Hepatitis c and cirrhotic liver disease in the Nile delta of Egypt: a community-based study.

Residents of Egypt's Nile river delta have among the world's highest seroprevalence of hepatitis C virus (HCV) infection. To assess the impact of HCV on chronic liver disease, we studied the association between HCV, other hepatitis viruses, and cirrhotic liver disease in a cross-sectional, community-based survey of 801 persons aged > or = 10 years living in a semi-urban, Nile delta village. Residents were systematically sampled using questionnaires, physical examination, abdominal ultrasonography and serologically for antibodies to HCV (confirmed by a third-generation immunoblot assay) and to hepatitis A virus (HAV), hepatitis B virus (HBV), and hepatitis E virus (HEV). The seroprevalence of HCV increased with age from 19% in persons 10-19 years old to about 60% in persons 30 years and older. Although no practices that might facilitate HCV transmission were discovered, the seroprevalence of HCV was significantly associated with remote (> 1 year) histories of schistosomiasis. Sonographic evidence of cirrhosis was present in 3% (95% CI: 1%, 4%) of the population (0.7% of persons under 30 years of age and in 5% of older persons), and was significantly associated with HCV seroreactivity. Our findings are consistent with the hypothesis that past mass parenteral chemotherapy campaigns for schistosomiasis facilitated HCV transmission, and that HCV may be a major cause of the high prevalence of liver cirrhosis in this Nile village.

Hepatitis G virus in Egyptians infected with other parenterally transmitted hepatitis viruses.

A novel hepatitis-associated virus, hepatitis G virus (HGV) has recently been identified. The virus is known to be parenterally transmitted and has been found frequently in subjects chronically infected with hepatitis C virus (HCV). We investigated the seroprevalence of HGV infection in 91 Egyptians infected with hepatitis C and/or B virus including 52 patients with chronic liver disease and 39 asymptomatic subjects. A newly developed immunoassay was used to detect antibody to HGV envelope protein E2. The overall prevalence of anti-HGV in study subjects was 34.1%. Hepatitis G virus antibody was more frequent in patients with chronic liver disease (36.4%-43.9%) than in asymptomatic persons (23.1%). Analysis of demographic features, risk factors and clinical history of the study population revealed that older age and history of schistosomiasis were the factors significantly associated with anti-HGV positivity. The study demonstrated that HGV is highly prevalent in individuals infected with other parenterally transmitted hepatitis viruses. The impact of such observation rises in view of the endemicity of hepatitis C and B viruses in Egypt.

Cell mediated immune response in chronic liver diseases: schistosomal, viral and neoplastic.

Cell mediated immune response (CMIR) was studies in 120 patients having chronic liver diseases. Patients were divided into 6 groups, (20 each). (1) Early hepatosplenic Schistosomiasis. (EHSS), (2) Late hepatosplenic Schistosomiasis. (LHSS), (3) Hepatosplenic Schistosomiasis with hepatitis B and/or C infections, (4) Hepatitis B virus cases. (HBV), (5) Hepatitis C virus cases (HCV), (6) Hepatocellular carcinoma cases. (HCC). Twenty within normal subjects taken as controls. Laboratory investigations revealed significant esinophilia in patients of group (1), haemoglobin level was significantly reduced in patients of group (1, 2, 3, & 6), serum albumin was significantly reduced in group (2). The percentage of positivity of skin testing using purified protein derivative, ranged between 10% of patients with LHSS, HBV, HCC and HSS with HBV and/or HCV, 20% of patients with HCV and 25% of patients with EHSS. Percentage of positivity in control group was 100%. The mean diameter of delayed intradermal reaction (2.2 +/- 0.5-6.1 +/- 2.1 mms.) was significantly lower in patients than controls. The response of lymphocyte transformation test to phytohaemmagglutinin was significantly lower in patients when compared to controls. The association of HBV and/or HCV with hepatosplenomegaly was accompanied with a marked depression in cell mediated immune response. Anaemia, hypoalbuminemia and nutritional status of the patients with chronic liver diseases play a major role in the suppression of cell mediated immune response.

Association of hepatitis C virus with liver cirrhosis and hepatocellular carcinoma compared with hepatitis B virus in Egyptian patients.

Hepatocellular carcinoma (HCC) is an aggressive malignancy and carries a poor prognosis. Documentation of the wide geographical variation in its incidence has led to clear identification of several risk factors. These include hepatitis B virus (HBV) and hepatitis C virus (HCV) infections in endemic areas. The present study investigated the association of HBV with HCV and cirrhosis, the latter is regarded as a premalignant lesion and underlies most cases with HCC. Serum samples from 94 patients with HCC (n=25) and cirrhosis (n=69) were tested for hepatitis C virus antibody (anti-HCV), hepatitis B surface antigen (HBsAg), hepatitis B core antibody (anti-HBc) and serum alphafetoprotein (AFP). Of the 94 patients, 71 (75.5%) had anti-HCV, 6 (6.4%) were positive to HBsAg, while 64 (68.1%) were positive to anti-HBc. These viral markers were more prevalent among HCC patients, 19 (76.0%) had hepatitis C antibody, 3 (12.0%) were positive to HBsAg and 22 (88.0%) were positive to anti-HBc compared with 52 (75.4%), 3 (4.3%) and 42 (60.9%), respectively in patients with cirrhosis. Regarding serum AFP measurement, 14 (56%) of patients with carcinoma and 35 (50.7%) of patients with cirrhosis demonstrated levels above 7 ng/ml. In patients with cirrhosis, elevated serum AFP and presence of anti-HCV in serum were significantly associated. In conclusion, this study shows that viral hepatitis is strongly associated with the development of cirrhosis and HCC in Egyptian patients. Hepatitis C virus seems to play a predominant role compared with hepatitis B virus.

High seroprevalence of hepatitis A, B, C, and E viruses in residents in an Egyptian village in The Nile Delta: a pilot study.

Hepatitis C virus (HCV) infection is hyperendemic in Egypt, with seroprevalence rates of 10-20% among volunteer blood donors, and even higher rates reported among segments of the general population. We attempted to confirm the high seroprevalence of HCV and to compare it with the age-specific seroprevalence rates for hepatitis A, hepatitis B, and hepatitis E among 155 nonrandomly selected residents of a semiurban village in the Nile River delta. Of the two orally transmitted viruses (HAV and HEV), all 1-3-year-old children had been infected by HAV and the seroprevalence rate of 100% persisted until age 67. In contrast, HEV infections were not detected until children were 4-9-years old, and the 57% seroprevalence rate in this age group did not increase appreciably in older age groups. Of the two parenterally transmitted viruses, HBV was first detected in 1-3-year-olds, whereas HCV was first detected later, in 10-19-year-olds. The seroprevalence rates of both viruses increased progressively with age, peaking in the 40-67-year-old group at 66% for HBV and at 51% for HCV. The number of persons who had only one infection, or no infection at all, was too small to allow meaningful statistical analysis of serologically pure groups infected only by HBV, HCV, or HEV. The results of this pilot study revealed extraordinarily high seroprevalence rates of HBV, HCV, and HEV in this village, and distinctive age-specific seroprevalence rates suggesting different patterns of transmission.

Hepatitis E antibodies in Egyptian adolescent females: their prevalence and possible relevance.

Hepatitis E virus has been implicated as a frequent cause of acute sporadic hepatitis among Egyptian children. Moreover, an extraordinarily high seroprevalence rate was previously reported in a semiurban Nile Delta population. A conspicuous feature of hepatitis E is the high morbidity and mortality it can cause among infected pregnant women. We therefore evaluated the prevalence of HEV antibodies in adolescent females using a solid-phase enzyme linked immunoassay based on two recombinant hepatitis E virus antigens. A high prevalence rate (38.9%) was found in 95 apparently healthy adolescent females. The mean age of the study subjects was 21.81 +/- 2.5 (SD) range 16-25 years. Eighty (84.2%) subjects resided in Alexandria, while 15 (15.8%) came from semiurban villages of Alexandria Governorate. An increased prevalence was noted with age, as anti-HEV antibodies were detected in 32.1% and 41.8% of study participants in the second and third decades of life, respectively. Similarly, those illiterate or having received less than primary education exhibited a higher HEV prevalence than those with higher education (46.3% vs 29.3%). The majority of subjects having serological evidence of HEV infection denied previous history of jaundice which shows that HEV infection was subclinical in those cases. Ten (55.6%) pregnant females participating in the study, as well as 48 (62.3%) non pregnant females lacked serological evidence of HEV infection; i.e., 60.01% (10 + 48 out of 95) of women in the childbearing age may be susceptible to infection. This report suggests that HEV is endemic in Alexandria, Egypt; the epidemiologic risk factors associated with HEV infection need further exploration.

Antibodies to certain arboviruses in humans from a flooded village in Egypt.

A study was carried out on 180 sera collected from inhabitants of a seepage flooded village (Begiram) in a Nile Delta governorate in Egypt. The aim of the study was to monitor the prevalence of certain arboviruses; some of them are known to be endemic in Egypt. Sera were screened by ELISA except for the HTN by IF, and the results indicated that WN and SFS exhibited the highest prevalence 45.5% followed by SFN (21%). These 3 viruses are known to be endemic in Egypt. The high prevalence of W.N. and S.F.S viruses in Begiram village in comparison to lower rates detected in sera from nearby Sharkqiya governorate collected almost at the same time may reflect the adverse effect of the environmental change in the flooded village. RNF virus which caused a major epidemic in Egypt in 1977 and continued to be circulating until 1980, its antibodies were detected only in those above 20 years of age with a prevalence rate of 5%. Antibodies against two tick borne viruses viz QRF and CCHF were also detected with low prevalence rate 2.75% and 1.1% respectively; also antibodies to the rodent-borne HTN virus were detected with prevalence rate 1.1%. Antibodies to mosquito borne SIN and BAT viruses were not detected in the tested sera.

Recurrence of Rift Valley fever in Egypt.

Rift Valley fever (RVF) has been recorded in man and in domestic animals in Egypt after a 12-year absence. Human infections were first noted in the Aswan Governorate in late May, 1993. Only cases of ocular disease, an infrequent and late manifestation, were reported. Of 41 cases, 35 were tested serologically and 27 (77%) had RVF virus-specific IgM antibodies. An estimated 600-1500 infections occurred in the region. Abortions in cattle and buffalo were seen concurrently and antibodies to RVFV were present in 39% of domestic livestock, presumably unvaccinated. RVFV was isolated from an aborted water buffalo fetus.

Risk factors associated with a high seroprevalence of hepatitis C virus infection in Egyptian blood donors.

We performed serologic tests for hepatitis C virus (HCV) infection on sera obtained from 163 volunteer blood donors seen at one Cairo hospital. We found HCV infection in 36 donors (22%) measured by a second generation enzyme immunoassay. Thirty-five of these 36 positive sera were tested with a second generation recombinant immunoblot assay (RIBA-2); 22 (63%) were reactive and another 12 (34%) showed an indeterminate reaction. Overall, 13.6% (95% confidence interval [CI] = 8.3-18.9%) of these Egyptian blood donors were serologically confirmed to be infected with HCV. Of several demographic variables and medical risk factors examined, the serologically confirmed (RIBA-2 reactive) donors were significantly older than nonreactive donors, and the age-adjusted risk of being HCV-positive was significantly greater in individuals residing outside Cairo. A knowledge of having received injections, of having a history of schistosomiasis, or of having concomitant hepatitis B surface antigen or antibody were significantly associated with an increased risk of HCV-seropositivity; however, after adjusting for confounding demographic factors, only schistosomiasis (odds ratio = 8.9, 95% CI = 2.35-33.52) was significantly associated with HCV infection. The HCV seropositive rate of 13.6% among Egyptians is 5-35-fold higher than that reported from volunteer blood donors in other countries. Screening for HCV should be instituted in Egyptian blood banks. Blood banks that do not test for HCV should include a history of schistosomiasis in their exclusion criteria used for routine screening of blood donors.

Hepatitis C and B viruses, and their association with hepatocellular carcinoma in Egypt.

Hepatitis C and B viruses are associated with hepatocellular carcinoma in Europe, Asia and Southern Africa. A study of hepatitis C and hepatitis B virus infection was carried out on 70 patients with HCC, from the National Cancer Institute, Cairo University. Sera from patients were tested for anti-HCV and HBsAg markers. Twenty patients (30%) were anti HCV positive alone, 15 (21.4%) were HBsAg positive alone, 28 (40%) were positive for both anti-HCV and HBsAg and the remaining 6 patients (8.6%) were negative for the two markers. The total positivity for anti-HCV and for HBsAg in these patients was 70% and 61.4% respectively. The comparable figures in a recent study on 90 blood donors from Egypt, were 24.4% for anti-HCV and 4.4% for HBSAg. These data suggest a possible link between HCV and HBV infection and the development of hepatocellular carcinoma in Egypt, as has been found elsewhere in the world.

Hepatitis B & D viral infections among schistosomal patients in Egypt.

A comparative study was done between schistosomal and non-schistosomal groups of acute and chronic HB patients to explore the possible role of schistosomiasis in predisposition to HBV and HDV infections in Egypt. The studied groups were 116 cases of acute hepatitis (78 cases without schistosomiasis and 38 cases with schistosomiasis). The second group of the study was 51 chronic HB patients (31 with schistosomiasis and 20 cases without schistosomiasis). All cases were tested for HBV markers and anti-HDV using ELISA technique. In acute hepatitis patients, the percentage of HBV infection as detected by HBsAg was significantly higher in the schistosomal group (63.15%: 24 out of 38) compared to non-schistosomal patients (37.17%: 29 out of 78) (Table 1). Also, Anti-HBs was detected in a significantly higher proportion among schistosomal group (85.71%: 12 out of 14) compared to non-schistosomal acute HB cases (44.9%: 22 out of 49) (Table 2). The infection rate of HBV (HBsAg+anti-HBs) was found to be statistically higher among schistosomal compared to non-schistosomal patients (94.73%: 36 out of 38 and 65.38%: 51 out of 78 respectively) (Table 3). As regards HDV among schistosomal and non-schistosomal patients suffering from acute HB, frequency of anti-HDV was found to be 33.33% (8 out of 24 HB cases) in schistosomal group versus 17.24% (5 out of 29 HB cases) in the non-schistosomal (Table 4). In chronic HB patients, anti HDV was present as 29.03% (9 out of 31) and 15% (3 out of 20) in schistosomal and non-schistosomal groups respectively (Table 5). But the differences between schistosomal and non-schistosomal groups, as regards delta infection (anti-HDV) among acute and chronic HB patients, were not statistically significant. From the present study, it was concluded that schistosomiasis contributes to significantly increased HBV infection and possibly also HDV infection.

Hepatitis C virus infection in blood donors in Egypt.

A study was carried out on 90 serum samples from non-professional blood donors to find out the relative prevalence of HBV and HCV among those blood donors. Results demonstrated overall positivity rate of 14.4% for anti-HCV by RIBA test. The percentage of reactive sera was 6% for the age group of 20 to below 30 years, and 37.5% in those aged above 30 years, and this difference was statistically significant. Considering the combined reactivity of the tested 90 sera for anti-HBs and anti-HCV, the results showed that 41.1% of the sera were positive for anti-HBs; 10% reacted positively with both anti-HBs and anti-HCV, and 4.4% of the sera were positive for anti-HCV only. The high prevalence of anti-HCV in this study (14.4%) exceeds that reported in other countries, and is comparable with that of Saeed and associates (1991). These results may indicate endemicity of HCV in Egypt and/or a possible role of the endemic schistosomiasis. On the basis of data, suggesting that anti-HCV reflects persistent infection rather than immunity, screening for anti-HCV should be included in all blood transfusion services to exclude HCV which is responsible for 90% of PTH (Van der Poel et al., 1990; Weiner et al., 1990; and Esteban et al., 1991). The remarkably high seroprevalence of anti-HCV among Egyptian volunteer blood donors, which has not so far been reported from other countries, should be thoroughly studied. This should cover many aspects including large epidemiological studies, factors pertinent to Egypt as schistosomiasis, and other possible factors that might enhance HCV transmission in Egyptian population. High risk groups as the polytransfused and renal dialysis patients should be studied. Needless to say that, an accurate measure of HCV prevalence depends on specificity and sensitivity of the employed laboratory diagnostic tests; development of new tests for the detection of antibodies to HCV, together with development of tests for other markers such as HCV antigen and the polymerase chain reaction to detect HCV DNA in blood, will be of great help.

Antibody level after measles vaccination.

The present study was designed to estimate the level of measles IgG antibody in infants early after vaccination and in preschool children to determine their immune status. Three groups were studied: Group I, unvaccinated infants, Group II, recently vaccinated infants and Group III vaccinated preschool children. Measles IgG antibody was measured using the ELISA technique. The study showed that 90% (18/20) of the unvaccinated Group I infants were seronegative and only 10% were seropositive for measles IgG antibody representing most probably persisting maternal antibodies. Fifty percent (15/30) of recently vaccinated Group II infants were seropositive. A statistically significant higher antibody level was observed in Group II infants in comparison to those of Group I. The majority of seropositive infants of Group II (10/15 = 66.7%) showed high antibody level representing successful vaccination. Seropositives represented 77.4% (24/31) of Group III preschool children and the majority of them 75% (18/24) showed high antibody level which was significantly higher than the comparable in Group II infants, most probably due to subclinical infection in addition to successful vaccination. Fifty percent (15/30) of Group II infants and 22.6% (7/31) of Group III children were seronegative, more likely due to failure of initial vaccination.

Delta virus infection in Egypt.

The present study was carried out on 124 serum samples of acute hepatitis B, 51 with chronic HBV infection, and 41 chronic HBsAg carriers. Sera were tested by ELISA for HBV markers and anti-delta (anti-HDV). Delta infection (anti-HDV) in acute HB was found to be 16.9% (21 out of 124), 23.5% in chronic HB cases (12 out of 51), and 21.9% among chronic HBsAg carriers (9 out of 41). Out of the twelve delta positive in chronic HB patients, ten (83%) were suffering from CAH (chronic active hepatitis) denoting a possible role of delta infection in deteriorating the course of the disease. A competitive inhibition of HBV replication by coexistent delta infection was demonstrated in the present study. This was reflected on anti-HBc IgM in the acute cases and on HBeAg in chronic HB cases. Anti-HBc IgM was 71.42% (15 out of 21) in delta positive acute HB patients versus 92.23% (95 out of 103) in delta negative acute HB patients. On the other hand, HBeAg percentage was 8.33% (1 out of 12) and 46.15% (18 out of 39) in delta and non-delta chronic HB patients respectively. The difference in both anti-HBc IgM and HBeAg as regards delta positive and negative patients was found to be statistically significant. Out of the twelve chronic HB cases with delta infection, four cases were negative for HBsAg (33.33%). This observation might be attributed to the clearance effect of hepatitis D virus (HDV) on HBsAg (Ischimura et al., 1988) or due to suppressing effect resulting in low undetectable HBsAg level in serum, (Sherlock, 1989). From the present study it may be concluded that delta infection is endemic in Egypt (its incidence ranged from 16.94% in acute HB to 23.53% in chronic HB infection), delta infection possibly also worsens the outcome of chronic HB patients. Delta infection may exert a competitive inhibitory effect on HBV replication.

Non-A, non-B viral hepatitis in Egypt.

A study was carried out on 200 patients of ages 20-40 years suffering from acute viral hepatitis. Sera were tested for markers of hepatitis B (HBsAg, and IgM anti-HBc) and hepatitis A (IgM-anti-HAV) by the ELISA technique. Sera negative for the markers of both viruses: Hepatitis A (HAV) and Hepatitis B (HBV) were subsequently tested for IGM Heterophil antibodies against Epstein-Barr virus (EBV) by the Monospot slide test to diagnose acute infectious mononucleosis and tested for anti-CMV (IgM) by ELISA technique for the diagnosis of acute Cytomegalovirus (CMV) infection. Non-A, non-B hepatitis (NANB) was diagnosed by exclusion. The results of the study showed that 133 (66.5%) patients had evidence of HBV infection, while only 9(4.5%) were diagnosed as HAV infection. EBV and CMV were the possible etiological agents of acute viral hepatitis in (3.5%) and 1%) respectively. Accordingly the Non-A, non-B hepatitis in this study amounts to (24.5%) of the acute viral hepatitis.

Rubella virus antibodies in women of childbearing age.

Rubella is a common contagious disease with mild constitutional symptoms, but when it occurs during pregnancy there is significant risk of severe damage to the fetus. A study was undertaken to determine the level of rubella virus antibodies in females in the childbearing age (from 15-40). A total of one hundred and thirty sera were examined for rubella-specific IgG antibodies by hemagglutination inhibition (HAI) test. Ninety out of these sera were examined also by ELISA, for comparative purposes. It was found that, by HAI test, the percentage of antibody positive sera in the females was 72.2% (HAI titer greater than 1:16), while by the more sensitive ELISA test, the percentage of antibody positive sera was 92.2% (50 IU/ml antirubella IgG). The most susceptible females were in the age group of 20-25 years. The need to ensure the protection of seronegative susceptible women of childbearing age by immunization before marriage or pregnancy is emphasized. ELISA is more sensitive, rapid, specific, reproducible and easily adaptable test to large scale screening than the conventional HAI test.

Sand fly fever-Naples infection in Egypt.

Two Egyptian male patients with sand fly fever-Naples virus infection are presented. The virus was isolated from one patient while both patients had diagnostic rises in indirect fluorescent antibody titers to the virus. The viral isolate, SFN 85055, grows to much higher titers and plaques more efficiently than the prototype sand fly fever-Naples virus and should facilitate work with this virus.

Arboviral causes of non-specific fever and myalgia in a fever hospital patient population in Cairo, Egypt.

Fever and myalgia are non-specific clinical manifestations of illness which commonly occur in patients with arboviral disease. In Egypt, such illness is often mis-diagnosed as "influenza". To determine arboviral aetiology in patients admitted with fever and myalgia, acute and convalescent sera samples were obtained from 55 patients admitted with these clinical manifestations to the Imbaba Fever Hospital, Giza, Egypt, during October and November 1984. Based on viral isolation, and a comparison of acute and convalescent sera, 4 patients (7%) had acute arboviral infections. Haemagglutination inhibition and indirect immunofluorescence tests showed that one had West Nile virus (WNV) infection, 2 had sandfly fever virus-Naples (SFN), and 1 had sandfly fever virus-Sicilian (SFS) infection. SFN was isolated from the acute serum sample of 1 of the 2 patients with SFN infection.

Serological tests for detecting Rift Valley fever viral antibodies in sheep from the Nile Delta.

To determine the accuracy of serological methods in detecting Rift Valley fever (RVF) viral antibodies, we examined serum samples obtained from 418 sheep in the Nile Delta by using five tests. The plaque reduction neutralization test (PRNT) was considered the standard serological method against which the four other tests were compared. Twenty-four serum samples had RVF viral antibodies detected by PRNT. Hemagglutination inhibition and enzyme-linked immunosorbent assay antibodies to RVF virus were also present in the same 24 serum samples. Indirect immunofluorescence was less sensitive in comparison with PRNT, and complement fixation was the least sensitive. These results extend observations made with laboratory animals to a large field-collected group of Egyptian sheep.