Acute Viral Hepatitis in Pediatric Age Groups.

INTRODUCTION: Our clinical experience showed that there has been no decrease in pediatric cases of acute viral hepatitis in Kathmandu. The objective of the study was to analyze the etiology, clinical features, laboratory parameters, sonological findings and other to determine the probable prognostic factors of Acute Viral Hepatitis in pediatric population. METHODS: Consecutive patients of suspected Acute Viral Hepatitis, below the age of 15 years, attending the liver clinic between January 2006 and December 2010 were studied. After clinical examination they were subjected to blood tests and ultrasound examination of abdomen. The patients were divided in 3 age groups; 0-5, 5-10 and 5-15 years. Clinical features, laboratory parameters, ultrasound findings were compared in three age groups. RESULTS: Etiology of Acute Viral Hepatitis was Hepatitis A virus 266 (85%), Hepatitis E virus in 24 (8%), Hepatitis B virus in 15 (5%). In 7(2%) patients etiology was unknown. Three patients went to acute liver failure but improved with conservative treatment. There was no statistical difference in most of the parameters studied in different age groups. Ascites was more common in 5-10 years age group. Patients with secondary bacterial infection, ultrasound evidence of prominent biliary tree and ascites were associated with increased duration of illness. Patients with history of herbal medications had prolonged cholestasis. CONCLUSIONS: Hepatitis A is most common cause of Acute Viral Hepatitis in pediatric population. Improper use of herbal medications, secondary bacterial infection and faulty dietary intake was associated with prolonged illness. Patients with prominent biliary radicals should be treated with antibiotics even with normal blood counts for earlier recovery.

Screening utility, local perceptions, and care-seeking for reported jaundeesh among respondents lacking signs of icterus in rural Bangladesh.

In rural Bangladesh, acute viral hepatitis presents a significant burden on the public-health system. As part of the formative work for a large epidemiologic study of hepatitis E in rural Bangladesh, we sought to identify local terms that could be used for population-based screening of acute viral hepatitis. Exploration of the local term jaundeesh for screening utility identified a high burden of reported jaundeesh among individuals without symptoms of icterus. Recognizing that local perceptions of illness may differ from biomedical definitions of disease, we also sought to characterize the perceived aetiology, care-seeking patterns, diagnostic symptoms, and treatments for reported jaundeesh in the absence of icteric symptoms to inform future population-based studies on reported morbidities. We conducted a cross-sectional survey among 1,441 randomly-selected subjects to identify the prevalence of reported jaundeesh and to test the validity of this local term to detect signs of icterus. To characterize the perceived aetiology and care-seeking patterns for jaundeesh among the majority of respondents, we conducted in-depth interviews with 100 respondents who self-reported jaundeesh but lacked clinical signs of icterus. To describe diagnostic symptoms and treatments, in-depth interviews were also performed with 25 kabirajs or traditional faith healers commonly visited for jaundeesh. Of the 1,441 randomly-selected participants, one-fourth (n=361) reported jaundeesh, with only a third (n=122) reporting yellow eyes or skin, representative of icterus; Jaundeesh had a positive predictive value of 34% for detection of yellow eyes or skin. Anicteric patients with reported jaundeesh perceived their illnesses to result from humoral imbalances, most commonly treated by amulets, ritual handwashing, and bathing with herbal medicines. Jaundeesh patients primarily sought folk and spiritual remedies from informal care providers, with only 19% visiting allopathic care providers. Although the local term jaundeesh appeared to have limited epidemiologic utility to screen for acute symptomatic viral hepatitis, this term described a syndrome perceived to occur frequently in this population. Future population-based studies conducting surveillance for acute hepatitis should use caution in the use and interpretation of self-reported jaundeesh. Further study of jaundeesh may provide insight into the appropriate public-health response to this syndrome.

Enhancing HIV/AIDS, viral hepatitis, sexually transmitted disease, and tuberculosis prevention in the United States through program collaboration and service integration: the case for broader implementation.

HIV infection, viral hepatitis, sexually transmitted diseases, and tuberculosis in the United States remain major public health concerns. The current disease-specific prevention approach oftentimes has led to narrow success and missed opportunities for increasing program capacity, leveraging resources, addressing social and structural determinants, and accelerating health impact-suggesting a need for greater innovation to prevent related diseases. The National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention's Program Collaboration and Service Integration (PCSI) strategic priority aims to strengthen collaborative engagement across these disease areas and to integrate services at the client level. In this review, we articulate the 5 principles of PCSI-appropriateness, effectiveness, flexibility, accountability, and acceptability. Drawing upon these principles and published literature, we discuss the case for change that underlies PCSI, summarize advances in the field since 2007, and articulate key next steps. Although formal evaluation is needed to fully assess the health impact of PCSI, available evidence suggests that this approach is a promising tool to advance prevention goals.

[Epidemiology of viral hepatitis]. / Epidemiologija virusnih hepatitisa.

Understanding the country-specific epidemiology of disease, which may vary greatly among countries, is crucial for identifying the most appropriate preventive and control measures. An overview of the local epidemiology of viral hepatitis in Croatia is given in this paper. The overall prevalence of hepatitis B in Croatia is low (less than 2% HBsAg carriers in the general population). Hepatitis B incidence and prevalence began to decline significantly following the introduction of universal hepatitis B vaccination in 1999. Information on HBsAg seroprevalence is derived from routine testing of certain subpopulations (pregnant women, blood donors) and seroprevalence studies mostly targeted at high-risk populations. Universal childhood vaccination against hepatitis B remains the main preventive measure. We recommend testing for immunity one to two months after the third dose of hepatitis B vaccine for health-care workers. The incidence and prevalence of hepatitis C have also been declining in the general population. The main preventive measures are ensuring safety of blood products, prevention of drug abuse, and harm reduction programs for intravenous drug users. Hepatitis A incidence has declined dramatically since fifty years ago, when thousands of cases were reported annually. In the last five years, an average of twenty cases have been reported per year. The reduction of hepatitis A is a consequence of improved personal and community hygiene and sanitation. Hepatitis D has not been reported in Croatia. The risk of hepatitis D will get to be even smaller as the proportion of population vaccinated against hepatitis B builds up. Hepatitis E is reported only sporadically in Croatia, mostly in persons occupationally in contact with pigs and in travelers to endemic countries. In conclusion, Croatia is a low prevalence country for hepatitides A, B and C. Hepatitis D has not been reported to occur in Croatia and there are only sporadic cases of hepatitis E. Since hepatitis A is a rare disease occurring sporadically, which is a consequence of improved sanitation and hygiene, hepatitides B and C are the main causes of viral hepatitis in Croatia. The introduction of universal mandatory hepatitis B vaccination of schoolchildren in 1999 resulted in a decrease in the incidence of hepatitis B, which is most pronounced in adolescents and young adults, and further decrease in the incidence and prevalence is expected as the pool of susceptible individuals decreases through vaccination. The incidence of hepatitis C is decreasing as well. In spite of a relatively favorable epidemiological situation, hepatitis B and C are still a significant public health burden with an estimated 25,000 persons chronically infected with HBV and about 40,000 persons chronically infected with HCV in Croatia.

Integrated prevention services for HIV infection, viral hepatitis, sexually transmitted diseases, and tuberculosis for persons who use drugs illicitly: summary guidance from CDC and the U.S. Department of Health and Human Services.

This report summarizes current (as of 2011) guidelines or recommendations published by multiple agencies of the U.S. Department of Health and Human Services (DHHS) for prevention and control of human immunodeficiency virus (HIV) infection, viral hepatitis, sexually transmitted diseases (STDs), and tuberculosis (TB) for persons who use drugs illicitly. It also summarizes existing evidence of effectiveness for practices to support delivery of integrated prevention services. Implementing integrated services for prevention of HIV infection, viral hepatitis, STDs, and TB is intended to provide persons who use drugs illicitly with increased access to services, to improve timeliness of service delivery, and to increase effectiveness of efforts to prevent infectious diseases that share common risk factors, behaviors, and social determinants. This guidance is intended for use by decision makers (e.g., local and federal agencies and leaders and managers of prevention and treatment services), health-care providers, social service providers, and prevention and treatment support groups. Consolidated guidance can strengthen efforts of health-care providers and public health providers to prevent and treat infectious diseases and substance use and mental disorders, use resources efficiently, and improve health-care services and outcomes in persons who use drugs illicitly. An integrated approach to service delivery for persons who use drugs incorporates recommended science-based public health strategies, including 1) prevention and treatment of substance use and mental disorders; 2) outreach programs; 3) risk assessment for illicit use of drugs; 4) risk assessment for infectious diseases; 5) screening, diagnosis, and counseling for infectious diseases; 6) vaccination; 7) prevention of mother-to-child transmission of infectious diseases; 8) interventions for reduction of risk behaviors; 9) partner services and contact follow-up; 10) referrals and linkage to care; 11) medical treatment for infectious diseases; and 12) delivery of integrated prevention services. These strategies are science-based, public health strategies to prevent and treat infectious diseases, substance use disorders, and mental disorders. Treatment of infectious diseases and treatment of substance use and mental disorders contribute to prevention of transmission of infectious diseases. Integrating prevention services can increase access to and timeliness of prevention and treatment.

[Hepatitis: a longstanding companion in human history]. / L'epatite: un compagno di lungo corso della storia umana.

Hepatitis has gone along with human history since its origins, due to its prompt identifiability linked to jaundice as a symptom. Written evidence of outbreaks of epidemic jaundice can be tracked back a few millenniums before Christ. Unavoidable confusion arises due to the overlap of different sources possibly linked to different aetiologies, identified over time as epidemic jaundice (HAV or HEV hepatitis?) and serum hepatitis (HBV or HCV hepatitis?). The journey that brought to recognize viruses as the main cause of jaundice was long and started midway during the last century, when the infectious hypothesis, which had taken place step by step, was finally confirmed by epidemiological investigations of an outbreak occurring in the US army in 1942, after a yellow fever immunization campaign. Further research identified two clinically different types of hepatitis, called for the first time hepatitis A and hepatitis B.

[Clinical characteristics, staging and treatment of patients with hepatocellular carcinoma in clinical practice. Prospective study of 136 patients]. / Características clínicas, estadificación y tratamiento de los pacientes con carcinoma hepatocelular en la práctica clínica. Estudio prospectivo de una serie de 136 pacientes.

UNLABELLED: Hepatocellular carcinoma (HCC) is the most frequent cause of mortality in patients with liver cirrhosis. There are no prospective series from a single tertiary hospital in Spain. MATERIAL AND METHODS: We performed a prospective study of patients with HCC in our center. Clinical and epidemiological characteristics, diagnostic method, staging according to the Barcelona Clinic Liver Cancer (BCLC) system and treatment were analyzed. RESULTS: A total of 136 patients were included (80.9% men). The mean age was 66.62 ± 11.68 years and 91.2% were cirrhotic. Hepatitis C virus (HCV) was the leading cause of liver disease (38.97%). The suspected diagnosis was established by a surveillance program in 63.2%. Noninvasive American Association criteria for the Study of Liver Diseases (AASLD) were the main diagnostic method (73.5%). According to the BCLC, 58.1% were in the early stage (0-A), 21.3% in stage B, 12.5% in stage C and 8.1% in stage D. Early stage patients had followed a surveillance program more frequently than those with non-early stages (79.75% versus 44.35%, p <0.001). Potentially curative initial treatment was used in 45.58%, the most common treatment being percutaneous ethanol injection (23.13%). CONCLUSIONS: Most patients with HCC in our hospital have cirrhosis, the most frequent cause being HCV. HCC surveillance in at-risk patients could increase diagnosis of HCC at an early stage. We achieved an early diagnosis in more than half of cases. The most common initial treatment was percutaneous therapy.

[ALT screening for chronic liver diseases: scrutinizing the evidence]. / ALT als Screeningparameter für Lebererkrankungen: eine kritische Evaluation der Evidenz.

Elevated serum amino-transferase levels may be associated with liver injury. Testing for aspartate aminotransferase (AST) or alanine aminotransferase (ALT) is part of many routine screening approaches. The aim of this manuscript was to scrutinize the evidence for using ALT testing as a primary screening parameter for liver diseases. We conclude that (i) elevated serum ALT levels indicate a high specificity and a reasonable sensitivity liver injury, (ii) 10 - 25 % of German adults have elevated ALT levels, (iii) ALT values are increased in the majority but not all patients with acute and chronic liver disease (iv) elevated ALT-values are associated with an increased risk of liver-specific mortality, (v) elevated ALT values are also a risk factor for non-hepatic diseases including diabetes mellitus type 2, metabolic syndrome, cardiovascular diseases and malignancies, (vi) many liver diseases identified by an ALT screening can be treated successfully including prevention of development of clinical endpoints, (vii) an ALT-screening is very likely to be cost-effective although studies are needed for Germany to support this conclusion.

[Treatment approach of hepatocellular carcinoma in Spain. Analysis of 705 patients from 62 centers]. / Tratamiento del carcinoma hepatocelular en España. Análisis de 705 casos en 62 centros.

BACKGROUND AND OBJECTIVE: Hepatocellular carcinoma (HCC) is the leading cause of death in patients with cirrhosis and its current situation in Spain is not well known. Therefore, a national registry was created to assess the characteristics of patients with de novo HCC. PATIENTS AND METHOD: Between 1/10/2008 and 31/1/2009, 62 centers reported the baseline demographic, clinical and tumor characteristics, the first choice of treatment and eligibility for transplantation (OLT) of HCC diagnosed during this time. RESULTS: There were 705 new cases of HCC, 78% men, mean age 65 years, 89% cirrhosis (58% Child-Pugh class A, 42% HCV, 30% alcohol). Only 334 cases (47%) were diagnosed by screening. The size of the main nodule and BCLC stage were significantly lower in the screening group than in the rest (p<0.001). The applicability of radical therapies (resection and percutaneous ablation) was significantly higher (47.5% versus 24.6%, p<0.001) as well as the evaluation for OLT (31% versus 12%, p<0.001). The screening did not differ according to gender (p=0.204) or age (<50 years, <65, <75, >75 years) (p=0.171). Chemoembolization was the most common treatment: initial tumors (46.4%), tumors >5 cm (15.7%), multifocal HCC (37.9%) and as a bridge to OLT (33%). CONCLUSION: The majority of HCC patients are diagnosed in Spain out of early detection programs, and this limits the chance for early diagnosis and effective therapy.

Autologous blood donor screening indicated a lower prevalence of viral hepatitis in East vs West Germany: epidemiological benefit from established health resources.

Prevalence data concerning viral hepatitis and human immunodeficiency virus (HIV) in the general population are usually scarce. We aimed for a large cohort representative of the general population that required little funding. Autologous blood donors are relatively representative of the general population, and are tested for viral hepatitis and HIV in many countries. However, frequently these data are not captured for epidemiologic purposes. We analysed data from well over 35,000 autologous blood donors as recorded in 21 different transfusion centres for anti-hepatitis C virus (HCV), HBsAg and anti-HIV, as well as TPHA if available. We found a lower prevalence of hepatitis B virus and HCV in East vs West Germany, 0.2%vs 0.32% and 0.16%vs 0.32% respectively, which confirms earlier data in smaller cohorts, thus supporting the value of our approach. HIV was too rare to disclose significant differences, 0.01%vs 0.02%. TPHA was higher in East (0.34%) vs West Germany (0.29%) without significant differences. HCV was more frequent in women vs men. Transfusion institutes managing autologous blood donations should be used as a resource for epidemiological data relating to viral hepatitis and HIV, if such testing is performed routinely. This approach generates data relating to the general population with special emphasis on undiagnosed cases.

Epidemiological and clinical aspects of hepatitis G virus infection in blood donors and immunocompromised recipients of HGV-contaminated blood.

BACKGROUND AND OBJECTIVES: The infectiousness and clinical relevance of the newly discovered blood-borne Flaviviridae-like agent, termed hepatitis G virus (HGV), are not well understood. MATERIALS AND METHODS: Twenty-three transfusion recipients of two HGV-affected long-term blood donors were studied for HGV genome and antibodies to the putative envelope 2 glycoprotein (anti-E2) of HGV. Nine recipients had nonhematological disorders and 14 suffered from severe hematological diseases and 7 of them received allogeneic bone marrow or blood stem cell transplantation. The molecular epidemiology of the observed HGV infection was studied by direct sequencing of parts of the 5'-noncoding region, NS3, and NS5 region of HGV in the 2 long-term donors and in their 6 recipients who became HGV RNA positive. Additionally, 549 individuals-homologous (n = 254) and autologous blood donors (n = 202), and medical staff (n = 89)--were investigated for the presence of HGV RNA. RESULTS: HGV RNA in serum was found in 15 of the 23 (65%) transfusion recipients with known exposure of HGV-contaminated blood. Seven of the remaining 8 recipients showed only an anti-E2 response, indicating previous HGV infection with spontaneous clearance of the virus. In one recipient neither HGV RNA nor anti-E2 could be detected. Molecular evidence for HGV transmission by the 2 donors was found in 3 of the 6 recipients studied. The alanine aminotransferase levels were not significantly different in the HGV RNA positive and negative recipients, and none of the 23 recipients developed posttransfusion hepatitis. Persistent HGV infection was observed especially in recipients with severe hematological disorders or in those in whom intensive immunosuppressive treatment was necessary. Of the 549 individuals studied, 10 (1.8%) were healthy carriers of HGV RNA. CONCLUSION: The persistence of transfusion-acquired HGV infection is not associated with acute or chronic hepatitis, but may be influenced by the recipient's underlying disease.

Past and present hepatitis G virus infections in areas where hepatitis C is highly endemic and those where it is not endemic.

We reported previously on an area in Japan where over 30% of the inhabitants were positive for hepatitis C virus (HCV) antibody. In the present study, clinical features of hepatitis G virus (HGV) infection in this area of high endemicity were compared to those in an area where HCV is not endemic. A total of 400 individuals were selected randomly from those who were medically screened for liver disease in 1993; 200 were from the high-endemicity area, and the other 200 were from the no-endemicity area. HGV RNA was measured by reverse transcription and PCR with primers in the 5' noncoding region. Antibody to HGV envelope protein E2 was measured by an enzyme-linked immunosorbent assay. Prevalence of any HGV marker in the high-endemicity area (32%) was significantly (P < 0.0001) higher than that in the no-endemicity area (6%); similar differences, 32% versus 3% (P < 0.0001), had been observed for HCV markers (HCV RNA and HCV antibody). In areas of both high and no endemicity, HCV markers were significantly more prevalent in individuals with any HGV marker than in those without HGV markers, and age-specific prevalence of HGV markers was distributed similarly to that of any HCV marker. Among possible routes of HGV transmission that were analyzed, folk medicine was significant in the high-endemicity area, but blood transfusion was the major route in the no-endemicity area. The rate of accompanying viremia in HGV infection (15%) was significantly lower than that in HCV infection (78%) (P < 0.0001). In conclusion, HGV infection was highly prevalent in the area of high HCV endemicity and was closely associated with HCV infection. HGV seemed to be transmitted via the practice of folk medicine as well as blood transfusion. HGV resulted in a chronic carrier state less frequently than did HCV.

Prevalence and risk factor analysis of GBV-C/HGV infection in prostitutes.

GB virus-C (GBV-C) and Hepatitis G virus (HGV) are variants of a recently cloned virus transmitted parenterally. It is unclear if sexual contact also transmits this virus. In this study, we detected serum GBV-C/HGV RNA in 140 prostitutes by reverse transcription polymerase chain reaction (RT-PCR) using different primers. Thirty (21%) were found with GBV-C RNA by nested PCR although only 22 (73%) had HGV RNA by single round RT-PCR. Both assays had a nearly perfect agreement (kappa value, 0.812). The prevalence of GBV-C RNA in prostitutes was significantly higher than the control group (30/140 vs. 2/40, P < 0.02). Multivariate analysis revealed that a frequency of paid sex more than 120 times per month was the only factor significantly associated with positive GBV-C RNA in prostitutes (P < 0.003). In summary, prostitutes are a high risk group and reservoir of GBV-C/HGV infection due to high frequency of paid-sex.

Hepatitis No A No B (NANB) en el Perú?: estudio de marcadores serológicos en 100 pacientes con diagnóstico clínico de hepatitis viral en Huanta-Ayacucho / Non A Non B hepatitis in Perú: study of serological markers in 100 patients with clinical diagnosis of viral hepatitis in Huanta-Ayacucho

Se estudia, mediante marcadores serológicos. 100 sueros de pacientes con diagnóstico clínico de hepatitis viral aguda que concurren al Hospital Central de Huanta-Ayacucho, durante los meses de mayo 1985 a febrero 1986, y 36 sueros de población normal ayacuchana (grupo control). Se utiliza la técnica de microenzimainmunoensayo (Hepanostika, Organon-Teknika). La edad promedio fue de 21.1 y 27.4 años de edad respectivamente (4-76 años), 55 mujeres y 81 varones. En ellos se anota, además de la ictericia, los valores de transaminasas y, bilirrubinas séricas. se encontró que 29% de los casos no presentaron evidencias de hepatitis, mientras que el 29% fue Hepatitis B. el 23% NANM y el 19% Hepatitis A. El 14% de los pacientes con HBV cursan con hepatitis fulminante, sin co-infección Delta. No se encontró portadores de HBV en la población menor de 10 años. En el grupo control, el 94% tiene algún marcador de hepatitis (89% HAV y 41% HBV). Existe una alta prevalencia serológica de Hepatitis A.B y NANB en la zona. este sería el primer reporte de Hepatitis NANB en el Perú