Letter to Editor

To the Editor: Viral hepatitis due to hepatitis B virus infection is a growing public health problem. Hepatitis B is the world’s most common blood borne viral infection (1). It was reported recently that worldwide about 400 million chronic hepatitis and 30000 liver cancer cases were due to hepatitis B virus alone (2). Hepatitis B occurs mostly transmitted from household or sexual contacts with infected persons and contaminated medical equipments and transfusions. Hepatitis B surface antigen (HBsAg) is found on the outer surface of the virus and is produced in excess quantities that circulates in the blood as 22 nm spherical and tubular particles and can be identified in serum 30 to 60 days after exposure to HBV. It can be detected in the serum from several weeks before onset of symptoms to months after onset during incubation period, acute hepatitis, chronic active hepatitis and asymptomatic carrier state. (3,4). The presence of HBsAg indicates that the person is potentially infectious (5).

In India hepatitis B surface antigenemia in the patient population varies greatly depending on the nature of patient population. Therefore we performed the study at Hindu Rao Hospital in Delhi, a northern Indian state investigating the prevalence of HBsAg seropositivity in patients attending this hospital. This study was carried out in 3705 patients for a period of seven years from 1997 to 2003. During this seven year period patients were referred to the microbiology laboratory from different clinical departments. They are categorized broadly into four category according to the brief clinical history obtained. Patients with clinical history of jaundice are considered in the hepatitis category; those undergoing routine test before dialysis and endoscopy are clustered into pre-dialytic and pre-endoscopic category respectively. Antenatal cases are also considered in this study in a separate group to find out the potentially infected pregnancy cases. The hepatitis category patients mainly presented with symptoms of jaundice including nausea, vomiting, lethargy and pigmentation. The other three groups presented with gastrointestinal and urinary symptoms unrelated to viral hepatitis. The fasting serum samples were collected under aseptic precautions in the microbiological laboratory. The samples were tested by BIOELISA (biokit; Spain) according to the manufacture’s instruction. The positive samples were tested again for confirmation.

It was found that out of total 3705 patients, 314 (8.4%) serum samples were HBsAg positive. The 95% confidence interval (CI) calculated by t-test is lying between 1.67 and 1.84 (0.7 was the cut off value recommended by the manufacturer). Two hundred and eighty six samples (14.8%) out of 1923 hepatitis category patients were positive for HBsAg (95% CI between 1.67 and 1.85). It was found that the serum samples of 428 pre-dialysis and 539 pre-endoscopy category patients showed 15 (3.5%) and 8 (1.4%) positivity (95% CI between 1.28-2.03 in pre-dialysis and 1.31-2.29 in pre-endoscopic cases respectively). Amongst the routine antenatal cases only 5 (0.6%) out of 815 cases were found positive for HBsAg in serum (95% CI between 0.94 and 1.98). During this seven-year period the rate of positivity has increased gradually (Table 1). Interestingly, only for last three years pregnant mothers were found to be seropositive which is rather serious indication for vertical transmission. It was observed that male patients exhibited a positivity rate that is higher (8.7%) than females (7.3%). The most common age group affected was 20-40 years (56 %) while the other age groups <20 years were consisting (32%) and rest (12%) seropositivity was observed in patients with an age >40 years.

HBV hepatitis is a major public health problem in developing countries (6). Earlier it was reported by Mahoney et al. (3) that the prevalence of HBsAg in India is between 2-7%. In South East Asia the seropositivity ranges from 8 to 20 percentages (7). In this study it was found that the overall percentage has increased from 6.6% in the year 1997 to 9.2% in the year 2003. This trend is highly alarming. Our study also indicates that the seropositivity is higher mainly in the hepatitis (14.8%) and pre-dialysis (3.5%) patient categories. In summary, our data indicates the epidemiological and public health importance of high rates of HBV infection in India and the need for more stringent public health measures to control the spread.

REFERENCES

1. Chhabra P, Grover VL, Agrawal K. Do our medical students have enough knowledge of hepatitis B? A Delhi based study. J Commun Dis 2002; 34:221-5.

2. Lai CL, Ratziu U, Yuen MF, Poynard T. Viral Hepatitis B. Lancet 2003; 362: 2089-94.

3. Francis J Mahoney. Update on Diagnosis, management and Prevention of Hepatitis B virus infection. Clin Microbiol Rev 1999; 12:351-66.

4. Jawetz, Melnick & Adelberg. Medical Microbiology. Hepatitis viruses. 21st ed. Connecticut: Appleton & Lange; 1998.

5. Hollinger FB, Liang TJ. Hepatitis B Virus. In: Knipe DM et al., eds. Fields Virology, 4th ed. Philadelphia, Lippincott Williams&Wilkins, 2001:2971-3036.

6. Hoofnagale JH. Acute viral hepatitis. In: Principles and practice of infective diseases, 4th ed. Mandell GL, Bennett JE, Dolin R, eds. New York: Churchill-Livingstone, 1995; 1001-7.

7. Zuckerman AJ. Hepatitis virus. In: Baron’s, eds Medical Microbiology 4th edition Galveston, Texas, The University of Texas Medical Branch 1996; 849-63.

Seropozitivnost površinskog hepatitis B antigena u regionalnoj bolnici u Severnoj Indiji

u periodu 1997. – 2003. godine

Izdavaču: Virusni hepatitis uzrokovan infekcijom hepatitis B virusom je rastući problem javnog zdravlja. U svetu je hepatitis B najčešća infekcija koja se prenosi putem krvi (1). Nedavno je saopšteno da širom sveta samo hepatitis B virus uzrokuje oko 400 miliona bolesnika sa hroničnim hepatitisom i 30.000 sa karcinomom jetre (2). Hepatitis B se javlja ponajviše prenošenjem kućnim ili seksualnim kontaktima sa zaraženim osobama, kontaminiranim medicinskim instrumentima i transfuzijom. Površinski hepatitis B antigen (HBsAg) je otkriven na spoljašnoj površini virusa i produkuje se u višku kao sferične i tubularne čestice veličine 22 nm koje cirkulišu u krvi i mogu se otkriti u serumu 30 do 60 dana posle infekcije hepatitis B virusom (HBV). U serumu se može naći od nekoliko nedelja pre pojave prvih simptoma do nekoliko meseci od početka bolesti, tokom inkubacionog perioda, u akutnom hepatitisu, hroničnom aktivnom hepatitisu i u asimptomatskom nosilaštvu (3,4). Prisustvo HBsAg ukazuje da je osoba potencijalno infektivna (5).

Antigenemija površinskog hepatitis B antigena u Indiji u velikoj meri varira u zavisnosti od karakteristike bolesničke populacije. Zbog toga smo mi uradili studiju u Hindu Rao Bolnici u Delhiju u severnoj državi Indije ispitujući prevalencu seropozitivnosti HBsAg kod pacijenata ove bolnice. Studija je urađena sa 3705 pacijenta u periodu od 7 godina, od 1997. do 2003. godine. Tokom ovog sedmogodišnjeg perioda pacijenti su upućivani u mikrobiološku laboratoriju iz različitih kliničkih odeljenja i grubo su grupisani u četiri kategorije prema dobijenoj kratkoj kliničkoj anamnezi. Pacijenti sa kliničkom anamnezom o žutici su svrstani u kategoriju hepatitisa; oni koji su bili podvrgnuti rutinskom testu pre dijalize ili pre endoskopije svrstani su u kategorije “pre dijalize”, odnosno “pre endoskopije”. U ovoj studiji su uključene i osobe pre porođaja kao posebna grupa radi otkrivanja potencijalno infektivnih trudnica. U kategoriji hepatitisa pacijenti su uglavnom ispoljavali žuticu uključujući muku, povraćanje, letargiju i pigmentaciju. Ostale tri grupe su imale gastrointestinalne i urinarne simptome koji nisu bili u vezi sa virusnim hepatitisom. U mikrobiološkoj laboratoriji su skupljeni serumi uzeti našte uz aseptičke predostrožnosti. Uzorci su bili testirani BIOELISOM (biokit; Španija) prema instrukciji proizvođača. Pozitivni uzorci su bili ponovo testirani radi potvrde.

U uzorcima seruma od ukupno 3705 bolesnika nađeno je da je HBsAg bio pozitivan u 314 (8,4%). Konfidencijalni interval (KI) od 95% izračunat t-testom je bio od 1,67 do 1,84 ( 0,7 je bila granična vrednost preporučena od strane proizvođača ). Od ukupno 1923 pacijenta u kategoriji hepatitisa, 286 uzoraka (14,8%) je bilo HBsAg pozitivno (95% KI je bio od 1,67 do 1,85). U uzorcima seruma od 428 pacijenata u kategoriji “pre dijalize” pozitivnih je bilo 15 (3,5%), od 539 pacijenta “pre endoskopije”, pozitivnih je bilo 8 (1,4%) ( 95% KI je bio između 1,28 do 2,03 kod bolesnika “pre dijalize” i 1,31 do 2,29 kod bolesnika “pre endoskopije”). Među ukupno 815 rutinski testiranim trudnicama, HBsAg je nadjen samo u 5 (0,6%) ( 95% KI je bio između 0,94 do 1,98). Tokom ovog sedmogodišnjeg perioda procenat pozitivnosti se postepeno povećavao (Tabela 1). Zanimljivo je da je kod trudnica otkrivena seropozitivnost samo u poslednje tri godine što je prilično značajan pokazatelj za vertikalnu transmisiju. Zapaženo je da su pacijenti muškog pola bili češće pozitivni (8,7%) nego pacijenti ženskog pola (7,3%). Najbrojnija pozitivna starosna grupa je bila od 20 do 40 godina (56%), dok su druge uzrasne grupe činile mlađi od 20 godina (32%) a ostali seropozitivni (12%) su bili pacijenti stariji od 40 godina.

Virusni hepatitis B je glavni problem javnog zdravlja u zemljama u razvoju (6) Mahoneu i saradnici su ranije saopštili da je u Indiji prevalenca HBsAg između 2 i 7%. Procenat seropozitivnosti u jugoistočnoj Aziji se kreće od 8 do 20% (7). U ovom istraživanju je nađeno da se ukupni procenat seropozitivnosti povećao sa 6,6% u 1997. godini na 9,2% u 2003. godini. Ovaj trend je veoma upozoravajući. Naša studija takođe ukazuje da je seropozitivnost veća uglavnom u bolesnika u kategorijama hepatitisa (14.8%) i “pre dijalize” (3,5%). U zaključku, naši podaci ukazuju na značaj visokog procenta HBV infekcije u Indiji za epidemiologiju i javno zdravlje i potrebu za strožije mere javnog zdravlja kojima se kontroliše njegovo širenje.