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ORIGINAL / RESEARCH

Prevalence of Hepatitis B and C in CRF Patients on Maintenance Haemodialysis
SS Sudan, Rajesh Kumar Sharma
Fifty patients of CRF on maintenance haemodialysis were studied to find out the prevalence of hepatitis B and C infection and compared with the prevalence in healthy voluntary blood donors.

The prevalence of hepatitis B and C infection in the study group was 6% and 8% respectively. Whereas it was 1.8% and 0.2% respectively in voluntary blood donors.

Out of 40 immunised cases only one (2.5%) acquired hepatitis B infection as against 2 out of 10 cases (20%) in the un-immunized group.

Increasingly prevalence of hepatitis B and C seropositively with significant correlation P value < 0.001 was observed with duration of illness, severity of azotaemia, increased number of blood transfusion and haemodialysis sessions.
Hepatitis B vaccination has a definite protective role against hepatitis B transmission in CRF patients.

INTRODUCTION
In India, there are 43 millions estimated HBSAg
carriers (4.7%) comprising the second largest pool
of HBV carriers in world.
The prevalence of HBV in the dialysis population in India is reported to range between 3.4-43% which is several folds higher than the carrier rate in general population.
However, the prevalence of HCV infection in western countries ranges between 0.4-2.3%. There is a limited literature available on HCV prevalence from India.18
The risk of exposure increases with the number of dialysis sessions and is maximum in patients on maintenance haemodialysis.9
Hence the CRF patients on maintenance haemodialysis constitute a high risk group for both HBV and HCV infection as these patients are immunosuppressed and receive multiple transfusion for anaemia.
These observations together with a negative history of blood transfusion in several HBSAg and Anti-HCV positive patients suggest that HBV and HCV may be transmitted within the haemodialysis environment.10
The efficacy of DNA derived recombinant, hepatitis-B vaccine in the haemodialysis patients is generally lower than in healthy subjects due to defective cellular immunity.7 Currently no vaccine is available for hepatitis C.
The incidence and magnitude of infection with HBV and HCV had encouraged us to undertake this study with following aims and objectives :
1. To find out the prevalence of hepatitis B and C infection in CRF patients on maintenance haemodialysis and to compare with the prevalence of HBsAg and Anti HCV in healthy blood donors.
2. To find out the efficacy of recombinant hepatitis B vaccine (Engirix - B) in preventing the occurrence of hepatitis E in CRF patients.

MATERIAL AND METHODS

One year prospective study of CRF patients on maintenance haemodialysis was carried out in medical wards and dialysis unit, Department of Medicine of Government Medical College, Jammu. A total number of 50 cases of CRF of different aetiology were studied. Diagnosis of CRF and its aetiology was made on the basis of detailed history, physical examination and various investigations carried out such as complete haemogram, HB, TLC, DLC, BT, CT, Platelet count PBF, complete urine analysis, 24 hours urinary proteins, blood sugar, urea, creatinine, electrolytes (Na, K) uric acid, cholesterol, proteins, calcium phosphorus, serum bilirubin, SGot, Sgpt, alkaline phosphatase, X-ray chest, ECG. Usg abdomen for kidney size, urinary tract and prostate, patient already suffering from liver diseases. Deranged liver functions or having received hepatitis B vaccine before entry into haemodialysis programme were excluded from the study. CRF patients were screened for HBsAg and anti HCV by 3rd generation elisa method carried out in postgraduate research laboratory of microbiology department, screening was done before entry into dialysis programme, and after two and four months during the haemodialysis programme.

Hepatitis B vaccine (engerix - B) was given in dosage schedule of 40 micro gm on day one, after one and two months in 40 patients out of 50 cases of CRF enrolled in the study to assess its efficacy in the prevention of hepatitis B infection. Clinically healthy blood donors in the age group of 16 to 65 years of age of either sex were also screened for HBS Ag and anti HCV in the blood transfusion department during the same period.

OBSERVATION AND RESULTS

The observation and results obtained are depicted in tabulated form.

DISCUSSION

In the present study, 50 patients of CRF of different aetiology on maintenance haemodialysis were studied.
The prevalence of hepatitis B virus infection (HBsAg +ve) was 6% in our set-up i.e. 3 out of 50 cases studied showed HBs Ag positivity while prevalence of hepatitis C virus infection (Anti HCV +ve) was 8% with 4 out of 50 cases being positive for anti-HCV. Comparative analysis from Indian studies showed prevalence of hepatitis C virus infection as 33% by sumathy et al16 from south India, 24.5% by Arankalie1 from western India, 24.9% by Jaiswal from Indore and 27.8% by Gosavi4 from Mumbai.

TABLE 1
Prevalence of hepatitis B and C in chronic renal failure patients on maintenance haemodialysis
(Study group)
Total
cases
HBS Ag
+ve cases
Percentage Anti HCV
+ve cases
Percentage
50 3 6 4 8
         
The patients of chronic renal failure on maintenance haemodialysis were screened for HBs Ag and anti HCV at 0, 2 and 4 months during the study period. Three out of 50 (6%) were detected HBsAg positive while 4 out of 50 (8%) were found to be anti HCV positive.
         
TABLE 2
Prevalence of HBS Ag and HCV positivity in voluntary blood donors screened during the study period (Control group)
Total
cases
HBS Ag
+ve cases
Percentage Anti HCV
+ve cases
Percentage
12449 147 1.8 26 0.2
         
The prevalence of HBS Ag found in healthy voluntary blood donors screened in the blood bank of Medical College Hospital, Jammu during the year 1999 was 1.8% while that of anti HCV was 0.2%.
         
TABLE 3
Incidence of hepatitis B positivity in immunized and non immunised patients
Group No. of
cases
HBS Ag
+ve cases
Percentage
Immunized 40 1 2.5
Non-immunized 10 2 20
         


World-wise studies have also shown very variable prevalence of hepatitits C virus infection incidence of 5.4-12% have been reported from different dialysis centres in Hamburg by K Uhni.8
HBs Ag positivity has been reported as 26.5% by phenoichphant13 from Bangkok. AJ Elavia et al3 from India found a prevalence rate of 5.2% for HBs Ag positivity in high risk CRF patients on maintenance haemodialysis.
We have found incidence of HBs Ag and anti-HCV positivity as 1.8% and 0.2% respectively in healthy asymptomatic voluntary blood donors as against 6% and 8% respectively in the study group.
Oguchi et al12 from Japan had reported the incidence of hepatitis B and C in voluntary blood donors as 1.8% and 0.9% respectively.

TABLE 4
Correlation of HBs Ag and anti HCV positivity with number of haemodialysis
No. of
dialysis
HBS Ag
+ve cases
Anti HCV
+ve cases
HBS Ag +ve cases and Anti HCV-ve cases
1-2 Nil Nil Nil
3-4 Nil Nil 2
5-6 Nil 1 24l
7-8 1 2 14
9-10 1 1 3
11-12 1 Nil Nil
       
TABLE 5
Correlation of HBs Ag and anti HCV positivity with number of blood transfusion during maintenance haemodialysis
No. of blood transfusions HBS Ag
+ve cases
Anti HCV
+ve cases
HBS Ag +ve cases and Anti HCV-ve cases
1-2 Nil Nil 14
3-4 Nil 2 28
5-6 3 2 1
Total cases 3 4 43
9-10 1 1 3
Average no.
of transfusion
5.6 4.7 2.9
 
TABLE 6
Relationship of blood urea and serum creatinine in HBs Ag and anti HCV positive patients compared with HBs Ag and anti HCV negative patients
n our study the mean blood urea in HBS Ag and HCV positive cases was 187.7 ± 38.48 mg% (standard deviation). While in HBsAg and anti HCV negative patients the mean blood urea was 154.1 ± 31.65 mg%.
Similarly mean serum creatinine was 12.1 ± 3.7 mg% in HBs Ag and anti HCV positive cases as compared to 7.4 ± 1.2 mg% in the patients negative for HBs Ag and anti-HCV.
 
TABLE 7
Relationship of duration of CRF in HBs Ag and HCV positive cases as compared with HBs Ag and anti HCV negative patients
Duration of
CRF prior to
haemodialysis

No. of
HBs Ag

No. of
Anti HCV
+ve cases
HBS Ag and Anti HCV-ve cases
0-3 months Nil Nil Nil
3-6 months Nil Nil Nil
6-9 months Nil 1 20
9-12 months 2 1 3
12-15 months 1 2 Nil
Total cases 3 4 43
Mean duration 12.6 ± 2.1
months
11.5 ± 2.4
months
6.7 ± 1.7
months
 


It has been observed that hepatitis B and C virus infection, being more commonly associated with transfusion of blood and blood products.
In our study all the 50 patients were given blood transfusion during the study period and a direct correlation has been observed with the number of blood transfusion received.
The average number of blood transfusion received by HBs +ve cases being 5.6% as against 4.7 in hepatitis C cases and 2.9 in hepatitis B and C negative cases.
Similar correlation of hepatitis B and C positivity with number of blood transfusion has been reported by Oguchi11 and Pijesa S et al.14 However Barton E2 from Jamaica and salunkhe -P15 from Lucknow has found number of blood transfusion being almost same in both hepatitis B and C positive and negative groups suggesting that other factor, may be responsible for transmission of hepatitis B and C virus infection.
Duration of haemodialysis treatment has strong bearing on hepatitis B and C virus infection. We have found that majority of our hepatitis B and C positive patients received 7-12 dialysis with average number of dialysis being 9.3 is HBS +ve and 8 in anti-HCV +ve cases as against 6.3 in patients, who were negative for HBS Ag and anti HCV. Similar correlation has been reported by Hardy et al,5 while oguchi12 from Japan had found no correlation of HBS Ag and anti HCV positivity with the number of dialysis sessions.
Vaccination against hepatitis B virus infection has reduced the prevalence of hepatitis B in dialysis patient. In our study, out of 40 immunized patients, only one patient (2.5%) acquired hepatitis B infection as against 2 out of 10 (20%) in unimmunized group. Thus showing the protective role of hepatitis B vaccination in CRF patients on maintenance haemodialysis.
Tales SA17 from central Brazil had also found that hepatitis B virus infection was more common in unimmunized patients.

SUMMARY AND CONCLUSION

Following conclusion were drawn from the study:
1. The prevalence of hepatitis B and C infection in haemodialysis unit in our set-up was 6% and 8% respectively.
2. The prevalence of hepatitis b and C in healthy voluntary blood donor, was 1.8% and 0.2% respectively during the same period.
3. There was greater risk of hepatitis B and C transmission with increasing number of blood transfusion, number of haemodialysis session, severity of illness and the duration of CRF.
4. Hepatitis B vaccination has a definite protective role.
5. Certain other risk factors related to the haemodialysis environment are also responsible for the transmission of hepatitis B and C infection.
Similar such studies in larger population are required to further strengthen our observation, so that a definite opinion regarding the prevention of hepatitis B and C in haemodialysis patients can be formulated.

REFERENCES

1. Arankaile VA, Chadha MS, Jha J, et al. Prevalence of anti HCV antibodies in western Indian J Med Res 1995; 101 : 91-3.
2. Barton EN, King SE, Douglas LL. The seroprevalence of hepatitis and retroviral infection in Jamaican haemodialysis patients. West Indian Med J 1998; 47 (3) : 105-7.
3. Elavia AJ, Banker DD. Prevalence of HBs Ag and its substypes in high risk group of subjects and blood donors India. J of Med Res 1991; 93 : 280-85.
4. Gosabi MA, SK, Shah SA, et al. Prevalence of hepatitis C virus (HCV) infection in Mumbai. Indian Journal of Medical Sciences 1997; 51 (10) : 378-85.
5. Hardy HM, Sandoroni S, Danielson S, et al. Antibody to clin Nephrol 1992; 38 (1) : 44-8.
6. Jaiswal SP, Chitnis DD, Naik G, et al. Prevalence of anti HCV antibodies in central India. Indian Journal of Medical Research 1996; 104 : 171-81.
7. Jilg W, Weinel B, Jutler t, et al. Immunogenecity of recombinant hepatitis B vaccine in dialysis patients. J Hepatol 1986; 3:190-5.
8. Unni KP, Roggrndorf M, Sibrowski W, et al. Hepatitis C virus antibodies in patients treated with chronic haemodialysis. Beitr Infusion Sther 1990; 26 : 27-9.
9. Malhotra KK, Prabhakar SP, Sharma RK. Hepatitis B in haemodialysis unit in New Delhi. J Associ Phys Ind 1985; 33 : 216.
10. Sampietro M, Salvatore, Giogio Graziani, Nosocomial Hepatitis C in dialysis unit. Nephron 1996; 74 : 251-160.
11. Oguchi H, Terashima H, Tokunage S, et al. Prevalence of anti HCV in patients on long term haemodialysis Nippo N Jinzo Gakkai Sh 1990; 32 (3) : 313-7.
12. Oguchi H, Miyasaka M, et al. Hepatitis virus infection HBV and HCV in eleven Japanese Haemodialysis unit clinNephrol 1992; 38 (2) : 36-43.
13. Phevicophant S, Nekawasbei Petal. Hepatitis B virus infection in Thai Haemodialysis patients south east Asian Jr Trop Md Public Health 1985; 16 (2) : 280-4.
14. Pijesa S, Golubovie LJ, et al. Hepatitis C virus infection patients on chronic haemodialysis. Srpski Arhiv Za celokupno Kekarstove 1996; 124 (Suppl 1) : 120-3.
15. Salunkhe PN, Naik SR, Semwal SW, et al. Prevalence of anti-bodies to hepatitis C virus in HBs Ag negative haemodialysis patients. Indian J Gastroenterol 1982; 11 (4) : 164-5.
16. Sumathy S, Valliammai T, Thyagrazan SP, et al. Prevalence of hepatitis C, virus infection in liver diseases renal disease and valuntary blood donors in south India. Indian J Med Microbiol 1993; 11 : 291-7.
17. Tales SA, Martin RM, Silva SA, et al. Hepatitis B virus infection in central Bazilian haemodialysis population. Rev Inst Med Trop Sao Paulo 1998; 40 (5) : 281.
18. Thomas P, Kurubakaran MG, Jacob C Metal. Hepatitis B infection in a dialysis unit in south India. J Assoc Physicians India 1987; 35 : 284.

SEVERE ACUTE RESPIRATORY SYNDROME - GLOBAL ALERT

A flu-like illnesses followed by atypical pneumonia and high case fatality rate have been its characteristics.
1. It is a new entity. 2. It is communicable disease with high case fatality. 3. Continental epidemic. 4. Occupational hazard for the Health Care Providers (HCPs).
Days after the WHO alert mass media poured voluminous material on the ‘action’ and ‘helplessness’ related to SARS. Such level of publicity helps create mass awareness; yet has the undesirable component of generating panic.
The good news of this week is that the causal agent could be a member of paramyxovirus family.
No doubt, the case fatality rate of SARS is around 3.72 per cent and appears high. But we may compare it with around 2 per cent case fatality rate with typhoid fever even in the best of the centres. Perhaps we are unaccustomed to community acquired pneumonias not being amenable to any therapy.
The 1918 flu epidemic killed 20 million people worldwide. Fortunately, it is not the influenza virus.
The metro cities in India are at high risk of importing and spreading SARS from South East Asia. Population density and public transport systems make them particularly vulnerable. Concerns over travel to affected areas may call for postponing unnecessary or elective travel to these areas.



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