Seroprevalence of hepatitis B virus infection, anti-HCV antibodies and HIV and knowledge among people who use drugs attending methadone therapy clinic in Tanzania; a cross-sectional study.

BACKGROUND: Methadone therapy clinics have been recently introduced in Tanzania, aiming at reducing risk behaviors and infection rates of viral hepatitis and HIV among people who use drugs. The objective of this study was to estimate the prevalence, associated factors and knowledge level of these conditions among people who use drugs attending a methadone clinic in Tanzania. METHODS: We enrolled 253 People who using drugs receiving Methadone therapy. Clinical data was retrospectively collected from the medical records and face-to face interviews were conducted to determine the behavioral risk factors and respondents' knowledge on viral hepatitis and HIV. RESULTS: An overall seroprevalence of viral hepatitis (either hepatitis B surface antigen or anti-hepatitis C virus) was 6.3%, while that of hepatitis B virus mono infection was 3.5% and anti-hepatitis C antibodies was 3.5%. Seroprevalence of HIV was 12.6%. Viral hepatitis was strongly predicted by advanced age (> 35 years) (p = 0.02) and staying at Kirumba area (p = 0.004), and HIV infection was predicted by increased age (> 37 years) (p = 0.04) and female sex (p < 0.001). Regarding the knowledge of viral hepatitis, majority of the respondents were unaware of the transmission methods and availability of hepatitis B virus vaccines and only 17% were classified as well informed (provided ≥4 correct answers out of 7 questions). Good knowledge was highly predicted by higher education level of the individual (p = 0.001). CONCLUSIONS: Despite the efforts to curb viral hepatitis and HIV infections through Methadone clinics, infection rates among people who use drugs are still high and the general knowledge on preventive measures is inadequate.

Schistosoma mansoni-related periportal fibrosis; can we use APRI and PSDR levels in the real-time selection of patients for targeted endoscopy in a resource-limited setting? A case-control study.

BACKGROUND: Schistosoma mansoni related hepatic fibrosis is usually associated with hemodynamic alteration with increased mortality due to bleeding varices. The diagnosis of varices before bleeding imposes a big challenge in resource-limited countries using endoscopy. Published evidence on the utility of non-invasive clinical tools in predicting the presence of varices among patients with S. mansoni related periportal fibrosis is still inadequate including Aspartate to platelet ratio index (APRI) and Platelet to splenic diameter ratio (PSDR) levels. This study describes the determinants of portal varices and assesses the potential utility of the APRI and PSDR level in the discrimination of portal varices among patients with S. mansoni related periportal fibrosis (PPF). METHODS: A case-control study using cross-sectional data was done among patients with Schistosoma mansoni related periportal fibrosis at Bugando Medical Centre, in Mwanza Tanzania. The derivation cohort included patients enrolled between 2015 and 2019 and the validation cohort included patients enrolled from 2019 till March 2021. Socio-demographic, laboratory, ultrasound, and upper digestive endoscopic information were analyzed using STATA 13. The prevalence and determinants of varices were determined by logistic regression. The sensitivity and specificity of independent factors were determined to assess their utility in discriminating the presence of portal varices in patients with PPF. RESULTS: In total, 250 patients were included in the derivation cohort, 109 (43.6%; 95% CI 37.3-49.9) of them had varices. The odds of having varices were independently increased among patients with higher APRI levels than 1.51, (AOR: 5.8; 95% CI 3.1-11.1; p < 0.001) and PSDR levels that were lower than 5700 (AOR: 5.9; 95% CI 3.2-11.2; p < 0.001). Both APRI and PSDR levels had significantly high sensitivity and specificity in predicting the presence of esophageal varices. However, the combined values of APRI and PSDR had higher specificity than any of the two markers. Of the 200 patients in the validation cohort 94 (47.0%; 95% CI 40.0-54.2) had varices, the discriminative power of the final model and the predictive ability of both APRI, PSDR, and APRI-PSDR combined levels were highly maintained. CONCLUSIONS: This study indicates that varices are a common encounter among patients with S. mansoni related periportal fibrosis and it is independently associated with higher APRI and lower PSDR levels suggesting that these tools are potential discriminators of varices in this subgroup of patients. The reproducibility of these results should further be assessed longitudinally as potential non-invasive tools in selecting patients at high risk of having esophageal varices who could benefit from the targeted endoscopic intervention in a resource-limited setting like ours.

Can Early Diagnosis of Varices, Regular Praziquantel, and Reduction of Hepatitis Coinfection Reduce Mortality among Patients Attended for Periportal Fibrosis in Northwestern Tanzania? A Case-Control Study.

BACKGROUND: Schistosoma mansoni is highly endemic in the Lake Zone part of Tanzania and most people are chronically infected. Periportal fibrosis (PPF) is the commonest complication of chronic S. mansoni infection documented in up to 42% of studied participants in the community-based studies. These patients are at high risk of mortality since most of them are diagnosed late with bleeding varices. At Bugando, Schistosoma-related varices contributed to 70% of patients admitted due to vomiting blood with a two months' mortality of over 10%. Earlier studies had reported higher mortality of up to 29% among patients with PPF even with the best in-hospital care. Understanding factors that increased the risk of mortality is important clinically in devising ways that can improve the outcome of this subgroup of patients. METHODS: A retrospective analysis of patients with PPF from 2015 through 2018 was done. Their sociodemographic, clinical, laboratory, ultrasonographic, endoscopic, and survival status data were collected for analysis. STATA 13 was used for analysis, the prevalence of varices, active schistosomiasis, and hepatitis B coinfection was determined. Cumulative mortality as a major outcome was also determined, and factors associated with increased risk of mortality were assessed by a logistic regression model. RESULTS: In total, 250 participants were included in this analysis. Majority, 222 (88.8%; 95% CI: 84.2-92.4) had active S. mansoni infection, and 40 (16.0%; 95% CI: 11.6-21.1) had S. mansoni-HBV coinfection. Cumulatively, 39 (15.6%; 95% CI: 11.3-20.7) patients died, with most deaths, 31 (79.5%; 95% CI: 63.5-90.7) occurring within two years following the diagnosis of PPF (chi2 = 6.3; p = 0.012). The odds of mortality were independently associated with fishing (OR: 10.8; 95% CI: 2.2-52; p = 0.003), upper gastro intestinal bleeding (OR: 2.4; 95% CI: 1.1-5.4; p = 0.037), HBV coinfection (OR: 3.3; 95% CI: 1.2-91; p = 0.019), and ascites (OR: 3.3; 95% CI: 1.3-8.2; p = 0.010). CONCLUSIONS: In this, S. mansoni endemic area, varices, actives schistosomiasis, hepatitis B coinfection, and mortality are highly common. Screening for varices and initiation of prophylaxis, administration of praziquantel, and screening for hepatitis B should be part and parcel of care of these patients. The first two years of diagnosis, patients are at high risk of mortality; risk factors in this study should assist planning a closer follow-up of patients at risk of mortality to improve their long-term outcome.

Morbidity and Mortality Due to Schistosoma mansoni Related Periportal Fibrosis: Could Early Diagnosis of Varices Improve the Outcome Following Available Treatment Modalities in Sub Saharan Africa? A Scoping Review.

Schistosomiasis affects about 240 million people worldwide and Schistosoma mansoni alone affects over 54 million people leaving 400 million at-risk especially in Sub Saharan Africa (SSA). About 20 million people are currently suffering from complications of chronic S. mansoni infection and up to 42% of those infected have been found with periportal fibrosis (PPF). About 0.2 million deaths are attributed to chronic S. mansoni every year, which is mainly due to varices. Death occurs in up to 29% of those who present late with bleeding varices even with the best available in-hospital care. The diagnosis of varices before incident bleeding could potentially improve the outcome of this subgroup of patients is SSA. However, there is no prior review which has ever evaluated this issue detailing the magnitude and outcome of varices following available treatment modalities among patients with Schistosoma PPF in SSA. This review summarizes the available literature on this matter and exposes potential practical gaps that could be bridged to maximize the long-term outcome of patients with S. mansoni related PPF in SSA. A total of 22 studies were included in this review. The average prevalence of varices was 82.1% (SD: 29.6; range: 11.1%-100%) among patients with PPF. Late diagnosis of varices was frequent with average bleeding and mortality of 71.2% (SD: 36.5; range: 4.3%-100.0%) and 13.6% (SD: 9.9; range: 3.5%-29%), respectively. Predictors were reported in seven (31.8%) studies including platelet count to splenic diameter ratio (PSDR) for prediction large varices in one study. Active S. mansoni infection was very prevalent, (mean: 69.9%; SD: 24.4; range: 29.2-100.0%). Praziquantel could reverse PPF and use of non-selective B-blockers reduced both rebleeding and mortality. Use of sclerotherapy for secondary prevention of variceal bleeding was associated with high rebleeding and mortality rates. Conclusions: This review shows that varices due to schistosomal PPF are a big problem in SSA. However, patients are often diagnosed late with fatal bleeding varices. No study had reported a clinical tool that could be useful in early diagnosis of patients with varices and no study reported on primary and effective secondary prevention of bleeding and its outcome. Regular screening for S. mansoni and the provision of Praziquantel (PZQ) is suggested in this review. More studies are required to bridge these practical gaps in Sub Saharan Africa.

The magnitude and correlates of esophageal Varices among newly diagnosed cirrhotic patients undergoing screening fibre optic endoscope before incident bleeding in North-Western Tanzania; a cross-sectional study.

BACKGROUND: Bleeding esophageal varices is a deadly complication of liver cirrhosis. Guidelines recommend an early diagnosis of esophageal varices before incident bleeding by screening all patients diagnosed with liver cirrhosis. Though it has been reported elsewhere that the presence of esophageal varices varies widely among cirrhotic patients this has not been assessed in Tanzania since endoscopy is not readily available for routine use in our setting. This study was designed to determine the prevalence of esophageal varices and assess the utility of clinical parameters in predicting the presence of varices among cirrhotic patients in northwestern Tanzania. METHODS: A cross-sectional analysis of adult patients with liver cirrhosis was done at Bugando Medical Centre. Demographic, clinical, laboratory and endoscopic data were collected and analyzed using STATA 13. The presence of esophageal varices was detected using endoscopic examination and associated factors were assessed by logistic regression. The predictive value of clinical predictors was also assessed by calculating sensitivity and specificity. RESULTS: A total of 223 patients were enrolled, where 88 (39.5%; 95%CI: 33.0-45.9) had esophageal varices. The varices were independently associated with increased age (OR: 1.02; 95%CI: 1.0-1.04; p = 0.030); increased splenic diameter (OR:1.3; 95%CI:1.2-1.5; p <  0.001), increased portal vein diameter (OR:1.2; 95%CI: 1.07-1.4; p = 0.003), having ascites (OR: 3.0; 95%CI: 1.01-8.7; p = 0.046), and advanced liver disease (OR: 2.9; 95%CI: 1.3-6.7; p = 0.008). PSDR least performed in predicting varices, (AUC: 0.382; 95%CI: 0.304-0.459; cutoff: < 640; Sensitivity: 58.0%; 95%CI: 46.9-68.4; specificity: 57.0%; 95%CI: 48.2-65.5). SPD had better prediction; (AUC: 0.713; 95%CI: 0.646-0.781; cut off: > 15.2 cm; sensitivity: 65.9%; (95% CI: 55-75.7 and specificity:65.2%; 95%CI: 56.5-73.2), followed by PVD, (AUC: 0.6392; 95%CI: 0.566-0.712;cutoff: > 1.45 cm; sensitivity: 62.5%; 95CI: 51.5-72.6; specificity: 61.5%; 95%CI: 52.7-69.7). CONCLUSION: Esophageal varices were prevalent among cirrhotic patients, most of which were at risk of bleeding. The non-invasive prediction of varices was not strong enough to replace endoscopic diagnosis. However, the predictors in this study can potentially assist in the selection of patients at high risk of having varices and prioritize them for endoscopic screening and appropriate management.