Adult hospitalizations due to hepatitis A virus infection in six tertiary hospitals across Bangladesh: December 2014 – September 2017

Adult hospitalizations due to hepatitis A virus infection in six tertiary hospitals across Bangladesh: December 2014 – September 2017 | medRxiv /* */ /* */ <!-- <!-- /*! * yepnope1.5.4 * (c) WTFPL, GPLv2 */ (function(a,b,c){function d(a){return"[object Function]"==o.call(a)}function e(a){return"string"==typeof a}function f(){}function g(a){return!a||"loaded"==a||"complete"==a||"uninitialized"==a}function h(){var a=p.shift();q=1,a?a.t?m(function(){("c"==a.t?B.injectCss:B.injectJs)(a.s,0,a.a,a.x,a.e,1)},0):(a(),h()):q=0}function i(a,c,d,e,f,i,j){function k(b){if(!o&&g(l.readyState)&&(u.r=o=1,!q&&h(),l.onload=l.onreadystatechange=null,b)){"img"!=a&&m(function(){t.removeChild(l)},50);for(var d in y[c])y[c].hasOwnProperty(d)&&y[c][d].onload()}}var j=j||B.errorTimeout,l=b.createElement(a),o=0,r=0,u={t:d,s:c,e:f,a:i,x:j};1===y[c]&&(r=1,y[c]=[]),"object"==a?l.data=c:(l.src=c,l.type=a),l.width=l.height="0",l.onerror=l.onload=l.onreadystatechange=function(){k.call(this,r)},p.splice(e,0,u),"img"!=a&&(r||2===y[c]?(t.insertBefore(l,s?null:n),m(k,j)):y[c].push(l))}function j(a,b,c,d,f){return q=0,b=b||"j",e(a)?i("c"==b?v:u,a,b,this.i++,c,d,f):(p.splice(this.i++,0,a),1==p.length&&h()),this}function k(){var a=B;return a.loader={load:j,i:0},a}var l=b.documentElement,m=a.setTimeout,n=b.getElementsByTagName("script")[0],o={}.toString,p=[],q=0,r="MozAppearance"in l.style,s=r&&!!b.createRange().compareNode,t=s?l:n.parentNode,l=a.opera&&"[object Opera]"==o.call(a.opera),l=!!b.attachEvent&&!l,u=r?"object":l?"script":"img",v=l?"script":u,w=Array.isArray||function(a){return"[object Array]"==o.call(a)},x=[],y={},z={timeout:function(a,b){return b.length&&(a.timeout=b[0]),a}},A,B;B=function(a){function b(a){var a=a.split("!"),b=x.length,c=a.pop(),d=a.length,c={url:c,origUrl:c,prefixes:a},e,f,g;for(f=0;f<d;f++)g=a[f].split("="),(e=z[g.shift()])&&(c=e(c,g));for(f=0;f<b;f++)c=x[f](c);return c}function g(a,e,f,g,h){var i=b(a),j=i.autoCallback;i.url.split(".").pop().split("?").shift(),i.bypass||(e&&(e=d(e)?e:e[a]||e[g]||e[a.split("/").pop().split("?")[0]]),i.instead?i.instead(a,e,f,g,h):(y[i.url]?i.noexec=!0:y[i.url]=1,f.load(i.url,i.forceCSS||!i.forceJS&&"css"==i.url.split(".").pop().split("?").shift()?"c":c,i.noexec,i.attrs,i.timeout),(d(e)||d(j))&&f.load(function(){k(),e&&e(i.origUrl,h,g),j&&j(i.origUrl,h,g),y[i.url]=2})))}function h(a,b){function c(a,c){if(a){if(e(a))c||(j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}),g(a,j,b,0,h);else if(Object(a)===a)for(n in m=function(){var b=0,c;for(c in a)a.hasOwnProperty(c)&&b++;return b}(),a)a.hasOwnProperty(n)&&(!c&&!--m&&(d(j)?j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}:j[n]=function(a){return function(){var b=[].slice.call(arguments);a&&a.apply(this,b),l()}}(k[n])),g(a[n],j,b,n,h))}else!c&&l()}var h=!!a.test,i=a.load||a.both,j=a.callback||f,k=j,l=a.complete||f,m,n;c(h?a.yep:a.nope,!!i),i&&c(i)}var i,j,l=this.yepnope.loader;if(e(a))g(a,0,l,0);else if(w(a))for(i=0;i (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0];var j=d.createElement(s);var dl=l!='dataLayer'?'&l='+l:'';j.src='//www.googletagmanager.com/gtm.js?id='+i+dl;j.type='text/javascript';j.async=true;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-P4HH5NV'); Skip to main content Home About Submit ALERTS / RSS Search for this keyword Advanced Search Adult hospitalizations due to hepatitis A virus infection in six tertiary hospitals across Bangladesh: December 2014 – September 2017 Banda AA Khalifa , Repon C Paul , Arifa Nazneen , Kajal C Banik , Shariful Amin Sumon , Kishor K Paul , Arifa Akram , M Salim Uzzaman , Stephen P Luby , Emily S Gurley doi: https://doi.org/10.1101/2025.06.26.25330300 Banda AA Khalifa 1 Johns Hopkins Bloomberg School of Public Health , Baltimore, USA Find this author on Google Scholar Find this author on PubMed Search for this author on this site Repon C Paul 2 National Perinatal Epidemiology and Statistics Unit (NPESU), Centre for Big Data Research in Health (CBDRH), University of New South Wales , Sydney, Australia 3 icddr,b , Dhaka, Bangladesh Find this author on Google Scholar Find this author on PubMed Search for this author on this site Arifa Nazneen 3 icddr,b , Dhaka, Bangladesh Find this author on Google Scholar Find this author on PubMed Search for this author on this site Kajal C Banik 3 icddr,b , Dhaka, Bangladesh Find this author on Google Scholar Find this author on PubMed Search for this author on this site Shariful Amin Sumon 3 icddr,b , Dhaka, Bangladesh Find this author on Google Scholar Find this author on PubMed Search for this author on this site Kishor K Paul 4 School of Population Health, University of New South Wales , Sydney, Australia Find this author on Google Scholar Find this author on PubMed Search for this author on this site Arifa Akram 5 Institute of Epidemiology, Disease Control and Research , Bangladesh Find this author on Google Scholar Find this author on PubMed Search for this author on this site M Salim Uzzaman 5 Institute of Epidemiology, Disease Control and Research , Bangladesh Find this author on Google Scholar Find this author on PubMed Search for this author on this site Stephen P Luby 6 Infectious Diseases and Geographic Medicine, Stanford University , Stanford, California, United States of America Find this author on Google Scholar Find this author on PubMed Search for this author on this site Emily S Gurley 1 Johns Hopkins Bloomberg School of Public Health , Baltimore, USA 3 icddr,b , Dhaka, Bangladesh Find this author on Google Scholar Find this author on PubMed Search for this author on this site For correspondence: egurley1{at}jhu.edu Abstract Full Text Info/History Metrics Data/Code Preview PDF Abstract Hepatitis A virus (HAV) is spread through the fecal-oral route. The age of infection largely determines the clinical severity; children typically have asymptomatic or mild illness, but infected adults more commonly develop clinical disease. Many countries have experienced improvements in water and sanitation which could lead to increases in the burden of HAV due to increases in the age of infection. This report summarizes the contribution of HAV to hospitalizations among patients aged >14 years from acute jaundice during 2014 - 2017 across Bangladesh. Among 1,923 patients, 148 (8%) had anti-HAV IgM antibodies in their serum; 26% were co-infected with hepatitis E or B viruses, or both, including 3 of the 4 deaths among patients with HAV infection. An outbreak of HAV was detected at one hospital during 2016. HBV vaccination was introduced in 2005, but additional hepatitis vaccination strategies may be needed to further reduce hepatitis hospitalizations and deaths. Introduction Hepatitis A virus (HAV) is a picornavirus, spread through the fecal-oral route. 1 Consequently, populations with inadequate access to clean water and food are at highest risk for transmission. 1 While the infection is generally self-limiting and asymptomatic in children, it can cause severe illness in adults, including acute liver failure, and even death, particularly among elderly and immunocompromised individuals. 2 According to estimates from the World Health Organization, approximately 100 million people contract hepatitis A annually, leading to 1.5 million clinical cases and 15,000–30,000 deaths. 3 Paradoxically, areas with high transmission rates of HAV tend to have a lower burden of disease compared to areas with moderate transmission. This is because when transmission is high, nearly everyone is infected during childhood when most infections are asymptomatic or mild. Once transmission decreases, more people survive into adulthood susceptible to infection, creating a higher burden of disease if infection occurs. High income countries typically have very low burden of clinical disease, due to low transmission and protection of high risk groups through vaccination. 1 However, many lower and middle income countries have experienced improvements in water and sanitation in recent decades, and consequently, an increased burden of disease as infections during adulthood become more common. 1 In Bangladesh, people have historically been infected with HAV early in life. A study conducted in 2005 in Sylhet, Bangladesh found that 15% of children between 1-2 years of age already had IgG antibodies against HAV, and by age 21-25 years, 100% of the study participants had IgG antibodies. 4 Among study participants from rural areas and lower socioeconomic backgrounds - presumably with less access to clean water - antibody prevalence reached 100% at even younger ages. Since the early 2000’s, access to clean water and improved sanitation facilities has increased in Bangladesh 5 , which could lead to decreases in HAV risk during childhood. More recently, studies have shown that the burden of HAV disease in Bangladesh may be increasing. One study of patients presenting to hospitals with acute hepatitis from 2014-2015 showed that 19% of patients aged 15-60 years had IgM antibodies against HAV, suggesting that changes in transmission could be causing increases in burden of clinical disease. 6 However, the lack of details about severity of disease or age breakdown among these patients makes the results difficult to interpret in terms of changes to disease burden. This analysis presents results from surveillance for hospitalizations from acute hepatitis associated with HAV among adults in six tertiary hospitals in Bangladesh from 2014 - 2017, including clinical outcomes. Methods From December 2014 to September 2017, physicians reviewed hospital admission records daily to identify patients aged 14 years and older who presented with acute jaundice, defined as a new onset of yellow eyes or skin within the preceding three months; details of the surveillance methods have been published elsewhere. 7 Each patient had blood collected and tested for serum bilirubin and serum glutamic-pyruvic transaminase levels, as well as IgM antibodies against HAV, hepatitis E virus, and surface antigens for hepatitis B virus. Information was collected from patients about their signs and symptoms and they were contacted three months post discharge to ascertain disease outcomes. We described patients with HAV infections in terms of sociodemographics, geography, and clinical presentation, and identified risk factors for infection. Ethical Considerations Written informed consent for participation was provided by patients or from their guardians if patients were seriously ill or they were aged <17 years. Patients aged 14 to 17, also provided assent for participation. The study received ethical approval from the institutional review board of the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b). Results Of 1,923 patients hospitalized with acute jaundice, 148 (8%) had evidence of anti-HAV IgM antibodies in their serum, indicating an acute HAV infection ( Table 1 ). Barisal reported the highest proportion of patients with HAV infection (20%); other hospitals had 3-7%. Males (9%) were more frequently affected compared to females (6%) (p=0.028). Younger patients aged 14 - 29 years were more likely to have HAV IgM antibodies (14%) compared to older age groups (0-3%) (p<0.001). Patients hospitalized with acute jaundice and HAV antibodies were also more likely to live in urban areas, have more education, and wealth than those without antibodies ( Table 1 ). View this table: View inline View popup Download powerpoint Table 1. Hepatitis A IgM antibody test results by demographic characteristics of patients with acute jaundice in six tertiary hospitals in Bangladesh, December 2014– September 2017. Patients with HAV IgM antibodies were hospitalized during every month of the study and from all hospital locations; no notable patterns were observed except for an apparent outbreak in Barisal during August - November 2016 when 36 patients with HAV infection were identified, representing 24% of all cases detected in this study ( Figure 1 ). Download figure Open in new tab Figure 1: Stacked chart showing the number of patients with acute jaundice and IgM antibodies against hepatitis A virus admitted in six tertiary hospitals in Bangladesh, Dec 2014–September 2017. All patients presented with yellow skin, yellow eyes, and dark-colored urine, per the surveillance case definition. Other symptoms, such as abdominal pain (45%), drowsiness (18%), altered mental status (2%), and unconsciousness (2%), were less common among patients with HAV compared to others ( Table 2 ). Seventy-two percent of patients with HAV infection presented for care within 2 weeks of onset of illness, compared to 48% of other acute jaundice patients ( Table 2 ). Six percent of patients with HAV infections also had anti-HEV IgM antibodies, and 20% HBsAg in serum, indicating co-infections. One patient had evidence of infection with all three viruses. Among the 305 deaths reported in patients with acute jaundice in this study, 1.3% (4 out of 305) had HAV infection ( Table 2 ). View this table: View inline View popup Table 2. Signs and symptoms during illness among patients admitted in six tertiary hospitals in Bangladesh, December 2014– September 2017 by results from hepatitis A IgM antibody results. Four out of 148 patients with HAV infection died (3%); three of them had co-infections. Patients who died ranged in age from 22 - 70 years; two patients died in the hospital, the other two at home (Supplementary information). Discussion This study of HAV infection among patients hospitalized with acute jaundice across six hospitals in Bangladesh between 2014-2017 found that 8% had IgM antibodies against HAV, which is lower than two other studies from Bangladesh during similar time periods (19% in 2014 6 and 32% in 2012 8 ). One possible reason for the lower prevalence in our study was the age of participants; our study focused on adults while the other studies enrolled all age groups and identified higher prevalence of HAV infection among children. While most studies do not investigate co-infections with other viral hepatitis viruses, our diagnostic approach identified that 27% of patients hospitalized with HAV infection were co-infected with either HEV, HBV, or both. Co-infections can increase the likelihood of severe infection and hospitalization 9 , and therefore, interventions to reduce HEV and HBV infections will also likely reduce hospitalizations associated with HAV infection. Importantly, 3 out of the 4 deaths among patients with HAV infection had co-infections, suggesting that preventing any of these infections could have prevented fatal outcomes. An analysis of this same surveillance dataset identified that among patients hospitalized with HEV infections, 9% (154/1765) had co-infections with either HAV or HBV 7 . The majority of HEV coinfections were with HBV. Bangladesh introduced HBV vaccine into routine childhood immunizations during 2003-2005 and future generations might be at decreased risk for co-infections and the associated severity because of this intervention. 10 Similar to other studies, we identified that younger patients and those from wealthier, more urban environments were more likely to have HAV infections. One explanation for this might be that early exposure to this pathogen continues to decline among these groups, likely due to improvements to living conditions and water systems. It is possible that people are reaching adulthood without being infected more commonly; however, earlier studies of adult hospitalizations from HAV infection are limited by sample size and geographic scope, making inferences about changes over time difficult. One study from Dhaka in 2004 – 2006 identified that 6% of adults seeking care for acute hepatitis had HAV infection, similar to our findings. 11 A quarter of all patients with HAV infection in this study sought care during the second half of 2016 at the Barisal hospital surveillance site, suggesting an outbreak occurred there. The burden of HAV in Bangladesh is dynamic and could be increasing, influenced by the prevalence of co-infections with other hepatitis viruses, and the age of infection. As birth cohorts immunized against HBV age into older adult ages, hospital admissions for HBV should decrease, and hospitalizations from co-infections with HEV and HAV may decrease as well. Studies to monitor changes in the causes of viral hepatitis hospitalizations over time could be useful for policy makers interested in reducing the burden of acute hepatitis. Data Availability All data produced in the present study are available upon reasonable request to icddr,b. Financial support Data collection and testing was funded by the Centers for Disease Control and Prevention (CDC), USA. icddr,b is also grateful to the Government of Bangladesh, Canada, Sweden and the UK for providing core/unrestricted support. Support to Paul RC was given by the UIPA (University International Postgraduate award) scholarship from UNSW. The Bill and Melinda Gates Foundation provided support for this analysis (INV-064112). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Disclosures regarding conflicts of interest The authors have no real or perceived conflicts of interest. Supplementary information Case descriptions of hepatitis A virus (HAV) infection related deaths Patient 1 Patient 1, a pregnant female in her 20’s from a rural district of Sylhet, had a primary education and a household income of less than 10,000 Taka (US$ 125). She reported illness for ten days before she was hospitalized in June 2016. She reported symptoms such as yellow skin, yellow eyes, dark urine, abdominal pain, nausea, vomiting, and fever. Upon examination, the patient had yellow skin and yellow eyes. Laboratory tests revealed a bilirubin level of 4.6 mg/dL and an SGPT level of 56 IU/L, categorizing her bilirubin levels as above normal, while her SGPT levels were within normal limits. Testing indicated co-infection with HBV, evidenced by HBsAg. She was discharged seven days after hospitalization and died at home on the same day. Patient 2 Patient 2 was a pregnant female in her 40’s from a rural district of Kishoreganj with a primary education and household income below 10,000 Taka (US$ 125). The patient reported illness for 15 days before hospitalization in March of 2016. She reported yellow skin, yellow eyes, dark urine, fever, convulsions, unconsciousness, and an altered mental status. Examination confirmed yellow skin and yellow eyes. Laboratory results showed a bilirubin level of 17.4 mg/dL and an SGPT level of 42 IU/L, categorizing her bilirubin levels as above normal, while SGPT levels were normal. She also had IgM antibodies against HEV, suggesting co-infection. She died after two days in hospital. Patient 3 Patient 3, a female in her 70’s from the rural district of Kishoreganj with no formal education, had an illness duration of 60 days before hospitalization. Her household income was below 10,000 taka (US$125). The patient reported yellow skin, yellow eyes, dark urine, abdominal pain, nausea, and fever. The examination revealed yellow and yellow eyes. Her bilirubin level was 20.8 mg/dL, and SGPT was 159 IU/L, categorizing both levels as above normal. The patient tested negative for HEV IgM and HBsAg. She was admitted in June 2016 for nine days and died at home 39 days after being discharged. Patient 4 Patient 4 was a male in his 30’s from a rural district of Joypurhat with secondary education and a household income below 10,000 Taka (US$125). His illness began 12 days prior to hospitalization. The patient reported yellow skin, yellow eyes, dark urine, nausea, and fever. Examination confirmed yellow skin and yellow eyes. Bilirubin and SGPT levels were not measured. He tested positive for HEV IgM and negative for HBsAg, indicating a co-infection with HAV and HEV. He was admitted in May 2016 and died at home 10 days after he left the hospital. He did not exhibit unconsciousness or altered mental status, and details about the distended abdomen and diagnosis were not recorded. Acknowledgements We are grateful to the collaborating hospitals for their interest, enthusiasm and efforts for this study. We gratefully acknowledge the contribution of the study participants and the surveillance medical officers. We are thankful to the field assistants of icddr,b and laboratory staff of IEDCR for their hard work in this study. Footnotes ↵ * denotes shared first-authorship References 1. ↵ Van Damme , P. et al. Hepatitis A virus infection . Nat. Rev. Dis. Primers 9 , 51 ( 2023 ). OpenUrl PubMed 2. ↵ Gholizadeh , O. et al. Hepatitis A: Viral structure, classification, life cycle, clinical symptoms, diagnosis error, and vaccination . Can. J. Infect. Dis. Med. Microbiol . 2023 , 4263309 ( 2023 ). OpenUrl PubMed 3. ↵ Cao , G. , Jing , W. , Liu , J. & Liu , M. The global trends and regional differences in incidence and mortality of hepatitis A from 1990 to 2019 and implications for its prevention . Hepatol. Int . 15 , 1068 – 1082 ( 2021 ). OpenUrl CrossRef PubMed 4. ↵ Ahmed , M. S. et al. Seroprevalence of hepatitis virus antibodies in newly admitted students of Sylhet MAG Osmani Medical College . Banglad. J. Med. Microbiol . 3 , 20 – 26 ( 2009 ). OpenUrl 5. ↵ Zheng , Y. , Hakim , S. A. I. , Nahar , Q. , van Agthoven , A. & Flanagan , S. V. Sanitation coverage in Bangladesh since the millennium: consistency matters . J. Water Sanit. Hyg. Dev . 3 , 240 – 251 ( 2013 ). OpenUrl Abstract / FREE Full Text 6. ↵ Khan , A. I. et al. Nationwide hospital-based seroprevalence of hepatitis A and hepatitis E virus in Bangladesh . Ann. Glob. Health 86 , 29 ( 2020 ). OpenUrl PubMed 7. ↵ Paul , R. C. et al. Hepatitis E as a cause of adult hospitalization in Bangladesh: Results from an acute jaundice surveillance study in six tertiary hospitals, 2014-2017 . PLoS Negl. Trop. Dis . 14 , e0007586 ( 2020 ). OpenUrl PubMed 8. ↵ Arafat , D. S. M. et al. Epidemiology and aetiology of acute viral hepatitis in a tertiary care hospital . Sch. J. Appl. Med. Sci . 11 , 41 – 45 ( 2023 ). OpenUrl 9. ↵ Barde , P. V. , Chouksey , V. K. , Shivlata , L. , Sahare , L. K. & Thakur , A. K. Viral hepatitis among acute hepatitis patients attending tertiary care hospital in central India . Virusdisease 30 , 367 – 372 ( 2019 ). OpenUrl PubMed 10. ↵ Paul , R. C. et al. Hepatitis B surface antigen seroprevalence among prevaccine and vaccine era children in Bangladesh . Am. J. Trop. Med. Hyg . 99 , 764 – 771 ( 2018 ). OpenUrl PubMed 11. ↵ Mahtab M.A. et al. HEV infection as an aetiologic factor for acute hepatitis: Experience from a tertiary hospital in Bangladesh . Health Popul. Nutr . 27 ( 1 ): 14 – 19 ( 2009 ). OpenUrl View the discussion thread. Back to top Previous Next Posted June 28, 2025. Download PDF Data/Code Email Thank you for your interest in spreading the word about medRxiv. NOTE: Your email address is requested solely to identify you as the sender of this article. Your Email * Your Name * Send To * Enter multiple addresses on separate lines or separate them with commas. You are going to email the following Adult hospitalizations due to hepatitis A virus infection in six tertiary hospitals across Bangladesh: December 2014 – September 2017 Message Subject (Your Name) has forwarded a page to you from medRxiv Message Body (Your Name) thought you would like to see this page from the medRxiv website. Your Personal Message CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Share Adult hospitalizations due to hepatitis A virus infection in six tertiary hospitals across Bangladesh: December 2014 – September 2017 Banda AA Khalifa , Repon C Paul , Arifa Nazneen , Kajal C Banik , Shariful Amin Sumon , Kishor K Paul , Arifa Akram , M Salim Uzzaman , Stephen P Luby , Emily S Gurley medRxiv 2025.06.26.25330300; doi: https://doi.org/10.1101/2025.06.26.25330300 Share This Article: Copy Citation Tools Adult hospitalizations due to hepatitis A virus infection in six tertiary hospitals across Bangladesh: December 2014 – September 2017 Banda AA Khalifa , Repon C Paul , Arifa Nazneen , Kajal C Banik , Shariful Amin Sumon , Kishor K Paul , Arifa Akram , M Salim Uzzaman , Stephen P Luby , Emily S Gurley medRxiv 2025.06.26.25330300; doi: https://doi.org/10.1101/2025.06.26.25330300 Citation Manager Formats BibTeX Bookends EasyBib EndNote (tagged) EndNote 8 (xml) Medlars Mendeley Papers RefWorks Tagged Ref Manager RIS Zotero Tweet Widget Facebook Like Google Plus One Subject Area Epidemiology Subject Areas All Articles Addiction Medicine (567) Allergy and Immunology (863) Anesthesia (297) Cardiovascular Medicine (4411) Dentistry and Oral Medicine (443) Dermatology (380) Emergency Medicine (606) Endocrinology (including Diabetes Mellitus and Metabolic Disease) (1505) Epidemiology (15205) Forensic Medicine (30) Gastroenterology (1119) Genetic and Genomic Medicine (6574) Geriatric Medicine (666) Health Economics (994) Health Informatics (4511) Health Policy (1365) Health Systems and Quality Improvement (1608) Hematology (537) HIV/AIDS (1263) Infectious Diseases (except HIV/AIDS) (15903) Intensive Care and Critical Care Medicine (1103) Medical Education (620) Medical Ethics (144) Nephrology (666) Neurology (6573) Nursing (345) Nutrition (998) Obstetrics and Gynecology (1139) Occupational and Environmental Health (954) Oncology (3319) Ophthalmology (968) Orthopedics (369) Otolaryngology (420) Pain Medicine (435) Palliative Medicine (129) Pathology (662) Pediatrics (1689) Pharmacology and Therapeutics (691) Primary Care Research (710) Psychiatry and Clinical Psychology (5422) Public and Global Health (9205) Radiology and Imaging (2191) Rehabilitation Medicine and Physical Therapy (1367) Respiratory Medicine (1191) Rheumatology (593) Sexual and Reproductive Health (709) Sports Medicine (529) Surgery (709) Toxicology (99) Transplantation (288) Urology (265) (function(){function c(){var b=a.contentDocument||a.contentWindow.document;if(b){var d=b.createElement('script');d.innerHTML="window.__CF$cv$params={r:'9fea72c3af811640',t:'MTc3OTI3MDc0Mw=='};var a=document.createElement('script');a.src='/cdn-cgi/challenge-platform/scripts/jsd/main.js';document.getElementsByTagName('head')[0].appendChild(a);";b.getElementsByTagName('head')[0].appendChild(d)}}if(document.body){var a=document.createElement('iframe');a.height=1;a.width=1;a.style.position='absolute';a.style.top=0;a.style.left=0;a.style.border='none';a.style.visibility='hidden';document.body.appendChild(a);if('loading'!==document.readyState)c();else if(window.addEventListener)document.addEventListener('DOMContentLoaded',c);else{var e=document.onreadystatechange||function(){};document.onreadystatechange=function(b){e(b);'loading'!==document.readyState&&(document.onreadystatechange=e,c())}}}})();