Turning the tides against infectious diseases: The microbial pathologist’s nexus – Part 6
Continued from last week Friday
We found that among 467 patients screened for HBsAg, aged 0-65 years from July 2009 to February 2012 in Delight Specialist Clinic and Maternity, Makurdi. A total of 96 was HBsAg sero positive. Among the HBsAg sero positive patients, only 3(3.1%) were HBeAg positive. All (100%) Hepatitis B “e‟ Antigen sero-positive patients were under age of 22 years. The study showed a low seroprevalence of HBeAg in a high hepatitis B sero-positive endemic population with adolescent age posing a higher risk for HBeAg. HBeAg is a marker of aggressive hepatitis B viral disease and possibly of liver cancer development. The next question was, why was ‘e’ antigen so low in our environment with high HBsAg seroprevalence and endemic liver pathologies? Other plausible explanation had been given by You et al (2004) that HBV mutations may result in ‘e’ antigen gene deletion and yet be aggressive with risk of hepatocellular carcinoma. Since hepatitis B viral load was difficult to achieve, we decided to focus on other HBVserologic markers (Odimayo MS et al 2010, Nwokedi et al 2011, Odimayo 2013).
After many years of active HBV campaign. We needed to know if our campaign was making impact. This was done through a cross sectional survey conducted on HBV awareness among members of Benue State University community in Makurdi, Benue state, Nigeria. A total of 728 individuals were recruited into this study consisting of 308 (42.31%) females and 420 (57.69%) males. Our subjects came from different parts of Benue state and beyond. Majority (63%) were between 21 and 30 years of age. Over 90% of the study group attained up to tertiary level of education; about 30% were married. We found that there was a significant awareness of hepatitis B virus infection among the study population as 81.1% had heard of HBV. However, some misconceptions which can result in stigmatization of HBV infected individuals existed. We recommend the strengthening of ongoing Health Education programs on HBV in our environment (Odimayo et al2015).
Since Hepatitis B Viral DNA load determination was difficult to achieve on routine basis for general diagnostic and treatment purposes. We thought of ways round it. How can we diagnose HBV and determine need for treatment or otherwise without viral loads for all patients. Fortunately, more serologic tools as diagnostic markers were becoming more available but the interpretations were complex. We moved ahead to determine the pattern of HBV serologic markers in HBV surface antigen (HBsAg) seropositive patients. HBsAg seropositive patients were screened for other HBV serologic markers namely, antibody to HBsAg (HBaAb), HBV e antigen (HBeAg), antibody to HBeAg (HBeAb) and antibody to HBV core antigen (HBcAb).
Liver enzymes (AST and ALT), age, sex and complaints of subjects were also documented. Sixty three HBsAg seropositive patients consisting of 65.1% males and 34.9% females with age ranging from 15 to 80 years were enrolled. Majority (70%) was between 20 and 40 years. We found that all patients with HbsAg seropositivity were sero-negative for HBsAb. Among the 5 patients (8%) which were seropositive for HBeAb, 2 of them were also HBeAg seropositive. HBcAb seropositivity was 95.2% (n=60/63). Serum transaminase enzymes level was normal in 80% of patients. Commonest complaint (over 80%) was upper abdominal pain. We concluded that in absence of Hepatitis B Viral DNA load determination, understanding of serological markers of HBV is important in the management of patients with chronic HBV infections.
With appropriate literature reviews, we discovered that most of our HBV seropositive patients actually requires treatment because they were symptomatic and positive for core IgM immunoglobulin (HBcAb) (Odimayo et al, 2016). Further study in this direction among blood donors confirmed that HBcAb was the only marker that correlated with detectable viral loads in occult HBV infections (Nwadioha et al 2018).
We are currently working on comparing the serologic pattern with viral load. This is very important to allow us to correlate viral load with HBV profile with a high degree of certainty in order to help our patients who may not be able to afford viral load determination. This is of serious concern. The second most important point of study is the determination of HBV genotypes circulating in our environment as this is important to determine response to therapy and prediction of complications. We are doing a lot of underground work to achieve this. We look forward to opportunity and support to commence studies in this direction.
Other research efforts at HBV showed that our Health care workers (HCWs) are still particularly at risk of hepatitis B virus (HBV) infection due to contact with infectious material like contaminated blood and body fluids or contact with HBV contaminated fomites. And that routine vaccination of HCWs is often not implemented due to cost in our setting. A cross-sectional study conducted among Staff from various cadres in EKSUTH, Ado Ekiti showed that among a total of 965 participants, 43(4.5%) were HBsAg positive out of which 40 (93%) had HBV infection as predicted by HBcAb seropositivty. Prevalence of HBV infection was significantly higher among males than females. Majority (60.5%) of infected individuals were 30 to 49years of age. None could afford viral load testing. All infected participants had no previous vaccination. We concluded that Hepatitis B virus infection is still high among HCWs and significantly higher among males than females. Vaccinated individuals were found to be HBsAg negative but had no detectable protective immunoglobulin against HBV.
We recommended pre-employment screening and continuation of free vaccination for all staff in our health institutions. In addition, post vaccination immunization status should be determined. There should be provision of standard and affordable treatment for infected individuals (Odimayo et al 2018). Currently, quantification (not just detection) of HBsAg has been found valuable in the assessment of treatment needs of patients. This should be available in the next few weeks within the Microbial Pathology Laboratory of UNIMED for the benefits of our people.
Our next target is affordable solutions to HBV in our environment. We have created awareness to thousands of individuals, vaccinated thousands and commenced treatment for many of our people. We just must keep up efforts at reducing the prevalence of the disease as the global community is working at elimination of viral hepatitis by 2030. Currently the effort at this major milestone is on as the University of Medical Sciences is about to install our hepatitis B viral load quantification equipment to enhance HBV molecular diagnosis. The work is in progress.
To be continued tomorrow.
Odimayo a Professor of Microbial Pathology/Infectious Diseases delivered this inaugural lecture series 1 in Ondo State, recently.