Hepatitis C virus in Pakistan: A systematic review of prevalence, genotypes and risk factors

Immigration and viral hepatitis

WHO estimates reveal that the global prevalence of viral hepatitis may be as high as 500 million, with an annual mortality rate of up to 1.3 million individuals. The majority of this global burden of disease is borne by nations of the developing world with high rates of vertical and iatrogenic transmission of HBV and HCV, as well as poor access to healthcare. In 2013, 3.2% of the global population (231 million individuals) migrated into a new host nation. Migrants predominantly originate from the developing countries of the south, into the developed economies of North America and Western Europe. This mass migration of individuals from areas of high-prevalence of viral hepatitis poses a unique challenge to the healthcare systems of the host nations. Due to a lack of universal standards for screening, vaccination and treatment of viral hepatitis, the burden of chronic liver disease and hepatocellular carcinoma continues to increase among migrant populations globally. Efforts to increase case identification and treatment among migrants have largely been limited to small outreach programs in urban centers, such that the majority of migrants with viral hepatitis continue to remain unaware of their infection. This review summarizes the data on prevalence of viral hepatitis and burden of chronic liver disease among migrants, current standards for screening and treatment of immigrants and refugees, and efforts to improve the identification and treatment of viral hepatitis among migrants.

Evidence-based consensus on the diagnosis, prevention and management of hepatitis C virus disease

Hepatitis C virus (HCV) is a potent human pathogen and is one of the main causes of chronic hepatitis round the world. The present review describes the evidence-based consensus on the diagnosis, prevention and management of HCV disease. Various techniques, for the detection of anti-HCV immunoglobulin G immunoassays, detection of HCV RNA by identifying virus-specific molecules nucleic acid testings, recognition of core antigen for diagnosis of HCV, quantitative antigen assay, have been used to detect HCV RNA and core antigen. Advanced technologies such as nanoparticle-based diagnostic assays, loop-mediated isothermal amplification and aptamers and Ortho trak-C assay have also come to the front that provides best detection results with greater ease and specificity for detection of HCV. It is of immense importance to prevent this infection especially among the sexual partners, injecting drug users, mother-to-infant transmission of HCV, household contact, healthcare workers and people who get tattoos and piercing on their skin. Management of this infection is intended to eradicate it out of the body of patients. Management includes examining the treatment (efficacy and protection), assessment of hepatic condition before commencing therapy, controlling the parameters upon which dual and triple therapies work, monitoring the body after treatment and adjusting the co-factors. Examining the treatment in some special groups of people (HIV/HCV co-infected, hemodialysis patients, renal transplanted patients).

Effect of interferon plus ribavirin therapy on hepatitis C virus genotype 3 patients from Pakistan: Treatment response, side effects and future prospective

More than 10 million people are suffering from hepatitis C virus (HCV) in Pakistan. The available treatment option is a combination of interferon and ribavirin. Treatment response is linked with several factors and also induces a number of side effects. We searched in Pubmed, Pak Medi Net and Google Scholar for the articles presenting the effect of interferon plus ribavirin therapy on HCV patients from Pakistan, their side effects and future prospects. The major prevalent HCV genotype in Pakistan is 3. Conventional interferon alpha plus ribavirin showed sustained virological response of 54%-64% while pegylated interferon alpha plus ribavirin showed sustained virological response of 58%-75%. IL-28B CC genotype is linked with better sustained virological response. Studies on patients with HCV genotype 3 infections showed no correlation between treatment response and interferon sensitivity determining region mutations. Interferon therapy is linked with a number of side effects like thyroid dysfuncton, haematological disorders, weight loss, gastrointestinal tract side effects and neuropsychiatric side effects. Unusual side effects of clubbing of fingers and seizures were also observed in a couple of patients. Interferon alpha plus ribavirin therapy showed better response rate in HCV genotype 3 patients from Pakistan with number of side effects. A couple of interferon free therapies are light of hope for the patients living with HCV.

Epidemiology of Viral Hepatitis and Liver Diseases in Bangladesh

Bangladesh is a South Asian country with a homogeneous population. However, some difference has been demonstrated in the distribution of liver disease in different parts of the country. Hepatitis E remains the principal cause of acute hepatitis in Bangladesh, while chronic liver disease in Bangladesh, including hepatocelullar carcinoma, is predominantly due to hepatitis B virus. Hepatitis B has been extensively studied and characterized in Bangladesh, and some major clinical trials with HBV-related antigens have also been conducted.

Diagnostically untypable hepatitis C virus variants: it is time to resolve the problem

Pakistan is a low income country with more than 10 million hepatitis C virus (HCV) infections and the burden is on continuous raise. Accurate viral genotyping is very critical for proper treatment of the infected individuals as the sustained virological response of the standard antiviral interferon therapy is genotype dependent. We observed at our diagnostic center that 15.6% of HCV patient's samples were not genotype-able by using Ohno et al method. The genotyped samples showed that 3a (68.3%) is the major prevalent genotype in Pakistan followed by 2a (10.3%), 3b (2.6%), 1b (1.5%), 2b (1.2%) and 1a (0.5%). Presence of large number of untypable HCV variants in the current study highlights an important issue of health care setup in Pakistan. Untypable HCV cases create difficulties in treatment of these patients. The problem of routine diagnostics setup of Pakistan should be addressed on priority basis to facilitate the medical professionals in patient's treatment and to help in achieving the maximum sustained virological response.

The genetic diversity and evolutionary history of hepatitis C virus in Vietnam

Vietnam has a unique history in association with foreign countries, which may have resulted in multiple introductions of the alien HCV strains to mix with those indigenous ones. In this study, we characterized the HCV sequences in Core-E1 and NS5B regions from 236 Vietnamese individuals. We identified multiple HCV lineages; 6a, 6 e, 6h, 6k, 6l, 6 o, 6p, and two novel variants may represent the indigenous strains; 1a was probably introduced from the US; 1b and 2a possibly originated in East Asia; while 2i, 2j, and 2m were likely brought by French explorers. We inferred the evolutionary history for four major subtypes: 1a, 1b, 6a, and 6 e. The obtained Bayesian Skyline Plots (BSPs) consistently showed the rapid HCV population growth from 1955 to 1963 until 1984 or after, corresponding to the era of the Vietnam War. We also estimated HCV growth rates and reconstructed phylogeographic trees for comparing subtypes 1a, 1b, and HCV-2.

Distribution of Hepatitis C virus genotypes in city of Mashhad, North-east of Iran

PURPOSE

Six major hepatitis C virus genotypes have been characterised, which vary in their geographical distribution. The prevalence of hepatitis C virus (HCV) in an area is not constant, and depends on the changes in route of infection, which may change over time. In this study, the distribution of HCV genotypes in Mashhad, the capital of Razavi Khorasan province in north-east of Iran was investigated. Mashhad is a holy city of Shiate Moslems, which attracts more than 20 million tourists and pilgrims every year.

MATERIALS AND METHODS

Two hundred and seventy-eight HCV infected subjects (227 males and 51 females) were included in this study. HCV genotypes were analysed by type specific reverse transcriptase polymerase chain reaction (RT-PCR).

RESULTS

Genotype 3a was detected in 49.6%, 1a in 36.3%, 1b in 12.6% and 2a in 0.4%. Two HCV genotypes were detected in 1.1% cases; 1a +3a in 1%, 3a + 1b in 0.4%. Genotypes 2b and 3b were not detected in any samples.

CONCLUSION

We demonstrated that despite the previous reports on the frequency of HCV genotypes in Iran, 3a is the predominant genotype in Mashhad.

Risk factors for bloodborne viral hepatitis in healthcare workers of Pakistan: a population based case-control study

OBJECTIVES

A high prevalence of viral hepatitis B and C was found among healthcare workers during a province-wide screening in Sindh Province, Pakistan. A follow-up study was undertaken to identify risk factors for this high prevalence in healthcare workers.

DESIGN

Population based case-control design.

SETTING

Public sector healthcare facilities in a rural district of Pakistan.

PARTICIPANTS

Healthcare workers who were screened for hepatitis B surface antigen (HBsAg) and hepatitis C virus (HCV) antibodies. 178 healthcare workers employed at the public sector clinics and hospitals of the district were approached, of which 14 refused to participate. Cases had detectable serum antibodies against HCV and the presence of HBsAg. Healthcare workers non-reactive to HCV antibodies and with no HBsAg were controls. These were matched in a ratio of 1:1.

OUTCOME MEASURE

Detectable serum HBsAg and HCV antibody titer were taken as outcome. OR for various exposures was calculated; those with p<0.25 were entered in a multivariate logistic regression model to find out significant predictors.

RESULTS

Needle stick injury (OR=6; CI95 1.4 to 23), recapping the needle (OR=5.7; CI95 1.1 to 28), wound care at accident and emergency of a hospital (OR=5.5; CI95 1 to 28), female gender (OR=3.4; CI95 1 to 12) and more than 10 years of formal education (OR=0.25; CI95 0.07 to 0.8) were associated with hepatitis C. Hepatitis B was found to be associated with trying to bend or break a needle after use (OR=4.9; CI95 1 to 24).

CONCLUSIONS

Healthcare workers in Pakistan are at additional risk of exposure to bloodborne pathogens. Bi-dimensional risk factors present at individual and broader health systems levels are responsible. Occupational safety, health trainings and redesigning of the curriculum for allied health professionals are required.

Chemiluminescent microparticle immunoassay based detection and prevalence of HCV infection in district Peshawar Pakistan

Background

Due to the high rate of asymptomatic infections an advanced screening assay is of prompt importance to be used for the clinical diagnosis of HCV. Early detection of anti HCV is the first step in the management of chronic hepatitis and in the selection of patients needing treatments. In the current study we have first time used the advanced serological diagnostic technique i.e. Chemiluminescent Microparticle Immuno Assay (CMIA) for the detection of HCV infection in Peshawar Pakistan.

Methods

A total number of 982 samples were collected among the general public belongs to the different areas of district Peshawar. The samples were centrifuged at high speed to obtain a clear supernatant serum. All the samples were run on Architect system a fully automated immuno analyzer CMIA base technology.

Results

Out of 982 blood samples analyzed in this study, 160 (15.9%) were confirmed to be positive for active HCV infection. The overall prevalence was found to be 13.4%. Gender wise prevalence was recorded to be higher in male (19.1%) than female (12.7%). The age group 21-30 years was identified as the highest risk group among the studied population.

Conclusion

Among the tested samples, overall prevalence of active HCV infection was found to be 13.4% in the general population of Peshawar Pakistan. The young middle aged population of this region was at higher risk of HCV ailments compared to the other age groups.

Prevalence of hepatitis C virus genotypes in district bannu, khyber pakhtunkhwa, pakistan

Determination of an individual's hepatitis C virus (HCV) genotypes prior to antiviral therapy has become increasingly important for the clinical management and prognosis of HCV infection. Therefore, this study was conducted to investigate the prevalence of HCV genotypes in HCV infected patients of district Bannu in Khyber Pakhtunkhwa region of Pakistan. Serum samples of 117 seropositive patients were screened for HCV-RNA by using reverse transcriptase-nested polymerase chain reaction (RT-nested PCR) and then PCR positive samples were subjected to HCV genotyping. Out of 117 seropositive samples, 110 samples were found positive by PCR analysis. Genotype 3a was the most prevalent one detected in 38% of patients, followed by genotype 3b in 21% of patients, and then genotype 2a in 12% of patients. However 21% of HCV-PCR positive samples could not be genotyped by method used in this study. Genotype 3a was the most prevalent genotype in patients of all age groups and its prevalence was found high among patients with increasing age (>34 years). Moreover, genotypes 3a and 3b were found to be the most prevalent genotypes in patients with history of shaving by barbers, receiving multiple injections, and dental procedures. In conclusion there is need of further investigation of genotypes of HCV by using more sensitive assays and considering large sample size in district Bannu.

A model of bi-mode transmission dynamics of hepatitis C with optimal control

In this paper, we present a rigorous mathematical analysis of a deterministic model for the transmission dynamics of hepatitis C. The model is suitable for populations where two frequent modes of transmission of hepatitis C virus, namely unsafe blood transfusions and intravenous drug use, are dominant. The susceptible population is divided into two distinct compartments, the intravenous drug users and individuals undergoing unsafe blood transfusions. Individuals belonging to each compartment may develop acute and then possibly chronic infections. Chronically infected individuals may be quarantined. The analysis indicates that the eradication and persistence of the disease is completely determined by the magnitude of basic reproduction number R(c). It is shown that for the basic reproduction number R(c) < 1, the disease-free equilibrium is locally and globally asymptotically stable. For R(c) > 1, an endemic equilibrium exists and the disease is uniformly persistent. In addition, we present the uncertainty and sensitivity analyses to investigate the influence of different important model parameters on the disease prevalence. When the infected population persists, we have designed a time-dependent optimal quarantine strategy to minimize it. The Pontryagin's Maximum Principle is used to characterize the optimal control in terms of an optimality system which is solved numerically. Numerical results for the optimal control are compared against the constant controls and their efficiency is discussed.

Sequence comparison and phylogenetic analysis of hepatitis C virus genotype 3 polymerase

Hepatitis C virus (HCV) is a worldwide health problem with high morbidity and mortality. HCV polymerase is an attractive target for the development of antiviral strategies. The aim of the present study was to report the sequence variation in the HCV NS5B gene from genotype 3 patient samples. The gene was amplified, cloned and sequenced. A nucleotide and amino acid sequence comparison of conserved motifs of HCV NS5B from the current reported sequences and previously reported genotype 3 sequences was performed. The sequence comparison indicated that the motifs A, B, C and F and β loop sequences are conserved in the reported sequences, while sequence variation was observed in motifs D and E. Amino acids E18, Y191, C274, Y276 and H502, which are involved in the interaction between template and primer, are highly conserved in the reported sequences. R48, R158, D225, S367, R386 and R394 amino acids interact with initiating GTP, and are also highly conserved in the reported sequences. A phylogenetic tree revealed that the sequences are clustered with sequences from India. HCV polymerase lacks proofreading ability and has high error rates. The present study revealed that the residues that form the important motifs of HCV NS5B remain conserved. However, it was observed that numerous place changes in the nucleotide sequences did not affect the amino acid sequences of HCV NS5B. The conserved motifs are strong targets for the development of peptide vaccines against HCV.

Correlation of OAS1 gene polymorphism at exon 7 splice accepter site with interferon-based therapy of HCV infection in Pakistan

The most useful treatment for HCV infection worldwide is peg-interferon plus ribavirin, although the response varies from person to person. Hence, host genetics are significantly involved in the treatment response to HCV infection. The 2'-5' oligoadenylate synthetase (OAS) is one of the most important components of the immune system having significant antiviral functions. The aim of this study was to investigate the role of single nucleotide polymorphism (SNP) at the exon 7 splice acceptor site (SAS) of OAS1 to interferon-based therapy of HCV infection. OAS1 genotyping was performed in 140 HCV patients by restriction fragment length polymorphism polymerase chain reaction method (RFLP-PCR). These patients were enrolled for the study in 2010-2013. OAS1 SNP was also established in 120 healthy controls. Correlation of HCV genotypes, OAS1 SNP, and other factors with response to interferon therapy were statistically analyzed by SPSS 13 software. There were no significant differences in the distribution of OAS1 genotypes between healthy and patients subjects. The distribution of AG and AA genotypes of OAS1 genotypes between sustained virological responders (SVRs) and the non-responders (NRs) group were also comparable. However, Pearson chi square analysis indicated that the patients possessing a GG genotype of the OAS1 gene at exon 7 SAS demonstrated significantly positive association with treatment response to HCV infection (p=0.039). This study determined that SNP at exon 7 SAS of OAS1 was significantly associated with response to interferon-based therapy of HCV infection in our population.

Transfusion transmitted infections in thalassaemics: need for reappraisal of blood screening strategy in India

The aim of the study was to assess the blood safety in India through prevalence in thalassaemic population. Safety of the blood supply is a subject of great concern for all recipients. This review attempts to assess the relevance and format of tests for viruses in the context of transfusion transmitted infection (TTI) prevalence in India. Serological marker testing for human immunodeficiency virus-1/2 (HIV-1/2), hepatitis C virus (HCV) and hepatitis B virus (HBV) is mandatory in India. Numerous TTI incidents in the repeat recipients supported by results from nucleic acid technology (NAT) testing indicate the deficiencies in blood safety. The β-thalassaemic population (3-17%) in India has been used to reflect on blood safety. The prevalence of HIV-1/2, HCV and HBV in the Indian donor population, the limitations in accessing safe donors, quality of serological tests and the impact on repeat recipients is evaluated. The reports point to prevalence of ˜2% of viral diseases in the blood donor population, and the insufficiency of serology testing resulting in up to 45% TTIs in thalassaemics. The revelation by individual donation (ID) NAT testing, of 1 per 310 units being serology negative-NAT reactive is alarming. Extrapolating the serology negative NAT reactive yields, for an annual blood supply of 7.9 million units, 23,700 units or nearly 100,000 blood components are likely to be infectious. Though the cost for ID-NAT testing is considered unaffordable for a medium development country such as India, the enormity of TTIs will place an unmanageable cost burden on the society.

Acute hepatitis C: management in the rapidly evolving world of HCV

The acute phase of hepatitis C (HCV) infection is typically defined as the initial 6 months following exposure to the virus; however, in some individuals, the acute phase of the infection can last much longer (Orland et al. Hepatology 33:321-27, 2001). Although some patients have symptoms of acute hepatitis, most infected individuals are entirely asymptomatic. As a result, many patients are unaware of the infection until it progresses to chronic infection, and may not develop symptoms until decades later with the onset of decompensated cirrhosis or hepatocellular carcinoma (HCC). A substantial proportion (20-40%) of infected patients clear the virus during the acute phase. Interferon-based treatment is also much more likely to be successful in the acute phase of infection but is relatively poorly tolerated. Therefore, recognition of acute HCV infection is critical to prioritize those patients who do not spontaneously clear the infection for immediate therapy. However, the promise of highly effective well-tolerated all-oral therapies in development may alter the management approach. This review will focus on the epidemiology, natural history, diagnosis, and treatment of acute HCV infection.

Seroprevalence and risk factors for hepatitis C virus (HCV) infection in pregnant women attending public sector tertiary care hospital in Hyderabad Sindh

Background and Objectives: Pakistan is among the countries having high prevalence of HCV infection in the population but there is dearth of proper epidemiological data regarding acquisition of HCV infection in the pregnant population. Our objective was to determine the seroprevalence of HCV antibodies in healthy pregnant women and to assess the potential risk factors for HCV infection in HCV positive subjects and in the control group.

Methodology: This cross sectional and comparative study was conducted from 1^st January to 31^st December 2010 in the Department of Obstetrics/Gynaecology Unit–I, Liaquat University Hospital Hyderabad. Sera were collected from all admitted pregnant women and tested for HCV anti bodies using Elisa kits (Abbott, USA). Data were analyzed using SPSS version 16.0 statistical package.

Results: The seroprevalence of HCV among pregnant population was found to be 4.7%. HCV positive women were more likely to have a history of blood transfusion (OR 1.99, 95% CI 1.26- 3.12), History of therapeutic injection use (OR 2.46, 95% CI 1.43-4.26), history of surgery (OR 1.72, 95% CI 1.12-2.66) and history of sharing household products (OR 1.81, 95% CI 1.14-2.87).

Conclusion: HCV seropositive pregnant women were more likely to have a history of blood transfusion, therapeutic injection use, surgery and sharing household items.

Prevalence of active hepatitis C virus infections among general public of Lahore, Pakistan

Background

To find out the prevalence of active hepatitis C virus (HCV) infections among general public in Lahore city, since data concerning the prevalence of active HCV in this city is currently unavailable.

Methods

Blood samples were collected randomly from individuals visiting different clinical laboratories in Lahore. Serum was separated and processed by nested PCR qualitative assay for the detection of HCV RNA. The samples were categorized into different age groups on the basis of pre-test questionnaires in order to record the age-wise differences regarding the prevalence of active HCV. Data were analyzed statistically using Chi-Square test.

Results

Out of the 4246 blood samples analyzed in this study, 210 were confirmed to be positive for active HCV infection. Gender-wise active HCV prevalence revealed no significant difference [OR = 1.10 CI = (0.83-1.46), p > 0.05]. However, among the age groups the highest prevalence was observed in the age groups 20–29 (7.7%) and 30–39 years (6.4%) with odds of prevalence of 14.8% (OR = 2.48, CI = (1.40-4.38), p < 0.05) and 10.3% (OR = 2.03, CI = (1.10-3.71), respectively. In age groups above 40 years (40–49, 50–59 and >59 years), a decrease in levels of active HCV prevalence was observed.

Conclusions

Among tested samples, 4.9% of the subjects were confirmed to harbour active HCV infections and the “middle aged” population in Lahore was found to be at a higher risk of the HCV ailments compared to both their younger and older peers.

Over-expression and characterization of NS3 and NS5A of Hepatitis C virus genotype 3a

Background

Hepatitis C virus (HCV) is a common and leading cause for liver cirrhosis and hepatocellular carcinoma. Current therapies to treat HCV infection are shown to be partially effective and poorly tolerated. Therefore, ample efforts are underway to rationally design therapies targeting the HCV non-structural proteins. Most of the work carried out in this direction has been focusing mainly on HCV genotype 1. Two direct-acting antiviral agents (DAAs) Telaprevir and Boceprevir are being used against genotype 1a infection in combination therapy with interferon and ribavirin. Unfortunately these DAAs are not effective against genotype 3a. Considering the wide spread infection by HCV genotype 3a in developing countries especially South Asia, we have focused on the recombinant production of antiviral drug targets NS3 and NS5A from HCV genotype 3a. These protein targets are to be used for screening of inhibitors.

Results

High-level expression of NS3 and NS5A was achieved at 25°C, using ~1 and 0.5 mM Isopropyl β-D-1-thiogalactopyranoside (IPTG), respectively. Yields of the purified NS3 and NS5A were 4 and 1 mg per liter culture volume, respectively. Although similar amounts of purified NS3 were obtained at 25 and 14°C, specificity constant (K_cat/K_m) was somewhat higher at expression temperature of 25°C. Circular dichroism (CD) and Fourier-transform infrared (FT-IR) spectroscopy revealed that both NS3 and NS5A contain a mixture of alpha-helix and beta-sheet secondary structures. For NS3 protein, percentages of secondary structures were similar to the values predicted from homology modeling.

Conclusions

NS3 and NS5A were over-expressed and using Nickel-affinity method both proteins were purified to ~ 95% purity. Yield of the purified NS3 obtained is four fold higher than previous reports. CD spectroscopy revealed that difference in activity of NS3 expressed at various temperatures is not related to changes in global structural features of the protein. Moreover, CD and FT-IR analysis showed that NS3 and NS5A contain both alpha-helical and beta-sheet structures and for NS5A, the proportion is almost equal. The production of NS3 and NS5A in milligram quantities will allow their characterization by biophysical and biochemical means that will help in designing new strategies to fight against HCV infection.

Epidemiology and natural history of HCV infection

Worldwide, an estimated 130-170 million people have HCV infection. HCV prevalence is highest in Egypt at >10% of the general population and China has the most people with HCV (29.8 million). Differences in past HCV incidence and current HCV prevalence, together with the generally protracted nature of HCV disease progression, has led to considerable diversity in the burden of advanced liver disease in different countries. Countries with a high incidence of HCV or peak incidence in the recent past will have further escalations in HCV-related cirrhosis and hepatocellular carcinoma (HCC) over the next two decades. Acute HCV infection is difficult to detect because of the generally asymptomatic nature of the disease and the marginalization of at-risk populations. Around 25% of patients with acute HCV infection undergo spontaneous clearance, with increased rates among those with favourable IL28B genotypes, acute symptoms and in women. The remaining 75% of patients progress to chronic HCV infection and are subsequently at risk of progression to hepatic fibrosis, cirrhosis and HCC. Chronic hepatitis C generally progresses slowly in the initial two decades, but can be accelerated during this time as a result of advancing age and co-factors such as heavy alcohol intake and HIV co-infection.

Knowledge and attitude of medical science students toward hepatitis B and C infections

The present survey aimed to determine the knowledge level and attitude of medical students in Guilan University toward Hepatitis B and C viruses' infections. In a cross-sectional survey, the knowledge and attitude of 424 medical science undergraduate students of nursing, midwifery, operating room technician, laboratory, anesthesiology and radiology in Guilan University of Medical Sciences toward Hepatitis B virus (HBV) and Hepatitis C virus (HCV) infections were investigated using a standardized questionnaire. The mean (SD) knowledge level of the medical students toward HBV and HCV were 17 ± 5 from 28 and 10.58 ± 6.7 from 29 questions respectively. Females, nursing students, forth year students, those who worked in hospital and those who had needle stick injuries (NSI) history showed significantly higher knowledge scores toward HBV (P< 0.05). Married students, anesthesiology students, those who were in their fourth year of study, and those who worked in hospital had significantly higher mean knowledge scores toward HCV (P< 0.05). Also students' attitude toward HBV and HCV was positively correlated with their mean knowledge level (r=0.14, p=0.004), (r=0.18, p=0.0001). Education on the nature, symptoms, transmission, prevention and treatment of HBV and HCV infections may increase the willingness of health care workers to care for infected persons.

RNA dependent RNA polymerase of HCV: a potential target for the development of antiviral drugs

Hepatitis C virus (HCV) is a major cause of hepatocellular carcinoma, cirrhosis and end stage liver disease. More than 200million people are living with HCV worldwide with high morbidity and mortality. There is no vaccine available for this virus; the approved treatment option for the majority of HCV genotypes is the combination of pegylated (Peg) interferon and ribavirin. The therapy has a different response rate on different HCV genotypes and has a number of side effects. Recently, as well as Peg interferon and ribavirin, two protease inhibitors have been introduced to treat patients with HCV genotype 1 infection. The protease inhibitors have rapid onset of resistance and are not approved for use for infections with other HCV genotypes. The HCV NS5B gene encodes RNA dependent RNA polymerase (RdRp), which is the key player in viral replication and is a promising target for the development of antiviral drugs. HCV NS5B has been studied in various biochemical assays, cell based assays and animal model systems. So far, a number of nucleoside and non-nucleoside inhibitors have been screened for effects on viral replication. This review presents a deep insight into the structure and function of HCV polymerase and the effect of various nucleoside and non-nucleoside inhibitors on viral replication.

Persisting role of healthcare settings in hepatitis C transmission in Pakistan: cause for concern

Transmission of hepatitis C (HCV) in Pakistan is a continuing public health problem; 15 years ago it was linked to the practice of reusing therapeutic instruments in healthcare settings. We sought to examine current risk factors for HCV transmission in a hospital population in Karachi, Pakistan. We enrolled 300 laboratory-confirmed HCV-positive participants and 300 laboratory-confirmed HCV-negative participants from clinics at Indus Hospital. Independent and significant risk factors for both men and women were: receiving ⩾12 injections in the past year, blood transfusions, having had dental work performed, and delivery in hospital or transfusion for women. Interestingly, being of Mohajir origin or born in Sindh province were protective. Encouragingly, a strong protective effect was observed for those that reported bringing their own needle for injections (59%). The widespread reuse of therapeutic needles in healthcare settings in Karachi remains a major driver of the HCV epidemic.

Development of Global Consensus Sequence and Analysis of Highly Conserved Domains of the HCV NS5B Prote in

BACKGROUND

Hepatitis C virus (HCV) is a plus stranded RNA virus which encodes 10 different genes. The HCV NS5B gene encodes a polymerase, which is responsible for the replication of the virus and is a potential target for the development of antiviral agents. HCV has a high mutation rate and is classified into six major genotypes.

OBJECTIVES

The aim of this study was to draw a representing consensus sequence of each HCV genotype, align all six consensus sequences to draw a global consensus sequence and also study the highly conserved residues.

MATERIALS AND METHODS

236 HCV NS5B sequences, belonging to all six genotypes, reported from all over the world were aligned then a representing phylogenetic tree wasdrawn.

RESULTS

The active site residues D220, D225, D318 and D319, which bind the divalent cations, are highly conserved among all the HCV genotypes. The other catalytic pocket residues, R158, S367, R386, and T390 and R394, which interact with the triphosphate of NTPs, are also highly conserved while T390 is mutated to valine in the genotype 5. The motif B residues G283, T286, T287 and N291, which take part in sugar selection by RdRp, are also highly conserved except for T286 which is mutated to proline in the genotypes 3 and 6. The residues E18, Y191, C274, Y276 and H502, which take part in primer/template interaction, are also high conserved except for H502 which is mutated to serine in genotype 2. High variation in all the six consensus sequences was observed in a 12 amino acid beta hairpin loop, which interacts with the double stranded RNA. Nine different peptides from the highly conserved regions of HCV NS5B protein were drawn which can be used as a peptide vaccine. The HCV NS5B phylogenetic tree shows the clusters of different genotypes and their evolutionary association.

CONCLUSIONS

In spite of a high mutation rate in HCV, the residues which are present in the catalytic pocket, sugar selection and template/primer interaction are highly conserved. These are target sites for the development of antiviral agents or peptide vaccines. The phylogenetic analysis suggests that different HCV genotypes have been evolved from the genotype 1a.

Study of the effect of antiviral therapy on homocysteinemia in hepatitis C virus- infected patients

BACKGROUND

Hepatitis C virus (HCV) infection is one of the leading causes of chronic liver disease (CLD). About 80% of those exposed to the virus develop a chronic infection. Hyperhomocysteinemia, which is an independent risk factor for atherosclerotic vascular disease and thromboembolism, may develop in HCV-infected patients although altered alanine amino transferase (ALT) enzyme levels are generally associated with damage to liver cells. The gold standard therapy for chronic hepatitis C patients is pegylated interferon combined with an anti-viral drug (ribavirin). The current study aimed to investigate the effect of antiviral therapy on plasma homocysteine (Hcy) levels in HCV patients in addition to other parameters.

METHODS

532 HCV-infected patients and 70 healthy controls were recruited for the study. All patients were subjected to laboratory investigations including HCV-RNA levels, complete blood cell counts, serum levels of homocysteine, ALT, alkaline phosphatase (ALP), lipid profile and liver ultrasonographic examination. The outcome of treatment with pegylated interferon α plus ribavirin treatment and sustained virologic response (SVR) was determined 6-9 months post-therapy.

RESULTS

Hyperhomocysteinemia was found in 91.35% of HCV-infected patients. The difference in plasma Hcy concentrations reached statistical significance between the patient and control groups. ALT, cholesterol and triglycerides (TGs) levels were found higher than normal in the patients group. After receiving a combined therapy for 24 weeks, 43.66% patients showed an SVR (responders); 30.98% patients were non-responders while 25.35% patients initially responded to therapy but again retrieved positive status of HCV infection six months post-therapy (relapse-cirrhotic patients). The mean levels of plasma Hcy, ALT and ALP were significantly reduced in responders within 10 weeks of therapy when compared with non-responders and relapse-cirrhotic patients.

CONCLUSION

Elevated homocysteine levels in serum due to HCV infection can be reduced to normal range with the standard interferon α plus ribavirin treatment. This study highlights the significance of the measurement of serum homocysteine levels in the diagnosis and monitoring of HCV infection treatment in addition to other laboratory parameters.

Prevalence of hepatitis B and C infections and HCV genotypes among haemophilia patients in ahvaz, southwest iran

BACKGROUND

Transfusion-transmitted hepatitis is the most important cause of transmitted infections by the parenteral route in patients with haemophilia.

OBJECTIVES

This study was performed to determine the prevalence of HBV, HCV, and different genotypes of HCV among haemophilia patients in Ahvaz city, southwest Iran.

PATIENTS AND METHODS

A cross-sectional study was conducted on 87 haemophilia patients referred to the Hemoglobinopathy and Thalassemia research centre during February 2008 to March 2009. Patients, sera were tested for HBsAg and anti-HCV using ELISA and confirmed by PCR (HBV) and RT-PCR (HCV). HCV genotypes were determined with HCV genotype specific primers using HCV genotyping kit.

RESULTS

The overall prevalence rate of HBsAg and anti-HCV were 1.1% (95% CI: 0-3.39) and 54% (95% CI: 43.5-64.4), respectively. Forty two of the anti-HCV patients (89.3%) were also HCV RNA positive. The prevalence of anti-HCV seropositivity was significantly higher (P = 0.0008) among patients who had started to receive transfusions before implementation of blood donor screening. Moreover, the number of transfusion were significantly associated with anti-HCV and HCV RNA positivity (P = 0.0041 and P = 0.023, respectively). The predominant HCV genotype among haemophilia patients in our region was 1a (26/42, 61.9%), although genotypes 1b and 3a were found in 26.1% (11/42) and 11.9% (5/42) of the patients, respectively.

CONCLUSIONS

It appears stringent donor selection procedures reduced HCV infection in multi-transfused patients, but it is still serious risk for these subjects.

Molecular study of HCV detection, genotypes and their routes of transmission in North West Frontier Province, Pakistan

OBJECTIVE

To determine hepatitis C virus (HCV) genotypes and explore the associated risk factors in chronic HCV patients.

METHODS

A total of 116 patients with chronic hepatitis C were subjected to polymerase chain reaction (PCR) based detection out of which 112 chronic HCV patients [53 male (47.32%), 59 female (52.68%); mean age (43.76±16.40) years; mean BMI (23.8±3.9) kg] were enrolled in this study. The frequency of 6 HCV genotypes and associated risk factors were evaluated from five districts of North West Frontier Province (NWFP).

RESULTS

Genotype 3 was the most prevalent in 73 samples (65.17%) followed by genotype 1 in 24 (21.42%) and genotype 2 in 13 (11.60%) samples. Genotype 3 had significantly high prevalence (P=0.000 2). The results showed that 48 (42.85%) samples were infected with HCV 3a; 25 (22.32%) with 3b; 14 (12.50%) with 1a; 10 (8.92%) with 1b; 11 (9.82%) with 2a; 2 (1.78%) with 2b; and 2 were untypable. The distribution of HCV genotypes in Mardan, Charsadda, Peshawar, Sawabi and Nowshehra districts was different. Use of unsterile equipment for medication, barbers and previous history of hospitalization were the main risk factors for HCV transmission.

CONCLUSIONS

Genotype 3a and 3b, 1a, 1b and 2a are the common genotypes in NWFP. Genotype 4, 5, and 6 can not be found in a single sample. The level of awareness about various modes of transmission of HCV among the population is found to be very low.

Interaction of Hepatitis C virus proteins with pattern recognition receptors

Hepatitis C virus (HCV) is an important human pathogen that causes acute and chronic hepatitis, cirrhosis and hepatocellular carcinoma worldwide. This positive stranded RNA virus is extremely efficient in establishing persistent infection by escaping immune detection or hindering the host immune responses. Recent studies have discovered two important signaling pathways that activate the host innate immunity against viral infection. One of these pathways utilizes members of Toll-like receptor (TLR) family and the other uses the RNA helicase retinoic acid inducible gene I (RIG-I) as the receptors for intracellular viral double stranded RNA (dsRNA), and activation of transcription factors. In this review article, we summarize the interaction of HCV proteins with various host receptors/sensors through one of these two pathways or both, and how they exploit these interactions to escape from host defense mechanisms. For this purpose, we searched data from Pubmed and Google Scholar. We found that three HCV proteins; Core (C), non structural 3/4 A (NS3/4A) and non structural 5A (NS5A) have direct interactions with these two pathways. Core protein only in the monomeric form stimulates TLR2 pathway assisting the virus to evade from the innate immune system. NS3/4A disrupts TLR3 and RIG-1 signaling pathways by cleaving Toll/IL-1 receptor domain-containing adapter inducing IFN-beta (TRIF) and Cardif, the two important adapter proteins of these signaling cascades respectively, thus halting the defense against HCV. NS5A downmodulates the expressions of NKG2D on natural killer cells (NK cells) via TLR4 pathway and impairs the functional ability of these cells. TLRs and RIG-1 pathways have a central role in innate immunity and despite their opposing natures to HCV proteins, when exploited together, HCV as an ever developing virus against host immunity is able to accumulate these mechanisms for near unbeatable survival.

Hepatitis C viral heterogeneity based on core gene and an attempt to design small interfering RNA against strains resistant to interferon in rawalpindi, pakistan

BACKGROUND

Global prevalence of Hepatitis C Virus (HCV) infection corresponds to about 130 million HCV positive patients worldwide. The only drug that effectively reduces viral load is interferon-α (IFN-α) and currently combination of IFN and ribavirin is the choice for treatment.

OBJECTIVES

The present study is aimed to resolve the genotypes based on core gene that might affect the response to interferon therapy. Furthermore an attempt was made to propose a powerful therapeutic approach by designing the siRNA from sequences of the same patients who remain resistant to IFN in this study.

PATIENTS AND METHODS

To achieve the objectives, a sequence analysis was performed in five HCV ELISA positive subjects who have completed IFN treatment. Neighbor Joining (NJ) method was used to study the evolutionary relationship. Atomic models were predicted using online software PROCHECK and i- TASSER.

RESULTS

Two new genotypes were reported for the first time namely 4a from suburban region of Rawalpindi and 6e from all over the Pakistan. According to Ramachandran plot, satisfactory atomic model was considered useful for further studies, i.e. to calculate HCV genotypes conservation at structural level, to find out critical binding sites for drug designing, or to silence those binding sites by using appropriate siRNA. Single siRNA can be used to inhibit HCV RNA synthesis against genotype 3 and 4, as the predicted siRNA were originated from the same domain in studied HCV core region in both genotypes.

CONCLUSIONS

We can conclude that any change or mutation in core region might be the cause of HCV strains to resist against IFN therapy. Therefore, further understanding of the complex mechanism involved in disrupting viral response to therapy would facilitate the development of more effective therapeutic regimens. Additionally, a single designed siRNA can be used as an alternative for current therapy against more than one resistant HCV genotypes.

Knowledge levels and attitudes of health care professionals toward patients with hepatitis C infection

AIM

To study knowledge levels and attitudes of health care providers toward patients with hepatitis C virus infection in Guilan, a northern province of Iran.

METHODS

This cross-sectional study was performed on 239 health care professionals from the Razi Hospital, including doctors, nurses, and operating room technicians. The questionnaires consisted of questions on demographic characteristics, knowledge levels, and attitudes toward hepatitis C patients. The questionnaire was tested in a pilot study and validated by Cronbach's alpha coefficient. Data were analyzed using SPSS16 software.

RESULTS

The mean ± SD knowledge score was 17.43 ± 2.65 (from a total of 22). 51.9% of the participants achieved scores higher than the mean. There was a significant relationship between knowledge score and age (P = 0.001), gender (P = 0.0001), occupational history (P = 0.0001), and educational history (P = 0.027). There was also a significant relationship between attitude level and age (P = 0.002), gender (P = 0.0001), occupational history (P = 0.0001), and educational history (P = 0.035). Physicians were significantly more knowledgeable and showed more positive attitudes. There was a positive correlation between knowledge and attitude scores (P = 0.02).

CONCLUSION

Discriminatory attitudes are common among health care providers toward hepatitis C patients. It is therefore necessary to improve their knowledge level and attitude toward this disease.

Disposal of syringes, needles, and lancets used by diabetic patients in Pakistan

OBJECTIVE

To assess the use, handling and disposal of insulin injection equipment by diabetic patients in Pakistan.

METHODS

We conducted a cross-sectional study at diabetic clinics in five tertiary centers in Pakistan. All diabetic patients (type 1/type 2) who were on insulin for more than 1 month, were included. An Urdu (local language)-translated questionnaire was used to collect information on insulin administration equipment, the site and frequency of needle use, insulin syringe/pen/lancet disposal, sharing of needles and knowledge about diseases that are spread by sharing contaminated needles.

RESULTS

Of 375 patients, 58% were female. The mean (SD) duration of diabetes was 12.3 (7.3) years, and the duration of insulin use was 4.4 (4.3) years. The majority of the patients used syringes (88.3%) for insulin administration. Additionally, the majority of the patients disposed of used devices (syringes, 92%; pens, 75%; and lancets, 91%) in the household garbage collection bin. About half of the patients (n=185) reported being educated by their physicians about the disposal of sharps. Those who were educated by a physician (adjusted odds ratio (adjOR): 0.36; 95%CI: 0.16-0.81) or could read/write English (adjOR: 0.32; 95%CI: 0.11-0.92) were less likely to dispose of syringes and needles in the household garbage.

CONCLUSION

The common disposal of sharps in the household garbage has implications for disease transmission. Education on the safe disposal of sharps may improve the disposal practices.

Risk factors for hepatitis C virus acquisition and predictors of persistence among Egyptian children

BACKGROUND

Hepatitis C virus (HCV) has a lower prevalence in children and knowledge is limited regarding the natural outcome of HCV infection in children.

AIM

To study the risk factors of HCV acquisition and predictors of persistence in Egyptian children.

METHODS

Children, 1-9 years of age, were evaluated for acquisition of HCV (anti-HCV positive regardless of viraemia) and persistence of HCV (anti-HCV and HCV-RNA positive) at two paediatric hepatology clinics in Cairo at enrollment and at 3 monthly intervals. Spontaneous clearance of HCV was defined as ≥ two positive anti-HCV antibody tests with negative HCV-RNA at least 6 months apart.

RESULTS

Over a 33-month-period a total of 226 children <9 years of age were screened for HCV antibodies. Of those, 146 (65%) were anti-HCV positive of which 87 (60%) were HCV-RNA positive. The HCV acquisition was more likely to occur in older children (P = 0.003) with comorbid conditions (P < 0.01) compared to anti-HCV negative children. In a multivariate logistic regression analysis, the highest risk factors for HCV acquisition were surgical interventions [odds ratio (OR): 4.7] and blood transfusions (OR: 2.3). The highest risk factor for HCV persistence was dental treatment (OR: 16.9) and male gender (OR: 7.5). HCV persistence was also strongly associated with elevated baseline alanine aminotransaminase (ALT) levels (OR: 4.9) and fluctuating aspartate aminotransferase (AST) levels (OR: 8.1).

CONCLUSION

Although surgical interventions and blood transfusion are significant risk factors for HCV acquisition in Egyptian children, dental treatment remains the highest risk factor for HCV chronic persistence in children.

Trend of transfusion transmitted infections frequency in blood donors: provide a road map for its prevention and control

Background

Transfusion transmitted infections create significant burden on health care system. Donor selection is of paramount importance because infected individuals serve as an asymptomatic reservoir and a potential source of transmission.

Methods

A retrospective study was carried out in healthy blood donors in the Lady Reading Hospital Peshawar, Pakistan over a period of three and a half years i.e., from January 2008 to June 2011, to determine the prevalence of HBV, HCV, HIV and syphilis in order to provide information for relevant polices.

Results

Out of 1,27,828 sample of blood donors, recorded mean prevalence for HBs Ag, anti-HCV, anti-HIV and syphilis was 2.68%, 2.46%, 0.06% and 0.43%, respectively, with an increasing trend in frequencies of transfusion transmitted infections (TTIs).

Conclusions

This study reflects that blood transfusion is one of the leading risk factor of spread of the TTIs, which showed the need and importance of the mandatory screening of these infectious markers in blood donations.

Rising burden of Hepatitis C Virus in hemodialysis patients

Aim

High prevalence of Hepatitis C virus (HCV) has been reported among the dialysis patients throughout the world. No serious efforts were taken to investigate HCV in patients undergoing hemodialysis (HD) treatment who are at great increased risk to HCV. HCV genotypes are important in the study of epidemiology, pathogenesis and reaction to antiviral therapy. This study was performed to investigate the prevalence of active HCV infection, HCV genotypes and to assess risk factors associated with HCV genotype infection in HD patients of Khyber Pakhtunkhwa as well as comparing this prevalence data with past studies in Pakistan.

Methods

Polymerase chain reaction was performed for HCV RNA detection and genotyping in 384 HD patients. The data obtained was compared with available past studies from Pakistan.

Results

Anti HCV antibodies were observed in 112 (29.2%), of whom 90 (80.4%) were HCV RNA positive. In rest of the anti HCV negative patients, HCV RNA was detected in 16 (5.9%) patients. The dominant HCV genotypes in HCV infected HD patients were found to be 3a (n = 36), 3b (n = 20), 1a (n = 16), 2a (n = 10), 2b (n = 2), 1b (n = 4), 4a (n = 2), untypeable (n = 10) and mixed (n = 12) genotype.

Conclusion

This study suggesting that i) the prevalence of HCV does not differentiate between past and present infection and continued to be elevated ii) HD patients may be a risk for HCV due to the involvement of multiple routes of infections especially poor blood screening of transfused blood and low standard of dialysis procedures in Pakistan and iii) need to apply infection control practice.

Occult HCV or delayed viral clearance from lymphocytes of Chronic HCV genotype 3 patients after interferon therapy

Background

A recently discovered occult HCV entity reported by various investigators seems to be highly controversial. Especially, the clinical significance of these findings remains uncertain. For optimal outcome of antiviral therapy, investigation of occult HCV needs a broad-based probe in order to investigate the results of viral therapy and its host/viral interaction. The current study was aimed at determining the prevalence of occult HCV in peripheral blood lymphocytes of predominantly genotype 3 HCV-infected patients after completion of antiviral therapy and to investigate long term outcomes in the presence or absence of PBMC positivity.

Method

A total of 151 chronic, antiHCV and serum RNA-positive patients were enrolled in the study. Patients with a complete virological response at the end of treatment were screened for the presence of viral RNA in their PBMCs and were followed for up to one year for the presence of serum and PBMC viral genomic RNA.

Results

Out of 151 patients, 104 (70%) responded to the prescribed interferon treatment and showed viral-clearance from serum. These were screened for the presence of genomic RNA in their PBMCs. Sixteen samples were PBMC-positive for viral RNA at the end of treatment (EOT). All these patients had also cleared the virus from peripheral blood cells after the 6-12 month follow-up study.

Conclusion

True occult hepatitis C virus does not exist in our cohort. Residual viremia at the EOT stage merely reflects a difference in viral kinetics in various compartments that remains a target of immune response even after the end of antiviral therapy and is eventually cleared out at the sustained viral response (SVR).

Prevalence and risk factors of asymptomatic hepatitis C virus infection in bangladesh

OBJECTIVES

There are paucity of information about prevalence and risk factor of hepatitis C virus (HCV) in Bangladesh.

METHODS

Blood was collected from 1018 randomly selected subjects from a semi-urban area of Bangladesh. Anti-HCVs were checked in the blood twice using a third-generation commercial kit. The data of the questionnaires were analyzed to find possible risk factors.

RESULTS

Nine of the 1018 subjects (88%) were tested positive for anti-HCV. The HCV-positive subjects were >28 years old. Major risk factors for HCV infection were treatment by unqualified and traditional practitioners, history of mass-vaccination against smallpox, hair cutting and shaving by barbers, and body piercing. However, known risk factors such as blood transfusion, surgery, invasive therapy, and intravenous drug use were not detected in any HCV-infected subjects.

CONCLUSION

Control of HCV infection in Bangladesh may be difficult because the risk factors are related to normal tradition and culture of Bangladeshi people.

Characterization of hepatitis C Virus genotype 3a hypervariable region 1 in patients achieved rapid virological response to alpha interferon and ribavirin combination therapy

BACKGROUND

Hepatitis C virus roots a chronic liver disease. Currently approved treatment strategy includes administration of alpha interferon and ribavirin combined therapy for 24-48 weeks. One of the predictor of sustained virological response is an early virological response to treatment characterized as rapid response. Hyper variable region 1 (HVR1) of E2 protein is responsible for viral entry and acts as a target for neutralizing antibodies. Any mutation in this region would effect virus interaction with target cell and viral persistence.

METHODS

Thirty one clones of six pre-treatment samples subjected to combination therapy were investigated. Three of the patients were rapid responders (R1, R2 and R3) and two were breakthrough responders (BT1 and BT2). Envelope 2 gene was amplified, cloned and sequenced. Amino acid substitution, frequency, composition and antigenic properties of HVR 1 of E2 protein were studied.

RESULTS

In both rapid responders (R.R) (14 amino acid sites) and breakthrough responders (BT.R) (13 amino acid sites) half of the amino acid sites were either conserved or resistant to any physiochemical change due to amino acid substitution. It also indicated that average composition of hydrophilic and basic amino acids were comparatively lower in rapid responders than other samples affecting probable interaction of virus with target cells. A central non antigenic region was constant among the breakthrough responders but differed in length significantly among rapid responders reflecting the adaptive nature of HVR1 to the immune response.

CONCLUSIONS

We observed that although HVR1is quite variable region in HCV 3a patients responding differently to treatment it still maintains its physiochemical properties for its proper functioning and viability.

Age-specific frequency of screen-detected hepatitis C virus seropositivity in men from the Punjab province of Pakistan

Pakistan is a South Asian country with a high population seroprevalence of anti-hepatitis C virus (anti-HCV) antibody. In administrative districts of its most populous province, Punjab, the frequency of seropositivity for HCV in different age groups of adult men, the usual bread winners for their families, is not known. This study describes the frequency and age-distribution of seropositivity for anti-HCV antibodies in 58,680 clinically healthy, adult men, from nine districts of the Punjab province in Pakistan, undergoing pre-employment health screening. Laboratory records belonging to these men, screened by enzyme-linked immunosorbent assay 3 for antiHCV antibodies in serum, were analysed and frequencies were calculated. A total of 4034 (6.9%) were seropositive for HCV. The highest frequency of HCV seropositivity was noted in men from Multan (9.6%), followed by Lahore (9.4%) district. The lowest (5.0%) was noted among men residing in Bahawalpur district. There was a progressive increase in seroprevalence with increasing age in men from all districts. Further research needs to be initiated to describe differential HCV risk factor distribution in various districts and sustainability of relatively low seroprevalence noted in younger men.

Role of Potash Alum in hepatitis C virus transmission at barber's shop

Hepatitis C virus (HCV) is the main cause of severe liver disease, including hepatocellular carcinoma, cirrhosis and end stage liver disease. In Pakistan most of HCV positive patients have history of facial/armpit shaving from barbers. 79% of barbers are rubbing Potash Alum stone on facial shaving cuts. Dark blood spots are analyzed on Potash Alum stones being used at different barber shops. The aim of the study was to check the viability of hepatitis C virus on potash alum stone being used at barber shops. Blood samples from HCV positive patients were taken and treated with 0.1, 0.2, 0.3, 0.4 and 0.5 molar concentrations of Potash Alum for different periods of time. Blood was centrifuged to isolate the serum; HCV RNA was extracted from serum and subjected to first strand synthesis and PCR. PCR fragments were confirmed by sequencing. PCR amplification was observed in all the samples, treated with different concentrations of Potash Alum, indicated that the virus remains alive on Potash Alum stone for a long period of time. Potash Alum being used by barbers on facial shaving cuts has definite role in HCV transmission in Pakistani population. Therefore use of Potash Alum stone should be banned on facial shaving cuts at barber shops.

Evolving epidemiology of hepatitis C virus

More than 20 years after the discovery of the hepatitis C virus (HCV), it is now well established that HCV is of global importance affecting all countries, leading to a major global health problem that requires widespread active interventions for its prevention and control. Chronic hepatitis C was linked to the development of cirrhosis and hepatocellular carcinoma in many areas of the world. Current epidemiological assessments have identified complex patterns with highly variable local prevalence rates between countries and within countries. HCV infection patterns have not significantly changed in most parts of the world since 1997, when first analyzed, partly due to the lack of new and more accurate data. The assessment of the national HCV prevalence and transmission modes should be completed to enable national authorities to prioritize preventive measures and to make the most appropriate use of available resources. The 'patchy' epidemiological situation in some areas will continue to complicate the task of the establishment of global, regional and national base line data. The present assessment finds a global prevalence of 2.35%, affecting 160 million chronically infected individuals. There is an urgent need for more accurate Information on the costs and burden of HCV to society. Twenty-one year after the discovery of HCV, the assessment is far from being complete and little progress has been made in the past 10 years in many countries. In some countries significant increases have been reported and this may also apply to countries were insufficient data exist. A safe and efficient vaccine against HCV is urgently needed.

Evaluation of prognostic factors for Peg Interferon alfa-2b plus ribavirin treatment on HCV infected patients in Pakistan

The effective standard therapeutic regimen for patients with chronic hepatitis C is pegylated interferon plus ribavirin. The efficacy of treatment in chronic hepatitis C is defined as absence of detectable virus at six months after treatment. Analysis of patient dependent and virus related factors that enable us to predict the response to antiviral treatment is very important. We prospectively studied 403 patients who received PEG-IFN alpha-2b 1.5 μg/kg/body weight plus ribavirin. Treatment was administrated for 24 weeks and 48 weeks for hepatitis C virus (HCV) genotypes 3 and 1, respectively. Out of 403 treated patients, 301 patients (74.7%) showed a sustained virologic response (SVR). Seven variables (age, sex, ethnic group, pretreatment viral load, HCV genotyping and pretreatment ALT) were chosen as possible predictors of SVR and were analysed by means of univariable and multivariable logistic regression analysis. Five variables were statistically significant (p<0.005) on univariable analysis: age, ethnic group, pretreatment viral load, response rate at week 4, and HCV genotype. In multivariable analysis independent factors associated with SVR were low pretreatment viral load (1.97; 95%CI, 1.06-3.66; p=0.03) and attainment of rapid virological response (RVR) (7.19; 95%CI, 4.15-12.45; p<0.001). Our findings support the association between viral load and SVR to PEG-IFN-alpha-2b plus ribavirin therapy. No achievement of RVR is an unfavorable marker for SVR. These findings suggest that all patients considered for treatment should have quantification of serum HCV RNA levels. The result can be used to counsel patients on the likelihood of achieving SVR and may influence the patient's decision on treatment. Future studies should confirm and explore this observation in other ethnic groups and in relation to HCV genotypes 1 and 3.

Molecular epidemiology of hcv among health care workers of khyber pakhtunkhwa

Background

Studies of the molecular epidemiology and risk factors for hepatitis C virus (HCV) in health care workers (HCWs) of Peshawar, Khyber Pakhtunkhwa region are scarce. Lack of awareness about the transmission of HCV and regular blood screening is contributing a great deal towards the spread of hepatitis C. This study is an attempt to investigate the prevalence of HCV and its possible association with both occupational and non-occupational risk factors among the HCWs of Peshawar.

Results

Blood samples of 824 HCWs, aged between 20-59 years were analysed for anti-HCV antibodies, HCV RNA and HCV genotypes by Immunochromatographic tests and PCR. All relevant information was obtained from the HCWs with the help of a questionnaire. The study revealed that 4.13% of the HCWs were positive for HCV antibodies, while HCV RNA was detected in 2.79% of the individuals. The most predominant HCV genotype was 3a and 2a.

Conclusion

A program for education about occupational risk factors and regular blood screening must be implemented in all healthcare setups of Khyber Pakhtunkhwa province in order to help reduce the burden of HCV infection.

Hepatitis B virus in Pakistan: a systematic review of prevalence, risk factors, awareness status and genotypes

In Pakistan, there are estimated 7-9 million carriers of hepatitis B virus (HBV) with a carrier rate of 3-5%. This article reviews the available literature about the prevalence, risk factors, awareness status and genotypes of the HBV in Pakistan by using key words; HBV prevalence, risk factors, awareness status and genotypes in Pakistani population in PubMed, PakMediNet, Directory of Open Access Journals (DOAJ) and Google Scholar. One hundred and six different studies published from 1998 to 2010 were included in this study. Weighted mean and standard deviation were determined for each population group. The percentage of hepatitis B virus infection in general population was 4.3318% ± 1.644%, healthy blood donors (3.93% ± 1.58%), military recruits (4.276% ± 1.646%), healthcare persons (3.25% ± 1.202%), pregnant women (5.872% ± 4.984), prisoners (5.75% ± 0.212%), surgical patients (7.397% ± 2.012%), patients with cirrhosis (28.87% ± 11.90%), patients with HCC (22% ± 2.645%), patients with hepatitis (15.896% ± 14.824%), patients with liver diseases (27.54% ± 6.385%), multiple transfused patients (6.223% ± 2.121%), opthalmic patients (3.89% ± 1.004%) and users of injectable drugs (14.95% ± 10.536%). Genotype D (63.71%) is the most prevalent genotype in Pakistani population. Mass vaccination and awareness programs should be initiated on urgent basis especially in populations with HBV infection rates of more than 5%.

Comparing aflatoxin contamination in chilies from Punjab, Pakistan produced in summer and winter

A comparison was made of total aflatoxins (AFs) in 43 samples of chilies collected during winter and 42 in summer to determine the effect of season on contamination. The samples were analyzed by HPLC with fluorescence detection. The limits of detection and quantification for AFB1 and AFG1 were 0.05 μg/kg and 0.50 μg/kg, whilst for AFG2 and AFB2 they were 0.10 μg/kg and 0.60 μg/kg. In the winter samples, AFs were detected in 18 (72%) whole and 14 (60%) ground chilies, with concentration ranges 0.00-52.30 μg/kg and 0.00-74.60 μg/kg respectively. In the summer samples, 17 (64%) whole and 12 (76%) ground chilies were contaminated with AFs at concentrations 0.00-61.50 μg/kg and 0.00-95.90 μg/kg respectively. The percentage of samples greater than the European Union statutory limit for AFB1 and total AF for whole chilies were 48 and 36%, compared with ground chili values of 50 and 45%, respectively, in the winter season. In the summer season, the samples greater than the European Union limit for AFB1 and total AF in whole chilies were 52 and 38%, compared with values of 54 and 49% in ground chilies respectively. AF contamination was found to be higher in summer chili samples and hence winter chilies may provide a better quality product with respect to AF contamination. The ability to undertake this analysis in Pakistan will enhance greatly the ability to improve chili production in that country, as described herein.

Liver fibrosis in hepatitis C patients of Pakistani versus Scandinavian origin

OBJECTIVE

The aim of this study was to examine the significance of native country for the stage of liver fibrosis in a population of HCV patients of Pakistani or Scandinavian origin living in Oslo.

PATIENTS AND METHODS

We included 122 consecutive HCV patients at two hepatitis clinics in Oslo, 73 of Scandinavian and 49 of Pakistani origin. Inclusion criteria were being HCV RNA positive, treatment naïve and having an adequate liver biopsy. The biopsies were scored according to the Metavir index, which scores fibrosis on a scale from 0 to 4 and necroinflammatory activity on a scale from 0 to 3. Steatosis was scored according to the percentage of hepatocytes having lipid droplets in their cytoplasm. Demographical, clinical, virological and biochemical data for the two groups were registered from the patient files.

RESULTS

The median age was 43 and 42 years and 53% and 51% were male among the Scandinavian and Pakistani patients, respectively. Among the patients of Pakistani origin 18/49 (37%) had bridging fibrosis (F3) or cirrhosis (F4) compared to 11/73 (15%) Scandinavian patients (p=0.006). The mean fibrosis score was 1.78 in the Pakistani and 0.82 in the Scandinavian group (p<0.001). The mean necroinflammatory activity score was 1.22 and 0.78 in the Pakistanis and Scandinavians, respectively (p<0.001). In the Pakistani group more patients had ≥5% steatosis (59% vs. 33%; p=0.004), diabetes mellitus (24% vs. 0%; p<0.001), overweight (46% vs. 34%; p=0.232), genotype 3 (84% vs. 42%; p<0.001) and ALT and AST levels above the reference range (84% vs. 64%; p=0.020 and 88% vs. 68%; p=0.014) compared to the Scandinavian. Multivariate regression analyses identified age ≥40 years (OR 10.13; 95% CI 2.65-39.12) and genotype 3 (OR 5.02; 95% CI 1.19-21.17) as independent predictors of bridging fibrosis/cirrhosis.

CONCLUSIONS

In HCV patients of similar age, those of Pakistani origin had more advanced liver disease than those of Scandinavian origin. Possible explanations are longer duration of the infection and higher occurrence of diabetes mellitus, liver steatosis and genotype 3 in the Pakistani group.

Epidemiological manifestations of hepatitis C virus genotypes and its association with potential risk factors among Libyan patients

Background

The information on hepatitis C virus genotypes and subtypes among Libyan population and its association with various risk factors is not known. The objectives of this study were to determine the epidemiological manifestations of HCV genotypes among Libyan patients and their association with certain potential risk factors.

Methods

A total of 1240 of HCV infected patients registered at Tripoli Medical Centre were studied in five years period from January 2005 to October 2009. The information were reviewed and the data were collected. A sample from each patient (785 male; 455 female) was analysed for genotyping and sub-typing using specific genotyping assay. The information was correlated with the risk factors studied and the statistical data were analyzed using SPSS version 11.5.

Results

Off the total patients studied, four different genotypes were reported, including genotypes 1, 2, 3, and 4. Genotype4 was the commonest (35.7%), followed by genotype1 (32.6%). According to subtypes 28% were unclassified genotype 4, 14.6% were genotype 1b and some patients infected with more than one subtype (2.3% genotype 4c/d, 1% genotype 2a/c). Genotypes 1 was the commonest among males, while genotype 4 among females. According to the risk factors studied, Genotype1 and genotype 4 were found with most of the risk factors. Though they were particularly evident surgical intervention, dental procedures and blood transfusion while genotype 1 was only followed by genotype 3 mainly which mainly associated with certain risk groups such as intravenous drug abusers.

Conclusion

Here in we report on a detailed description of HCV genotype among Libyans. The most common genotype was type 4 followed by genotype 1, other genotypes were also reported at a low rate. The distribution of such genotypes were also variable according to gender and age. The commonly prevalent genotypes found to be attributable to the medical -related transmission of HCV, such as blood, surgery and dental procedures when compared with other risk factors. This however, raises an alarming signal on the major steps to be taken to reduce such infection in Libya

Epidemiological patterns and risk factors associated with hepatitis B virus in Pakistani population

Hepatitis B virus prevalence is increasing in Pakistani population. National level estimates regarding the prevalence are missing. People are unaware of the risk factors involved in HBV transmission. The objective of the study was to review the prevalence, genotypes, and risk factors associated with HBV transmission in Pakistani Population. Literature search was done by using keyword HBV prevalence, genotypes and risk factors from Pakistani population at Pubmed, PakMediNet and Google scholar. Six different studies showed that the percentage prevalence of HBV in general population was 4.61±0.73%, and 21 different studies showed the percentage prevalence of 2.33±0.46% in blood donors. High prevalence of 7.94±1.49% and 12.86±4.52% were observed in multi transfused and IDU populations. Six different studies showed that the major prevalent genotype was D. Awareness regarding various risk factors involved in-viral transmission was very low. Prevalence of HBV was very high in multitransfused populations due to non-implementations of international standards regarding blood transfusions. Barbers were unaware of the risk factors associated with their shops in viral transmission. Practices of unsterilized dental and surgical instruments and recycling of syringes were major factors in viral transmission. Massive awareness and vaccination programs are required to decrease the future burden of HBV from Pakistani population.

Awareness and risk factors associated with barbers in transmission of hepatitis B and C from Pakistani population: barber’s role in viral transmission

Background: In Pakistan, most patients with Hepatitis B and C have history of facial and armpit shaving from barbers. Objective: Evaluate the awareness and risk factors associated with barbers in transmission of Hepatitis B and C. Subjects and methods: A cross sectional survey was conducted in Rawalpindi and Islamabad, the twin capital cities of Pakistan between January and July 2009. Five hundred and eight barbershops were surveyed. Results: Out of 508 barber shops, 99.8% and 98.2% were washing their razor with water and water plus antiseptic solution, respectively, while 99.8% were using new blades. Only 39.6% knew that hepatitis B virus (HBV) and hepatitis C virus (HCV) were viral diseases, 26.6% knew that it can lead to cancer, 90.7% thought that hepatitis could be transferred by blade sharing, 47.8% knew that a vaccine for HBV was available, and 43.0% had education beyond the primary level. None of the barbers used a new or washed apron/towel on every customer. Conclusion: In Pakistan, a small number of barbers are shaving clients with an old style razor with a permanent blade. There is moderate awareness about the various modes of transmission of hepatitis among the barbers, and most of them don’t know about vaccination. A predominant number of them are considering interferon treatment as a vaccine for hepatitis B and C.