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Tuberculosis at the United Nations: a missed chance

To examine trends in and correlates of liver disease and viral hepatitis in an human immunodeficiency virus (HIV)-infected cohort. The multi-site adult/adolescent spectrum of HIV-related diseases (ASD) followed 29 490 HIV-infected individuals receiving medical care in 11 U.S. metropolitan areas for an average of 2.4 years, and a total of 69 487 person-years, between 1998 and 2004. ASD collected data on the presentation, treatment, and outcomes of HIV, including liver disease, hepatitis screening, and hepatitis diagnoses. Incident liver disease, chronic hepatitis B virus (HBV), and hepatitis C virus (HCV) were diagnosed in 0.9, 1.8, and 4.7 per 100 person-years. HBV and HCV screening increased from fewer than 20% to over 60% during this period of observation (P < 0.001). Deaths occurred in 57% of those diagnosed with liver disease relative to 15% overall (P < 0.001). Overall 10% of deaths occurred among individuals with a diagnosis of liver disease. Despite care guidelines promoting screening and vaccination for HBV and screening for HCV, screening and vaccination were not universally conducted or, if conducted, not documented. Due to high rates of incident liver disease, viral hepatitis screening, vaccination, and treatment among HIV-infected individuals should be a priority.

Hepatocellular carcinoma (HCC) is one of the most common and devastating malignant tumors in the world, particularly in Asia and Africa (1). With the estimated 1 million cases per year worldwide, HCC is the seventh most common cancer in men and the ninth most common in women. In high prevalence areas such as Southeast Asia, the Far East including Taiwan, and sub-Saharan Africa, the annual incidence of HCC reaches 30 cases per 100,000 population; this contrasts with an annual incidence of fewer than 2 cases per 100,000 population in low-risk areas such as the United States and most of Europe. Symptomatic HCCs usually run a rapidly progressive course with low rate of resectability and poor response to nonsurgical therapy and thus have a very poor prognosis (2). The risk factors associated with the development of HCC include chronic infection with either hepatitis B virus (HBV) or hepatitis C virus (HCV), the presence of liver cirrhosis, carcinogen exposure especially aflatoxin B1, alcohol abuse, genetic factors, male gender, cigaret smoking, and advanced age. Among these risk factors, chronic hepatitis virus infections, particularly those occurring in the presence of cirrhosis, show the strongest association with the development of HCC (2,3). This chapter reviews the virologic characteristics, animal models, and molecular pathogenesis of both HBV and HCV.

Dietary salt and cardiovascular disease

Screening of viral hepatitis and HIV among migrants from Southeast Asia

To identify the stochastic autoregressive integrated moving average (ARIMA) model for short term forecasting of hepatitis C virus (HCV) seropositivity among volunteer blood donors in Karachi, Pakistan. Ninety-six months (1998-2005) data on HCV seropositive cases (1000(-1) x month(-1)) among male volunteer blood donors tested at four major blood banks in Karachi, Pakistan were subjected to ARIMA modeling. Subsequently, a fitted ARIMA model was used to forecast HCV seropositive donors for 91-96 mo to contrast with observed series of the same months. To assess the forecast accuracy, the mean absolute error rate (%) between the observed and predicted HCV seroprevalence was calculated. Finally, a fitted ARIMA model was used for short-term forecasts beyond the observed series. The goodness-of-fit test of the optimum ARIMA (2,1,7) model showed non-significant autocorrelations in the residuals of the model. The forecasts by ARIMA for 91-96 mo closely followed the pattern of observed series for the same months, with mean monthly absolute forecast errors (%) over 6 mo of 6.5%. The short-term forecasts beyond the observed series adequately captured the pattern in the data and showed increasing tendency of HCV seropositivity with a mean +/- SD HCV seroprevalence (1000(-1) x month(-1)) of 24.3 +/- 1.4 over the forecast interval. To curtail HCV spread, public health authorities need to educate communities and health care providers about HCV transmission routes based on known HCV epidemiology in Pakistan and its neighboring countries. Future research may focus on factors associated with hyperendemic levels of HCV infection.

BackgroundThe discovery of autochthonous hepatitis E in industrialized countries has changed the understanding of hepatitis E virus (HEV) infection in these regions, now known to be mainly due to zoonotic transmission of genotype 3. The foodborne route of transmission via consumption of contaminated meat from HEV infected pigs is well documented as well as the direct occupational exposure to animal reservoirs. Accumulating evidence also points to an emerging potential threat to blood safety after the identification of viremic blood donors and the documentation of HEV-contaminated blood or blood products. Moreover, the origin of several iatrogenic cases remains unclear and porcine-derived pharmaceutic products have been suspected as a cause. Severe morbidity following HEV infection in patients receiving immunosuppressive therapy and in those with severe immunodeficiency from other causes has been recently recognized as a serious consequence of this infection in industrialized countries. In Portugal no large-scale HEV seroprevalence study has been undertaken, no professional risk groups have been identified, and the risk of blood donation from HEV silent infected donors is unknown. The present paper describes seroepidemiological and molecular approaches to answer these questions.Methods/designTo address these issues a study protocol was designed that will approach: i) the seroprevalence of HEV among the Portuguese general population; ii) HEV infection among butchers and slaughterhouse workers (occupational risk); iii) the silent HEV infection in Portuguese blood donors (HEV transfusion-associated risk); iv) the potential HEV contamination of porcine-derived pharmaceutical products. Commercial enzyme immunoassays and real-time/conventional RT-PCR assays will be used.DiscussionThis study is the first evaluation of the seroepidemiological status to HEV infection of the Portuguese population, the first to potentially identify professional risk groups, and to evaluate the safety of blood and blood products and porcine-derived pharmaceutics in Portugal. It will generate valuable data applicable for preventive and control measures against HEV infection (e.g., introduction of systematic screening of blood donors, control of blood products or porcine derived pharmaceutical products), thus helping to manage the burden of this viral disease.

The aim of this study was to evaluate retrospectively the prevalence of hepatitis B virus (HBV) and hepatitis C virus (HCV) infection, epidemiological parameters, and the clinical data from the antiviral treatment of hepatitis C in a large cohort of intravenous drug users (IDUs) followed-up from 1994 until 2008. A total of 1179 former IDUs followed up either in the liver unit or in the context of a substitution program organization were included in this study. A retrospective chart review was prepared to retrieve data on the patients' demographic characteristics, the prevalence of viral hepatitis, and information on HCV treatment. The prevalence of HBsAg positive was 5%. A substantial number of patients were anti-HCV positive (847/1170, 73%), 189 were lost to follow-up, 526 (80%) were HCV RNA positive and 132 (20%) had a self-limited disease. The most prevalent genotype was 3 (59.7%). Twenty-five percent of the study population received antiviral treatment against HCV infection. Patients seen in the Liver Unit were more likely to receive antiviral treatment. The sustained virological response (SVR) was 80% with patients treated with pegylated interferon and ribavirin having a significantly higher SVR rate. Our results show that (a) the majority of IDUs in Greece have chronic hepatitis C and the prevalent genotype is 3 (b) patients who complete therapy have SVR rates similar to those without drug-dependence, and (c) since IDUs constitute the core of the hepatitis C epidemic and the main route of HCV transmission, efforts to treat these patients should be made.

Screening for viral hepatitis by automatically ordering hepatitis B and C serology on blood samples already collected from patients presenting to the emergency department (ED) is a relatively novel concept, with modest costs involved. The aim of this study was to determine patient and healthcare worker perspectives of automatic hepatitis screening at a large metropolitan hospital in Sydney, Australia. In this cross-sectional survey study, patients admitted via ED and ED healthcare workers (HCWs) were invited to participate. The primary outcome was the level of patient and HCW acceptability of an automatic hepatitis screening process. Secondary outcomes were patient and HCW knowledge of viral hepatitis, perceptions and barriers to ED hepatitis screening in the absence of an automatic process. Ninety-two percent of 273 patients who participated in the survey wished to know their viral hepatitis status, and 82% found automatic hepatitis B and C testing acceptable as part of their ED blood work. HCWs surveyed (48) believed this strategy would increase testing, as most did not routinely interrogate patients for risk factors or other eligibility criteria for hepatitis testing, as the presenting ED complaint was their priority. Even when indications for testing based on current guidelines were present, few (32%) HCWs initiated testing. Automatic viral hepatitis testing in ED is supported by the majority of patients and HCWs, and the latter believe it would increase testing rates. Increasing identification of patients with hepatitis, if accompanied by effective linkage to care, could facilitate World Health Organization elimination goals.

India is a repository of herbal medicines, and there are evidences of herbs being used in the treatment of diseases and for revitalizing various body systems in almost all ancient civilizations. Plants have traditionally served as man’s most important weapon against pathogens. Herbal medicines are widely used by all sections of the community, either as folk remedies or as medicaments in the indigenous as well as modern system of medicine. Th e present survey was conducted to record the medicinal herbs that tribes use for the treatment of viral hepatitis. Data were collected by interviewing local traditional therapists and tribes of the region. A total of 14 medicinal plants were obtained. Information on local names, plant parts, chemical constituents and dosage used were also recorded and reported in this paper. Th e present study aims to draw the attention of researchers towards the need of future critical study. Key words: Traditional herbal medicine, tribes, folk remedies, viral hepatitis, Vindhaya region, Madhya Pradesh

Road safety: more than reducing injuries

Of 253 prospectively studied cases of acute viral hepatitis (AVH), 47 were fulminant (18.6%). There were 15 males and 32 females. Their age ranged from 7 to 60 years (mean, 29 years). Serological evidence of AVH-A was found in one case (2%), AVH-B in 13 cases (28%), AVH-D in one case (2%), and AVH-NANB in 32 cases (68%). Fulminant hepatitis was found in 2.6% of AVH-A cases, in 16.25% of AVH-B cases, in one of two AVH-D superinfections, and in 24.8% of the AVH-non-A, non-B (NANB) cases. The clinical picture in the two main etiological categories, namely the AVH-B and the AVH-NANB, showed that the latter possessed a more prolonged and severe clinical course with higher mortality (P<0.001). It also showed a higher mortality in females of the child bearing age, compared with males of the same age group (P<0.001).

Chronic hepatitis B virus (HBV) and hepatitis C virus (HCV) infection are the most important underlying causes for the development of hepatocellular carcinoma (HCC) worldwide. Determining the optimal approach for management of the viral infection and the HCC depends on the virus and the stage of the cancer. In patients with HCV-associated HCC, there are multiple reasons to first treat the HCC. Firstly, in case of a curable HCC, the urgency for HCC treatment is important to avoid progression during HCV treatment. Secondly, the presence of HCC itself appears to reduce the rates of sustained virological response (SVR) achieved with direct-acting antivirals (DAAs). And finally, the evidence does not support the concept of an increase in HCC recurrence due to DAAs, so a patient can safely be treated after HCC cure. For patients with very advanced HCC, the benefits of HCV therapy are questionable. In contrast, those who develop HCC in the setting of chronic HBV infection, treatment with nucleoside analogues (NAs) is recommended prior to treating HCC, to prevent further liver injury and reduce the risk for HCC recurrence. Ultimately, earlier diagnosis and treatment of HBV and HCV will hopefully reduce the incidence of HCC worldwide.

INTRODUCTION: In 2015, 40,326 or 12.5 per 100,000 population died from chronic liver disease. Viral hepatitis is associated with 18.5% of chronic liver disease related deaths. The vast majority of patients with liver disease present in the chronic phase, however, Community Regional Medical Center was using an acute hepatitis panel (HAV Ab IgM, HBsAg, HBcAb IgM, and HCV Ab) to evaluate for viral hepatitis. We created and implemented a chronic hepatitis panel (HAV Ab Total, HBsAg, HBsAb, HBcAb Total, and HCV Ab) with the aim of improving screening for chronic viral hepatitis, identifying patients at risk for HBV reactivation and patients in need for HAV and HBV vaccinations. METHODS: Baseline clinical and laboratory data including the number of acute hepatitis panels were collected from July 2017 to June 2018. Post-implementation data were collected from November 2018 to April 2019. The primary outcome was the utilization of the appropriate hepatitis panel to the presenting clinical syndrome. Secondary outcomes were vaccination rates for HAV and HBV in the setting of chronic liver disease and healthcare cost utilization of patients with chronic liver disease. RESULTS: Of 17,357 patients screened, acute hepatitis panel was ordered in 40.2%, mainly in the emergency department (42%) and inpatient (40%) setting. Of these, 26.9% of acute hepatitis panels were ordered with ALT &lt; 150 or prior to ALT results. 64.7% of patients completed chronic hepatitis panel components afterward. Chronic hepatitis panel components were ordered more than once in 47.4%. Post-implementation data was collected in 6298 patients of which, 14% completed the chronic hepatitis panel. There was a 220% increase in the number of chronic hepatitis panels ordered, from November 2018 to April 2019. The average number of hepatitis labs (panel or components) ordered per patient decreased from 3.4 to 2.2 post implementation of the chronic panel. The cost for the chronic hepatitis panel is $214.20 compared to $325.38 for the acute hepatitis panel, reflecting a cost savings of 34% per panel. This is in addition to the projected savings from the decrease in the inappropriate ordering of labs. CONCLUSION: The chronic hepatitis panel can improve screening for chronic viral hepatitis, and potentially improve vaccination rates against Hepatitis A and Hepatitis B, as well as help prevent HBV reactivations, while lowering costs, in chronic liver disease. Longitudinal studies are needed to assess the impact of chronic hepatitis panel on disease outcomes.

To explore how well professional education and post-qualification clinical supervision support equips health visitors to deal with ethical tensions associated with implementing the public health agenda while also being responsive to individual clients. Current health policy in England gives health visitors a key role in implementing the government's public health agenda. Health visitors are also required by their Professional Code to respond to the health-related concerns and preferences of their individual clients. This generates a number of public health-related ethical tensions. Exploratory cross-sectional qualitative (interpretive) study using 29 semi-structured individual interviews with health visitors, practice teachers and university lecturers exploring how well health visitors' professional education and post-qualification clinical supervision support equips them for dealing with these ethical tensions and whether they thought further ethics education was needed. Interviews were audio-recorded, transcribed and analysed thematically using a Framework approach. Health visitors' professional education did not always equip them to deal with ethical tensions, which arose from delivering public health interventions to their clients. However, the majority of participants thought that ethics could not be taught in a way that would equip health visitors for every situation and that ongoing post-qualification clinical supervision support was also needed, particularly in the first year after qualifying. The amount of post-qualification support available to practising health visitors was variable with some health visitors unable to access such support due to their working circumstances and pressures on staff time. Literature on the ethical tensions associated with evidence-based practice; public health ethics and ethics of care might be useful for health visitors in gaining greater understanding of the ethical tensions they face. This could be introduced as part of health visitors' professional education or on post-qualification study days.