Ananta Shrestha

High prevalence of hepatitis B virus infection and inferior vena cava obstruction among patients with liver cirrhosis or hepatocellular carcinoma in Nepal

Background:  Little is known about the prevalence of hepatitis B virus (HBV) DNA and the genotype distribution among patients with liver diseases in Nepal, where obstruction of the hepatic portion of the inferior vena cava (IVCO) is common. The aim of the present paper was to assess the roles of HBV infection and IVCO in liver cirrhosis (LC) and hepatocellular carcinoma (HCC) in Nepal.

Hepatitis E virus outbreak in postearthquake Nepal: is a vaccine really needed?

Dear Editor, The massive earthquakes that hit Nepal on April 25 and May 12, 2015 claimed more than 8500 lives and displaced more than one million people to temporary shelters. During the recovery period, the monsoon season raised the possibility of significant water borne diseases such as bacterial diarrhoea, typhoid, hepatitis E and cholera. Some experts recommended that the HEV239 vaccine should be used to prevent an outbreak of hepatitis E virus (HEV) infections [1]. In the past, there have been several epidemics of HEV in Nepal – in Kathmandu in 1973, 1981–1982, 1987 and 2006–2007 and Biratnagar in 2014 [2–6] – and 310 HEV-infected pregnant women were documented in those epidemics [2–4]. Repeated epidemics of HEV in the Kathmandu valley may be related to the consumption of contaminated drinking water and the periodic migration of nonimmune people from the endemic areas of the country [5]. Following the earthquake, many predicted that the monsoon would be associated with another epidemic of HEV and suggested that immunization should be introduced. Local residents of the Kathmandu valley have a high prevalence of immunity against HEV (78% of people have IgG antibodies against HEV), whereas people from other cities and nearby areas have a much lower prevalence (25%). Although outbreaks of diarrhoeal and other waterborne diseases are frequent in rural hilly areas, outbreaks of HEV have not been documented in this population, and following the earthquake, there were concerns that an outbreak of HEV may develop. Basnyat et al. projected that nearly 2000 pregnant women in disaster-affected areas might acquire HEV infection with mortality of 500 [1]. However, in our opinion, vaccinating pregnant women (comprising less than 5% of the population) would have little value as the remaining 95% of the displaced population would remain at risk of acquiring HEV. The resulting morbidity and mortality could be substantial among the nonimmune population, and we do not believe that it is justified to ignore them. Furthermore, vaccinating 48 000 pregnant women with three doses on the dawn of monsoon would take six months, and this would make the present vaccination campaign ineffective, at a considerable cost. Vaccination against HEV would clearly not protect recipients from other water borne diseases and might provoke a false sense of security. In our view, safe provision of drinking water alone would be the single most important preventive measure and would be likely to prove cost-effective and generalizable to both pregnant and nonpregnant populations. Rapid and extensive campaigns to ensure safe water at household levels would have a profound impact on prevention and control of HEV outbreaks and should be preferred to vaccination, the safety of which has yet to be established in pregnancy.

Current Treatment of Acute and Chronic Hepatitis E Virus Infection: Role of Antivirals

Hepatitis E virus (HEV) infection results in nearly 20 million new infections, resulting in 70,000 deaths globally each year. Previously thought as a disease limited to developing nations with poor sanitation and hygiene, it is increasingly recognized that even the most developed nations are not spared. A clear dichotomy in epidemiology of HEV is noted between developing and industrialized nations. The HEV genotypes 1 and 2 are common in Asia and Africa and are transmitted mainly by contaminated drinking water. Sporadic as well as large-scale epidemics of acute hepatitis have been noted with HEV genotype 1 infection in developing countries of Asia and Africa. On the contrary, HEV genotypes 3 and 4 are common in industrialized nations and unlike genotypes 1 and 2, they are transmitted by consumption of raw meat products, fruits, and blood transfusion. Large epidemics have not been reported with HEV genotypes 3 and 4 and manifestation is usually indolent, though severe acute hepatitis has been reported. How to cite this article: Shrestha A, Gupta BP, Lama TK. Current Treatment of Acute and Chronic Hepatitis E Virus Infection: Role of Antivirals. Euroasian J Hepato-Gastroenterol 2017;7(1):73-77.

Acute hepatitis E virus infection in human immunodeficiency virus–positive men and women in Nepal: Not quite a rare entity

inject drugs. HEPATOLOGY 2016;63:1090-1101. 2) van der Meer AJ, Veldt BJ, Feld JJ, Wedemeyer H, Dufour JF, Lammert F, et al. Association between sustained virological response and all-cause mortality among patients with chronic hepatitis C and advanced hepatic fibrosis. JAMA 2012;308:2584-2593. 3) Melin P, Chousterman M, Fontanges T, Ouzan D, Rotily M, Lang JP, et al. Effectiveness of chronic hepatitis C treatment in drug users in routine clinical practice: results of a prospective cohort study. Eur J Gastroenterol Hepatol 2010;22:1050-1057. 4) Jauffret-Roustide M, Pillonel J, Weill-Barillet L, L eon L, Strat Y, Brunet S. Estimation of HIV and hepatitis C prevalence among drug users in France—first results from the ANRS-COQUELICOT 2011 survey. Bulletin Epid emiologie Hebdomadaire 2013;39:40.

Prevalence and risk of hepatitis E virus infection in the HIV population of Nepal

BackgroundInfection with the hepatitis E virus (HEV) can cause acute hepatitis in endemic areas in immune-competent hosts, as well as chronic infection in immune-compromised subjects in non-endemic areas. Most studies assessing HEV infection in HIV-infected populations have been performed in developed countries that are usually affected by HEV genotype 3. The objective of this study is to measure the prevalence and risk of acquiring HEV among HIV-infected individuals in Nepal.MethodsWe prospectively evaluated 459 Human Immunodeficiency Virus (HIV)-positive individuals from Nepal, an endemic country for HEV, for seroprevalence of HEV and assessed risk factors associated with HEV infection. All individuals were on antiretroviral therapy and healthy blood donors were used as controls.ResultsWe found a high prevalence of HEV IgG (39.4%) and HEV IgM (15.3%) in HIV-positive subjects when compared to healthy HIV-negative controls: 9.5% and 4.4%, respectively (OR: 6.17, 95% CI 4.42–8.61, p < 0.001 and OR: 3.7, 95% CI 2.35–5.92, p < 0.001, respectively). Individuals residing in the Kathmandu area showed a significantly higher HEV IgG seroprevalance compared to individuals residing outside of Kathmandu (76.8% vs 11.1%, OR: 30.33, 95% CI 18.02–51.04, p = 0.001). Mean CD4 counts, HIV viral load and presence of hepatitis B surface antigen correlated with higher HEV IgM rate, while presence of hepatitis C antibody correlated with higher rate of HEV IgG in serum. Overall, individuals with HEV IgM positivity had higher levels of alanine aminotransferase (ALT) than IgM negative subjects, suggesting active acute infection. However, no specific symptoms for hepatitis were identified.ConclusionsHIV-positive subjects living in Kathmandu are at higher risk of acquiring HEV infection as compared to the general population and to HIV-positive subjects living outside Kathmandu.

Liver Cancer in Nepal

Hepatocellular carcinoma (HCC) is highly incidental in South Asian countries. Nepal, however, has low incidence for HCC owing to low prevalence for hepatitis B virus (HBV) and hepatitis C virus (HCV) infections. Nepal lacked national cancer registry until 2003. Though there has been some effort in having one, the current registry incorporates twelve centers and may not properly represent the total cancer burden in the country. Serology for HBV and HCV is seen to be positive in nearly 25 to 30% and 5 to 10% of HCCs respectively. Clinical characteristics of HCCs in Nepal have been discussed in this mini-review and it features poor performance status and advanced stage at presentation, making only a small fraction of these subjects eligible for curative treatment options. Most of the standard treatment modalities are available in Nepal and appear to be reasonably affordable as compared with other developed nations. How to cite this article: Shrestha A. Liver Cancer in Nepal. Euroasian J Hepato-Gastroenterol 2018;8(1):63-65.