Delta Agent Associated Hepatitis In Polytransfused Children:

Farida Farid Negm

- 268 -SUMMARY, CONCLUSIONS AND RECOMMENDATIONSThe present work is a follow up study for 12 months.It was conducted on 60 Egyptian infants and children receivingrepeated blood transfusions for long period or smallernumber of blood transfusions beside continous parenteralinjections for treatment for long period. Their agesranged between 6 months to 15 years with mean of 5.4 yearsand included 27 cases of thalassaemia, 29 cases of acuteleukemia and other malignancies and 2 cases of idiopathicthrombocytopenic purpura and 2 cases of sickle cell and hypoplasticanaemias. Another group of 60 normal infants andchildren of the same age and socioeconomic class with nohistory of previous blood transfusions or continous parenteralinjections, also without present or past history of liveraffection as jaundice and change of colour of urine and stools,this group was taken as control group.Every month, a full history and thorough clinicalexamination was done for each case. Laboratory investigationsdone included complete hemogram, bilirubin level,total, direct and indirect. Serum transaminases were done forthose gave history of jaundice or presented with jaundice.- 269 -Search for HBsAg by ELISA technique was performedon sera of all control cases and polytransfused cases on thefirst and last samples. Then the sera gave positive HBsAgwere investigated for delta antigen in the first and lastsamples and for anti-delta in the last sample usingELISA technique to assess the frequency of delta infectionamong Egyptian poly transfused patients and those takingcontinous parenteral injections in comparison with thenormal cases.- The incidence of HBsAg among normal Egyptian infantsand children was 8.3% which was close to other investigatorsin Egypt, and it was found to be 6.7% of the diseasedcases in case of the first sample and increasedmarkedly after one year to reach 41.7% in the last samplebeing (11.1%, and 44.4%) in case of thalassaemics and(3.5% and 41.4%) in case of acute leukemias and othermalignancies in the first and last samples respectivelyindicating that the incidence of HBV infection increasewith increased amount of blood transfused or parenteralinjections. One case of sickle cell anaemia gavepositive HBsAg.Our results agree with others in Egypt and elsewilere.- 270 -- The total incidence of anti-delta among cases ofHBsAg’positive in the diseased cases (high risk group)was found to be 60% of HBsAg carriers, being 66.7%in thalassaemics and 58.3% in the group of acute leukemiaand other malignancies and was not reported in the thirdgroup representing I.T.P., sickle and hypoplastic anaemias.Our results are in agreement with that obtained byother investigators in other countries.- The delta antigen was detected in one case onlyduring the first sample and disappeared in the last sample,where anti-delta was detected. The case was male, aged4 years, suffering from thalassaemia. This is in agreementwith other investigators.-Delta hepatitis infection was not detected in thenormal cases in this study, but other investigators detecteddelta hepatitis in normal cases (HBsAg carrier) inEgypt.- In the present study, there was higher incidenceof HBsAg and anti-delta in females than males, but thedifferences were statistically insignificant.Other workers found higher incidence in males.- 271 -_ The ages of cases giving positivity for HBsAg andanti-delta were between 1! - 10 years with mean of 4.3 incase of HBsAg positivity and 4.7 in case of anti-delta .mfe -ction which was correlated with other workers._ There was significant relation between HBV and deltahepatitis infection and the increase level of bilirubinand serum transaminases. HBsAg was found in 71.4% anddelta hepatitis associated with HBV in 66.6% in caseswith jaundice, increase bilirubin and transaminases. Theratio of icteric to non icteric cases was 3:2 in casespositive for HBsAg and 2:1 in cases positive for anti-delta.Our results are correlated with other investigators inEgypt, as regards the level of bilirubin but differ fromthem as regards level of transaminasesput our results are inagreement with others elsewhere._ There is significant difference between thesecases affected with delta infection and those withoutdelta hepatitis, in causing hepatomegaly indicating thatdelta hepatitis has an important role in the eatiologyof hepatomegaly among Egyptian infants and children. Butthere was no different effect on causing splenomegaly._ There was correlation between the number, duration,and amount of blood transfused and the incidence of hepatitisB virus infection (HBV) and delta hepatitis infection.- 272 -An intresting observation is that, those were affectedwith delta hepatitis associated with hepatitis Bvirus infection were found to take larger number andamount of blood and for longer duration than those withhepatitis B virus infection only) suggesting that amongpoly transfused HBsAg carriers, the ~ -associated agentwas transmitted by superinfection on HBsAg carriers amongour cases._ There was high significant difference between casestaking continous parenteral injections and the normalcontrol cases indicating that delta hepatitis infectionis common and has an important role in the liver diseasein patients receiving drugs parentrally.But there is no statistical significant differencewas detected between those taking blood transfusions andthose taking continous parentral injections) indicatingthat both parentral injections and blood transfusions playan important role in transmitting delta hepatitis, but itwas found that the incidence of delta hepatitis was morein those taking repeated blood transfusions (66.7%) ,whileit was (58.3%) of HBsAg carriers in case of continousparentral injections._It is evident that there 1S high staitstical significantdifference between the normal cases and those taking- 273 -repeated blood transfusions and continous parentral inje-ctions indicating that In Egypt, delta agent is transmittedby parentral route and has an important role as a cause ofliver disease in poly transfused infants and children andthose taking drugs parentrally.The only hope at present is in prophylaxis. Eliminationof the HBsAg population predisposed to become carriersof the agent implies prevention of delta infection.- The following recommendations may be suggested toprevent or minimize the risk of hepatitis B infectionand accordingly delta hepatitis infection:1. Screening for HBsAg carriers in cases got jaundice,hepatomegaly, and increased serum transaminases.2. It is important to know HBV carriers of blooddonors to be excluded from donating blood.3. Using sterilized needles during injections andvaccination.4. Vaccination against hepatitis B and its widespreadapplication, at present seems the only feasiblemethod to control cfinfection, especially to polytransfusedchildren and those with malignancies.