International university of Africa Faculty of medicine

Community Medicine Department

Research Title:
Prevalence of hepatitiss B in patients attending Ibrahim Malik teaching hospital laboratory from October 2012 to July 2013.

By: Ahmed Ali Ahmed Mohanad Mammon Zulaikha Abaulmalik Supervisor: Dr Shawgi Harbi Muotz Awed Siddig Mussa Witness Amal Abd Alla Omar

 Dedication

Acknowledge:

The authors want to thank the staff of the Laboratory of Virology, as well as staff at the IMTH and IUA .Mr. Shawgi Harbi is thanked for his precious help in conducting the study, Mr. abd alkareem the head office of IMTH .and the thanks for those whom support us in the dark of the life and for the families whom build those minds .

 Abbreviations

 Table of contents

Research title

Dedication

Acknowledge

Abbreviations

Table of contents

Chapter (1) Introduction

Background Justification Objective

Chapter (2): Literature review

EPIDEMIOLOGY SOURCES OF HBV INFECTION PATHOGENESIS CLINICAL FEATURES INVESTIGATION MANAGEMENT

Chapter (3) Methodology 5

Chapter (4) Results

Data per month

BLOOD BANK DATA Lab data Analysis

total number of people tested Blood bank data Lab data Total of positive Total negative

Chapter (1)

Introduction

a) Background:
HBV is a member of the Hepadnaviridae family, genus Hepadnavirus. The infectious virion, the Dane particle, is 42 to 47 nm in diameter. It possesses an envelope and a capsid or core that contains the partially double-stranded, circular DNA genome. The HBV genome is the smallest known human virus genome, with approximately 3000 nucleotides (1) .The hepatitis B virus (HBV) is present world-wide with an estimated 360 million carriers
(2)

. HBV has been extensively characterized. The complete HBV virion (Dane particle)

consists of several components that elicit distinct antibody responses from the host. Clinically relevant is the surface envelope (hepatitis B surface antigen [HBsAg]), a core of partially double-stranded circular DNA (HBV DNA) to which is attached a DNA polymerase, and a nucleocapsid (hepatitis B core antigen [HBcAg] and hepatitis B early antigen [HBeAg]) that encloses the DNA and the polymerase . HBV transmitted parenterally. Four principal routes of transmission are responsible for acute HBV infections: (1) sexual transmission, which is the principal route in industrialized areas; (2) perinatal mother-to-infant transmission, which is associated with a very high (>90%) rate of chronic infection and is the principal cause of HBV transmission in Asia; (3) horizontal transmission through nonsexual interindividual contact, which is frequent at a young age in Africa and is associated with evolution to chronicity in approximately 15% of cases; and (4) percutaneous transmission by blood and blood products, unsafe medical or surgical materials, or injection drug use. In industrialized countries, groups at high risk for HBV infection include individuals born in areas where HBV is endemic, including immigrants and adopted children; individuals who were not vaccinated as infants and whose parents were born in regions where HBV is endemic; household and sexual contacts of HBsAgpositive individuals; persons who have ever injected drugs; persons with multiple sexual partners or a history of sexually transmitted disease; men who have sex with men; inmates of correctional facilities; patients infected with HCV or HIV; patients undergoing renal dialysis; recipients of blood or blood products before and health care workers. The HBV genome contains at least four overlapping open reading frames that encode a number of structural and nonstructural viral proteins. The pre-S/S gene encodes the three surface proteinssmall (S), middle (M), and large (L)which express HBsAg. The pre-C/C gene
8

encodes the core protein that expresses the hepatitis B core (HBc) antigen and the hepatitis B e (HBe) protein, a nonstructural protein that plays a role in immune tolerance to HBV replication. The P gene encodes the HBV polymerase, whose two motifsa reverse transcriptase motif and an RNAse H motifcode for two enzymes involved in HBV replication. Finally, the X gene encodes the X protein, which is a transactivator involved in HBV replication that bears oncogenic properties. The blood of infected patients contains not only infectious viruses but also a large excess of empty, noninfectious HBV envelopes. Typically, the incubation period is 30 to 150 days. Four markers should be sought for the diagnosis of acute hepatitis B: HBsAg, total anti-HBc antibodies, anti-HBc IgM, and antiHBs antibodies. Prevention of HBV infection is based on vaccination. Universal infant vaccination programs have been initiated in many countries. High-risk individuals (e.g., health care workers, dialysis patients, family members and sexual partners of HBV carriers, pregnant women, and men who have sex with men) should be screened for HBV infection by HBsAg and anti-HBs antibody testing, and seronegative persons should be vaccinated.(3)

b) Justification:

WHO estimates that around 4.3 million persons are newly infected with hepatitis B virus in the eastern Mediterranean region .In the acute infection treatment with Antiviral therapy with lamivudine can decrease HBV DNA levels more rapidly but does not result in better clinical or biochemical improvement and may be associated with lower levels of protective anti-HBs at 1 year. Chronic HBV infection is not curable, but it can usually be controlled by appropriate antiviral drugs. HBV infection cannot be completely eradicated because of the persistence of covalently closed circular DNA in the nucleus of infected hepatocytes. Vaccination is the most effective tool in preventing the transmission of HBV infection. Passive and active immunization Vaccination is universally available in most developed countries as well as countries with high endemicity.

c) Objective:
General objective:
To detect the prevalence of hepatitis B in the patient attending Ibrahim Malik Teaching Hospital (IMTH).

Specific objective:
Proportion of hepatitis b in blood Proportion of hepatitis b in lab

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Chapter (2): Literature review

EPIDEMIOLOGY
The hepatitis B virus is present worldwide with an estimated 360 million carriers with Africa having the higher rates .The UK and USA have low carrier rates (0.5%-2%) vertical transmission from mother to child in utero during delivery or soon after birth, is the usual means of transmission worldwide. Hepatitis B is not transmitted by breast feeding, horizontal transmission occurs in children by minor abrasions or contact with other infected children. Other ways are through transmission of infected blood or blood products or by contaminated needles used by drug users, tattooist or close personal contact such as during sexual intercourse. The virus can be found in saliva and semen (1).

SOURCES OF HBV INFECTION Horizontal transmission Injection drug used Infected unscreened blood products Tattoos or acupuncture needles Sexual contact Closed living quarters or play ground as a toddler may contribute to high rate of horizontal transmission in Africa Vertical transmission HBsAg positive mother (2) (1) kumar and clarks clinical medicine,7th edition ,page 335 (2)davidsons principles and practice of medicine,21st edition ,page 949

PATHOGENESIS The adaptive immune response is thought to be responsible for viral clearance and the disease pathogenesis during hepatitis B virus infection. It is generally acknowledged that the humeral clearance of circulating particles and the prevention of viral spread within the host while the

11

cellular immune system eliminates infected cells .The cell response to the hepatitis B virus is vigorous . Polyclonal and multispecific in acutely infected patients who successfully clear the virus and relatively weak and narrowly focused in chronically infected patient, suggesting that clearance of HBV is T cell dependent. The pathogenic and ant viral potential of the cytotoxic T lymphocyte response to HBV has been proven by the induction of a severe necro inflammatory liver disease following the adoptive transfer of HBsAg specific CTL into HBV transgenic mice. Remarkably the CTL also purge HBV replicative intermediates from the liver by secreting type1 inflammatory cytokines thereby limiting virus spread to uninfected cells and reducing the degree of immunopathology required to terminate the infection.

Persistent HBV is characterized by a weak adaptive immune response ,thought to be due to inefficient CD4+Tcells priming early in the infection and subsequent development of a quantitatively and qualitatively ineffective CD8+Tcell response .other factors that could could not contribute to viral persistence are immunological tolerance, incomplete down regulation of viral replication, mutational epitome inactivation, T cell receptor antagonist.() However, these pathways become apparent only in the setting of an ineffective immune response, which is therefore the fundamental underlying cause. Persistent infection is characterized by chronic liver cell injury regeneration ,inflammation, widespread DNA damage and in sectional deregulation of cellular growth control genes, which collectively, lead to cirrhosis of the liver and hepatocellular carcinoma (3)

12

(3)

pathologie

biologie,volume

58,issue

4,pages

258

266,f.v,chisavi.m.isogawa,s.f Wieland

CLINICAL FEATURES Acute illness: anon specific proclonal illness characterized by headache, myalgia, arthragia, nausea and anorexia usually preceed the development of jaundice by a few days to 2 weeks. Vomiting and diarrhea may follow abdominal discomfort is common. Dark urine and pale stools may preceed jaundice. There are usually few physical signs .the liver is often tender but only minimally enlarged. Occasionally mild splenomegaly and cervical lymphadenopathy are seen. Symptoms rarely last longer than 3-6 weeks.

Chronic illness: may be asymptomatic or may be associated with a chronic inflammation of the liver leading to liver cirrhosis over a period of several years. This type of infection dramatically increases the incidence of hepatocellular carcinoma. Chronic carrier are advised to avoid alcohol consumption as it increases the risk of cirrhosis and cancer. HBV has been linked to the development of membranous glomerulonephritis(4).

13

(4)

davidsons

principles

and

practice

of

medicine,21st

edition,edited

by

Nicki.R.Colledge,Bran.R.Walker, Stuart .H.Ralston, page 948.

INVESTIGATION Serology: HBV contains several antigens to which the infected patients can make immune response. These and their antibodies are important in identifying HBV infection. The hepatitis B surface antigen is an indicator of active infection and if its negative makes HBV infection very unlikely. Usually it lasts for 3 to 6weeks and can persist up to 5 months. The persistence longer than 6 months indicate chronic infection. antibody to HBsAg usually appear after 3 to 6 months and persist for many years on perhaps permanently. Hepatitis B core antigen, it is not found in blood but antibody to it appears early in the illness and rapidly reaches a high titre, which subsides gradually but then persists.the antibody is initially of IgM type with IgG antibodies appearing later. Ant bodies (IgM) can sometimes reveal an acute HBV infection when the HBsAg has disappeared and before ant-HBs has developed. The hepatitis B e antigen:(HBeAg) is an indicator of viral replication in acute hepatitis B it may appear only transiently at the onset of the illness ,its appearance is followed by the production of antibody. The HBeAg indicate active replication of the virus in the liver. Chronic hepatitis B infection is marked by the presence of HBsAg and ant HBs (Ig G) in the blood. Usually HBeAg or ant HBe usually implies low viral replication; the exception is HBeAb positive replicating chronic hepatitis B in which high levels of serum HBV are seen despite negative HBeAg. Viral load HBV-DNA can be measured by PCR in the blood.in contrast to those with low viral replication , HBsAg and ant HBe positive viral loads .the exception is in patients who have a mutation in the pre- core protein, which means they cannot secrete e antigen into serum. such individual will be ant HBe positive but have a high load and often evidence of chronic hepatitis.
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Measurement of viral load is very important in monitoring ant viral therapy and identifying patients with pre-core mutants. Specific HBV genotypes can also be identified using PCR. Genotype B and C appear to have more aggressive disease that responds less well to interferon. Reference

MANAGEMENT Acute HB: treatment is supportive with monitoring for acute liver failure which occurs in less than 1% of the cases. There is no definitive evidence that ant viral therapy reduces the severity of acute hepatitis B. Full recovery occurs in 90-95% of adults following acute HBV infection .the remaining 5-10% develop a chronic infection which usually continue for life, although later recover may occur. Infection passing from mother to child at birth lead to chronic infection in the child in 90% of the cases and recovery are rare. Chronic infection is also common in immunodeficient individuals such as those with Down s syndrome. Recovery from acute HBV infection occurs within 6 months and is characterized by the appearance of antibody to viral antigens. persistence of HBeAg beyond this time indicates chronic infection.

Chronic HB: treatment is still limited ,as no drug is able to eradicate hepatitis B infection completely. the goals of treatment are HBeAg conversion, reduction in HBV- DNA and normalization of LFTs . The indication for treatment is a high viral load in the presence of acute hepatitis as demonstrated by elevated serum transminases and /or histological evidence of inflammation and fibrosis. The oral ant viral agent are more effective in reducing viral loads in patients with e antigen negative chronic hepatitis B than those with e antigen-positive chronic hepatitis B, as the pre15

treatment viral load are lower most patients with chronic hepatitis B are asymptomatic and develop complications such as cirrhosis and hepatocellular carcinoma only after many years.

Antviral therapy Alfa-interferon: this is most effective in selected patients with low viral load and serum transaminases greater than twice the upper limit of normal , in whom it acts by augmenting a native immune response. In HBeAg - negative chronic hepatitis ,even when patients are given longer course of treatment. Interferon is contraindicated in the presence of cirrhosis,as it may cause rise in serum transaminases and precipitate liver failure. Other ant viral therapies may be required because many patients with chronic hepatitis B have high level of viraemia and /or low transaminase levels and are therefore not candidate for interferon . side effects are common and include fatigue, depression, irritability, bone marrow suppression and thyroid disease.

Lamivudine: this is nucleoside analogue which inhibits DNA polymerase and suppresses HBV-DNA levels .it is effective in improving liver function in patients with decompensated liver cirrhosis and may prevent the need for transplantation . long term therapy is complicated by the development of HBV-DNA polymerase mutants which may occur after 9 months of treatment and is characterized by a rise in viral load during treatment these viral mutants are less hepatotoxic than native virus. Elevations in transaminases occur when lamivudine is stopped if mutant virus is present.in the event of mutation occurring ,other ant viral agents can be added. Adefovir :this is anucleotide analogue that is phosphorylated to yield active drug which inhibits HBV-DNA polymerase.it reduces HBV-DNA by 3-4 logs, enhances the frequency of HBsAg seroconversion and leads to histological improvement, but is contraindicated in renal failure. The HBV-DNA mutants develop at a lower rate than with lamivudine ,2% are identified after 2 years but this figure increases to 18% after 3 years .relapse occur on stopping treatment ,and the optimum length of treatment remains

16

unknown .adefovir is effective in suppressing most of the lamivudine-induced DNA polymerase mutant virus .

17

Chapter (3)

Methodology

18

The study was done on patients who were attending Ibrahim Malik Teaching Hospital (IMTH). We were collecting blood bank and lab test results from the hospital almost by the end of each month from December 2012 to September 2013. We considered all the cases which were tested and recorded in the lab sheets. The suspected people who are investigated in the section of the laboratory data, and every donated individual where blood screen done for him randomly. The study builds on cross section of the suspected people in ten month from December 2012 to September 2013.the sample consider the entire patient which was about 1689 patient. The collection was done in a sheet which content three columns for; date, positive, negative. Then the collected data formulated in four tables which are; blood bank data, laboratory data, total positive, total negative. The blood bank data was 1533 patient, 56 was positive, 1477 was negative. The laboratory test data was 166 patients, 31 was positive, 135 was negative. The total positive 193 patient and the total negative 1508. Methodology Study design: Study area: (describe IM hospital) Study population: ( describe your study population HBV test..etc) Sample size: How much respondents were included? And based on what? Sampling technique: What sampling technique did you follow? Data collection technique and tools:
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- laboratory records of individuals referred for

What is the source of data ? how did you collect it ? using what tool( questionnaire or check list) Data analysis: How did you analyse the data? Using which programme Ethical Issues:

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Chapter (4)

Results

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Analysis:

total number of people tested

date DEC JAN FEB MAR APR MAY JUN JUL AUG SEP Sum

Lab data 39 25 16 18 21 28 9 3 5 2 166

Blood bank data 27 132 77 85 198 201 188 240 147 238 1533

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Lab data % Blood bank

total tested
lab data blood bank

10%

90%

23

Blood bank data

date DEC JAN FEB MAR APR MAY JUN JUL AUG SEP Sum

+ve
1 3 5 1 7 9 6 10 7 7 56

-ve
26 129 72 84 191 192 182 230 140 231 1477

24

Positive =56 Negative=1477

Blood bank Positive %= Blood bank Negative %=

blood bank
positive +ve negative -ve

4%

96%

25

Lab data Date

DEC JAN FEB MAR APR MAY JUN JUL AUG SEP SUM

+ve
4 2 2 11 3 3 2 1 2 1 31

-ve
35 23 14 7 18 25 7 2 3 1 135

26

Positive =31 Negative =135 Lab data positive %= Lab data negative%= %

lab data
positive +ve negative -ve

19%

81%

27

Total of positive :

Date

Blood bank 1 3 5 1 7 9 6 10 7 7

Lab 4 2 2 11 3 3 2 1 2 1 31

DEC JAN FEB MAR APR MAY JUN JUL AUG SEP SUM

56

28

Lab =31 Blood bank=56 Total positive lab %=

Total positive blood bank%=

total positive data

lab blood bank

36% 64%

29

Total negitive

date
Dec Jan Feb Mar Apr May Jun Jul Aug Sep

Blood bank 26 129 72 84 191 192 182 230 140 231 1477

Lab 35 23 14 7 17 25 7 2 3 1 135

sum

30

Lab =109 Blood bank =1297 Total negative lab%=

Total negative blood bank%=

total negative data

lab blood bank

8%

92%

31

Prevalence; 87 positive cases out of the total tested 1699 individuals. Rate=

1406 negative cases out of the total tested 1699 individuals Rate=

32

prevaleance
positive negative

5%

95%

33

Chapter 5 Conclusion and recommendation

34

Conclusion;
The result of the research among the total people tested for hepatitis b who attending Ibrahim Malik teaching hospital laboratory from December 2012 to September 2013. 95%was negative and 5% was positive. The laboratory data result was 19%positive and 81%negative .the blood bank data result was 4%positive and 96% negative. There is no care for the recorded data which has been seen in the new change where they leave the files behind them in the old office, and the data wasnt computerized. They use screening in the laboratory and no conformation done in the hospital .the blood bank use to send The blood bottles sample to Stak laboratory in the center of Khartoum and wait for the result. The laboratory screen tools are not fixed to one pharmacological company which changed twice in the specific period.

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Recommendation; 1. Provision of new equipment for confirmation of HBV positive cases by the hospital instead of sending them to stak laboratory. 2. Maintenance of a clean environment by the lab staff at the hospital 3.safe keeping and computerization of the recorded data of screened cases by the hospital for easy access by researchers and other people interested in developing the health system. 4. Sensitization of the people over voluntary testing for HBV by the local health service providers. 5. Provision of free HBV vaccination to people who tested negative by the ministry of health. 6. Public civic education on the spreading and complications of HBV infection by the health service providers.

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