Seroprevalence of HBV and HCV among Children in the
Kilimanjaro Region, TanzaniaFlorida J. Muro, Suzanne P. Fiorillo, Christopher Odhiambo,
Coleen K. Cunningham, Ann M. Buchanan
KCMC-Duke Collaboration
Moshi Tanzania
XIX International AIDS Conference, Washington, DC
24 July 2012
Kilimanjaro Christian Medical CentreMoshi, Tanzania
BackgroundMore than 350 million people worldwide are infected
with hepatitis B virus (HBV), 170 million with hepatitis C virus (HCV)
HBV and HCV are more prevalent among HIV-infected individuals
HIV increases the speed of liver dysfunction among those with co-infection
Liver disease due to chronic hepatitis: increasing cause of morbidity and mortality among those with HIV
Background
Chronic HBV infection risk:
up to a 90% risk with perinatal infection
25-30% risk with early childhood infection
< 5% risk among adults
HCV infection: chronic infection in 75-80% of adults
Data on hepatitis-HIV co-infection among African populations are scarce
Background
Three phases of chronic HBV infection:
Phase HBsAg HBeAg HBV DNA ALT Fibrosis
Immune Tolerant
Pos Pos High Nml No
Immune Active
Pos Pos High High Yes
Inactive Phase
Pos Neg Low Nml No
Children are typically in the immune tolerant phase.
ObjectiveTo determine Hepatitis B and Hepatitis C
prevalence in healthy HIV-negative and HIV-infected children in Kilimanjaro Region, Tanzania
Methods
Banked serum/plasma samplesHIV-uninfected, healthy children: 1 month -18 years N=385
HIV-infected children on HAART, 1-16 years N=158
HBV testing:Hepatitis B surface ag (HBsAg)Hepatitis B core antibody (HBcAb)Hepatitis B surface antibody (HBsAb)
Study Location: Moshi, Kilimanjaro Region,
Tanzania, East Africa
Methods
HCV testing:Anti-HCV ELISA
Validation studies performed on all assays prior to useAll assays FDA-approvedDefinitions:
Any prior HBV infection: HBcAb or HBsAg +
Presumptive chronic HBV infection: HBsAg + at time of test
Results
543 serum/plasma samples tested385 HIV-negative158 HIV-infected
Evidence of any HBV infection: 4.2% (95% CI: 2.5, 5.9)Among HIV-negative children: 2.1%
(95% CI: 0.6, 3.5)Among HIV-infected children: 9.5%
(95% CI 4.9, 14.1)
Results
Children with HIV infection were more likely to have evidence of HBV infection
than HIV-negative children:
OR 4.9 (95% CI 2.1, 11.9)
p < 0.0001
Results
*These 2 patients were HBcAb and HBsAb positive, likely reflecting maternal antibody transmission
Evidence of any HBV Infection by HIV Status and Age Group
Age < 12 months ≥ 1 < 5 years ≥ 5 < 13 years ≥13 <18 years
HIV-positive 0/1 (0.0%) 4/31 (12.9%) 9/109 (8.3%) 2/17 (11.8%)
95% CI -- (0.4, 25.4) (3.0, 13.5) (0.0, 28.8)
HIV-negative 2/41 (4.9%) 0/106 (0.0%) 2/150 (1.3%) 4/88 (4.5%)
95% CI (0.0, 11.8) -- (0.0, 3.2) (0.1, 9.0)
Overall 2*/42 (4.8%) 4/137 (2.9%) 11/259 (4.2%) 6/105 (5.7%)
95% CI (20, 11.5) (0.1, 5.8) (1.8, 6.7) (1.2, 10.2)
Results
Prevalence of presumed chronic HBV infection: 3.0% (1.6, 4.5) Among HIV-negative children: 1.3% (0.2, 2.5)
Among HIV-infected children: 7.5% (3.2, 11.9)
Resolved infection (HBcAb and HBsAb positive) was found in 5 patients: 2 HIV-infected and 3 HIV-negative
Isolated HBcAb was found in two patients
Hepatitis C: 541 samples tested by anti-HCV ELISA 0.0%
Results
Characteristics of HIV-Infected Children with and without Evidence of HBV-Coinfection
Patient Characteristics HBV Pos(n=15)
HBV Neg(n=143)
P-value
Mean (SD) Age, years 8.9 (3.8) 8.6 (3.6) 0.7
Female Gender, # (%) 7 (46.7%) 67 (46.9%) 0.9
Mean (SD) CD4 lymphocyte count 814 (434) 1,000 (566) 0.3
Mean (SD) CD4 percent 26.2 (9.4) 29.4 (8.9) 0.3
Lamivudine-containing HAART, # (%) 12 (80%) 119 (88.8%) 0.3
Results
< 12 mos ≥1 < 5 yrs ≥5 < 13 yrs ≥13 <18 yrs0
102030405060708090
HBV Protection by HBsAb+
N=138
N=259N=105
N=44
Conclusions
HCV was not found in this large pediatric cohort
HBV prevalence is high among HIV-infected children in the Kilimanjaro Region of Tanzania
Children with HIV are almost 5 times as likely to show evidence of infection than children without HIV
Conclusions
The prevalence of chronic HBV-HIV co-infection in this population (7.5%) is higher than that reported recently in many other pediatric populations: 3.3% Thailand 4.9% China 4% Kenya 1.2% Dar es Salaam, Tanzania
Though lower than some other African countries: Nigeria (7.7%) Namibia (8.7%) Ivory Coast (12.1%)
Conclusions
High prevalence of HIV-HBV co-infection in this pediatric population Need for routine HBsAg screening of all HIV-infected
children
Prior to HAART initiation
More comprehensive prevalence data needed – across all age groups
Prevention of HBV could be strengthened by wider vaccination coverage
Vaccinate high risk children
Birth dose?
Limitations
Chronic hepatitis B could not be confirmed
Samples tested at a single timepoint
Larger sample size needed to determine true prevalence of HIV-HBV co-infection among children in this region
The significance of isolated HBcAb in two patients is unclear
No measurement of HBV DNA
Further Study
Follow up study planned for a larger prospective study of HIV-infected children
Unanswered questions:Best treatment options for HIV-HBV infected
children?Already on HAART?
Immune tolerant disease Immune active disease
Initiating HAART? Immune tolerant disease Immune active disease
Acknowledgements
Co-authors: Florida Muro, Chris Odhiambo, Suzanne Fiorillo, Coleen Cunningham
Duke University Center for AIDS Research (CFAR)2010 developmental grant (5P30 AI064518) (AM
Buchanan)Duke Global Health Institute
Transition Award (FJ Muro)Kilimanjaro Christian Medical Centre LeadershipPatients and families in the Kilimanjaro Region