Hepatitis B and C viral infections in Indian kala-azar patients receiving injectable anti-leishmanial drugs: a community-based study.
BACKGROUND
Human immunodeficiency virus (HIV) and hepatitis B and hepatitis C viruses have emerged as major blood-borne infections. Several cases of infections through the use of unsterile injection needles also are on record. Kala-azar, or visceral leishmaniasis, is a hemoparasitic disease caused by Leishmania donovani. All the anti-kala-azar medications require multiple intramuscular injections of the anti-leishmanial drugs. To find whether these patients were at higher risk of contracting blood-borne infection, than those who were not on medication, a community-based study was conducted in the kala-azar-endemic state of Bihar, India.


METHODS
Five villages (4050 families) of three highly endemic districts of Bihar were included in this study. The sociodemographic data of the affected families and their annual income were determined as per Government of India guidelines. The diagnosis of kala-azar and its sequelae, post-kala-azar dermal leishmaniasis (PKDL), was made, and their therapeutic details were noted. All the leishmania-infected patients, their spouses, family members, and villagemates were tested for hepatitis B surface antigen, hepatitis C virus antibodies, and anti-HIV (1 + 2) antibodies, using commercially available kits.


RESULTS
Of the 4050 families, 61 (1.5%) were found affected with kala-azar or PKDL. These 61 families had 77 cases of leishmaniasis, of which 64 (83%) had kala-azar and 13 (17%) PKDL. The most affected (4.5%) age group was 11 to 40 years. Of the 61 families, 57 (93.4%) families belonged to so-called untouchable castes, and 9 of them could not afford to have any anti-kala-azar treatment. Only 64 patients received treatment in the form of injectables. The number of injections received by these patients ranged from 3 to 120. Hepatitis B and C viral infections were found to be significantly more prevalent in those who received multiple injections. Compared to their male counterparts infected with L. donovani, females who received injectable medicines were at higher risk of contracting hepatitis B infections (20% vs. 11.3%) and hepatitis C virus infection (26.7% vs. 18.9%). Overall, hepatitis C virus infections were more common (20.6%) than hepatitis B virus infection (13.2%) in this group of patients. Villagemates with a history of injections for other ailments also were found to have a high rate of infection with hepatitis viruses. One patient with kala-azar was found to be co-infected with HIV, although probably not related to injections.


CONCLUSIONS
The treatment of Indian kala-azar and post-kala-azar dermal leishmaniasis consists of multiple intramuscular injections of sodium stibogluconate, pentamidine, or amphotericin B. Though the original disease gets cured, all these therapeutic regimens were found to carry a significantly high risk of transmitting yet more dangerous blood-borne infections, such as HIV and hepatitis B and C viruses, through the shared use of unsterile injection needles. All needles should be appropriately sterilized, if they are to be re-used.
Department of Laboratory Medicine, All India Institute of Medical Sciences, New Delhi-110029, India. ssingh@medinst.ernet.in (and/or) ssingh56@hotmail.com
Singh S
J
J
Kumar
R
R
Singh
S N
SN
Dwivedi
D000293:Adolescent; D000328:Adult; D000666:Amphotericin B / Q000008:administration & dosage / Q000627:therapeutic use; D000967:Antimony Sodium Gluconate / Q000008:administration & dosage / Q000627:therapeutic use; D000981:Antiprotozoal Agents / Q000008:administration & dosage / Q000627:therapeutic use; D002648:Child; D004866:Equipment Contamination; D005260:Female; D015483:HIV Antibodies / Q000097:blood; D015658:HIV Infections / Q000453:epidemiology / Q000635:transmission; D006509:Hepatitis B / Q000453:epidemiology* / Q000635:transmission; D006514:Hepatitis B Surface Antigens / Q000032:analysis; D006526:Hepatitis C / Q000453:epidemiology* / Q000635:transmission; D018937:Hepatitis C Antibodies / Q000097:blood; D006801:Humans; D007194:India / Q000453:epidemiology; D007273:Injections, Intramuscular; D007898:Leishmaniasis, Visceral / Q000150:complications* / Q000188:drug therapy; D008297:Male; D009339:Needles; D010419:Pentamidine / Q000008:administration & dosage / Q000627:therapeutic use; D015995:Prevalence; D012923:Social Class
D000981:Antiprotozoal Agents; D015483:HIV Antibodies; D006514:Hepatitis B Surface Antigens; D018937:Hepatitis C Antibodies; D010419:Pentamidine; D000666:Amphotericin B; D000967:Antimony Sodium Gluconate