Methods of disposal of used syringes by hepatitis B and C patients at an urban and rural setting.

OBJECTIVE: To evaluate the methods of disposal of used syringes employed by patients with hepatitis B and hepatitis C. METHODS: This cross sectional study was conducted at a tertiary care hospital of Karachi and a clinic at Khairpur, Sindh. Diagnosed cases of Hepatitis B and C currently receiving treatment in the form of Interferon alpha injection were included by convenient sampling. The study instrument was a well structured questionnaire meant to ascertain the disposal methods of used syringes once they had been employed for treatment purpose. Open-epi sample size calculator (Multi-purpose statistical software for calculation of the sample size) and SPSS 15.0 was used for data entry and analysis. RESULTS: A total of 203 patients were interviewed, 147 from Karachi and 56 from interior. The majority i.e. 164 were suffering from Hepatitis C, 27 from Hepatitis B and 2 were co-infected with Hepatitis B and D. The mean age of patients was 35.8 +/- 11.5 years. Regarding disposal of injections, the most frequent mode was disposal of used syringes in house trash i.e. 71 (37.4%), patients 46 (24.2%) responded that they utilized a needle cutter, 37 (19.5%) safety box (disposal method in tertiary hospitals where the needle is disposed off safely in a box), 12 (6.3%) disposed in sewage, 3 (1.6%) disposal in water, 3 (1.6%) buried the used syringes, while 2 (1.1%) reused the syringe and needle once they had been used for therapeutic purposes. CONCLUSIONS: The study suggests that the injection practices by the majority of patients suffering from viral hepatitis were unsafe. Majority of the patients were disposing the used syringes and needles in the house trash.

Treatment outcome of HCV infected paediatric patients and young adults at Karachi, Pakistan.

BACKGROUND: Scanty data are available regarding outcome of children and young adults treated conventionally for Hepatitis C. The present study was undertaken to evaluate the outcome of paediatric and young adult patients treated with PEG-IFN-alpha or conventional interferon (IFN) plus Ribavirin at a public sector hospital of Karachi. METHODS: This was an observational study, conducted at Sarwar Zuberi Liver Centre, Civil Hospital Karachi, from 2007 to 2010. Patients up to 20 year of age were tested for Anti-HCV antibodies by 4th generation ELISA and in positive cases HCV RNA was done by PCR. Patients with HBV, HIV and other comorbids such as thalassaemia minor, haemophilia, kidney disease, and co-existing active illness other than HCV were excluded. Depending upon the genotype, patients were treated for 24-48 weeks with IFN 3 MIU x3 per week or PEG-IFN-alpha (1.5 microg/Kg) per week plus Ribavirin 15 mg/Kg/day. Nearly all patients were followed till the end of treatment. RESULTS: Mean age of 55 patients, was 18.42 +/- 2.59 years (range 9-20 years) and BMI 19.56 +/- 2.36 Kg/m2. Females were 70.9% (n = 39). More than 80% had genotype 3 (subtype a or b). Remaining had genotype 1, 4 or mixed. Slight decreases in haemoglobin, platelet and white cell count at 1, 3 and 6 months of treatment were noted. No significant side effects were noted. There was a marked decrease in the ALT post treatment (pre-treatment values 72.69 +/- 50.73 versus post-treatment 24.81 +/- 14.09 IU/l). End-treatment response (ETR) was 90.9%; of these sustained viral response (SVR) was achieved in 86.3%. CONCLUSION: HCV infected paediatric and young adult patients treated with PEG-IFN-alpha/or conventional interferon plus Ribavirin (combination therapy) achieved an ETR of 90.9% and SVR of 86.3%.

Treatment profile of hepatitis C patients - a comparison of interferon alpha 2a and 2b treatment regimes.

OBJECTIVE: To compare the side effects, cost, end treatment response (ETR) and Sustained viral response (SVR) with combination therapy of either interferon alpha 2a or 2b in combination with Ribavarin. STUDY DESIGN: Randomized Control Clinical Trial (RCCT). PLACE AND DURATION OF STUDY: The study was conducted at Sarwar Zuberi Liver Centre (SZLC), Civil Hospital Karachi (CHK), from May 2004 to July 2009. METHODOLOGY: Patients positive for qualitative HCV ribonucleic acid (RNA) by Polymerase chain reaction (PCR) and genotype 3 were included. Patients with decompensated cirrhosis, severe depressive illness, autoimmune hepatitis, hyperthyroidism, pregnancy, heart failure, uncontrolled diabetes, obstructive pulmonary disease, children less than three years and patients who had previously received treatment were excluded. Single blind randomization using computerized randomization list was done and patients divided into groups A and B, those requiring treatment were given injection Interferon 3 million units (MU) subcutaneously (SC) three times/week and Ribavarin 1000 mg per day (weight ≤ 75kg) and 1200 mg/day (weight > 75kg) orally with either interferon alpha 2a (group A; FDA approved products) or alpha 2b (group B; non FDA approved product). Demographics, side effects, ETR and SVR were noted. ETR was defined as absence of virus at the end of treatment and SVR was taken as absence of HCV RNA at 6 months after completion of treatment. RESULTS: There were a total 310 patients with mean age of 34.07 +/- 9.38 years including 52.4% males, (n=162). Majority of the patients were from North Pakistan. There were 155 patients each in group A and group B respectively. The cost of treatment for interferon alpha for a single patient for 6 months was Rs 60,000, while for Interferon alpha 2b was Rs 30,000. Side effects (fever initially, followed by fatigue, headache, musculoskeletal pain, depression, alopecia, insomnia, and anorexia) were more prominent in group B when compared with group A. In group A, ETR was 83.8% (130/155) while in group B was 83.2% (129/155). While SVR available in group A was 61/70 (87.1%) and in group B was 60/72 (83.3%). CONCLUSION: Response to combination therapy for HCV was 83%. ETR and SVR were similar for both interferon alpha 2a and 2b. Side effects though minor are more with alpha 2b (non FDA approved products).

Frequency of hepatitis B and C in rural and periurban Sindh.

OBJECTIVES: To determine the frequency of HBV and HCV and identify risk factors for transmission of these viruses in rural and periurban Sindh. METHOD: This is a descriptive/cross sectional study done between June 2007 to May 2008, in which screening and evaluation of risk factors for Hepatitis B virus surface antigen (HBsAg) and HCV Antibody. (Anti-HCV) in two remote villages namely Taluka Tharo Shah and Jalbani, District Nausheroferoz (where investigators had to walk in the area to reach the population) and a subsection of Gharo District Thatta (periurban area) was done. Included were children of more than one year of age and all previously unscreened adults who were counseled and a written consent was obtained. All drug addicts by history were excluded. A structured information sheet regarding risk factors was filled and screening done by immunochromatography (ICT) kits. RESULTS: Of the 573 subjects enrolled who met the inclusion criteria, females were 52.5%. Mean age (years) of participants was 24.74 +/- 14.41. In two remote villages 7.0% were HBsAg positive and 28.6% were Anti HCV reactive, whereas in periurban area 3.1% were HBsAg reactive and 3.9% were Anti HCV positive. In the analysis of risk factors for transmission of infection, blood related factors especially for HCV like surgical, dental procedures and body piercing were main factors noted more in rural as compared to the periurban area. CONCLUSION: The frequency of HCV in our study is alarming and that of HBV also quite high which underline the need of mass HBV vaccination. Overall (in both urban and rural areas) immediate steps must be taken to reduce transmission of these viruses by limiting use of unsafe (unsterilized/reused) injections for therapeutic purposes), razor blades, body piercing equipment and proper sterilization of surgical, dental and circumcision equipment.

Interferon-alpha treatment of children and young adults with chronic hepatitis delta virus (HDV) infection.

OBJECTIVE: To determine the response of one-year interferon-alpha therapy in hepatitis delta virus (HDV) infection in children and young adults at a tertiary care hospital, Karachi, Pakistan. STUDY DESIGN: An observational study. PLACE AND DURATION OF STUDY: Sarwar Zuberi Liver Centre (SZLC), Medical Unit IV, Civil Hospital, Karachi/Dow University of Health Sciences (DUHS), from June 2009 to July 2010. METHODOLOGY: Paediatric patients (< 18 years age) and young adults (18-35 years) presenting were screened for hepatitis B virus (HBV) and HDV sero-markers. HDV anti-body positive by ELISA were further screened for hepatitis D ribonucleic acid (HDV-RNA) by real time PCR. HDV RNA PCR positive patients were treated with INF-a (children 6 MIU/m2/day and adults 5 MIU/day) for a period of one year. Patients were assessed monthly. Haematological parameters and ALT were monitored during treatment. Clinical progress (side effects) and negative HDV RNA were used as response criteria. RESULTS: Overall 49 patients were HDV RNA positive (children: n=15, mean age 15±2.92 years adults: n=34, mean age 27±4 years). Eighty percent were male. Treatment was given to 25 patients (children: n=11, adults: n=14). HBV genotype D was the predominant in all HDV RNA positive patients (73%). Eighty percent (20/25) were HDV-RNA negative after one year of treatment, and remaining patients are still under treatment. Side effects were tolerated well and children continued regular activity. Haematological parameters were unremarkable. Children maintained their pre-treatment centile for height and weight (growth parameters). ALT levels were significantly decreased post-treatment. CONCLUSION: Conventional INF-a was safe in children with HDV infection in terms of side effects and growth parameters. Eighty percent were HDV-RNA negative one year after treatment. Further follow-up 2 years post-treatment will give conclusive results.

Vertical transmission of hepatitis C virus in low to middle socio-economic pregnant population of Karachi.

PURPOSE: To determine the rate of vertical transmission (transmission from mother to child) of hepatitis C virus in low to middle socio-economic pregnant women. METHODS: This study was conducted at Sarwar Zuberi Liver Centre (SZLC) in collaboration with the department of Gynaecology and Obstetrics, Civil Hospital Karachi (CHK) and Abbasi Shaheed Hospital (ASH) for a period of 4 years from September 2005 to December 2009. Total 18,000 women seeking antenatal care were screened for hepatitis C antibodies (Anti-HCV) using 4th generation ELISA technique. Positive 1,043 women were further offered HCV ribonucleic acid (RNA) by polymerase chain reaction (PCR). Six hundred and forty women agreed to have PCR done, and 510 PCR positive women were finally included in the study, followed till delivery and treated if required. Newborns of 510 PCR positive mothers were advised HCV-RNA by PCR from 3 to 12 months of age and Anti-HCV at 18 up to 24 months and followed up to 3 years. RESULTS: 1,043/18,000 (5.79%) mothers were Anti-HCV positive, of which PCR results of 640 mothers are available where 510/640 (79.7%) were PCR positive, 357/510 (70%) delivered by spontaneous vaginal delivery (SVD), 33 (6.4%) by forceps delivery, 70 (13.7%) had elective, and 50 (9.8%) had emergency caesarian section. Premature rupture of membranes (PROM) was present in 81 mothers. Data of 510 babies from 3 months to 3 years of age was available of which only 215 had their laboratory tests done (HCV-RNA-PCR in 86 and Anti-HCV in 129). Mean birth weight (kg), height (cm) and OFC (cm) were 2.74 ± 0.43, 52.4 ± 7.5, and 35 ± 4. Apgar score median at 1 and 5 min was 7 (range 2-10), 8 (range 4-10), respectively. Low birth weight was present in 49 (9.6%), 37 (7.2%) had history of Neonatal Intensive Care Unit (NICU) admission. PCR of none of the 86 babies done at 3-12 months was positive. Five babies out of 129 were Anti-HCV positive at 18 months of age. Of this, 3/5 was HCV-RNA-PCR positive. Rate of vertical transmission of HCV was 1.39. CONCLUSION: In spite of the high hepatitis C positivity in pregnant population, the rate of vertical transmission to the neonate is low.