JOURNAL READING BY: BAGORIO, GENICA DIANNE L.

ARTICLE: Prevalence of Hepatitis B and C in Patients Admitted in ENT Ward, JPMC, Karachi
ABSTRACT: OBJECTIVE: Prevalence of hepatitis B and their risk factors in patients admitted in ENT and Head and Neck Surgery department, Jinnah Post Graduate Medical Centre, Karachi. STUDY DESIGN: Non-interventional, descriptive study. PLACE & DURATION OF STUDY: ENT and Head and Neck Surgery department, Jinnah Post Graduate Medical Centre from December 2007 to November 2008. PATIENTS & METHODS: Study includes every patient admitted in ENT and Head and Neck surgery department, Jinnah Post Graduate Medical Centre. RESULTS: Out of 1315 patients 756 (57.49%) were male and 557 (42.35%) were female. Hepatitis B and C was present in 87 (6.62%) patients in which 61 (8.06%) were male and 26 (4.66%) were female. Out of 87 infected patients 67 (5.09%) were suffering from HCV and 18 (1.36%) were from HBV. In 2 (0.15%) patients both hepatitis B and C were found. CONCLUSION: Hepatitis C is the most prevalent liver disease in the world. WHO considers hepatitis C an epidemic because a patient living with hepatitis C can be infected for decades before discovered. This is found to be true in our study because 2 patients were known cases of hepatitis, rest of all are diagnosed during our study. Key Words: Prevalence, Hepatitis B & C, Infectious diseases. INTRODUCTION: The term hepatitis describes inflammation of the liver. Hepatitis may be cause by alcohols, autoimmune diseases, metabolic diseases and viruses. Serum hepatitis received its name in 1942 after an outbreak of hepatitis among American soldiers. The outbreak was traced to yellow fever vaccine that was contaminated with human serum. In 1965 Baruch Blumberg and colleagues described the Australian Antigen, which later was called hepatitis B surface antigen (HBsAg). Antigen in serum from an Australian aborigine precipitated with antibody from the serum of a patient with haemophilia who has a history of blood transfusion1. In 1970, DS Dane used electron microscopy to describe hepatitis B viral particles in human serum2. Blood test capable of detecting HAV and HBV became available in 1973. After this, the term non-A/non-B (NANAB) hepatitis was used to describe the purported virus or viruses responsible for otherwise unexplained cases of post transfusion hepatitis, chronic hepatitis and cirrhosis. A major break through came in 1988 when Mechael Houghton and colleagues cloned and sequenced the hepatitis C virus genome3. A clinical assay for detecting anti-HCV antibody was developed shortly thereafter. Hepatitis B and C is a global problem but it is rapidly spreading in developing countries due to lack of community health education, illiteracy and poverty. Majority of these patients are asymptomatic and pose great danger of spreading the infections to the society and medical personal particularly. Hepatitis C has been found in 0.5-29% population sample around the world14. Its prevalence is 5.1% in blood donors in India, 1.5% in Saudi Arabia, 0.3% in Kosovo and 0.5% to 25.7% in Pakistan5,6. Both hepatitis B and C are transmitted through blood either by percutaneous or body fluids (semen, saliva or vaginal secretions)7. As vaccine available against HBV but no vaccine is available against HCV and once infected most individuals will develop chronic HCV infection, a disease with considerable morbidity and mortality8. Almost two billion people are infected with hepatitis B and more than 350 million have life long chronic liver infection9. Hepatitis B is 100 times more infectious than HIV and ten times more than HCV10. Each year around 1.2 million die of HBV related chronic liver disease11,12. 170 million people are infected with hepatitis C and 3 to 4 million people get infected each year13. There is high risk of infections in patients who receive blood, undergo dental treatment, have unsterilized injections, skin tattooing, shave history of the face or armpits by barbers or sexual abuse history. HBV and HCV can persist as chronic infections and represent a leading cause of chronic liver disease and hepatoma14. Chances of surgeons contracting hepatitis B infections are 1%15 and HCV infections are 0.001%-0.032% per anum8. Study in Australia demonstrate between 30-65% of chronic infected adults are unaware they are infected until they were screened16. Accepting that, high risk hospitalized patients are not the ideal

population for epidemiological studies, over estimating the problem, nonetheless they contribute in the epidemiological mapping of a serious public health problem like viral hepatitis, in certain geographical area. PATIENTS AND METHODS: Non interventional, descriptive study was conducted in the department of ENT and Head and Neck Surgery, Jinnah Post Graduate Medical Centre, Karachi from December 2007 to November 2008. Every patient admitted in the department included for study and were 1315 in number. All the patients were asked about past history of jaundice, blood transfusion, surgery history, dental history, injection history, barber shave history, visit abroad and family history. The positive patients of hepatitis B and C were again checked by ELISA method and other relevant investigations also done, i.e., liver function tests (LFT), abdominal ultrasound, prothrombine time and physician opinion RESULTS: Out of 1315 patients 756 (57.49%)

Male and 557 (42.35%) were female. Hepatitis B and C was present in 87 (6.62%) patients in which 61 (8.06%) were male and 26 (4.66%) were female. Out of 87 infected patients 67 (5.09%) were suffering from HCV and 18 (1.36%) were from C were found. DISCUSSION: Hepatitis prevalence subject to geographical variation17. Hepatitis B and C are most prevalent diseases in the world. WHO considers hepatitis C an epidemic because a patient living with hepatitis C can be infected for decades before discovered. Hepatitis C virus infection is endemic in certain parts of the world, which is 3%18 and ranges from 0.4% in general adult population of Fukuoka Japan to 2.4% in Turkey19 and 14.4% in Southern Italy20. In another study21 the anti-HCV antibodies were found in 11.6% patients which is significantly higher in comparison to Japanese study and our study, and slightly lower than the Italian study. In our study the hepatitis B and C was present in 6.62% cases with patients having HCV as 5.09% and HBV in 1.36% cases and 0.15% were suffered from both hepatitis B and C. the male percentages in having hepatitis B is 1.20% and in hepatitis C is 6.08% respectively. In a local study22 the prevalence of hepatitis C was 4.57% with higher prevalence among the males compared to females as in our study. Not in our study but overall HCV infections are prevalent than

HBV17. In another study21prevalence of hepatitis B was 8.66% and HCV 11.66%. In our study the predisposing factors of hepatitis B and C were previous history of surgery in 16 patients, blood transfusion history in 14 patients, and dental procedure in 08 patients. Positive family history was recorded in 08 patients. 02 patients were intravenous drug users. 21 patients were having previous hospitalization history due to some reasons like pregnancy, accidental trauma etc. In our study some patients was having multiple risk factors like dental work, blood transfusion, previous surgery aSUMnd shaving by community barbers. The risk factors of hepatitis B and C in other studies21 are previous blood transfusion in 25% and previous hospitalization in 3.2% of cases. In intravenous drug users a study23 suggests that prevalence of hepatitis B and C are 34% and 70% respectively. The risk factors in hepatitis C in another study22 were major surgery 6.92% previous blood transfusion 1.06%, dental procedure 9.72% tattoing in 0.39% and shaving by community barbers 44.2%. The risk of surgeon acquiring the HCV through occupational exposure is dependent on the prevalence of HCV infection in the patient population, the probability of a percutaneous injury transmitting HCV, and the incidence of percutaneous injury during surgery8. Some studies suggest the possibility of interfamilial spread of hepatitis B and C viruses as in our study24,25.

SUMMARY: Hepatitis may be cause by alcohols, autoimmune diseases, metabolic diseases and viruses. Serum hepatitis received its name in 1942 after an outbreak of hepatitis among American soldiers. The outbreak was traced to yellow fever vaccine that was contaminated with human serum. the term non-A/non-B (NANAB) hepatitis was used to describe the purported virus or viruses responsible for otherwise unexplained cases of post transfusion hepatitis, chronic hepatitis and cirrhosis. A major break through came in 1988 when Mechael Houghton and colleagues cloned and sequenced the hepatitis C virus genome3. A clinical assay for detecting anti-HCV antibody was developed shortly thereafter. Hepatitis B and C is a global problem but it is rapidly spreading in developing countries due to lack of community health education, illiteracy and poverty. Majority of these patients are asymptomatic and pose great danger of spreading the infections to the society and medical personal particularly. Hepatitis C has been found in 0.5-29% population sample around the world14. Its prevalence is 5.1% in blood donors in India, 1.5% in Saudi Arabia, 0.3% in Kosovo and 0.5% to 25.7% in Pakistan5,6. Both hepatitis B and C are transmitted through blood either by percutaneous or body fluids (semen, saliva or vaginal secretions)7. As vaccine available against HBV but no vaccine is available against HCV and once infected most individuals will develop chronic HCV infection, a disease with considerable morbidity and mortality8. Almost two billion people are infected with hepatitis B and more than 350 million have life long chronic liver infection9. Hepatitis B is 100 times more infectious than HIV and ten times more than HCV10. Each year around 1.2 million die of HBV related chronic liver disease11,12. 170 million people are infected with hepatitis C and 3 to 4 million people get infected each year13. There is high risk of infections in patients who receive blood, undergo dental treatment, have unsterilized injections, skin tattooing, shave history of the face or armpits by barbers or sexual abuse history. HBV and HCV can persist as chronic infections and represent a leading cause of chronic liver disease and hepatoma14. Chances of surgeons contracting hepatitis B infections are 1%15 and HCV infections are 0.001%-0.032% per anum8. REACTION: The prevalence of hepatitis B and C in ENT patients is quite high with the most common risk factors as previous surgery, blood transfusion, dental procedures and the family history. Therefore all patients who need surgery should be routinely screened for hepatitis B and C. Identification of hepatitis B and C in asymptomatic phase has become an effective strategy. Importantly there is also likely to be benefit to the wider community as infected individuals can be educated about their infectivity, at risk contacts can be offered vaccination and potentially transmission can be reduced. Even without a vaccine success can be reported in the field of hepatitis C by screening of blood and blood products and identification and counseling of infected people and implementation of

universal precautionary measures in health care settings like separate operation theatre facilities for hepatitis B and C patients, policy by the government for protection of medical personnel and compensation for those who infected during their service. Surgeons however should be encouraged to observe universal precautions and present for assessment after needle stick injuries to protect them