Anti-HBc screening in Egyptian blood donors reduces the risk of hepatitis B virus transmission.

Occult hepatitis B virus (HBV) in blood donors is considered as a potential risk for transmission of HBV infection. The aim of this study was to determine the prevalence of anti-hepatitis B core antibody (anti-HBC) positivity in Egyptian blood donations as well as to estimate the frequency of HBV-DNA in anti-HBc-positive donations. The study included 760 Egyptian healthy blood donors, representing 26 different Egyptian governorates screened according to routine practice for the presence of hepatitis B surface antigen (HBsAg), hepatitis C virus (HCV) antibodies (Abs), HIV-1/2 Abs and Treponema Abs. The accepted blood units for donation were tested for the presence of total anti-HBc Abs by two tests. Positive units for anti-HBc were further tested for HBV-DNA by polymerase chain reaction. According to routine screening, a total of 48/760 units (6.3%) were rejected [38 (5%) HCV-Ab-positive units, 9 (1.18%) HbsAg-positive units and 1 (0.13%) Treponema-Ab-positive unit]. Among the accepted blood units for donation, prevalence of anti-HBc was 78/712 units (10.96%). HBV-DNA was detected in 9/78 (11.54%) of the anti-HBc-positive units, and thus, occult HBV infection was detected in 9/712 (1.26%) of the accepted blood donations. Implementing anti-HBc test to the routine assay for the forthcoming two decades would certainly eliminate possible HBV-infected units. Rejection of these units will be beneficial to decrease the risk of HBV transmission with its potential consequences particularly in immunocompromised recipients.

Prevalence of GBV-C/hepatitis G virus viraemia among blood donors, health care personnel, chronic non-B non-C hepatitis, chronic hepatitis C and hemodialysis patients in Egypt.

A new RNA virus, designated GBV-C/hepatitis G virus (HGV) has been identified recently. To evaluate the prevalence of GBV-C/HGV infection among Egyptians, five groups were enrolled in this study: group I, healthy blood donors (82); group II, health care personnel (30); group III, chronic non-B non-C hepatitis patients (63); group IV, chronic hepatitis C patients (100); group V, renal dialysis patients (79). GBV-C/HGV-RNA was detected by nested reverse transcription-polymerase chain reaction (RT-PCR) using primers derived from 5'-non coding region of GBV-C/HGV. GBV-C/HGV-RNA was detected in 57 of 354 tested sera with an overall prevalence of 16.1%. Meanwhile, isolated GBV-C/HGV infection was detected in 16/57 (28.1%), GBV-C/HGV coinfection with hepatitis C virus (HCV) in 37/57 (64.9%) and with hepatitis B virus (HBV) in 4/57 (7.6%) of cases. The highest prevalence was encountered among dialysis patients reaching 30% followed by chronic hepatitis C (14%), blood donors (12.2%), chronic non-B non-C hepatitis (11.1%), whereas the lowest prevalence rate of 6.6% was detected among health care personnel. Nucleotide sequence analysis in three Egyptians confirmed that these PCR products were derived from GBV-C/HGV genome and all isolates classified into US/European type (type 2) of GBV-C/HGV genotypes. The risk factors of all cases were non-transfusion parenteral exposure, e.g. reusing syringes, dental treatment, surgery, invasive medical maneuvers, with an exception of renal dialysis patients who have had repeated blood transfusion. It is concluded that there is a relatively high prevalence of GBV-C/HGV-RNA among different Egyptian groups compared to international figures. The main risk factors were direct percutaneous exposure rather than blood transfusion. The Egyptian GBV-C/HGV isolates are very similar to the American isolate PNF 2161.

Prevalence and epidemiological features of hepatocellular carcinoma in Egypt-a single center experience.

Background: The studies carried out on hepatocellular carcinoma (HCC) are scarce in Egypt. Nevertheless, they presumed an upward trend for HCC among chronic liver disease (CLD) patients. The objectives of this research were to determine the trend of HCC, the possible risk factors implicated in its development and the population attributable risk of HCVAb and HBsAg positivity for HCC. Methods: Medical records of all patients attending Cairo Liver Center during the years 1992-1995 were reviewed to determine the sociodemographic characteristics, HCVAb, HBsAg and HCC status. Prospectively, 200 HCC cases' stored sera as well as 120 healthy control were tested for aflatoxin B(1) quantitatively and qualitatively. Results: HCC accounted for 4.7% (321/6850) of CLD patients included in the study. HCVAb positive cases were strikingly high (71.1%) and HBsAg positive cases were reported in 22.4% of patients. There was an annual significant rise of HCC ranging from 3.6% in 1992 to 5.3% in 1995. HCC was significantly more prevalent among old age groups (60 years) than younger age groups. The impact of gender and past history of schistosomiasis on HCC was not proved by this study. HCVAb and HBsAg positivity were the two significant independent risk factors for HCC. The population attributable risk percent has shown that HCC cases attributed to HCVAb positivity accounted for 51.1%; while HBsAg positivity only explained 21.3% of cases. Aflatoxin B(1) was detected in 17% of HCC cases compared to 9.4% of healthy control. Risk ratio=2(95%). Conclusion: HCC is showing an increasing trend among our patients. Its development is mainly due to high rates of HCVAb and HBsAg positivity. HBsAg positive patients were at double risk to develop HCC and HCVAb positive patients were at 1.6 more risk. The high prevalence of HCVAb positivity renders its contribution to the development of HCC over seven-fold higher than HBsAg positivity. Short and long term health strategies are crucial to prevent and control HCC in Egypt.

Impact of cigarette smoking on response to interferon therapy in chronic hepatitis C Egyptian patients.

AIM: Smoking may affect adversely the response rate to interferon-alpha. Our objective was to verify this issue among chronic hepatitis C patients. METHODS: Over the year 1998, 138 chronic hepatitis C male Egyptian patients presenting to Cairo Liver Center, were divided on the basis of smoking habit into: group I which comprised 38 smoker patients (>30 cigarettes/d) and group II which included 84 non-smoker patients. Irregular and mild smokers (16 patients) were excluded. Non eligible patients for interferon-alpha therapy were excluded from the study and comprised 3/38 (normal ALT) in group I and 22/84 in group II (normal ALT, advanced cirrhosis and thrombocytopenia). Group I was randomly allocated into 2 sub-groups: group Ia comprised 18 patients who were subjected to therapeutic phlebotomy while sub-group Ib consisted of 17 patients who had no phlebotomy. In sub-group Ia, 3 patients with normal ALT after repeated phlebotomies were excluded from the study. Interferon-alpha 2b 3 MU/TIW was given for 6 mo to 15 patients in group Ia, 17 patients in group Ib and 62 patients in group II. Biochemical, virological end-of- treatment and sustained responses were evaluated. RESULTS: At the end of interferon-alpha treatment, ALT was normalized in 3/15 patients (20%) in group Ia and 2/17 patients (11.8%) in group Ib compared to 17/62 patients (27.4%) in group II (P = 0.1). Whereas 2/15 patients (13.3%) in group Ia. and 2/17 patients (11.8%) in group Ib lost viraemia compared to 13/62 patients (26%) in group II (P = 0.3). Six months later, ALT was persistently normal in 2/15 patients (13.3%) in group 1a and 1/17 patients (5.9%) in group Ib compared to 9/62 patients (14.5%) in group II (P = 0.47). Viraemia was eliminated in 1/15 patients (6.7%) in group Ia and 1/17 patients (5.9%) in group Ib compared to 7/62 patients (11.3%) in group II, but the results did not mount to statistical significance (P = 0.4). CONCLUSION: Smokers suffering from chronic hepatitis C tend to have a lower response rate to interferon-alpha compared to non-smokers. Therapeutic phlebotomy improves the response rate to interferon-alpha therapy among this group.

Bile duct carcinoma in Egypt: possible etiological factors.

Contrary to an old belief, bile duct carcinoma is not a rare disorder in Egypt. Among 730 patients referred for an ERCP examination, twenty-nine consecutive patients were diagnosed as having bile duct carcinoma. The cause of this type of carcinoma remains unknown. In the present study, only seven of the 29 (24.1%) with bile duct carcinoma patients had associated gallstones. In order to investigate the possible association between typhoid carrier state and bile duct carcinoma, stool cultures were performed for Salmonella typhi and Salmonella paratyphi A and B. Nine out of 23 patients (39.1%) with bile duct carcinoma, 17 out of 50 (34%) with calcular obstructive jaundice, and 1 out of 50 (2%) healthy individuals proved to be salmonella carriers. Statistical analysis of the results confirmed the presence of a significant association between chronic fecal thyphoid carrier state and bile duct carcinoma, while that between calcular obstructive jaundice and bile duct carcinoma was not significant. In conclusion, there might be an association between chronic fecal typhoid carrier state and bile duct carcinoma.

Vascular alterations of the colonic mucosa in schistosomiasis and portal colopathy.

BACKGROUND/AIM: Portal colopathy, the occurrence of vascular-ectasia like lesions has been observed in patients with portal hypertension of variable etiology. Schistosomiasis is a major cause of liver damage and portal hypertension. In colonic schistosomiasis, vascular alterations are commonly observed. It is therefore possible that schistosomiasis may induce portal colopathy in addition to inflammatory changes directly induced by oviposition. MATERIALS AND METHODS: In order to examine this possibility, we reviewed the endoscopic data obtained in 100 consecutive patients with established bilharziosis. In addition, endoscopic biopsies from all patients were examined for the presence of inflammation, parasite eggs, granulomas and mucosal vascular congestion. The latter was assessed using immunohistochemical staining for Ulex Europaeus. RESULTS: Endoscopic abnormalities were observed in 66/100 patients. The main lesions were abnormalities in vascularisation of the mucosa, especially hyperemia, defined as the presence of numerous, prominent and irregular vessels (62%) and telangiectasia (4%). The mucosal biopsies revealed prominent vascularisation in 60% of the cases. Positivity for ulex staining was significantly correlated with the finding of hyperemia during endoscopy and with the presence of ova. No good correlation was found with the clinical presentation. The lesions were not well correlated with the presence of an increased cellular infiltrate in mucosal biopsies. CONCLUSIONS: This observation suggests that portal colopathy may explain some of the endoscopic lesions observed in the colon of patients with Schistosomiasis.

Effect of the oral antibilharzial niridazole (ambilhar) on patients with concomitant schistosomiasis and HBs antigenaemia.

Twenty-three patients received oral antibilharzial therapy in the form of niridazole tablets (10 mg/kg body weight for 20 days), and 10 patients served as controls. Three months post-therapy, 14 out of 23 treated patients (61%) had cleared the HBsAg. This was found to be statistically significant. In contrast, 2 of the controls (20%) had eliminated the HBsAg from the serum. It is concluded that patients suffering from concomitant schistosomiasis and HBs antigenaemia are enabled to eliminate the HBsAg after niridazole therapy.

Hepatic angiosarcoma among Egyptian farmers exposed to pesticides.

A greatly increased incidence of hepatic angiosarcoma (H.A.S.) among Egyptian farmers involved in pest-control spraying operations attracted our attention. Fourteen patients were diagnosed at Ain Shams University Hospital between the years 1980-1984 as having H.A.S. Eleven were males and 3 females with an average age of 49 years, and a male:female ratio of 3.8:1. Eleven patients reside in Lower Egypt and 3 in Upper Egypt. Ten out of the 14 patients had a definite history of a direct chronic recurrent exposure to agricultural pesticides of variable chemical nature, throughout the year. The period of exposure ranged from 11-20 years with an average of 14 years. The other 4 patients had no history of exposure to any of the known carcinogenic factors. This significant increase in angiosarcoma among farmers involved in pesticide spraying suggests that agricultural pesticides might play a role in the genesis of H.A.S. in Egypt.

Prevalence of delta antibodies among urban HBsAg-positive chronic liver disease patients in Egypt.

The prevalence of delta infection among urban Egyptians is reported for the first time. Sera of 44 HBsAg-positive chronic liver disease (CLD) patients and 48 asymptomatic HBsAg carriers were screened for antibodies to hepatitis delta antigen (anti-HD). Anti-HD was found in 21 (47.7%) of the patients compared with 4 (8.3%) of the asymptomatic carriers. The difference was statistically significant at the 0.001 level. Anti-HD was present in 14 out of 24 (58.3%) subjects with histological diagnosis of chronic active hepatitis, 4 of 9 (44.9%) with cirrhosis, and 3 out of 11 (27.2%) with chronic persistent hepatitis. This study points to a high prevalence of hepatitis delta virus in Egypt.

Association of chronic hepatitis C infection and diabetes mellitus.

The aim of the study was to detect a possible aetiological association between chronic hepatitis C virus (HCV) infection and diabetes mellitus (DM). Among the 591 HCV seropositive chronic liver disease (CLD) patients, 150 (25.4%) had associated diabetes mellitus while only 25 of 223 HCV seronegatives (11.2%) were diabetics. The HCV seropositive patients were three times more likely to suffer from diabetes mellitus than those who were HCV seronegative and the results were highly significant (odds ratio = 2.7, CI = 1.7-4.4, P < 0.0001). Liver biopsy showed cirrhosis in 24 out of 53 (45.3%) HCV seropositive diabetics and 9/20 (45%) of the HCV seronegative diabetics. The association between the degree of liver disease and the development of diabetes mellitus did not differ statistically between the two groups. Islet cell antibody (ICA) was present in 44.4% of HCV seropositives compared to 73.3% of seronegative diabetics, while NIDDM showed 40% ICA positivity. Although ICA level was highest in HCV seronegative diabetics, the difference between the various groups was not significant statistically. About 29% of HCV seropositive diabetics were on insulin therapy while only 16% of HCV seronegative diabetics received insulin therapy. HCV seropositives were about 2 times more prone to require insulin therapy than HCV seronegatives (odds ratio = 2.0, CI = 1.2-5.7, P = 0.010). We conclude that chronic hepatitis C patients in Egypt are three times more likely to develop DM than HCV seronegative patients. Pancreatic beta -cells might be an extrahepatic target of HCV.

Does schistosomiasis play a role in the high sero prevalence of HCV antibody among Egyptians?

Many studies have demonstrated a very high prevalence of HCV antibodies among blood donors (BD) and chronic liver disease (CLD) patients in Egypt. This high prevalence might be attributed to cross reactivity between HCV antibodies and schistosome antibodies. We decided to study the association and cross serology between the presence of anti-HCV and Schistosomal infection among BD and CLD patients. Sera of blood donors and CLD patients were tested for anti-HCV by second generation ELISA. Antibodies to Schistosoma species were quantified by IHA test. Two tailed z score was used to detect significant difference. To test for cross reactivity between the two antibodies 20 BD and 20 CLD patients positive for both HCV-antibody and schistosome antibody were taken as controls. Another 20 samples also served as a control group; 10 of them seropositive for HCV only and 10 positive for IHA for schistosomiasis alone. All were subjected to: 1) RIBA-2 confirmatory test 2) Adsorption of schistosome antibodies using 100 microgram schistosome antigens per 100 microliters serum 3) Both HCV-ELISA-2 and RIBA-2 were checked after adsorption. The titre of schistosome antibodies in positive sera ranged from 1:128 to 1:1536. HCV seroprevalence was more pronounced among antischistosomal positive sera. This was seen in both BD and CLD patients where antischistosomal positive sera were at double risk to show positive HCV antibody. After adsorption of schistosome antibody, there was no change in reactivity of both ELISA-2 and RIBA-2. We conclude that HCV antibodies were significantly higher in schistosomal antibody positive Egyptians, there was no cross reactivity between the two antibodies and the high prevalence could be due to HCV transmission during anti-bilharzial parenteral therapy or due to depressed cell mediated immunity associated with schistosomal infection.

Problems of education and training in gastroenterology in the Middle East and Africa.

Gastrointestinal diseases are prevalent throughout the Middle East and Africa, causing high morbidity and mortality. The available data point to a morbidity of 20% in Zimbabwe and 18% in Egypt, and to a mortality of 26.6%, 17.9%, and 7.9% in Egypt, Mauretania, and Syria, respectively. However, most if not all the countries in our area of interest lack valid medical statistics. Gastroenterology is a neglected speciality in our region. Community-based curricula have only been tried in Egypt and Sudan universities. In Egypt, which tops the list, the number of gastroenterologists serving the community is 1/500,000, compared with 1/400,000 in Turkey and 1/100,000 in Denmark. Lack of funding is of considerable importance, as are low salaries, shortage of and insufficient service of equipment, and inability to attend international meetings. Gastroenterology is not represented at departmental levels in hospitals. There is a lack of team spirit among the medical profession, at the expense of much duplication of equipment. In most African countries training programs and gastrointestinal societies are lacking. The needs for the future: establishment of national programs for education and training in gastroenterology; creation of departments of gastroenterology and of membership/fellowship/university degrees; establishment of community-based curricula and promotionally based training; creation and reviving of societies of gastroenterology; and organization of activities, team work, and economic support of training programs.

Hepatitis C virus genotypes among HCV-chronic liver disease patients in Egypt: a leading trial.

UNLABELLED: In this trial, we have checked 50 anti-HCV positive, HCV-RNA PCR positive chronic liver disease cases, 44 males, 6 females with a mean age of 51 years. HCV-RNA extraction and genotyping was carried out at the Department of Medical Microbiology, University of Edinburgh, U.K. results showed that 47 (94%) of patients were of genotype 4 and 3 (6%) were of genotype 1. Liver biopsies were performed in 22 only out of the 50 patients studied. The 3 genotype 1 patients were biopsied, 2 had cirrhotic profile and one had CAH. Of 47 genotype 4 patients, 19 were biopsied, 3 were CPH, 2 had CLH, 9 had CAH, 4 had cirrhosis and one patient had HCC. CONCLUSION: It appears that Egypt hosts predominantly HCV genotype 4 and less commonly genotype 1. This finding might have important implications concerning the epidemiological aspects, pathogenesis and response to antiviral therapy.

Controlled trial with interferon alfa 2-b in chronic hepatitis C patients.

Thirty-eight chronic hepatitis C (CHC) Egyptian patients with persistently elevated serum alanine aminotransferase (ALT) for 6 months were randomly allocated into 2 groups: Group I (19 patients) received 3 million units (MU) of interferon alpha - 2b (Intron-A) subcutaneously thrice weekly for 6 months. In group I, complete response (normalization of ALT by the end of treatment) was achieved in 8 patients (42.1%), partial response (decrease of ALT by at least 50% of the pretreatment values) in 7 patients (36.8%) and no response in 4 (21.1%). Sustained response for 6 months after the end of therapy was attained in 4 of the 8 (50%) complete responders. Thus attaining an overall sustained response in 4 of the 19 patients (21.1%). In group II, spontaneous normalization of ALT was established in 1 patient (5.3%). Repeat liver biopsies in 16 patients of the interferon group, revealed moderate improvement in the degree of lobular inflammation, hepatocyte necrosis and portal inflammation. We conclude from this study that treatment of CHC with 3 MU of IFN-alfa 2b thrice weekly for 6 months is associated with a low response rate (21.1%). To improve the results, escalation of the IFN dose and/or prolongation of the treatment period should be considered.

High frequency of smooth muscle antibodies (SMA) among HCV positive chronic liver disease patients in Egypt.

UNLABELLED: Ninety-four HCV-positive CLD cases (56 males and 38 females with a mean age of 36 years) were matched to 50 HCV-ve CLD patients as a control group (30 males and 20 females with a mean age of 43 years). HCV antibody was screened by second generation ELISA, Ortho.. Autoantibodies (SMA, ANA, AMA, LKM1, SMA-anti-actin) were screened by immunofluorescence on cryostat murine sections using 1:40 serum dilution. Screening showed that 40 of 94 42.5%) HCV-positive CLD patients were positive for autoantibodies. Thirty eight of these were +ve for smooth muscle antibody (SMA) (40.4%), but all of them were negative for anti-actin, 3 were +ve for antinuclear antibody (ANA) (3.19%), while another 2 were +ve for antimitochondrial antibody (AMA) (2.1%). In the control group, 8(16%) were autoantibody +ve, 6 (12%) were SMA +ve, 2 (4%) were ANA +ve, 1 (2%) was AMA +ve and non had LKM1-Ab. There was significant difference between cases and controls concerning the autoantibody prevalence (P < 0.05). Although the prevalence of SMA among HCV +ve CLD cases was high (40%), yet, anti-actin antibody was totally negative, disclosing the insignificance of SMA positivity. It has been reported that the relevant SMA-AIH-1 is directed to the cell actin, whereas other SMAs have nothing to do with the immuno-pathogenesis of AIH. CONCLUSION: It seems that the predominant HCV genotype in Egypt is hardly associated with autoimmune phenomena.

Controlled trial with human lymphoblastoid interferon among HBeAg and anti-HBe-positive chronic hepatitis B patients in Egypt.

In a randomized controlled trial, sixty chronic hepatitis B liver disease patients (HBsAg +ve and HBV-DNA +ve) were randomly allocated into 2 groups. The first group comprised of 30 patients who were subdivided into 2 subgroups according to the HBeAg/anti-HBe system. One subgroup was HBeAg-positive (12 patients) and the other was anti-HBe-positive (18 patients). All were given human lymphoblastoid IFN alpha (Wellferon-R) at a dosage of 5 MU, thrice weekly for 4 months. The other 30 patients served as a control group, six of whom were lost during the study. The initial response was loss of HBV-DNA in 66.6% of the HBeAg +ve subgroup (8/12 patients), 33% in the anti-HBe subgroup (6/18 patients) and in 8% in the control group (2/24 patients). Patients and controls were followed up for 8 months after the end of IFN therapy. A sustained response (loss of HBV-DNA) 8 months after discontinuation of IFN was attained in 5/12 patients (41.6%) of the HBeAg-positive subgroup compared to none (0/24) in the control group (p < 0.05). In the anti-HBe subgroup, a sustained response in 2/18 patients (11%) compared to none (0/24) in the controls was not significant. We conclude from this study that (Wellferon-R) at a dosage of 5 MU given thrice weekly for 4 months was significantly better (p < 0.05) than no treatment in producing a sustained response among the HBeAg +ve subgroup of patients. On the other hand, in the anti-HBe subgroup the outcome of the previous schedule was not significantly better than in controls due to the small numbers involved although 2 patients did have a sustained response.

Evaluation of risk factors for intrafamilial transmission of HCV infection in Egypt.

The objectives of this study were to define the prevalence of intrafamilial transmission of HCV and evaluate the risk factors in this setting. A cross-sectional, family-based seroepidemiological study was performed in Cairo Liver Center and Oncology Diagnostic Unit, Ain Shams University. A total of 102 index patients (72 males and 30 females) with type C chronic liver disease and their 305 family contacts were studied. Only 265 family contacts were eligible for the study as they showed no previous history of exposure to risk factors. Overall, 15 family contacts (5.7%) were positive for anti-HCV, indicating a lower anti-HCV prevalence among family contacts than the general population in Egypt. Spouses were at higher risk of infection (16.7%) than family members (2.6%). Among the repeatedly positive samples for anti-HCV, only 3 samples were HCV-RNA positive (1.1%), all were spouses. Logistic regression analysis revealed that spouses reporting promiscuous sexual relations were at higher risk than those with normal sexual relations. Contacts sharing personal objects were also at higher risk to develop HCV infection. Index cases reporting previous blood transfusion (18.6%), i.v. antibilharzial therapy (33.3%), multiple sex partners (1.0%) or advanced liver diseases were more infective to their family contacts. The contacts of index cases had increasing risk of HCV infection with increase in age and duration of contact. The prevalence rate of intrafamilial spread of HCV infection is low compared to the rate among general population, emphasizing its limited role in transmitting HCV infection. Long duration of sexual contact and promiscuous sexual activities were major risk factors in this setting.

Liver function tests and electrophoretic pattern of serum protein in hepatic amoebiasis.

The liver function tests and the electrophoretic pattern of serum protein in a series of 11 patients admitted to Bernhard Nocht Institut with hepatic amoebiasis were reviewed. A constant pattern of hypoalbuminaemia and elevated alpha2 globulins were demonstrated in all patients. LDH enzyme levels were raised in all cases admitted with amoebic liver abscess. The pathogenesis of these disturbances was discussed.