Evaluation of Helicobacter pylori antigen positivity in stool samples of patients with dyspeptic complaints in a tertiary care hospital

Objective: Helicobacter pylori is a microorganism associatedwith gastritis, peptic ulcer disease and gastriccancer. We aimed to figure out the positivity rate in stoolsamples of outpatients with dyspeptic complaints visitinggastroenterology department and to evaluate its relationwith age, gender and seasonal changes.Methods: Between January 01, 2012 and December 31,2012, stool samples of 330 adult outpatients admitted togastroenterology department are investigated with an immunochromatographictest kit using monoclonal antibodiesfor detection of H. pylori antigen.Results: Among 330 patients’ stool samples tested, 67(20.3%) were positive. 18.6% of men and 22.2% of womenwere detected as positive. According to age groups,17.1% patients were positive for 15-35 age groups,27.1% patients were positive for 36-55 age groups and18.2% patients were positive for above 56. Seasonal differenceof H. pylori antigen positivity in stool samples wasstatistically significant (p=0.001). Highest positivity rate29.7% was detected for winter months (December-January-February). According to logistic regression analysis,winter is found as a risk factor with statistically significant2.295 times greater risk [p=0001, Exp (B) = 2.925, 95.0%C.I. for EXP (B) = 1.668-5.129].Conclusion: H. pylori antigen positivity rate of our study islower than other previously conducted studies in Turkey.But, positivity rates are higher among women comparedto men, concordant with other studies. Even more, detectionof high positivity rates in winter shows primary infectionand/or relapse can be affected by seasonal changes.Key words: Helicobacter pylori, gastroenterology, stool antigen tes

Investigation of extensive drug resistance in multidrug resistance tuberculosis isolates

Son yıllarda tüm dünyada ilaca dirençli tüberküloz (TB) olgularında izlenen artış, halk sağlığını önemli derecede tehdit etmektedir. Yaygın ilaca dirençli TB (YİD-TB), birinci seçenek anti-TB ilaçlardan izoniazid ve rifampisin direncine [çok ilaca dirençli TB (ÇİD-TB) tanımı] ek olarak herhangi bir florokinolona ve parenteral verilen ikinci seçenek anti-TB ilaçlardan en azından birisine direnç gelişmesi durumudur. Birinci seçenek anti-TB ilaçlardan olumlu yanıt alınamayan ÇİD-TB olgularında uygulanan anti-TB tedavi, klinik izolatların varsa ikinci seçenek anti-TB ilaç in vitro duyarlılık test sonuçlarına, yoksa standart tedavi protokollerine göre yapılmaktadır. Bireysel anti-TB tedavinin, ideal olarak izolatın duyarlılık test sonuçlarına bakılarak yapılması önerilse de, ikinci seçenek anti-TB ilaç duyarlılık testlerinin sıklıkla yapılamadığı ülkemiz gibi gelişmekte olan ülkelerde her zaman standart tedavi protokollerine gereksinim duyulmaktadır. Bu nedenle, uygun standart tedavi protokollerinin oluşturulabilmesi için ulusal ve bölgesel ölçekli direnç paternlerini ortaya koyacak çalışmalara ihtiyaç bulunmaktadır. Bu çalışmada, İstanbul, İzmir ve Manisa illerinin değişik sağlık merkezlerinde soyutlanan 81 ÇİD-TB izolatında, yaygın ilaç direnç varlığının araştırılması ile Marmara ve Ege Bölgelerinde YİD-TB insidansının belirlenmesine yönelik çalışmalara katkı sağlanması amaçlanmış; aynı zamanda klinisyenlere ÇİD-TB hastalarının tedavisinde ikinci seçenek anti- TB ilaçların seçimi konusunda faydalanabilecekleri epidemiyolojik verilerin sunulması hedeflenmiştir. İzolatların birinci ve ikinci seçenek anti-TB ilaçlara duyarlılık durumları, tam otomatize florometrik BACTEC MGIT 960 cihazında (Becton Dickinson, ABD) modifiye Middlebrook 7H9 sıvı besiyeri kullanılarak araştırılmıştır. Çalışmaya dahil edilen 81 ÇİD-TB izolatının 43 (%53.1) ü İstanbul, 26 (%32.1) sı İzmir ve 12 (%14.8) si Manisa ilinde yaşayan hastalardan soyutlanmıştır. Çalışma sonucunda YİD-TB tanımına uyan izolat saptanmamıştır. ÇİD-TB izolatlarının ikinci seçenek anti-TB ilaçlara direnç oranları, amikasin ve kanamisin için %1.2, ofloksasin ve levofloksasin için %2.5, kapreomisin için %14.8, etiyonamid için %37 olarak belirlenmiş, linezolide ise direnç tespit edilmemiştir. Levofloksasin-ofloksasin (p< 0.01), amikasin- kanamisin (p= 0.01) ve streptomisin-etiyonamid (p= 0.04) ilaçları arasında direnç durumları bakımından istatistiksel olarak anlamlı düzeyde uyum bulunduğu belirlenmiştir. Çalışmada, ÇİD-TB izolatlarında YİD-TB nin görülmediği, etiyonamid ve kapreomisine karşı direncin yüksek bulunduğu, ÇİD-TB tedavisinde parenteral aminoglikozid grubundan amikasin veya kanamisinle birlikte, kinolonların ve yeterli klinik çalışmalar sonrası linezolidin güvenle kullanılabileceği sonucuna ulaşılmıştır.Increasing number of drug resistant tuberculosis (TB) cases, observed in recent years, is an important public health problem. Extensively drug resistant TB (XDR-TB) is the development of resistance against any fluoroquinolones and at least one of the injectable second line anti-TB drugs in addition to resistance against isoniazide and rifampicin which are the first line anti-TB drugs [definition of multidrug resistant TB (MDR-TB)]. Anti-TB therapy failed with first-line anti-TB drugs due to MDR-TB cases is being planned according to second-line anti-TB drug susceptibility test results if available and if not, standart treatment protocols are used. Although it is recommended that individual anti-TB therapy should be designed according to the isolate s susceptibility test results, standart therapeutic protocols are always needed since second-line anti-TB drug susceptibility testing generally could not be performed in developing countries like Turkey. For this reason, nationwide and regional surveillance studies to determine the resistance patterns are always needed to make decisions about the standard therapy algorithms. In this study, it was aimed to investigate the presence of extensive drug resistance among 81 MDR-TB isolates obtained from various health care facilities from Istanbul, Izmir and Manisa and to determine the XDR-TB incidence in Marmara and Aegean regions. Furthermore, we aimed to provide epidemiological data to clinicians to support their choice of second-line anti-TB drugs for MDR-TB infections. Susceptibility testing of isolates for the first and the second-line anti-TB drugs were performed by using modified Middlebrook 7H9 broth in fluorometric BACTEC MGIT 960 system (Becton Dickinson, USA). Eighty-one MDR-TB isolates included in this study were isolated from 43 (53.1%) patients residing in Istanbul, 26 (32.1%) in Izmir and 12 (14.8%) in Manisa provinces. We could not find any isolate consistent with XDR-TB definition in this study. Second-line drug resistance rates of MDR-TB isolates to amikacin and kanamycin were 1.2%, ofloxacin and levofloxacin were 2.5%, capreomycin was 14.8%, ethionamide was 37% whereas linezolid resistance was not detected. Statistically significant correlation was detected between resistance rates of these antibiotic pairs; levofloxacin-ofloxacin (p&lt; 0.01), amikacin-kanamycin (p= 0.01) and streptomycin-ethionamide (p= 0.04). In our study, extensive drug resistance was not encountered in any MDR-TB isolates while high resistance rates was observed against ethionamide and capreomycin. It can be concluded that parenteral aminoglycosides amikasin and kanamycin, fluoroquinolones and linezolid seemed to be reliable anti-TB agents in MDR-TB treatment, however, further larger scale studies are needed

Investigation of extensive drug resistance in multidrug resistance tuberculosis isolates

Son yıllarda tüm dünyada ilaca dirençli tüberküloz (TB) olgularında izlenen artış, halk sağlığını önemli derecede tehdit etmektedir. Yaygın ilaca dirençli TB (YİD-TB), birinci seçenek anti-TB ilaçlardan izoniazid ve rifampisin direncine [çok ilaca dirençli TB (ÇİD-TB) tanımı] ek olarak herhangi bir florokinolona ve parenteral verilen ikinci seçenek anti-TB ilaçlardan en azından birisine direnç gelişmesi durumudur. Birinci seçenek anti-TB ilaçlardan olumlu yanıt alınamayan ÇİD-TB olgularında uygulanan anti-TB tedavi, klinik izolatların varsa ikinci seçenek anti-TB ilaç in vitro duyarlılık test sonuçlarına, yoksa standart tedavi protokollerine göre yapılmaktadır. Bireysel anti-TB tedavinin, ideal olarak izolatın duyarlılık test sonuçlarına bakılarak yapılması önerilse de, ikinci seçenek anti-TB ilaç duyarlılık testlerinin sıklıkla yapılamadığı ülkemiz gibi gelişmekte olan ülkelerde her zaman standart tedavi protokollerine gereksinim duyulmaktadır. Bu nedenle, uygun standart tedavi protokollerinin oluşturulabilmesi için ulusal ve bölgesel ölçekli direnç paternlerini ortaya koyacak çalışmalara ihtiyaç bulunmaktadır. Bu çalışmada, İstanbul, İzmir ve Manisa illerinin değişik sağlık merkezlerinde soyutlanan 81 ÇİD-TB izolatında, yaygın ilaç direnç varlığının araştırılması ile Marmara ve Ege Bölgelerinde YİD-TB insidansının belirlenmesine yönelik çalışmalara katkı sağlanması amaçlanmış; aynı zamanda klinisyenlere ÇİD-TB hastalarının tedavisinde ikinci seçenek anti- TB ilaçların seçimi konusunda faydalanabilecekleri epidemiyolojik verilerin sunulması hedeflenmiştir. İzolatların birinci ve ikinci seçenek anti-TB ilaçlara duyarlılık durumları, tam otomatize florometrik BACTEC MGIT 960 cihazında (Becton Dickinson, ABD) modifiye Middlebrook 7H9 sıvı besiyeri kullanılarak araştırılmıştır. Çalışmaya dahil edilen 81 ÇİD-TB izolatının 43 (%53.1) ü İstanbul, 26 (%32.1) sı İzmir ve 12 (%14.8) si Manisa ilinde yaşayan hastalardan soyutlanmıştır. Çalışma sonucunda YİD-TB tanımına uyan izolat saptanmamıştır. ÇİD-TB izolatlarının ikinci seçenek anti-TB ilaçlara direnç oranları, amikasin ve kanamisin için %1.2, ofloksasin ve levofloksasin için %2.5, kapreomisin için %14.8, etiyonamid için %37 olarak belirlenmiş, linezolide ise direnç tespit edilmemiştir. Levofloksasin-ofloksasin (p< 0.01), amikasin- kanamisin (p= 0.01) ve streptomisin-etiyonamid (p= 0.04) ilaçları arasında direnç durumları bakımından istatistiksel olarak anlamlı düzeyde uyum bulunduğu belirlenmiştir. Çalışmada, ÇİD-TB izolatlarında YİD-TB nin görülmediği, etiyonamid ve kapreomisine karşı direncin yüksek bulunduğu, ÇİD-TB tedavisinde parenteral aminoglikozid grubundan amikasin veya kanamisinle birlikte, kinolonların ve yeterli klinik çalışmalar sonrası linezolidin güvenle kullanılabileceği sonucuna ulaşılmıştır.Increasing number of drug resistant tuberculosis (TB) cases, observed in recent years, is an important public health problem. Extensively drug resistant TB (XDR-TB) is the development of resistance against any fluoroquinolones and at least one of the injectable second line anti-TB drugs in addition to resistance against isoniazide and rifampicin which are the first line anti-TB drugs [definition of multidrug resistant TB (MDR-TB)]. Anti-TB therapy failed with first-line anti-TB drugs due to MDR-TB cases is being planned according to second-line anti-TB drug susceptibility test results if available and if not, standart treatment protocols are used. Although it is recommended that individual anti-TB therapy should be designed according to the isolate s susceptibility test results, standart therapeutic protocols are always needed since second-line anti-TB drug susceptibility testing generally could not be performed in developing countries like Turkey. For this reason, nationwide and regional surveillance studies to determine the resistance patterns are always needed to make decisions about the standard therapy algorithms. In this study, it was aimed to investigate the presence of extensive drug resistance among 81 MDR-TB isolates obtained from various health care facilities from Istanbul, Izmir and Manisa and to determine the XDR-TB incidence in Marmara and Aegean regions. Furthermore, we aimed to provide epidemiological data to clinicians to support their choice of second-line anti-TB drugs for MDR-TB infections. Susceptibility testing of isolates for the first and the second-line anti-TB drugs were performed by using modified Middlebrook 7H9 broth in fluorometric BACTEC MGIT 960 system (Becton Dickinson, USA). Eighty-one MDR-TB isolates included in this study were isolated from 43 (53.1%) patients residing in Istanbul, 26 (32.1%) in Izmir and 12 (14.8%) in Manisa provinces. We could not find any isolate consistent with XDR-TB definition in this study. Second-line drug resistance rates of MDR-TB isolates to amikacin and kanamycin were 1.2%, ofloxacin and levofloxacin were 2.5%, capreomycin was 14.8%, ethionamide was 37% whereas linezolid resistance was not detected. Statistically significant correlation was detected between resistance rates of these antibiotic pairs; levofloxacin-ofloxacin (p&lt; 0.01), amikacin-kanamycin (p= 0.01) and streptomycin-ethionamide (p= 0.04). In our study, extensive drug resistance was not encountered in any MDR-TB isolates while high resistance rates was observed against ethionamide and capreomycin. It can be concluded that parenteral aminoglycosides amikasin and kanamycin, fluoroquinolones and linezolid seemed to be reliable anti-TB agents in MDR-TB treatment, however, further larger scale studies are needed

Investigation of the Minimal Inhibitory Concentration Values of Vancomycin, Teicoplanin and Linezolid among MRSA Isolated from Inpatients by E-test Method

Introduction: Although studies aimed at the prevention of mortality and morbidity in MRSA infections have been ongoing for years, methicillin resistan Staphylococcus aureus (MRSA) remains one of the most important pathogens leading to nosocomial infections. In the treatment of cases infected by MRSA, the most important and most common issue is multi-drug resistance and the limited therapy options. Today, in the therapy of MRSA infections, glycopeptide antibiotics such as vancomycin and teicoplanin and linezolid are the major therapeutic agents of choice. The aim of this study was to determine the minimal inhibitory concentration (MIC) values of vancomycin, teicoplanin and linezolid against MRSA strains isolated in our institution over a four year period, to compare with the results from our country, and to contribute to the therapeutic options in MRSA infections. Materials and Methods: Between January 2006 and December 2009, vancomycin, teicoplanin and linezolid susceptibilities of 138 nonduplicate MRSA strains isolated from inpatients were determined by E-test method according to the Clinical and Laboratory Standards Institute (CLSI) guidelines. Results: Resistance to vancomycin, teicoplanin and linezolide was not detected in MRSA strains isolated from inpatients in our hospital. MIC50 and MIC90 values for vancomycin, teicoplanin and linezolid were found 1.5 µg/mL and 2 µg/mL, 2 µg/mL and 4 µg/mL, and 0.75 µg/mL and 1 µg/mL, respectively. Conclusion: Our data are consistent with the data from our country. Our results indicate that linezolid could be used as a safe therapeutic option in addition to glycopeptides in the treatment of MRSA infections

Investigation of extensive drug resistance in multidrug resistance tuberculosis isolates

Son yıllarda tüm dünyada ilaca dirençli tüberküloz (TB) olgularında izlenen artış, halk sağlığını önemli derecede tehdit etmektedir. Yaygın ilaca dirençli TB (YİD-TB), birinci seçenek anti-TB ilaçlardan izoniazid ve rifampisin direncine [çok ilaca dirençli TB (ÇİD-TB) tanımı] ek olarak herhangi bir florokinolona ve parenteral verilen ikinci seçenek anti-TB ilaçlardan en azından birisine direnç gelişmesi durumudur. Birinci seçenek anti-TB ilaçlardan olumlu yanıt alınamayan ÇİD-TB olgularında uygulanan anti-TB tedavi, klinik izolatların varsa ikinci seçenek anti-TB ilaç in vitro duyarlılık test sonuçlarına, yoksa standart tedavi protokollerine göre yapılmaktadır. Bireysel anti-TB tedavinin, ideal olarak izolatın duyarlılık test sonuçlarına bakılarak yapılması önerilse de, ikinci seçenek anti-TB ilaç duyarlılık testlerinin sıklıkla yapılamadığı ülkemiz gibi gelişmekte olan ülkelerde her zaman standart tedavi protokollerine gereksinim duyulmaktadır. Bu nedenle, uygun standart tedavi protokollerinin oluşturulabilmesi için ulusal ve bölgesel ölçekli direnç paternlerini ortaya koyacak çalışmalara ihtiyaç bulunmaktadır. Bu çalışmada, İstanbul, İzmir ve Manisa illerinin değişik sağlık merkezlerinde soyutlanan 81 ÇİD-TB izolatında, yaygın ilaç direnç varlığının araştırılması ile Marmara ve Ege Bölgelerinde YİD-TB insidansının belirlenmesine yönelik çalışmalara katkı sağlanması amaçlanmış; aynı zamanda klinisyenlere ÇİD-TB hastalarının tedavisinde ikinci seçenek anti- TB ilaçların seçimi konusunda faydalanabilecekleri epidemiyolojik verilerin sunulması hedeflenmiştir. İzolatların birinci ve ikinci seçenek anti-TB ilaçlara duyarlılık durumları, tam otomatize florometrik BACTEC MGIT 960 cihazında (Becton Dickinson, ABD) modifiye Middlebrook 7H9 sıvı besiyeri kullanılarak araştırılmıştır. Çalışmaya dahil edilen 81 ÇİD-TB izolatının 43 (%53.1)’ü İstanbul, 26 (%32.1)’sı İzmir ve 12 (%14.8)’si Manisa ilinde yaşayan hastalardan soyutlanmıştır. Çalışma sonucunda YİD-TB tanımına uyan izolat saptanmamıştır. ÇİD-TB izolatlarının ikinci seçenek anti-TB ilaçlara direnç oranları, amikasin ve kanamisin için %1.2, ofloksasin ve levofloksasin için %2.5, kapreomisin için %14.8, etiyonamid için %37 olarak belirlenmiş, linezolide ise direnç tespit edilmemiştir. Levofloksasin-ofloksasin (p< 0.01), amikasin- kanamisin (p= 0.01) ve streptomisin-etiyonamid (p= 0.04) ilaçları arasında direnç durumları bakımından istatistiksel olarak anlamlı düzeyde uyum bulunduğu belirlenmiştir. Çalışmada, ÇİD-TB izolatlarında YİD-TB’nin görülmediği, etiyonamid ve kapreomisine karşı direncin yüksek bulunduğu, ÇİD-TB tedavisinde parenteral aminoglikozid grubundan amikasin veya kanamisinle birlikte, kinolonların ve yeterli klinik çalışmalar sonrası linezolidin güvenle kullanılabileceği sonucuna ulaşılmıştır.Increasing number of drug resistant tuberculosis (TB) cases, observed in recent years, is an important public health problem. Extensively drug resistant TB (XDR-TB) is the development of resistance against any fluoroquinolones and at least one of the injectable second line anti-TB drugs in addition to resistance against isoniazide and rifampicin which are the first line anti-TB drugs [definition of multidrug resistant TB (MDR-TB)]. Anti-TB therapy failed with first-line anti-TB drugs due to MDR-TB cases is being planned according to second-line anti-TB drug susceptibility test results if available and if not, standart treatment protocols are used. Although it is recommended that individual anti-TB therapy should be designed according to the isolate’s susceptibility test results, standart therapeutic protocols are always needed since second-line anti-TB drug susceptibility testing generally could not be performed in developing countries like Turkey. For this reason, nationwide and regional surveillance studies to determine the resistance patterns are always needed to make decisions about the standard therapy algorithms. In this study, it was aimed to investigate the presence of extensive drug resistance among 81 MDR-TB isolates obtained from various health care facilities from Istanbul, Izmir and Manisa and to determine the XDR-TB incidence in Marmara and Aegean regions. Furthermore, we aimed to provide epidemiological data to clinicians to support their choice of second-line anti-TB drugs for MDR-TB infections. Susceptibility testing of isolates for the first and the second-line anti-TB drugs were performed by using modified Middlebrook 7H9 broth in fluorometric BACTEC MGIT 960 system (Becton Dickinson, USA). Eighty-one MDR-TB isolates included in this study were isolated from 43 (53.1%) patients residing in Istanbul, 26 (32.1%) in Izmir and 12 (14.8%) in Manisa provinces. We could not find any isolate consistent with XDR-TB definition in this study. Second-line drug resistance rates of MDR-TB isolates to amikacin and kanamycin were 1.2%, ofloxacin and levofloxacin were 2.5%, capreomycin was 14.8%, ethionamide was 37% whereas linezolid resistance was not detected. Statistically significant correlation was detected between resistance rates of these antibiotic pairs; levofloxacin-ofloxacin (p&lt; 0.01), amikacin-kanamycin (p= 0.01) and streptomycin-ethionamide (p= 0.04). In our study, extensive drug resistance was not encountered in any MDR-TB isolates while high resistance rates was observed against ethionamide and capreomycin. It can be concluded that parenteral aminoglycosides amikasin and kanamycin, fluoroquinolones and linezolid seemed to be reliable anti-TB agents in MDR-TB treatment, however, further larger scale studies are needed

Plasmid-Mediated Quinolone Resistance Genes in Escherichia coli Urinary Isolates from Two Teaching Hospitals in Turkey: Coexistence of TEM, SHV, CTX-M and VEB-1 Type β-lactamases

Purpose: To evaluate the occurrence of plasmid-mediated quinolone resistance (PMQR) genes and the prevalence of extended spectrum β-lactamase (ESBL) types in Escherichia coli clinical isolates. Methods: Sixty-one ESBL-producing urinary E. coli isolates were studied. An antibiotic susceptibility test was performed using the disc diffusion method. ESBL production was determined using a double-disc synergy test for all isolates; E-test and Vitek 2 were used for plasmid-mediated quinolone resistance (PMQR)-positive isolates and their transconjugants. The presence of PMQR and β-lactamase genes was determined by polymerase chain reaction (PCR). Results: The strains displayed high rates of resistance to norfloxacin (80 %). The most frequent PMQR gene was aac(6’)-Ib-cr (45.9 %). In all, one qnrA1 (1.6 %), one qnrS1 (1.6 %), and two qepA1-positive isolates (5.7 %) were identified. The genes, qnrS1+aac(6’)-Ib-cr and qepA1, were co-expressed with blaCTX-M-15 gene, while qnrA1 occurred with blaTEM-1, blaSHV, and blaVEB-1 genes. The most frequent β-lactamase type was cefotaximase (CTX-M), which generally hydrolyzes cefotaxime (92 %) more than it does ceftazidime; followed by temoneira (TEM, 39 %); sulfhydryl variable (SHV, 5 %), and Vietnamese extended-spectrum beta– lactamase (VEB, 1.6 %). Conclusion: A high prevalence of aac(6’)-Ib-cr and CTX-M type β-lactamase was detected in ESBLproducing E. coli strains. This study also identified the co-expression of qnrA1 and blaVEB-1 genes and of qnrS1+aac(6’)-Ib-cr in E. coli isolates. The co-existence of PMQR genes with ESBLs may lead to a serious public health problem

15-year evaluation of changes in the HBsAg positivity rate in pregnant women in Turkey: the prominent effect of national vaccination

Background: The detection of hepatitis B surface antigen positivity in pregnant women before delivery is crucial to preventing mother-to-child transmission of hepatitis B virus.Aims: This study aimed to evaluate the status and rate of testing for hepatitis B surface antigen, rate of hepatitis B surface antigen positivity, hepatitis B surface antigen positivity distribution rate by age, and changes in hepatitis B surface antigen positivity rate in pregnant women over the study period.Methods: We conducted a multicentre, cross-sectional, descriptive study covering the period January 2005 to June 2019 for 2 145 668 pregnant women from 27 provinces in all 7 regions of Turkey, collected using Microsoft Excel before statistical analysis.Results: We found that 1 012 593 (47.1%) pregnant women were tested for hepatitis B surface antigen over the 15-year period, out of which 11 471 (1.1%) were hepatitis B surface antigen-positive. Overall, 97% of the hepatitis B surface antigen positive women were born before 1998, the year that national HBV vaccination was launched in Turkey. The rate of hepatitis B surface antigen positivity in that group was 1.1%, compared with 0.3% among women born after 1998.Conclusion: There was a downward trend in the hepatitis B surface antigen positivity rate among pregnant women in the younger age groups, especially among those born after universal hepatitis B vaccination was inaugurated, and low rate of HBsAg testing during pregnancy