Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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On Sep 2018




Prof. Somashekhar Nimbalkar

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Prof. Somashekhar Nimbalkar
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Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
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Professor and Head
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Saraswati Dental College
Lucknow
On Sep 2018




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Calcutta National Medical College & Hospital , Kolkata




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C.S. Ramesh Babu,
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On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
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Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
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In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : January | Volume : 16 | Issue : 1 | Page : OC28 - OC31 Full Version

Hepatitis B and C Viral Infections among Dialysis Patients and Related Factors of Dialysis Centres in Saudi Arabia


Published: January 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/52072.15922
Badr M Aljarallah

1. Associate Professor, Department of Gastroenterology and Hepatology, Qassim College of Medicine, Qassim University, Qassim, Buraida, Saudi Arabia.

Correspondence Address :
Badr M Aljarallah,
Associate Professor, Department of Gastroenterology and Hepatology, Qassim
College of Medicine, Qassim University, Qassim, Buraida, Saudi Arabia.
E-mail: ur_c4u@outlook.com; jarallh@qu.edu.sa

Abstract

Introduction: Viral Hepatitis is a global disease, affecting millions of patients around the world. Dialysis dependent patients use an artificial kidney (haemodialyser) to remove waste product from the blood in severe renal impairment patients. Hence, they are more vulnerable to viral hepatitis.

Aim: To investigate the prevalence of hepatitis B and C infections among dialysis patients and related factors of dialysis centres in the Qassim province, Saudi Arabia.

Materials and Methods: This cross-sectional study, reviewed the medical records of 707 patients from the data registry of 18 affiliated dialysis centres across Al Qassim region of Saudi Arabia, during August 2017 to August 2018. A detailed questionnaire regarding the general information about the dialysis centre, isolation and screen status, vaccination status, and vascular access was completed by the Dialysis Centre Manager of all the 18 affiliated centres. The details of Hepatitis B Surface Antigen (HBsAg) and Hepatitis C Virus (HCV) serology reports were extracted to establish the prevalence and epidemiological profile of these patients. Descriptive analysis was conducted, where numbers and percentages were used to summarise all categorical variables.

Results: The majority 14 (77.8%) of the centres were government entities and the rest were for profit centres. Out of the 18 centres, 10 (55.6%) were hospital based, 5 (27.8%) were free-standing and 3 (16.7%) were free-standing but owned by a hospital. The prevalence of HBsAg positive cases among incentre haemodialysis patients was 3.2% and the prevalence of Hepatitis C (HBC) antibody positive cases was 6.4% with 0.3% cases of the HBsAg and HBC converted to positive during the previous 12 months.

Conclusion: The incidence of hepatitis B and C positivity was common in patients receiving haemodialysis. The study found low prevalence of both Hepatitis B and C positive cases in comparison to several published articles. The decrease in HBV and HBC prevalence seen in the present study may be attributable to the development and implementation of preventive strategies, increased adherence by medical staff to aseptic measures, better infection management, immunisation, and isolation of affected patients. However, further studies are needed to generalise the outcome of the present study.

Keywords

Haemodialysis, Vaccination status, Vascular access

Viral hepatitis is caused by inflammation of the liver as a result of viral infection. Though five variants of Hepatitis viruses A, B, C, D, and E are responsible for its global spread, in majority of cases either Hepatitis B Virus (HBV) or Hepatitis C Virus (HCV) is responsible for the infection (1). Millions of people are infected each year with viral hepatitis, which can lead to Hepatocellular Carcinoma (HCC), liver cirrhosis, and death (2).

According to the World Health Organisation (WHO), global hepatitis report, in 2015, an estimated 3.5% of the population were living with chronic HBV infection, and 1% of the population, with chronic HCV infection. The African and Western Pacific regions accounted for 68% of HBV infection while the European and Eastern Mediterranean regions were maximally affected by HCV infection. As per the report, the mortality from viral hepatitis has increased by 22% since 2000 and an estimated 1.34 million deaths are reported due to the viral hepatitis. Of these deaths, 96% were the result of complications of chronic HBV (66%) and HCV (30%) infections, while hepatitis A and hepatitis E accounted for 0.8% and 3.3% of deaths, respectively (3).

The HBV infections continue to be a major burden on the Saudi healthcare system, though its prevalence has declined considerably since the introduction of the HBV vaccine in the national immunisation program and, currently, it stands at 1.3% (4). Hepatitis C virus endemicity is intermediate in Saudi Arabia with seroprevalence rates ranging from 0.9% to 5%, among children and adults, respectively (5).

Worldwide, the number of patients receiving Renal Replacement Therapy (RRT) is estimated at more than 1.4 million, with the incidence growing by approximately 8% annually (6). The Saudi Centre for Organ Transplantation’s 2019 statistics showed a total of 21,068 dialysis patients, 19,522 of them were treated by haemodialysis and the remaining 1,546 by peritoneal dialysis (7), as percutaneous or mucosal exposure to infected blood or other body fluids is the most common way for hepatitis to spread. Therefore, the patients with severe renal impairment who are on dialysis are at greater risk of acquiring these infections.

The prevalence rates of hepatitis B and hepatitis C infections vary widely around the world, from 1% in the United Kingdom to over 90% in Eastern Europe among haemodialysis patients (8). In Saudi Arabia, many reports from different parts of the country had shown the HBV prevalence ranging from 1.5% to 75.7% (9),(8),(9),(10),(11),(12) and HCV ranged between 15% and 80% (13),(14),(15). A recent study by Almawi WY et al., had shown the prevalence of HBV and HCV infection in dialysis patient as 5.9% and 9.2%, respectively (11). The sole study from the Qassim region has been done 20 years ago and showed a prevalence of 50% for the 96 included patients (14). Only five centres participated in this study with no follow-up studies conducted in the province since then, to assess the prevalence of HBV and HCV infections among dialysis patients. Therefore, the aim of the present study was to investigate the prevalence of hepatitis B and C infections among dialysis patients and related factors of dialysis centres in the Qassim province, Saudi Arabia.

Material and Methods

This cross-sectional study was conducted across Al-Qassim region of Saudi Arabia between August 2017 to August 2018. The present study was approved by the Regional Research Ethics Committee, Ministry of Health, Saudi Arabia (approved by Qassim Research Ethics Committee).

Inclusion and Exclusion criteria: A total of 623 patients monthly records, who reported regularly for haemodialysis, were included in the study and all the patients who underwent renal transplant, or moved to another region, or not reported for dialysis at the designated centres were excluded from the study.

Study Procedure

The prevalence was calculated by dividing the number of patients with positive HBsAg or HCV serology to the total number of patients undergoing haemodialysis at these centres. A detailed questionnaire regarding the general information about the dialysis centre, isolation and screen status, vaccination status, and vascular access was completed by the Dialysis Centre Manager of all the 18 affiliated centres. Also the medical records of 707 patients from the data registry of 18 affiliated dialysis centres were reviewed for prevalence of hepatitis B and C infections among dialysis patients. All the data were stored in password protected laptop or desktop, which could only be accessed by the research team to ensure patients confidentiality for studies and data. A hard copy of the code and identification variable were maintained in a locked file cabinet.

Statistical Analysis

After tabulating all the data in excel files, they were coded into numerical form for the purpose of analyses. It was then cleaned and verified, questionable data were validated and were excluded whenever necessary. Descriptive analysis was conducted, where numbers and percentages were used to summarise all categorical variables.

Results

Prevelence of HBV AND HCV

As per the medical records a total of 707 non transient dialysis patients were admitted with 623 (88.1%) patients receiving in-centre haemodialysis. Of the 707 patients, 69% received atleast three doses of the hepatitis B vaccine and 76.9% in the patients receiving incentre dialysis. The prevalence of positive HBsAg among incentre haemodialysis patients was found to be 3.2% (2.9% were already positive when first admitted to the centre, while 0.3% was converted to HBsAg positive during the previous 12 months). The prevalence of positive hepatitis C antibody {Enzyme-linked Immunosorbent Assay (ELISA) based testing} was 6.4%, with 2 cases converted to positive during the previous 12 months (Table/Fig 1).

Factors of dialysis centres

The study included information from 18 dialysis centres, as presented in (Table/Fig 2). The majority 14 (77.8%) of the centres were government entities and the rest were for profit centres. Out of the 18 centres, 55.5% were hospital based, 27.8% were free-standing and 16.7% were free-standing but owned by a hospital. Nearly, 94.4% of dialysis centres were incentre daytime haemodialysis. All the centres followed the same hygienic standard protocol from the Ministry of Health, including yearly Hepatitis B Surface Antigen (HBsAg) and Hepatitis C Virus Antibodies (HCVAb) testing.

Concerning routine isolation, 83.3% centres had hepatitis B isolation rooms and hepatitis C patients were routinely isolated 88.9%. Nearly 94.4% of the centres maintained records of the station where each patient received their haemodialysis treatment for every treatment session, while 83.3% of them maintained records of the machine used for each patient’s haemodialysis treatment for every treatment session. The majority of centres were able to determine that a bloodstream infection contributed to their hospital admission and were able to obtain a patient’s microbiology laboratory records from hospitalisation (Table/Fig 3).

Discussion

The prevalence of HBsAg positive cases among incentre haemodialysis patients in this study was 3.2% (n=20). This result was lower than the study by Alkhan AA (10), where he reported that the prevalence of HBsAg positive haemodialysis patients in Saudi Arabia was 14%. Another published study from the Najran region demonstrated a 4.4% prevalence of positive HBsAg cases which is higher than the prevalence reported in the present study (15). Globally, the prevalence of HBsAg positive cases has differed in different locations (16),(17),(18),(19),(20). In Iran, Roushan MRH et al., reported a very small percentage of HBsAg positive with 2.1% prevalence (18). On the contrary, Noori S et al., reported a higher prevalence of 70.8%, which was the highest prevalence of HBsAg positive cases among national and international articles on the same subject (19). Regionally, Rached AA et al., reported the least number of cases with HBsAg positivity with a prevalence of only 1.6% in Lebanon (20). In Brazil, the incidence of positive HBsAg cases among haemodialysis patients had seen a decline in recent years, from 4% in 2001 to 0.8% in 2014-2015 (21).

The prevalence of Hepatitis C antibody positive in the present study was 40 (6.4%). Alkhan AA et al., reported that among the haemodialysis patients, 7% were found to be Hepatitis C positive which were slightly higher than the present study’s findings (10). Shaheen FA et al., reported a relatively high prevalence with 72.3% which we perceived as the highest number of cases here in Saudi Arabia (22). In the present report, 38 of the incentre haemodialysis patients were already HCV positive before the admission and an incidence of two cases converting from HCV negative to positive during the course of treatment was reported. The present study had incidences of positive HCV findings before admission that can be attributed to different factors such as blood borne viruses and non human primates (23). Cordeiro VM et al., reported the least number of positive cases of hepatitis C in Brazil with a prevalence of 2.8%, which was lower than the prevalence reported in the present study (21). The previous studies have also reported a lower prevalence of HCV positive than the prevalence reported in the present study (20),(21). In accordance with results of the present study, Prakash S et al., reported similar incidence of HCV positive dialysis patients (24). On the other hand, different international studies (Table/Fig 4) elaborated the high prevalence of HCV positivity (16),(17),(18),(19),(21),[21,(25),(24),(25),(26),(27). A study conducted in Indonesia showed the highest prevalence of Hepatitis C positive with 61% (27). Globally, the prevalence of HBsAg positive cases has differed in accordance to the location (Table/Fig 4) (16),(17),(18),(19),(20),(21),(25),(26),(27). Though the prevalence of HBV and HCV infections among haemodialysis patients in private centres remains high (27) and, the low prevalence seen in the present study may be due to the fact that, majority of participating centres were Government owned, which followed a very strict hygienic standard protocol from the Saudi Ministry of Health.

Limitation(s)

As the present study included only limited number of centres from the Qassim Region, future study involving all the regions of Saudi Arabia with the random selection of participating centres may provide a better estimate of HBsAg and HCV prevalence and seroconversion.

Conclusion

The incidence of hepatitis B and C positivity was common in patients receiving haemodialysis. The study found low prevalence of both Hepatitis B and C positive cases in comparison to several published articles. However, further studies are needed to generalise the outcome of the present study.

Acknowledgement

The authors received no financial support for the research, authorship, and/or publication of this article. The author would like to thank Dr. Nora Alsedrani, Dr. Renad Alkheder,?sup? #sup#Dr. Nawaf Almutairi for their contribution in collecting the data and helping in preparing the manuscript.

References

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Rutherford A, Dienstag JL Greenberger NJ, Blumberg RS, Burakoff R. Viral hepatitis. Current diagnosis & treatment: Gastroenterology, hepatology, & endoscopy. 3rd ed. NewYork, NY: McGraw-Hill; 2016.
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Hajarizadeh B, Grebely J, Dore GJ. Epidemiology and natural history of HCV infection. Nat Rev Gastroenterol Hepatol. 2013;10(9):553-62. [crossref] [PubMed]
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World Health Organization. (2017). Global hepatitis report 2017. World Health Organization. https://apps.who.int/iris/handle/10665/255016. License: CC BY-NC-SA 3.0 IGO.
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Aljumah AA, Babatin M, Hashim A, Abaalkhail F, Bassil N, Safwat M, et al. Hepatitis B care pathway in Saudi Arabia: Current situation, gaps and actions. Saudi J Gastroenterol. 2019;25(2):73-80. Doi: 10.4103/sjg.SJG_421_18. [crossref] [PubMed]
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Saudi Center for Organ Transplantation. Annual Report for Organ Transplantation in Kingdom of Saudi Arabia 2019:19-25. Available from: https://scot.gov.sa/en/PagesList/FileList?pageid=30.
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Ott JJ, Stevens GA, Groeger J, Wiersma ST. Global epidemiology of hepatitis B virus infection: New estimates of age-specific HBsAg seroprevalence and endemicity. Vaccine. 2012;30(12):2212-19. https://doi.org/10.1016/j.vaccine.2011.12.116. [crossref] [PubMed]
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Algarni HS, Memish ZA, Assiri AM, Alhakeem RF, Alghamdi KS, Alshikh HA, et al. Trends of reported cases of hepatitis B virus infection, Kingdom of Saudi Arabia, 2009-2013. Am J Res Commun. 2013;2(6):33-44.
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DOI and Others

DOI: 10.7860/JCDR/2022/52072.15922

Date of Submission: Aug 23, 2021
Date of Peer Review: Sep 18, 2021
Date of Acceptance: Nov 17, 2021
Date of Publishing: Jan 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Aug 24, 2021
• Manual Googling: Sep 18, 2021
• iThenticate Software: Nov 17, 2021 (27%)

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