines, efforts are required to optimise uptake of the vaccine in universal and risk group immunisation programs

• because the development of a hepatitis C vaccine has not yet been successful, prevention and control measures are the major challenge to all those involved in public health

• screening for HBV and/or HCV should be followed by adequate management of positive patients, including counselling, referral, and possible treatment if available

• nosocomial transmission of viral hepatitis can and should be prevented by reinforcing and maintaining blood donor selection and screening procedures, strict adherence to universal safety measures in health-care settings, and thorough evaluation and communication of nosocomial infections

• immigrants should be socially fully integrated, including access to health services, to control the epidemic spread of imported infections

• the HBV and HCV epidemic among IDUs needs to be controlled by continuous educational programs for the general public and health professionals, accessible substance abuse treatment and rehabilitation programs (including outreach to homeless and socially excluded users), implementation/reinforcement of harm-reduction programs, HBV testing and vaccination of non-immune IDUs, and HCV testing and treatment in correctional facilities

• the possibility and benefits of HCV treatment should be established; adequate treatment can reduce the reservoir of chronic carriers, thereby diminishing transmission

• to make sure that HBV vaccination does not lose its place on the agenda of governments, agencies, and international organizations, as a consequence of its success so far and the interest in other vaccine-preventable diseases

• to further investigate the long-term protection after HBV vaccination and the role of cell-mediated immunity

• to assess the impact of HBIG in perinatal transmission and its possible effect on the immune response later in life

• to measure the impact of globalisation and international migration on the incidence of new hepatitis B cases

• to better understand the role of HBV genotypes in transmission, natural history and treatment

• to continue research on the treatment of (acute) HBV cases

• to improve/optimise HBV surveillance and to quantify the impact of HBV mutants.

• good surveillance data for HCV are absent in many regions of the world, and consequently there are gaps in our understanding of incidence, risk factors, transmission, and disease progression

• improvements in assays and/or testing algorithms for hepatitis C are required to optimise surveillance data

• development of hepatitis C vaccines is needed

• more insight into HCV immunology and cross-protection is required

• there is a need to measure the impact of globalisation and international migration on the incidence of new hepatitis B and C cases