impact of schistosomiasis on increase incidence of occult hepatitis b in chronic hepatitis c patients in egypt

G Model JIPH-674; No of Pages ARTICLE IN PRESS Journal of Infection and Public Health xxx (2017) xxx–xxx Contents lists available at ScienceDirect Journal of Infection and Public Health journal homepage: http://www.elsevier.com/locate/jiph Impact of schistosomiasis on increase incidence of occult hepatitis B in chronic hepatitis C patients in Egypt Hanan H Omar a,∗ , Samaa A Taha b , Wafaa H Hassan c , Hamdy H Omar d,e a Clinical Pathology Department, Faculty of Medicine, Suez Canal University, Ismailia, Egypt Microbiology and Immunology Department, Faculty of Medicine, Suez Canal University, Ismailia, Egypt Infectious and Endemic Department, Faculty of Medicine, Suez Canal University, Ismailia, Egypt d Internal Medicine Department, Faculty of Medicine, Suez Canal University, Ismailia, Egypt e Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden b c a r t i c l e i n f o Article history: Received 20 June 2016 Received in revised form 27 October 2016 Accepted 18 November 2016 Keywords: Co-infection HBV HCV Prevalence Schistosoma mansoni a b s t r a c t Co-infection of schistosomiasis, HBV and HCV is common in countries where schistosomiasis is endemic Occult hepatitis B occurs in patients at high risk for HBV infection (e.g., patients on hemodialysis, patients receiving blood transfusions) Schistosomal infection is a risk factor of HBV infection that can increase the incidence of occult hepatitis B We aimed to determine the prevalence of occult hepatitis B in chronic hepatitis C patients with and without schistosomiasis and to assess the effect of schistosomal infection on the increased risk of exposure to HBV infection and to occult hepatitis B Two hundred chronic hepatitis C patients who were negative for HBsAg participated All patients were tested for the following: Anti-schistosome antibodies, Anti-HBc, serum HBV DNA, CBC and liver function The prevalence of occult hepatitis B in CHC patients with/without schistosomiasis were 12.8% and 8.5% (P = 0.042), respectively Next, 63.8% of CHC patients with schistosomiasis were exposed to HBV infection (Anti-HBc +ve) during their lifetime In conclusion, the prevalence of occult hepatitis B is higher in CHC patients with schistosomiasis compared to those without schistosomiasis Periodic laboratory investigations of Schistosoma mansoni, HBV and HCV are recommended for the early detection of the infection and, especially in endemic areas, to avoid infection complications © 2017 The Authors Published by Elsevier Limited This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/) Introduction Schistosomiasis is a serious health problem in different areas in Africa, Asia and South America The rate of infection in these areas can reach one in 30 individuals [1,2] Schistosoma mansoni and Schistosoma hematobium are the most common species in Egypt, and the prevalence of these species lie between 3% to 10% [3] S mansoni causes liver fibrosis and cirrhosis because antigens on the eggs stimulate the cell mediated immune response This interaction causes a granulomatous reaction due to the subsequent stimulation of helper T cells (Th1 and Th2) with the recruitment of eosinophils Excessive accumulation of collagen leads to fibrogenesis and the degree of fibrosis depends on the ratio of cytokines released from each of the two T cell types [4–6] Infection by the hepatitis C virus (HCV) is a disease that affects approximately 180 million people all over the world Most infected patients develop chronic hepatitis C (CHC), which can cause liver ∗ Corresponding author E-mail address: hananhassan1978@gmail.com (H.H Omar) cirrhosis and hepatocellular carcinoma [7] Infection by the hepatitis B virus (HBV) affects approximately 300 million people worldwide; the virus can be detected in different clinical conditions such as acute hepatitis, chronic hepatitis, liver cirrhosis, and hepatocellular carcinoma (HCC) [8] Diagnosis of HBV infection depends on the detection of hepatitis B surface antigen (HBsAg) in serum, while the diagnosis of occult hepatitis B depends on the presence of HBV DNA in serum or liver cells and the presence of antibodies to the hepatitis B core antigen (anti-HBc) in the absence of HBsAg in serum [9,10] Occult HBV infection has been found in many patients with CHC This infection plays a role on the acceleration of liver damage, development of HCC and outcome of treatment against CHC [11] Genetic mutations of HBV have been detected in serum samples of HBsAg seronegative carriers Mutations in the S gene and regulation of abnormal expression are associated with occult HBV infection; pre-S deletion mutants influence both the disease progression and its response to treatments [12] These mutations change HBsAg antigenicity and may decrease its synthesis which can then lead to reduced detection of HBsAg [13] HBV DNA in patient with occult HBV infection is converted to covalently closed http://dx.doi.org/10.1016/j.jiph.2016.11.010 1876-0341/© 2017 The Authors Published by Elsevier Limited This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-ncnd/4.0/) Please cite this article in press as: Omar HH, et al Impact of schistosomiasis on increase incidence of occult hepatitis B in chronic hepatitis C patients in Egypt J Infect Public Health (2017), http://dx.doi.org/10.1016/j.jiph.2016.11.010 G Model JIPH-674; No of Pages ARTICLE IN PRESS H.H Omar et al / Journal of Infection and Public Health xxx (2017) xxx–xxx circular DNA (cccDNA), which persists indefinitely within the nuclei of hepatocytes by binding with different proteins; this binding increases its durability as a mini-chromosome [14] Concurrent infections with schistosomiasis, HBV and HCV are common in countries where schistosomiasis is endemic and impact the pathophysiology of liver dysfunction and liver disease progression [15] In Egypt, the prevalence of co-infection with HBV and S mansoni varies from 19.6 to 33.0% [16,17] and co-infection with HCV and schistosomiasis is approximately 27.3% [18] A high prevalence of HBV has been found among Chinese patients with chronic schistosomiasis (58.4%) [19] and a high prevalence (40.2%) of HCV and S mansoni has been found in 233 workers of wastewater treatment plants [20] Increased susceptibility to HBV infection may be caused by schistosomal infections [21,22] Repeated blood transfusions with poor infection control measures may explain this association, especially in endemic areas In Egypt, unsterile syringes which have been used during intravenous anti-schistosomiasis treatment in mass campaigns, may be responsible for the spread of hepatitis viruses [23] Occult hepatitis B has important clinical implications It can be diagnosed in high risk groups, such as in patients who receive hemodialysis, patients who receive blood transfusion, or recipients of organ transplants It is one of the causes of cryptogenic liver diseases, fulminant hepatitis, HCC development and a decreased response to HCV treatment [10] Our aim was to determine the prevalence of occult hepatitis B in chronic hepatitis C patients and in patients who are co-infected with shistosomiasis and chronic hepatitis C We also assessed the effect of schistosomal infections on the increased risk of exposure to HBV infection and the occurrence of occult hepatitis B Patients and methods Study population A total of 200 chronic hepatitis C patients, who had persistent anti-HCV antibodies with detected HCV-RNA over a period of months and were negative to HBs Ag, participated from the outpatient clinic at the gastroenterology and hepatology department in the Suez Canal University Hospital, Ismailia, Egypt from December 2014 to September 2015 Socio-demographic data were taken by a questionnaire after the patient had given informed consent to participate in the study The study was approved by the local ethics committee Laboratory investigation The studied groups were subjected to the following investigations: a hematological assessment with a complete blood count (CBC) by an automated cell counter (CELL-DYN 1700, Abbott diagnostic, USA); a biochemical assessment that measured serum ALT, AST, bilirubin, and albumin (HITACHI 912 automatic analyzer, Roche Diagnostics GmbH., Germany); assessment of anti-HBc IgG by MiniVIDAS (Immunoassay Analyzer, U.S.); assessment of antischistosomal antibodies by the Indirect Hemagglutination test kit (Fumouze Laboratories) as according to the manufacturer’s instructions Serum HBV DNA was assessed by real time (RT) PCR analysis (Rotor Gene Q 6000, Corbett Life Science, QIAGEN Company, and Germany) Statistical analysis We performed statistical analysis by contingency tables using x2 statistics and Fisher’s exact test where applicable Descriptive statistics, including number, percentage (%), mean and standard deviation (SD), were performed Analytical statistics included the Student’s t-test that was used to identify significant differences between two groups of quantitative variables All statistics were calculated with SPSS 16 software Results The mean age of the studied patients was 52 ± 7.2 years and approximately 119 (59.5%) were males and 62% lived in rural areas Table Demographic, clinical and laboratory data of studied patients Variables Chronic hepatitis C patients (No = 200) Age (years) Mean (±SD) 52 ± 7.2 Gender Male No (%) Female No (%) 119 (59.5%) 81 (40.5%) Residency Urban No (%) Rural No (%) Fever No (%) Ascites No (%) Jaundice No (%) Hematemsis and melena No (%) L.L Odema No (%) Hepatomegaly No (%) Splenomegaly No (%) 76 (38%) 124 (62%) (4.5%) 28 (14%) 52 (26% ) 37 (18.5%) 57 (28.5) 172 (86%) 61 (30.5%) Bil total mg/dL Mean (±SD) 1.31 ± 1.24 Bil direct mg/dL Mean (±SD) 0.45 ± 0.51 Bil indirect mg/dL Mean (±SD) 0.86 ± 0.73 S alb gm/dL Mean (±SD) 3.54 ± 0.67 AST U/L Mean (±SD) 105.57 ± 233 ALT U/L Mean (±SD) 68.53 ± 76.3 PT /sec Mean (±SD) 13.9 ± 1.2 INR Mean (±SD) 1.39 ± 0.13 Hb gm/dL Mean (±SD) 10.9 ± 2.32 WBCs x103 /␮L Mean (±SD) 10.43 ± 2.78 Platelets x103 /␮L Mean (±SD) 149 ± 86.9 Grades of activity Minimal to mild activity (A0-1) No (%) Moderate to severe activity (A2-3) No (%) 84 (42%) 116 (58%) Grades of fibrosis No to mild fibrosis (F0-1) No (%) Moderate fibrosis (F2) No (%) Severe fibrosis to cirrhosis (F3-4) No (%) 77 (38.5%) 112 (56%) 11(5.5%) Bil: Bilirubin, S.alb: serum Albumin, ALT: Alanine aminotransferease, AST: Aspartate aminotransferease, PT: prothrombin Time, WBC: white blood cell, HB: hemoglobin, L.L.odema: Lower Limb odema Metavir histological score A = Activity (graded according to the intensity of necroinflammatory lesions): A0 = no activity, A1 = mild activity, A2 = moderate activity, A3 = severe activity F = fibrosis (assessed on a five-point scale): F0 = no fibrosis, F1 = portal fibrosis without septa, F2 = portal fibrosis with rare septa, F3 = numerous septa without cirrhosis, F4 = cirrhosis Please cite this article in press as: Omar HH, et al Impact of schistosomiasis on increase incidence of occult hepatitis B in chronic hepatitis C patients in Egypt J Infect Public Health (2017), http://dx.doi.org/10.1016/j.jiph.2016.11.010 G Model ARTICLE IN PRESS JIPH-674; No of Pages H.H Omar et al / Journal of Infection and Public Health xxx (2017) xxx–xxx Table Prevalence of schistosomiasis and occult hepatitis B in studied group Anti-schistosomiasis antibody titer ≥160 Serum HBV DNA positive Anti-HBc IgG +ve Positive Negative 94 (47%) 17 (8,5%) 87 (43,5%) 106 (53%) 183 (91,5%) 113 (56,5%) Table Univariate analysis predicts schistosomiasis as independent risk factor for occurrence of occult HBV(HBsAg (−) and serum HBV DNA (+)) in CHC patients Variant ORa (95% CI) P value Occult HBV in CHC with Schistosomiasis Occult HBV in CHC without Schistosomiasis 1.575 (1.114–2.228) 0.533 (0.252–1.126) 0.042* * a Clinical and laboratory data of the studied patients showed that 86% had hepatomegaly and approximately 30% had splenomegaly 58% had moderate to severe inflammatory activity and 56% had moderate fibrosis Details of patients’ demographic, clinical and laboratory data are shown in Table We found that the prevalence of schistosomiasis, occult hepatitis B and exposure to HBV among CHC were 47%, 8.5% and 43.5%, respectively (Table 2) The prevalence of occult hepatitis B in CHC patients with schistosomiasis was 12.8% (p = 0.042) (Table 3) 63.8% of CHC patients with schistosomiasis were exposed to HBV infection during their lifetimes The risk of exposure to HBV in CHC patients with schistosomiasis was two and half times greater than that in CHC patients without schistosomiasis (odds ratio was 2.506) (Table 4) Co-infection with schistosomiasis, HBV and CHC was associated with elevated liver enzymes (AST and ALT, P = 0.048, 0.025) while there was no significant difference in grades of activity and fibrosis in both groups despite that 25% of patients positive to HBV-DNA had severe fibrosis when compared to 8.5% of HBV-DNA negative patients who had the same degree of fibrosis (Table 5) P-values below the level of 0.05 were considered significant OR: Odds ratio In our study, the risk to occult HBV occurrence in CHC with schistosomiasis was one and half times greater than CHC patients without schistosomiasis (odds ratio was 1.575) (Table 6) Discussion Occult HBV infection is found worldwide but its prevalence is closely related to endemic areas of HBV infection Occult HBV infections may develop due to mutations, the integration of HBV DNA into the host chromosome, infection of peripheral blood mononuclear cells with HBV, and/or the interference of HBV by other viruses while the host has an altered immune response Occult HBV infection may follow the sero-clearance of HBsAg either in acute self-limited hepatitis B or after anti-HBV therapy Clinically, anti-HBs antibodies and anti-HBc antibodies are developed after the sero-clearance of HBsAg; in some conditions, anti-HBs antibodies can remain undetected and anti-HBc antibodies are considered to be the only serological markers of past HBV infection and/or occult HBV infection [24,25] Table Prevalence of occult hepatitis B in CHC patients with schistosomiasis Serum HBV DNA positive (No = 17) Serum HBV DNA negative (No = 183) Total * Anti-schistosomiasis titer