Introduction: Pakistan, with a population of 180 million, has a 5% prevalence of hepatitis C and a 2.5% prevalence of hepatitis B. Although several studies have looked at individual risk factors, in particular, the practice of unsafe injections, there are many unresolved questions regarding the epidemiology of chronic hepatitis B and C infections in Pakistan.

Objective: To assess the potential risk factors for hepatitis B and C infections in Pakistani patients.

Methods: Consecutive patients with chronic hepatitis B or C presenting to a private gastroenterology clinic in Karachi, Pakistan were interviewed regarding potential risk factors for acquiring their infections

Results: 389 patients were interviewed, 239 (61%) with chronic hepatitis C and 150 (39%) with chronic hepatitis B.308 (79%) had more than one potential risk factor for viral infection. 71 (18%) had one risk factor and 12 (3%) had no identifiable risk factors. The following risk factors were identified: blood transfusion (96, 25%), surgery (171, 44%), dental work (202, 52%), injections (310, 80%), body piercings (144, 37%), spousal transmission (15, 4%), IVDU (1, 0.2%), hemodialysis (4, 1%), tattoos (1, 0.2%), sexual (1, 0.2%), and vertical transmission (5, 1%). 74 (11%) patients had a first degree relative with hepatitis B or C. Of the 71 patients with a single risk factor, in 58 (82%) the risk factor was having received an injection.

Conclusion: It is only by understanding the epidemiology of the acquisition of chronic hepatitis B and C infections in Pakistan that effective efforts can be made to control the spread of these infections. Most patients have multiple potential risk factors, highlighting the need for a multipronged approach to the control of these risk factors. Parenteral injections remain the single most common risk factor for infection.

An estimated 50 million dengue infections occur annually across approximately 100 tropical and subtropical countries. There is extensive clinical, biochemical, histological, radiographic, and experimental evidence of liver involvement in dengue virus infections. Transaminase elevations are commonly seen. Most cases of dengueassociated liver disease are mild. Severe acute hepatitis due to the dengue virus is uncommon. Proposed causes of liver dysfunction in dengue virus infections include a direct viral effect on hepatocytes and a dysregulated host immune response against the virus. Several avenues of future research are suggested.

Introduction: The treatment of chronic hepatitis C has been dramatically altered by the development of Directly Acting Antiviral (DAA) agents. The first two of these agents, telaprevir and boceprevir have resulted in significantly improved Sustained Virologic Response (SVR) rates in previously difficult to treat genotype 1 patients in the West. There appears to be very limited use of these new DAA agents in South and South East Asia.

Objective: To assess obstacles to DAA use among hepatologists in South and South East Asia.

Methods: Hepatologists from South and South East Asia attending the International Gastroenterology and Hepatology Forum (IGHF) in Yangon, Myanmar in November 2012 were surveyed, using a questionnaire, regarding DAA usage.

Results: 67 hepatologists were included in this study. The doctors were from the following countries: Pakistan 24 (36%), Sri Lanka 2 (3%), Myanmar 25 (37%), Philippines 8 (12%), Laos 5 (7%), and Cambodia 3 (4%). Eleven doctors said DAAs were available in their country (3 from Philippines, 4 from Burma, and 7 from Pakistan) and 4 doctors from Pakistan had previously prescribed DAAs. When asked about obstacles to DAA use in their countries, the following reasons were cited: 1. High cost 54% (36), 2. Lack of availability 54% (36), and 3. Lack of relevance of these DAAs to the genotypes prevalent in their countries 12% (8).

Conclusion: Based on this sample of hepatologists representing six countries from the region, there appears to be limited DAA use in South and South East Asia. Issues relating to cost, availability, and efficacy in prevalent genotypes limited DAA use in this region. These issues need to be addressed both for the existing DAAs as well as for the array of newer agents in development

Chronic Hepatitis C Virus (HCV) is a worldwide public health problem affecting over 170 million people, or about 3% of the world’s population. In Egypt, the situation is quite worse, with the overall prevalence (percentage of people) positive for antibody to HCV being 14.7% [1].

HCV predominantly affects the liver but it can also produce a number of extra hepatic manifestations. It has been reported that 74% of patients with hepatitis C have at least one extra hepatic manifestation, the most common conditions including essential mixed cryoglobulinemia (40%), arthralgia or joint pain (23%), paresthesia (17%), myalgia (15%), pruritus (15%), and sicca syndrome (11%) [2].

Cryoglobulinemia is a blood disorder caused by abnormal proteins in the blood called cryoglobulins that precipitate or clump together when blood is cooled and then dissolve again when rewarded. These proteins can be deposited in small and medium-sized blood vessels, which can lead to restricted blood flow to joints, muscles, and organs. There are three types of cryoglobulinemia (types I, II and III); types II and III have rheumatoid factor activity whereas type I does not (Table 1). The most common and severe form Is Mixed Cryoglobulinemia (MC), a systemic vacuities involving small and medium-sized arteries and veins. MC is characterized by the deposition of immune complexes containing mainly rheumatoid factor, IgG, HCV RNA, and complement on endothelial surfaces, resulting in vascular inflammation, albeit through poorly understood mechanisms. Moreover, HCV can trigger impairment in lymph proliferation with cryoglobulin production [3].

The syndrome of mixed cryoglobulinemia represents the consequence of an immune complex type vasculitis, characterized by the clinical triad of purpura, arthralgia, and asthenia, and may involve numerous organs, particularly the peripheral nervous system and the kidneys [4].

In a large prospective study of 1614 patients chronically infected with HCV, mixed cryoglobulinemia was the predominant extra-hepatic biologic manifestation, identified in 40% of patients. Using multivariate analysis, four independent factors were found to be significantly associated with the presence of cryoglobulins: female sex, alcohol consumption more than 50 g/d, HCV genotype II or III, and extensive liver fibrosis. Cryoglobulin-positive patients were examined for arthralgias, arterial hypertension, purpura, and systemic vasculitis. Considering the high frequency of positive cryoglobulins in patients with HCV, severely symptomatic mixed cryoglobulinemia with vasculitis was rare, noted in only 2 to 3% of cryoglobulin-positive patients [3,5].

Background: Hepatitis C Virus (HCV) is an endemic disease with chronic sequelae that include cirrhosis and liver cancer. Children acquire the disease mainly via the maternal-infant route. This study investigated its prevalence in pregnant women and the natural history of its vertical transmission.

Methods: This prospective study involved 618 randomly selected pregnant women in Al-Ain City (Abu Dhabi, UAE). Participants were screened in the first trimester by second-generation Enzyme-Linked Immunosorbent Assays (ELISA-2). Positive samples were further tested by third-generation ELISA (ELISA-3), third-generation recombinant immunoblot assay for detection of antibodies (anti-HCV), and Reverse Transcriptase-Polymerase Chain Reaction (RT-PCR) to detect HCV-RNA. Infants of mothers with positive anti-HCV antibody or HCV-RNA were followed for several years.

Results: Twenty-five women (4.0%) had positive ELISA-2; of which eleven (1.8%) had positive ELISA-3, nine (1.5%) had positive anti-HCV antibody, and three (0.5%) had positive HCV-RNA. All nine infants of mothers with positive anti-HCV antibody had positive anti-HCV antibody at 1, 6, and 12 months of age. All three infants of mothers with positive HCV-RNA had positive HCV-RNA and elevated Alanine Transaminase (ALT) for several years. All six infants of mothers with negative HCV-RNA had negative HCV-RNA and normal ALT at 1, 6, and 12 months of age.

Conclusion: The prevalence of positive anti-HCV antibody in infants of mothers with positive anti-HCV antibody was 9/9 at 12 months. The prevalence of HCV infection (positive HCV-RNA) among mothers in our region is about 0.5%. The prevalence of positive HCV-RNA in infants of mothers with positive HCV-RNA was 3/3 and of mothers with negative HCV-RNA 0/6 (p=0.012). These results justify long-term monitoring of infants born to mothers with positive anti-HCV or HCV-RNA