Liver and biliary tract
Jetra i bilijarni trakt
ARCH GASTROENTEROHEPATOL 2000; 19 ( No 2 – 3 ):
HEPATITIS A AND HEPATITIS E PREVALENCE IN CHILDREN IN KONYA, TURKEY
Prevalencija hepatitisa A i hepatitisa E u dece u gradu Konija, Turska
( accepted July 31st, 2000 )
Hepatitis A and E in children in Turkey
1Emel Turk Aribas, 2 Mustafa Altinidis, 3 Ayhan Ceri, 4 Hasan Koc.
1Department of Clinical Bacteriology and Infective Disease, Selcuk University Medical Faculty, Konya, 2 Department of Microbiology and Clinical Microbiology, Kotacepe University Medical Faculty, Afyon, 3 Department of Pediatrics, Selcuk University Medical Faculty, Konya, Turkey.
Address correspondence to: Mustafa Altinidis, MD,PhD.
Dumlupinar mah. Karazoglu sok Alimoglu apt No 25
03200 Afyon, Tyrkey
E-mail: [email protected]
Abbreviations used in this article: HAV, Hepatitis A virus; HEV, Hepatitis E virus.
We are reporting the prevalence of Hepatitis A and E virus infections among children in Konya, Turkey. Serum samples were taken from 162 children, which were admitted to hospital for complaints other than jaundice. HAV – antibodies and HEV- antibodies were determined by EIA. The sero-prevalence of HAV and HEV was 95% and 12.3% respectively. We conclude that beside high rate of HAV infection among children, HEV infection is the second most important liver viral infection in children in Konya region.
Key words: Herpatitis A virus, Hepatitis E virus, children, prevalence.
U radu se saopstavaju rezultati ispitivanja prevalencije infekcije virusima Hepatitis A i E dece u gradu Konija, Turska. U 162 dece koja nisu imale simptome zutice uzeti su uzorci krvi i odredjeno je prisustvo HAV- i HEV- antitela metodom EIA. HAV seropozitivitet je iznosio 95%, a HEV 12.3%. Zakljucili smo da je posle infekcije sa HAV, infekcija sa HEV druga po redu znacajna virusna infekcija jetre u regionu Konije.
Kljucne reci: Hepatitis A virus, Hepatitis E virus, deca, prevalencija.
Acute viral hepatitis is serious infection characterised by inflammation of liver parenchyma and hepatocelular necrosis. Among the hepatotropic viruses HAV and HEV are transferred by faecal – oral route ( 1 ). Hepatitis caused by HAV is common infection endemic in Mediterranean countries, Africa, South America, and Asia. This is the most common viral infection which causes acute viral hepatitis in Turkey as well ( 2 ). HEV is another hepatotropic virus transferred by faecal-oral route. This may causes sporadic or/and epidemics of hepatitis particularly in developing countries. HEV usually affects young and middle- age individuals but rarely children and old people ( 2 ).
Here we report the result of our study of sero-prevalence of HAV and HEV infections among children in one area of Turkey.
MATERIAL AND METHODS
162 consecutive children ( age: 1 to 15 years ) admitted to the paediatric outpatient service at Selcuk University Medical Faculty, Konya, Turkey for variety of reasons other than jaundice enrolled this study. A questionnaire asking parents about children age, family income, and housing facilities was recorded for each case. After consent of their parents, 2 blood specimens were taken from each child. Serum AST and ALT were determined from one sample. The other sample was tested for anti-HAV IgG and anti-HEV ( total ) antibodies by micro-EIA ( Pasteur ) with Sorin Biomedica EIA kits. The Chi-square test was used for statistical analysis.
In the whole group of 162 children 154 ( 95% ) were anti-HAV IgG positive. Twenty ( 12.3% ) were anti-HEV positive. Anti-HEV IgM antibody was not detected in any case. Anti-HAV IgG positivity rate was 93.7% in the age group 1 – 4 years, 95% in the age group 5 – 9, and 97.3% in the age group 1- 15. Anti-HEV total antibody positivity rates were 9.3%, 10%, and 21% respectively for the same age groups. Table 1. There was no statistical correlation between anti-HAV and anti-HEV antibody rates. Table 2. HAV and HEV infection prevalence did not show any sex preponderance.
When anti-HAV and anti-HEV positivity were related to family income level it was found that 100% of anti-HAV positive and 25% of anti-HEV positive children were from the families with low income level; 90.4% anti-HAV and 4.7% anti-HEV antibody positivity were found in children from the families with high income. There was no meaningful correlation between income levels and anti-HAV seropositivity rate ( p>0.05 ). Table 3. On the contrary, anti-HEV seropositivity rate was higher in children from the families with low income level( p<0.05 ).
Both anti-HAV and anti-HEV antibody positivity were simultaneously detected in 18 ( 11.1% ) children. AST and ALT in the whole group of 162 children were within normal limits.
Hepatitis A is still very common viral liver infection worldwide ( 1,3,4 ). Although this is benign disease, hepatitis A may rarely causes acute liver failure in endemic areas ( 2,5 ). Hepatitis A is frequent in underdeveloped and in developing countries where infection is transferred by contaminated water or food due to poor sanitation and low socioeconomic status.
HAV prevalence under the age of 20 was found to be 0% in Japan, whereas in Malaysia, Saudi Arabia and Senegal is 40.91% and 93.1% respectively ( 2,6,8 ). In Sweden anti-HAV prevalence is significantly higher among of foreign immigrants children then in native children ( 7 ). According to reports from Turkey anti-HAV positivity in paediatric age seems to be extremly high ( 2,9 ). In a study from Trabzon, Turkey seropositivity for HAV was 47%, 13.4%, 63.8%, and 88.6% in the following age groups: 6 months to 18 years, 6 months to 3 years, 8 to 12 years, and 13 to 18 years age group ( 9 ).
In this study we found that anti-HAV IgG positivity in the whole group of children ( age range: 1 to 15 years ) is 95%. When age stratified, the serpositivity rates are as follow: 93.7% in the age group 1 – 4 years, 95% in the group 5 – 9 years, and 97.3% in the group 10 – 15 years. Taking into account that anti-HAV antibodies in children younger than 2 years can be transferred from their mothers, a higher rate of seropositivity in the age group up to 4 years ( 93.7% ) may only partially reflect this phenomenon. High seropositivity rate in this group of children is a direct consequence of high infection rate in children up the age of 5. This is confirming intentional data, which indicate that 90% of HAV infections occur within first 5 years of life in developing countries. On the contrary, in developed world this happens up the age of 10 years ( 5 ).
In our group of children sex distribution of HAV infection is almost equal, 91.8% girls and 97.7% boys ( p>00.5 ). This is to confirm already reported data published elsewhere ( 5,6 ).
HAV infection is frequently acquired in public places and where sanitation is poor. High HAV prevalence is closely related with low secioeconomic status since infection route in faeco-oral ( 1,2,5,6,10 ). Thapa from India reported that anti-HAV positivity is 96% in socioeconomicaly deprived and 85% in higher socioeconomic group of school children ( 12 ). Tasyaran from Turkey found that anti-HEV positivity in school chidren in town of Erzum is 75% in lower and 53.5% in higher socioeconomic class. On the contrary we found that these rates are almost 100% and 94% in lower and higher socioeconomic group respectively, what is in line with other studies. This questions relationship between HAV infection rate and socioeconomic status is underdeveloped and in developing countries.
Hepatitis E virus may causes either epidemic and/or endemic infections. This epidemiological problem in underdeveloped countries where infrastructure and hygienic conditions are poor. In developed world HEV infection is sporadic ( 5 ). Although there are similarities between HAV and HEV infection, the second one has mild course with contamination risk switched to the adults. This viral agent usually infects youngsters and adults, but occasionally children and older age persons ( 14 ). In Hong Kong study HEV prevalence was found to be considerable higher among young adults over the age of 20 then than in the paediatric age group ( 25% versus 4% ). In Europe anti-HEV positivity prevalence is reported to be 0.5%.
Data about anti-HEV seropositivity in Turkey are scanty. Tasyaran reported anti-HEV positivity of 6% in general population over the age of 20. Interestingly in his study group he did not find any seroposititive child ( 16 ). Thomas found anti-HEV positivity of 3.1% in region of Adana town, 56.5% in town of Urfa. 7.7% in Southeast Anatolian region among healthy individuals ( 17 ). The first and the latest figures argue that low socioeconomic status, poor individual and public sanitation are influencing HEV infection rate. In our goup of healthy children anti-HEV seroposivity is 12.3% with highest infection rate in the age group 1 – 4 years. This figure is one of the highest in Turkey except Urfa region where it is 56.5%. We found that anti-HEV seropisitive children usually belong to the low socioeconomic class. HAV and HEV may lead to co-infection because of shared mode of infection (14). We found that 11.1% ( 18/162 ) children are anti-HAV and anti-HEV seropositive.
In conclusion, we found that high rate of HAV and HEV infections in town of Konya region is due to poor public and individual sanitation facilities, lack of proper water supply, and low socioeconomic level. Both infections are interrelated in some number of children.
1.Hoofnagale JH. Acute viral hepatitis. In: Mandell GL, Douglas RG, Bennet Je ( eds ). Principles and practice of infection diseases. New York: J.Willey, 1990; 1001 – 17.
2.Akbul A, Kilic SS, Felek S, Akbulut HH. The prevalence of hepatitis A in the Elazig region. Turk J Med Sci 1996; 26; 375-78.
3.Pasaquini P, Kahn HA, Pleggi D, et al. Prevalence of hepatitis A antibodies in Italy. Int J Epidemil 1984; 13: 83-6.
4.Chin KP, Lok ASF, Wong LSK, et al. Current seroepidemiology of hepatitis A in Hong Kong. J Med Virol 1991; 134: 191-3.
5.Krugman S, Katz SL, Gershon AA, Wilfert CM. Viral hepatitis A,B,C,D. Infectious diseases in children. New York: CV Mosby 1992; 143-74.
6.Forbes A, Williams R. Changing epidemiology and clinical aspects of hepatitis A. Br Med Bull 1990; 46: 303-18.
7.Christenson B. Epidemiology of hepatitis A in children in Sweden 1979-1983. Scand J Infect Dis 1986; 18: 281-5.
8.Baylet R, Lemaire JM, Ridet J. Seroepidemilogie de l, hepatite A. Resultant obtenues au Senegal regions du fleuve et de casamance. J Pathol Biol 1981; 29: 217-21.
9.Baki A, Kkkaaaaakksal I, Aynaci M. The prevalence of hepaitis A among children in Trabzon. Turk J Med Sci 1992; 16: 206-9.
10.Hsu HY, Chang MH, Chen D, et al. Changing seroepidemiology of hepatitis A in Taiwan. J Med Virol 1985; 17: 297-301.
11.Hwang L, Beasley RP, Yang CS, et al. Incidence of hepatitis A virus infection in children in Taipei, Taiwan. Int Virol 1983; 20: 149-54.
12.Thapa BR, Singh K, Singn V, et al. Pattern of hepatitis A and hepapatitis B virus markers in cases of acute sporadic hepatitis and in healathy school children from North West India. J Trop Pediatr 1995; 41: 328-9.
13.Tasyaran MA, Akdag R, Akyuz M, et al. Erzum bolgesi cocklarinda fekal oral bulasan hepatit viruslarinin prevalensi. Klimik Derg 1994: 7: 74-5 ( In Turkish ).
14.Uchida T. Hepatitis E: Review. Gastroenterol Jpn. 1992; 27: 687-96.
15.Lok AS, Kwan WK, Moeckli R, et al. Seroepidemiologic survey of hepatitis E in Hong Kong by recombinant-based enzyme immunoassay. Lancet 1992; 340: 12205-208.
16.Coursaget P, Depril N, Yene OS, et al. Hepatitis E virus infection in Turkey. Lancet 1983; 342: 810.
17.Thomas DL, Mahley RW, Badur S, et al. Epidemiology of hepatitis E virus infection in Turkey. Lancet 1983; 341: 1561-2.