Transmission of hepatitis B virus infection in Ethiopia with emphasis on the importance of vertical transmission.

This two-year controlled study was conducted to define the mode of transmission of hepatitis B infection in Ethiopia. Twenty-five of 500 (5%) expectant mothers were identified as HbsAg positive (Group A). A control group of 29 mothers negative for HBsAg (Group B) was randomly selected. These 54 mothers and their families (husbands, infants and the infants' older siblings) were followed for two years with determinations of serological markers of ongoing or past hepatitis B virus infection at 6, 12 and 24 months. Social and clinical data as well as possible factors contributing to the spread of HBV (ie tattoos, circumcision, etc.) were compiled from questionnaires. Twenty-one of the 25 (84%) HBsAg positive mothers had anti-HBe and none had HBeAg. One case of vertical hepatitis B virus transmission was seen while horizontal transmission during the study period occurred in two infants and in two older siblings. Potential risk factors for non-perinatal transmission were highly prevalent in both groups and may represent the main route of transmitting the infection, while, as shown in the present study, the vertical transmission of HBV infection only plays a minor role in the maintenance of the high infection rate in Ethiopia. Vaccinating all babies soon after birth would, therefore, be an effective means of eradicating or reducing the hepatitis B virus infection and its sequelae.

Hepatitis C virus infection and chronic liver disease in Ethiopia where hepatitis B infection is hyperendemic.

To assess the prevalence and possible aetiological association of hepatitis C virus (HCV) with chronic liver disease and hepatocellular carcinoma (HCC), antibodies to HCV (anti-HCV) were determined by enzyme-linked immunosorbent and recombinant immunoblot assays in 500 healthy volunteer blood donors, 14 patients with chronic hepatitis, 156 cirrhotics and 68 cases of hepatocellular carcinoma (HCC) in Ethiopia. The prevalences of anti-HCV were 1.4%, 21%, 36% and 46%, respectively. There was no apparent risk factor to suggest the mode of transmission of HCV. Of the 238 patients, 65 (27%) had circulating hepatitis B surface antigen (HBsAg) (denoting current infection), 131 (55%) had antibodies to hepatitis B surface (anti-HBs) and/or core (anti-HBc) antigens (past infection) and 42 (18%) had no hepatitis B virus (HBV) marker. Anti-HCV antibodies were present in only one patient with HBsAg, in 54% with past infection and in 68% of those without HBV markers. Thus, HCV infection was uncommon in HBsAg-positive patients but significantly more common in patients with chronic liver disease and HCC who had evidence of past HBV infection or no marker for HBV infection. HCV infection appeared to be a more common cause of chronic liver disease and HCC than HBV infection in this population. However, considering the high prevalence of overall exposure to HBV infection (68% in healthy blood donors and 82% in those with chronic liver disease, including HCC), HBV is significant in terms of national preventive strategies.

Chloroquine in the treatment of porphyria cutanea tarda.

Porphyria cutanea tarda (PCT) is common in Ethiopia and invariably affects the liver. Treatment by abstension from alcohol and avoidance of direct sunlight often failed to achieve lasting improvement. Phlebotomy is unacceptable to most of our patients and impractical as a routine therapy. Chloroquine phosphate 500 mg (300 mg base) given daily for 10 days to 24 patients with confirmed PCT, was found to be uniformly effective. Both clinical and biochemical remissions were complete, The side effects of chloroquine include fever, nausea, vomiting and myalgia which predictably occur on the third day of therapy and subside within 72 hours. Since all other modes of therapy are ineffective or impractical and since the response to chloroquine is prompt, effective and reproducible and the side effects are brief, mild and do not cause permanent hepatic damage, it is suggested that this drug is currently the most practical treatment for PCT in areas where repeated phlebotomy is unacceptable and patient follow-up is unsatisfactory.

Porphyria cutanea tarda in Ethiopia.

The clinical, biochemical and histological features of 75 Ethiopians with porphyria cutanea tarda (PCT) are described. PCT in Ethiopia is definitely related to alcohol abuse and there is no clinical evidence for hereditary predisposition. Significant elevation of transaminases and bromsulphthalein retention, moderate to marked hepatic siderosis and inflammation with little or no fibrosis, suggestive of mild or likely reversible parenchymal changes, characterize the liver affection in these patients. A similar study of 18 patients with hyperpigmentation of the face and hands but without blisters, an unexplained but common feature of liver disease in Ethiopia, revealed that serum iron and urinary uroporphyrin levels were normal in eight but significantly elevated in ten (56%). Neither elevated serum iron and hepatic siderosis nor increased urinary uroporphyrin completely explains the hyperpigmentation in this group of patients.

Serological and demographic survey of Epstein-Barr virus infection in Ethiopia.

A demographic and serological survey of Epstein-Barr virus infection was carried out in 5 geographically representative regions of Ethiopia. 80% of the 500 people studied were under 15 years of age. 82% of children under 5 years of age and 94% under 10 years of age were positive for IgG anti-viral capsid antigen (VCA) antibody. 51 of 100 children under 12 months of age and from 5 different provinces were positive for anti-VCA antibody. Of these, 23 were under 6 months. The distribution of anti-VCA antibody positivity was comparable in both sexes, in each age group and in the different provinces at different altitudes. Economic status, expressed in terms of estimated income, type of water supply, mode of excreta disposal and family size, did not significantly influence the distribution of anti-VCA antibody. Thus, early exposure to Epstein-Barr virus, with asymptomatic or subclinical presentation, probably accounts for the rarity of typical infectious mononucleosis in young adult Ethiopians. The lack of a relationship between Epstein-Barr virus infection and Burkitt's lymphoma, nasopharyngeal carcinoma, malaria as well as liver diseases is briefly discussed.

Antibody levels in Ethiopian children five years after vaccination with two different doses of hepatitis B vaccine: is there a need for booster vaccine?

It was hypothesized that, following effective initial vaccination, a booster dose of hepatitis B vaccine will not be necessary in areas of hyperendemicity for hepatitis B virus (HBV) infection. A total of 314 Ethiopian children, ranging from two to 14 years old, were alternatively vaccinated with 10 and 20 micrograms hepatitis B vaccine doses, using the initial, one- and six-month schedule. Five years later, 210 of the vaccinees were retested for anti-HBV surface antibody titres. Both 10 and 20 micrograms doses of hepatitis B rDNA yeast vaccine were equally immunogenic and protective against HBV infection for at least five years despite marked reduction of mean antibody levels and geometric mean titres, with 11% of the vaccinees showing antibodies below the protective level. For firm further recommendations a longer follow-up period of vaccinees is suggested.

HIV-1 infection in relation to educational status, use of hypodermic injections and other risk behaviours in Ethiopian sailors.

Information on the prevalence and risk factors for HIV infection among sailors is generally scarce. The objectives of the study were to determine the prevalence and risk factors for HIV-1 infection among sailors in Ethiopia. A cross-sectional study was carried out in a population of sailors identified from their employment records. Two hundred and sixty sailors were personally interviewed to obtain information on risk factors. Blood samples were collected for the determination of antibodies against HIV-1 infection by ELISA with confirmation by Western blot. The prevalence of HIV-1 infection was 9.6% and the prevalence was observed to decrease with increasing level of education. The risk of acquiring infection was also found to increase with the use of hypodermic injections (OR = 3.42, 95% CI: 1.19 to 9.80). Fourteen percent of the studied population reported condom use. However, the use was irregular. We did not find marital status and consumption of alcohol to be associated with HIV-1 infection. The high prevalence of HIV-1 infection in this population is alarming. Specific education programmes targeted to this group need to be established in order to reduce the increasing risk of infection in this population and the spread of infection to other segments of the population.

Comparison of diagnostic methods for detection of Helicobacter pylori.

Of two hundred Ethiopian patients with dyspepsia, multiple biopsies were taken from the antrum of the stomach. Helicobacter pylori was cultured from 85% of duodenal ulcer and in 75% of chronic antral gastritis patients. The overall Helicobacter pylori positivity was 70%. The sensitivity, specificity, positive and negative predictive values of the tests as compared to culture were as follows, respectively: direct urease test 100%/87%/95%/100%, direct gram stain 60%/98%/99%/51%, histological gram stain 66%/97%/98%/56%, Giemsa stain 100%/97%/99%/100% and Gimenez stain 100%/87%/95%/100%. It is concluded that gram staining of direct tissue smear or histology is an insensitive method in the diagnosis of Helicobacter pylori. All the other tests, are shown to be valid. Urease test is an excellent test for provision of presumptive diagnosis of Helicobacter pylori while awaiting confirmation either by culture of histology.

Ceftriaxone in the treatment of septicaemia due to multiple drug resistant bacteria.

Ceftriaxone, a highly effective, B-Lactamase resistant broad spectrum parenteral cephalosporin was used in the treatment of 26 consecutive patients with clinically and/or bacteriologically resistant infections at the Addis Ababa University Tikur Anbessa and Ethio-Swedish Paediatric Teaching Hospitals. The patients who had failed to respond to a combination of two or more previously appropriate antibiotics were treated with ceftriaxone administered in two divided doses (daily 50-100 mg/kg) in children and a single dose of 2-3 gm in adults for an average duration of 9.9 days. Of the 21 evaluable cases 16 (76%) were cured, three died and two developed superinfection with Pseudomonas and Staphylococcus species. Primary pathogenic bacteria were eradicated from all the 21 bacteraemic patients on the third day of therapy. Twelve of the 21 patients had serious underlying conditions. Except for the two superinfections, the results of the trial confirm that ceftriaxone is a very potent and effective agent in the treatment of resistant bacteraemic infections. No significant adverse effect of the drug was encountered during the therapy.

The demographic, social and clinical presentations of one hundred Ethiopian patients with human immunodeficiency virus (HIV) infection.

The demographic, social and clinical presentation of 100 HIV positive patients hospitalized in Tikur Anbessa Hospital, Addis Ababa, Ethiopia, between 1986 and 1989 are described. The mean age is 38.2 years with a range of 16 to 58. Over 75% of the patients are under 40 years. They came from ten different regions of Ethiopia. Only 82% of the patients fulfil the provisional World Health Organization clinical case definition of AIDS (acquired immunodeficiency syndrome). Tuberculosis is the commonest infection, presenting in unusual and aggressive ways. However, response to chemotherapy is similar to that in HIV-negative patients. It is recommended that all patients with unusual and aggressive tuberculosis should be screened for HIV and Mantoux-positive HIV carriers should receive INH prophylaxis. Also, all non-Hodgkin's lymphoma cases should be tested for HIV. Kaposi's sarcoma was not seen (see Addendum). As HIV infection is spreading rapidly and diagnostic facilities are limited, physicians and other health workers must develop a high index of suspicion to test for HIV among high risk groups, such as prostitutes, individuals having contacts with prostitutes, single, divorced and unemployed women living in towns and truck drivers, when they present with significant weight loss, unexplained and prolonged fever and diarrhoea, lymphadenopathy and oral thrush. Also, facilities and expertise for diagnosing opportunistic infections should be available in hospitals to prolong the lives of patients with AIDS.

Epidemiology, prevention and treatment of viral hepatitis with emphasis on new developments.

There are a large number of viruses, such as cytomegalovirus, Epstein-Barr, Herpes simplex, mumps, varicella, yellow fever, etc., known to cause inflammatory disease of the liver, but the term viral hepatitis generally refers to the five well described hepatotropic viruses which are divided into enteral and parenteral groups based on their mode of transmission. Hepatitis A and E viruses are enterically transmitted by the faecal-oral route and do not exist in a chronic carrier state. Hepatitis B, C and D viruses are parenterally transmitted, occur both in the acute and chronic forms, and, when they persist in a chronic carrier state, they serve as a reservoir for infection and give rise to chronic hepatitis, cirrhosis and hepatocellular carcinoma. Hepatitis G virus has recently been described but its significance in the causation of human liver disease is yet to be established. Also, the most recently described TT virus in patients with post-transfusion hepatitis awaits further studies. Acute sporadic and epidemic viral hepatitis are common world-wide, mostly in the developing countries, including Ethiopia, and account for high morbidity and mortality, especially among pregnant women. Chronic infection with hepatitis B virus is a significant problem on a global scale, affecting over 300 million people. Hepatitis C virus infection is probably the most common cause of chronic viral hepatitis, end-stage liver disease and hepatocellular carcinoma in the world, especially in sub-Saharan Africa, including Ethiopia. Therefore, this article will review and highlight the relevant epidemiological, preventive and therapeutic aspects of viral hepatitis with emphasis on new developments and recent data obtained from Ethiopian studies.

Current views on liver diseases in Ethiopia.

PIP: The chief causes of liver disease in Ethiopia are reviewed, considering hospital data on admissions for hepatitis, cirrhosis, ascites and hepatoma. Liver diseases account for 11.4% of all medical admissions in 3 medical wards in Addis Ababa. The causes are viral hepatitis, post- hepatic and post necrotic and mixed cirrhosis and hepatocellular carcinoma. Alcoholic cirrhosis is rare. Viral hepatitis with shivering, rigor and fever and elevated direct bilirubin levels are common in Ethiopians, especially in child-bearing women. The hepatitis B surface antigen (HBsAg) is often associated with hepatitis. The disease may be transmitted by several species of mosquitoes, placental transmission, or feces, urine, saliva or semen. Blood products are not screened for hepatitis B. Cirrhosis is common, and causes significant mortality, usually from esophageal varices and hepatic coma. Chronic active hepatitis patients may live for a time, especially if they are near a hospital and are treated with steroids. In Ethiopia presenting symptoms for hepatoma are anorexia, weight loss, persistent, burning, right upper quadrant pain, and a hard, nodular, tender RUQ mass. Over 5% of malignancies seen are primary hepatocellular carcinomas. 50% have HBsAG, compared to 3.8% of controls. 65% have alpha-fetoglobulins. It is suggested that some viral hepatitis cases progress to cirrhosis, of which some go on to hepatocellular carcinoma. Herbal medicines, aflatoxins and other toxins may also contribute to liver disease.^ieng

Idiopathic ulcerative colitis among Ethiopian patients with chronic diarrhoea.

Using both exclusion and inclusion criteria, a search for idiopathic ulcerative colitis was made among patients who presented with chronic diarrhoea over a period of 3 years. Five of 19 patients with chronic diarrhoea were clinically, histologically and radiologically compatible with idiopathic ulcerative colitis. Though rare, idiopathic ulcerative colitis does exist among this population and, therefore, should be looked for in patients presenting with chronic diarrhoea.

Glucose tolerance in adult Ethiopian patients with liver disease and porphyria cutanea tarda.

Glucose tolerance test was done in 61 patients with liver disease, 54 with porphyria cutanea tarda and 62 controls. The results showed that 45 patients (73.8%) from the liver disease group, 19 (35.2%) from the porphyria cutanea tarda (PCT) group and only 7 individuals (11.3%) from the control group had an abnormal glucose tolerance test. The differences were significant. Although nutritional state is known to influence the glucose tolerance test, we did not find any significant difference in the mean body mass index between those with an abnormal glucose tolerance test and those without in both groups of patients. Furthermore, the prevalence of an abnormal glucose tolerance test in those above and below 40 years in each group of patients was not significantly different, indicating that age probably played no significant role in this study. Therefore, glucose intolerance is common among Ethiopian patients with liver disease and PCT. As some patients with an abnormal glucose tolerance test may be expected to develop asymptomatic diabetes, we recommend that periodic blood glucose determinations should be part of the management.

The role of milk and lactose intolerance in Ethiopian patients with non-ulcer dyspepsia: a case control study.

Milk intolerance, lactose intolerance and non-ulcer dyspepsia are common among Ethiopians. This study, therefore, was designed to find out if milk intolerance associated with lactase deficiency account for non-ulcer dyspepsia. Ninety-eight patients with non-ulcer dyspepsia and 95 controls were examined and interviewed for demographic data and milk drinking habits. Then each had a lactose tolerance test (LTT), stool examination for pH, ova and parasites. The demographic characteristics and the number of milk drinkers were comparable in the 2 groups. However, milk intolerance and lactose intolerance were significantly higher among the patients with non-ulcer dyspepsia than among the control group (p less than 0.01, p less than 0.05 respectively). The combination of milk intolerance, lactose intolerance and LTT was also significantly different (p less than 0.01). The mean stool pH was markedly reduced after lactose ingestion and there were more ova and parasites in the stools of the control group. These observations suggest that milk intolerance and/or lactose intolerance account significantly for the symptoms of the patients with non-ulcer dyspepsia. However, since lactose intolerance and abnormal LTT are very common among adult Ethiopians symptoms related to the drinking of milk should be interpreted with caution vis-a-vis the results of the lactose loading test.

Helicobacter pylori, gastritis and non-ulcer dyspepsia in Ethiopian patients.

The aim of this study is to find out the prevalence of Helicobacter pylori infection in patients with nonulcer dyspepsia (NUD) and asymptomatic controls and to see if there is an etiological association between gastritis, NUD and Helicobacter pylori. One hundred thirty six patients with NUD and 71 controls had six endoscopic biopsies from different sites of the gastric mucosa for histological diagnosis. Helicobacter pylori was looked for in all biopsy specimens utilizing half Gram, Giemsa and Gimenez staining techniques. Type B chronic gastritis was detected in 96% of the NUD cases and in 100% of the asymptomatic controls (P > 0.05). Helicobacter pylori was found in 82 (65%) patients with NUD and in 38 (56%) asymptomatic controls (P > 0.05). Type B chronic gastritis is almost universal in both NUD cases and asymptomatic controls. There is no difference in the prevalence of Helicobacter pylori infection between the two groups. The absence of Helicobacter pylori in a significant number of patients (36%) and controls (45%) with gastritis contradicts the etiological association between Helicobacter pylori and gastritis reported by others, suggesting that in Ethiopia there may be a chronic environmental gastritis which may not be helicobacter-related. There is no correlation between NUD and Type B gastritis, and between symptoms and Helicobacter pylori infection in this population.

Serological survey of human immunodeficiency virus infection in Ethiopia.

PIP: A serological survey was conducted on 1754 people in various parts of Ethiopia from 1982-1987, with no HIV positive findings until 1984. The problem of Aids reached epidemic proportion in North America and Central Africa in the early 1980s. The reasons for delayed appearance and the source of HIV infection in Ethiopia are not clear. There were 4 groups of subjects tested. The 1st from 1982-83 consisted of 500 patients: 100 each from Asmara, Harar, Addis Ababa, Yirga Alem, and Nekemte; the 2nd in 1983 consisted of 459 volunteer blood donors in Addis Ababa; the 3rd in 1984 consisted of 167 patients with Bell's palsy, and 100 others; the 4th from 1985-87 consisted of 528 patients of the liver clinic of Tikur Anbessa Hospital. The 1st 2 HIV positive sera appeared in group 3 during 1984, and since then 13 patients examined for liver and gastrointestinal conditions were found to be positive. It may be speculated that the new and delayed introduction of HIV infection into Ethiopia is part of the transcontinental spread, caused by migration of refugees, frequent visits to existing harbors by sailors, and the influx of many international organizations to Addis Ababa where prostitution is common. Considering the high prevalence of HIV infection among prostitutes, promiscuity might be the major mode of transmission in this population. The multiple use of inadequately sterilized hypodermics and blood transfusions without screening also contribute to the spread of HIV infection.^ieng

Chronic liver disease in Ethiopia: a clinical study with emphasis on identifying common causes.

Between July 1986 and April 1989, 334 hospitalized adult Ethiopian patients with chronic liver disease were studied according to a protocol to define their clinical features and to identify risk factors with the aim of preventive intervention. Of these, 14 had chronic hepatitis, 208 cirrhosis and 112 hepatocellular carcinoma (HCC). Both clinical and histological diagnostic criteria were employed. A detailed questionnaire was used to document demographic and clinical data. A common clinical presentation among patients with chronic hepatitis was darkening of the face and hands with or without hypertrichosis of the face and blisters over the dorsi of the hands. This overt or latent form of porphyrea cutanea tarda (PCT) responds to chloroquine. Patients with cirrhosis of the liver commonly present for the first time with ascites, splenomegaly, haematemesis and/or melena from oesophageal varices, and mental changes due to hepatic encephalopathy. Overt or latent forms of PCT are also common features. Peculiar to these cirrhotics is the rarity of spider naevi, gynaecomastia, testicular atrophy, Dupuytren's contracture, parotid gland enlargement and clubbing of the fingers. Exhaustion, loss of appetite, rapid loss of weight, right upper quadrant and/or epigastric pain (all often of less than 6 months' duration, a big, hard, tender and grossly nodular liver with bruit, signs of portal hypertension, and/or hepatic encephalopathy, in a young male with a rapid down hill course characterize the Ethiopian patient with HCC. Serum anti-nuclear factor, anti-mitochondrial anti-bodies and anti-smooth muscle anti-bodies were absent in those with chronic hepatitis and were uncommon in the cirrhotics and HCC cases. One or more hepatitis B virus markers were found in 86% of chronic hepatitis, 88% cirrhosis and 78% HCC and the HBsAg carrier state was found in 36%, 29% and 23%, respectively. Among the HBsAg carriers, HBeAg positivity was less common than anti-HBe but anti-HDV was significantly higher than in the healthy general population. Alphafetoprotein (AFP) levels greater than 500 mg/ml were present in 16 (8%) cirrhotics and 58 (52%) patients with HCC. Histologically, 3 of the chronic hepatitis patients had progressed to cirrhosis, 8 of the cirrhotic patients had chronic active hepatitis and 85% of HCC cases occurred in a background of macronodular cirrhosis. Three cirrhotics developed HCC during follow-up.(ABSTRACT TRUNCATED AT 400 WORDS)

Hepatitis E virus infection in pregnancy in Ethiopia.

Thirty-two pregnant and 34 nonpregnant Ethiopian women between 15 and 45 years of age with sporadic acute viral hepatitis were studied consecutively. Demographic data including family size, monthly income and nutritional status as well as hepatitis virus markers were compared in the pregnant and nonpregnant groups. Only 3 nonpregnant women had hepatitis A infection. Hepatitis B infection was diagnosed in 4 pregnant and 9 nonpregnant women. Nineteen (59%) pregnant women had hepatitis E virus (HEV) infection as compared to 7 (22%) in the nonpregnant group (Relative risk = 2.88; 95% Confidence interval = 1.4-5.9). The remaining 9 pregnant and 15 nonpregnant women had non-A, non-B, non-E (NANBNE) hepatitis. Of a total of 10 maternal deaths, 9 occurred (7 during the third trimester) in the pregnant group, 8 in association with HEV infection. Two deaths, one from each group, were due to NANBNE hepatitis. In addition to 6 foetal losses as a result of maternal death, there were 2 foetal deaths and 7 premature deliveries as a direct result of acute viral hepatitis, all but 2 associated with HEV infection. Comparison of socioeconomic and nutritional status, clinical features, mean aminotransferase and bilirubin levels did not show differences in the two groups. Thus, pregnant women are more at risk to acquire HEV infection than nonpregnant women and HEV infection in this group of Ethiopian pregnant women is associated with high maternal mortality and neonatal complications.(ABSTRACT TRUNCATED AT 250 WORDS)

Do hospital personnel in hyperendemic areas require immunization against hepatitis B virus (HBV) infection? Is vertical transmission of HBV infection common in this group?

Medical personnel working in contact with blood and blood-contaminated body fluids are often considered to be a high-risk group for hepatitis B virus (HBV) infection and, as a result, it is recommended that they should be vaccinated against this infection. To find out if this is necessary in a country hyperendemic for HBV infection and to see if parents transmit the infection to their offspring, a total of 336 volunteer hospital employees, and 103 children of 47 of them, were tested for HBsAg, anti-HBc, anti-HBs, HBeAg and anti-HBe using the radioimmunoassay technique. Of these, 242 (72%) were found to have evidence of past or present HBV infection and only 94 (28%) had no such evidence. The infection prevalence in the 47 parents was 68% comparable to that of the total sample. Only 9 of their 103 children were positive for HBV markers. All tested parents of these positive children were either negative for all markers or positive for anti-HBs. The HBV infection prevalence among this hospital population is not different from that of the general Ethiopian population, and vertical transmission appears unlikely in this group. Therefore, mass vaccination of hospital staff in hyperendemic areas is unnecessary.