High HCV prevalence in Egyptian blood donors

Current situation of viral hepatitis in Egypt

An estimated 8-10 million people suffer from viral hepatitis in Egypt. Hepatitis A virus (HAV) and hepatitis E virus (HEV) are the major causes of viral hepatitis in Egypt as 50% or more of the Egyptian population are already exposed to HAV infection by the age of 15. In addition, over 60% of the Egyptian population test seropositive for anti-HEV in the first decade of life. HEV mainly causes self-limiting hepatitis; however, cases of fulminant hepatitis and liver failure were reported in Egypt. Hepatitis B virus (HBV), hepatitis C virus (HCV), and hepatitis D virus (HDV) are the main causes of chronic hepatitis, liver cirrhosis, and liver cancer (hepatocellular carcinoma [HCC]) in Egypt. Globally, Egypt had the highest age-standardized death rate due to cirrhosis from 1990 to 2017. The prevalence rate of HBV (1.3%-1.5%) has declined after national infantile immunization. Coinfection of HBV patients with HDV is common in Egypt because HDV antibodies (IgG) vary in range from 8.3% to 43% among total HBV patients. After the conduction of multiple national programs to control HCV infection, a lower rate of HCV prevalence (4.6%) was recently reported. Data about the incidence of HCV after treatment with direct antiviral agents (DAAs) are lacking. An HCC incidence of 29/1000/year in cirrhotic patients after DAA treatment is reported. A higher rate of infiltrative pattern among HCC patients after DAA treatment is also recognized. Viral hepatitis is one of the major public health concerns in Egypt that needs more attention and funding from health policymakers.

Characterizing the historical role of parenteral antischistosomal therapy in hepatitis C virus transmission in Egypt

Background

Egypt is the nation most affected by hepatitis C virus (HCV) infection, following an epidemic of historic proportions. We aimed to characterize the epidemic’s historical evolution and to delineate the role of parenteral antischistosomal therapy (PAT) campaigns in transmission.

Methods

A mathematical model was constructed and analysed in order to understand HCV-transmission dynamics. The model was fitted to Egypt’s Demographic and Health Survey data and to a systematic database of HCV-prevalence data.

Results

The incidence rate peaked in 1966 at 15.7 infections per 1000 person-years—a period of time that coincides with the PAT campaigns—and rapidly declined thereafter, beginning the mid-1990s. The annual number of new infections peaked in 1993 at 581 200 (with rapid demographic growth), leading to a high-incidence-cohort effect, and declined to 67 800 by 2018. The number of individuals ever infected (1950–2018) was 16.4 million, with HCV prevalence peaking in 1979. The number of individuals ever exposed to PAT was 8.3 million; however, of these individuals, 7.3 million were alive in 1980 and only 3.5 million alive in 2018. The number of individuals ever infected due to PAT exposure was 963 900, with 850 200 individuals alive in 1980 and only 389 800 alive in 2018. The proportion of PAT-attributed prevalent infections peaked at 19.9% in 1972, declining to 5.5% by 2018.

Conclusions

PAT campaigns played an important role in HCV transmission, yet explain only 6% of infections—they appear to be a manifestation, rather than a cause, of the epidemic. A possible driver of the epidemic could be the mass expansion of inadequate-quality healthcare during PAT campaigns and subsequent decades. Despite a historic toll, the epidemic has been rapidly diminishing since the mid-1990s.

Transfusion-transmitted hepatitis C: A cluster of cases in transfusion-dependent thalassaemia patients in Sri Lanka

OBJECTIVES

To report the clinical and virologic epidemiology of a recent epidemic of hepatitis C in thalassaemia patients in Sri Lanka.

BACKGROUND

Transfusion-dependent thalassaemia patients remain at risk for hepatitis C virus (HCV). Here, we report a cluster of recent HCV infections in Sri Lankan thalassaemia patients and examine the phylogenetic relationship of viral sequences.

METHODS

We conducted two prospective cross-sectional surveys of 513 patients in four Sri Lankan thalassaemia centres in 2014/2015 and re-surveyed one centre in 2016. We screened for anti-HCV antibodies using the CTK Biotech enzyme-linked immunosorbent assay (ELISA) kits and confirmed active infection by reverse transcription-polymerase chain reaction (RT-PCR) for HCV-RNA. HCV genomes were sequenced by unbiased target enrichment.

RESULTS

Anti-HCV antibodies were found in 116/513 (22.6%) of patients initially tested. Active hepatitis C infection was found in 26 patients with no cases of active hepatitis B infection. Of 26 patients with HCV, two were infected with genotype 1(a), and the rest had 3(a). In a single centre (Ragama), 122 patients (120 new cases and two previously tested, but negative) were retested for anti-HCV antibodies. 32/122 (26.2%) patients were seropositive. Twenty-three (23/122; 18.8%) of these new cases were confirmed by HCV PCR (all genotype 3[a]).

CONCLUSION

There is a significant cluster of recent HCV cases in multiply transfused thalassaemia patients in several centres in Sri Lanka. Most of the viruses shared a close phylogenetic relationship. The results are consistent with recent continuing transfusion-transmitted HCV infection. Routine surveillance for HCV of chronically transfused patients is required irrespective of screening of blood products.

Hepatitis C infection in Egypt: prevalence, impact and management strategies

Hepatitis C virus (HCV) infection is a major public health burden in Egypt, where it bears the highest prevalence rate in the world. Estimates for prevalence are based upon data reported from the 2008 and 2015 Egypt Demographic Health Surveys. In this review, we demonstrate the prevalence results of both surveys and analyze the difference in the results. The overall HCV prevalence is estimated to be declining. However, the clinical impact of chronic HCV infection is expected to grow considerably. A mathematical model shows that by increasing the rate of treatment, the expected number of patients will decline significantly in 2030. The current and expected future burden of chronic HCV infection to the Egyptian economy, including direct and indirect costs due to disability and loss of lives, has been estimated and discussed in this review. The economic burden will continue to grow, but a model shows that the introduction of highly effective therapies will result in a significant reduction in the cumulative total economic burden of HCV by 2030. In recognition of the HCV tremendous health and economic burden, the Egyptian government established the National Committee for Control of Viral Hepatitis to implement an integrated nationwide strategy to provide patient care and ensure global treatment access. This review illustrates the epidemiological and disease burden aspects of HCV in Egypt in addition to introducing the national plan and program for managing HCV, which has been successful so far in treating a large number of patients, with the aim of achieving disease control and eventual elimination in Egypt.

Hepatitis c virus genotype 4 replication in the hepatocellular carcinoma cell line HepG2/C3A

BACKGROUND/AIMS

The lack of a reliable cell culture system allowing persistent in vitro hepatitis C virus (HCV) propagation is still restraining the search for novel antiviral strategies. HepG2 cells transfection with HCV allows for viral replication. However, the replication is weak presumably because of HepG2 lack of miRNA-122, which is essential for viral replication. Other agents such as polyethylene glycol (PEG) and dimethyl sulfoxide (DMSO) have been shown to increase the efficiency of infection with other viruses. This study included comparison of HCV genotype 4 5'UTR and core RNA levels and HCV core protein expression at different time intervals in the absence or presence of PEG and/or DMSO postinfection.

MATERIALS AND METHODS

We used serum with native HCV particles in infecting HepG2 cells in vitro. HCV replication was assessed by reverse transcriptase polymerase chain reaction for detection of HCV RNA and immunofluorescence and flow cytometry for detection of HCV core protein.

RESULTS

HCV 5'UTR and core RNA expression was evident at different time intervals after viral infection, especially after cells were treated with PEG. HCV core protein was also evident at different time intervals using both immunofluorescence and flow cytometry. PEG, not DMSO, has increased the HCV core protein expression in the treated cells, similar to its effect on viral RNA expression.

CONCLUSIONS

These expression profiles suggest that the current model of cultured HepG2 cells allows the study of HCV genotype 4 replication and different stages of the viral life cycle.

Epidemiology of hepatitis C virus exposure in Egypt: Opportunities for prevention and evaluation

AIM: To critically evaluate the current epidemiology data on exposures, rather than infection, to hepatitis C virus (HCV) transmission and recommend epidemiologic strategies to fill gaps.

METHODS: Standard methods for identifying and evaluating relevant epidemiologic literature and available data were used.

RESULTS: There is a large body of literature on the epidemiology of HCV transmission in Egypt that collectively identifies ongoing iatrogenic exposures as the major driver for HCV transmission due to short comings in infection control and standard procedures. Additional epidemiologic studies on HCV transmission that requires the participation of human subject is unwarranted. Alternatively, very little literature was found on the epidemiology of exposure to HCV, infection control, and safe injection practices. The information that is available on patterns of HCV exposure shows high frequencies of inadequate infection control, problems in sterilization in health care facilities, low rates of hand washing, untrained personnel, lack of stated policies in facilities, HCV contamination of instruments and very large injection frequencies with low but very significant syringe and needle reuse. There is an important need to increase the number, size, and diversity of epidemiologic studies on HCV exposures, patterns of risk factors for infection, infection control, and safe injection practices. In addition to health care facilities evaluation, relevant knowledge attitude and practice studies are recommended.

CONCLUSION: Epidemiologic methods on HCV exposure can be used to characterize the magnitude of exposures to HCV infection, target interventions to reduce exposures, and provide the best method for evaluating interventions by demonstrating the reduction of exposure to HCV infection.

Economic development and diabetes prevalence in MENA countries: Egypt and Saudi Arabia comparison

Diabetes is increasing in epidemic proportions globally, exhibiting the most striking increase in third world countries with emerging economies. This phenomena is particularly evident in the Middle East and North Africa (MENA) region, which has the highest prevalence of diabetes in adults. The most concerning indirect cost of diabetes is the missed work by the adult population coupled with the economic burden of loss of productivity. The major drivers of this epidemic are the demographic changes with increased life expectancy and lifestyle changes due to rapid urbanization and industrialization. Our focus is to compare MENA region countries, particularly Egypt and Saudi Arabia, in terms of their economic development, labor force diversity and the prevalence of diabetes.

Spatial epidemiology of hepatitis C virus infection in Egypt: analyses and implications

Egypt has the highest hepatitis C virus (HCV) prevalence in the world (14.7%). The drivers of the HCV epidemic in Egypt are not well understood, but the mass parenteral antischistosomal therapy (PAT) campaigns in the second half of the 20th century are believed to be the determinant of the high prevalence. We studied HCV exposure in Egypt at a microscale through spatial mapping and epidemiological description of HCV clustering. The source of data was the 2008 Egypt Demographic and Health Survey. We identified clusters with high and low HCV prevalence and high and low PAT exposure using Kulldorff spatial scan statistics. Correlations across clusters were estimated, and each cluster age-specific HCV prevalence was described. We identified six clusters of high HCV prevalence, three clusters of low HCV prevalence, five clusters of high PAT exposure, and four clusters of low PAT exposure. HCV prevalence and PAT exposure were not significantly associated across clusters (Pearson correlation coefficient [PCC] = 0.36; 95% confidence interval [CI] -0.12 to 0.71). Meanwhile, there was a strong association between HCV prevalence in individuals older than 30 years of age (who could have been exposed to PAT) and HCV prevalence in individuals 30 years of age or younger (who could not have been exposed to PAT) (PCC = 0.81; 95% CI 0.55-0.93).

CONCLUSION

The findings illustrate a spatial variation in HCV exposure in Egypt. The observed clustering was suggestive of an array of iatrogenic risk factors, besides past PAT exposure, and ongoing transmission. The role of PAT exposure in the HCV epidemic could have been overstated. Our findings support the rationale for spatially prioritized interventions.

Hepatitis C screening beyond CDC guidelines in an Egyptian immigrant community

BACKGROUND & AIMS

Many Egyptian-born persons in the U.S. are at high risk of chronic hepatitis C virus (HCV) infection, yet are not aware of their infection and lack healthcare coverage or linkage to care. In this study, we target Egyptian-born persons living in the New York City area for screening and link to care.

METHODS

A unique partnership, the Hepatitis Outreach Network (HONE), combines the expertise and resources of the Mount Sinai School of Medicine, the NYC Department of Health and Mental Hygiene and community-based organizations, to provide education, screening and link to care in communities with high prevalence of chronic viral hepatitis.

RESULTS

Through four community-based screening events, 192 Egyptian-born persons were screened for HCV. Thirty (15.6%) persons were HCV positive. HCV antibody prevalence in those, whose national origin was Egypt, increased strongly with age and was associated with increasing number of years resident in Egypt and rural residents. Of the 30 Egyptian persons with HCV infection, 18 (60%) received a medical evaluation (2 with local providers and 16 at Mount Sinai). Of the HCV-infected persons evaluated, treatment was recommended in four and begun in three (75%).

CONCLUSION

Egyptian-born persons living in the New York City area have a high burden of HCV disease. HONE has successfully established targeted HCV screening in Egyptian-born persons through use of several unique elements that effectively link them to care.

A novel method to identify routes of hepatitis C virus transmission

Background

We propose a new approach based on genetic distances among viral strains to infer about risk exposures and location of transmission at population level.

Methods

We re-analysed 133 viral sequences obtained during a cross-sectional survey of 4020 subjects living in a hepatitis C virus (HCV) endemic area in 2002. A permutation test was used to analyze the correlation between matrices of genetic distances in the NS5b region of all pairwise combinations of the 133 viral strains and exposure status (jointly exposed or not) to several potential HCV risk factors.

Results

Compared to subjects who did not share the same characteristics or iatrogenic exposures, the median Kimura genetic distances of viral strains were significantly smaller between brothers and sisters (0.031 versus 0.102, P<0.001), mother and child (0.044 versus 0.102, P<0.001), father and child (0.045 versus 0.102, P<0.001), or subjects exposed to periodontal treatment (0.084 versus 0.102, P = 0.02). Conversely, viral strains were more divergent between subjects exposed to blood transfusions (0.216 versus 0.102, P = 0.04) or tooth filling or extraction (0.108, versus 0.097, P = 0.05), suggesting acquisition of the virus outside of the village.

Conclusion

This method provided insights on where infection took place (household, village) for several socio-demographic characteristics or iatrogenic procedures, information of great relevance for targeting prevention interventions. This method may have interesting applications for virologists and epidemiologists studying transmission networks in health-care facilities or among intravenous drug users.

An apparent lack of epidemiologic association between hepatitis C virus knowledge and the prevalence of hepatitis C infection in a national survey in Egypt

BACKGROUND

Egypt has by far the largest hepatitis C virus (HCV) prevalence in the world with 14.7% of the population being antibody positive for HCV. The aim of this study was to examine the association between knowledge of HCV and HCV antibody positivity among the Egyptian population.

METHODS

We characterized different measures of HCV knowledge and examined their associations with HCV prevalence, by analyzing a nationally representative database using standard epidemiologic methods. The database, the 2008 Egyptian Demographic and Health Survey, included demographic, health, and HCV biomarker information for a sample of over 12,000 individuals.

RESULTS

Basic knowledge of HCV was found to be high, but multiple gaps were identified in the specific knowledge of HCV and its modes of transmission. There was no statistically significant difference in HCV prevalence between those who have heard of HCV infection and those who have not (14.4% vs. 15.9%, p>.05). Similar results were found for the other HCV knowledge measures including those specific to HCV modes of transmission and to the sources of information for HCV awareness. Logistic regression analyses did not demonstrate an association between HCV knowledge and HCV prevalence.

CONCLUSIONS

Our results do not provide support for an effect of awareness on reducing the risk of HCV infection in Egypt. Public health messages directed at the lay public may not provide sufficient empowerment for individuals to avoid HCV infection, and should be complemented with prevention programs to promote and strengthen infection control in the settings of exposure, particularly in health care facilities.

The epidemiology of hepatitis C virus in Egypt: a systematic review and data synthesis

BACKGROUND

Egypt has the highest prevalence of hepatitis C virus (HCV) in the world, estimated nationally at 14.7%. Our study's objective was to delineate the evidence on the epidemiology of HCV infection among the different population groups in Egypt, and to draw analytical inferences about the nature of HCV transmission in this country.

METHODS

We conducted a systematic review of all data on HCV prevalence and incidence in Egypt following PRISMA guidelines. The main sources of data included PubMed and Embase databases. We also used a multivariate regression model to infer the temporal trend of HCV prevalence among the general population and high risk population in Egypt.

RESULTS

We identified 150 relevant records, four of which were incidence studies. HCV incidence ranged from 0.8 to 6.8 per 1,000 person-years. Overall, HCV prevalence among pregnant women ranged between 5-15%, among blood donors between 5-25%, and among other general population groups between 0-40%. HCV prevalence among multi-transfused patients ranged between 10-55%, among dialysis patients between 50-90%, and among other high risk populations between 10% and 85%. HCV prevalence varied widely among other clinical populations and populations at intermediate risk. Risk factors appear to be parenteral anti-schistosomal therapy, injections, transfusions, and surgical procedures, among others. Results of our time trend analysis suggest that there is no evidence of a statistically significant decline in HCV prevalence over time in both the general population (p-value: 0.215) and high risk population (p-value: 0.426).

CONCLUSIONS

Egypt is confronted with an HCV disease burden of historical proportions that distinguishes this nation from others. A massive HCV epidemic at the national level must have occurred with substantial transmission still ongoing today. HCV prevention in Egypt must become a national priority. Policymakers, and public health and medical care stakeholders need to introduce and implement further prevention measures targeting the routes of HCV transmission.

Evaluation of multiplex nested polymerase chain reaction for routine hepatitis C virus genotyping in egyptian patients

BACKGROUND

At least six HCV (hepatitis C virus) genotypes are unequally distributed worldwide. HCV genotyping guides the selection of treatment regimens and provides important epidemiological markers that enable the outbreak source to be traced and the spread of disease to be controlled. In Egypt, there is an increasing need for cost-effective, fast, and easily performable HCV genotyping assays.Recently, a multiplex PCR assay was developed to determine HCV genotypes. It employs genotype-specific primers, based on sequences of the entire core region and part of the 5'UTR of the genome.

OBJECTIVES

In this study, we compared a simple, new, modified multiplex PCR system for HCV genotyping with a commercially available line probe assay (INNO-LiPA) that is based on reverse hybridization.

PATIENTS AND METHODS

Serum samples from chronic HCV Egyptian patients (n = 73) were genotyped using the modified multiplex PCR assay, and genotypes were verified using the INNO-LiPA HCV II assay.

RESULTS

The modified multiplex PCR method was able to type HCV-4 in 65 of 70 typeable samples (92.86%) and had 100% concordance with the INNO-LiPA assay.

CONCLUSIONS

Genotype 4 was the most prevalent genotype in our study. Based on our results, the modified multiplex nested PCR assay is a sensitive and inexpensive alternative for HCV genotyping and can be used in routine diagnostic laboratories. INNO-LiPA may be useful as a second-line assay for genotyping samples that are indeterminate by multiplex PCR. This approach will effect better treatment optimization and a reduction of the spread of HCV.

Evaluation of interleukin-8 in hepatitis C virus infection: relation to combined peg-interferon ribavirin response and genotype 4

Hepatitis C virus (HCV), a major cause of liver disease worldwide, is frequently resistant to the antiviral alpha interferon (IFN). Previous studies have shown that HCV NS5A protein induces expression of the proinflammatory interleukin-8 (IL-8) and this may affect the therapeutic outcome. The aim of the present study was to investigate the relationship among levels of IL-8 in serum of subjects with past exposure to HCV indicated by positive IgG to HCV and negative PCR, patients with chronic HCV infections and in responder to combined alfa IFN and ribavirin therapy. The study included 48 Egyptian subjects with evidence of HCV infection. They were classified according to viremia to patients with chronic hepatitis C with positive viremia and immune subjects with positive HCV IgG alone. Chronic HCV patients were followed after therapy and 16 healthy adults as control group. It was found that viral load was dependent factor for the level of IL 8 (P = 0.003) and there was significant correlation between levels of IL-8 before treatment and after treatment. The present study highlights the kinetic of serum levels of interleukin-8 in patients with chronic hepatitis C genotype 4 before and after therapy with combined alfa interferon and ribavirin. It was demonstrated that HCV infection was associated with higher levels of interleukin-8 in pretreatment and posttreatment period. Moreover, immune subjects also had higher level of interleukin-8, indicating its role in immunity to HCV infection.

Evidence of intense ongoing endemic transmission of hepatitis C virus in Egypt

Egypt has the highest prevalence of antibodies to hepatitis C virus (HCV) in the world, estimated nationally at 14.7%. An estimated 9.8% are chronically infected. Numerous HCV prevalence studies in Egypt have published various estimates from different Egyptian communities, suggesting that Egypt, relative to the other nations of the world, might be experiencing intense ongoing HCV transmission. More importantly, a new national study provided an opportunity to apply established epidemiologic models to estimate incidence. Validated mathematical models for estimating incidence from age-specific prevalence were used. All previous prevalence studies of HCV in Egypt were reviewed and used to estimate incidence provided that there was sufficient age-specific data required by the models. All reports of anti-HCV antibody prevalence were much higher than any single other national estimate. Age was the strongest and most consistently associated factor to HCV prevalence and HCV RNA positivity. It was not possible to establish a prior reference point for HCV prevalence or incidence to compare with the 2009 incidence estimates. The modeled incidence from the national study and collectively from the modeled incidence from the previous community studies was 6.9/1,000 [95% confidence interval (CI), 5.5-7.4] per person per year and 6.6/1,000 (95% CI, 5.1-7.0) per person per year, respectively. Projected to the age structure of the Egyptian population, more than 500,000 new HCV infections per year were estimated. Iatrogenic transmission is the most likely, underlining exposure to the ongoing transmission. The study demonstrates the urgency to reduce HCV transmission in Egypt.

An overview about hepatitis C: a devastating virus

Hepatitis C (HCV) is the disease that has affected around 200 million people globally. HCV is a life threatening human pathogen, not only because of its high prevalence and worldwide burden but also because of the potentially serious complications of persistent HCV infection. Chronicity of the disease leads to cirrhosis, hepatocellular carcinoma and end-stage liver disease. HCV positive hepatocytes vary between less than 5% and up to 100%, indicating the high rate of replication of viral RNA. HCV has a very high mutational rate that enables it to escape the immune system. Viral diversity has two levels; the genotypes and Quasiaspecies. Major HCV genotypes constitute genotype 1, 2, 3, 4, 5 and 6 while more than 50 subtypes are known. All HCV genotypes have their particular patterns of geographical distribution and a slight drift in viral population has been observed in some parts of the globe.

Hepatocellular carcinoma: epidemiology, risk factors and pathogenesis

Hepatocellular carcinoma (HCC) is the commonest primary malignant cancer of the liver in the world. Given that the burden of chronic liver disease is expected to rise owing to increasing rates of alcoholism, hepatitis B and C prevalence and obesity-related fatty liver disease, it is expected that the incidence of HCC will also increase in the foreseeable future. This article summarizes the international epidemiology, the risk factors and the pathogenesis of HCC, including the roles of viral hepatitis, toxins, such as alcohol and aflatoxin, and insulin resistance.

Chronic viral hepatitis may diminish the gains of HIV antiretroviral therapy in sub-Saharan Africa

There is a heavy burden of HIV-hepatitis B virus (HBV) and HIV-hepatitis C virus (HCV) co-infection in many regions of the developing world. An often unmentioned illness, issues of poverty, socio-economic status, nutrition, access to medical care, and mistrust of Western-style medicine conspire to reduce the opportunity to receive clinical work-up and treatment for chronic viral hepatitis. We discuss key issues specific to the treatment of viral hepatitis and obstacles to success with this endeavor in the context of HIV co-infection in Africa. We predict that provision of viral hepatitis antiviral therapy will become a more pressing issue as more HIV-infected patients receive lifesaving combination antiretroviral therapy only to succumb thereafter from viral hepatitis-induced liver disease. Given the lessons learned from combination antiretroviral rollout in sub-Saharan Africa, establishing expertise and infrastructure for viral hepatitis care and antiviral therapy is relevant. Failure to act now may diminish the milestones and the gains made with antiretroviral therapy in the developing world.

Cutting the gordian knot-development and biological relevance of hepatitis C virus cell culture systems

Worldwide approximately 180 million people are chronically infected with hepatitis C virus (HCV). HCV isolates exhibit extensive genetic heterogeneity and have been grouped in six genotypes and various subtypes. Additionally, several naturally occurring intergenotypic recombinants have been described. Research on the viral life cycle, efficient therapeutics, and a vaccine has been hampered by the absence of suitable cell culture systems. The first system permitting studies of the full viral life cycle was intrahepatic transfection of RNA transcripts of HCV consensus complementary DNA (cDNA) clones into chimpanzees. However, such full-length clones were not infectious in vitro. The development of the replicon system and HCV pseudo-particles allowed in vitro studies of certain aspects of the viral life cycle, RNA replication, and viral entry, respectively. Identification of the genotype 2 isolate JFH1, which for unknown reasons showed an exceptional replication capability and resulted in formation of infectious viral particles in the human hepatoma cell line Huh7, led in 2005 to the development of the first full viral life cycle in vitro systems. JFH1-based systems now enable in vitro studies of the function of viral proteins, their interaction with each other and host proteins, new antivirals, and neutralizing antibodies in the context of the full viral life cycle. However, several challenges remain, including development of cell culture systems for all major HCV genotypes and identification of other susceptible cell lines.

Hepatocellular carcinoma: Epidemiology, risk factors and pathogenesis

Hepatocellular carcinoma (HCC) is the commonest primary malignant cancer of the liver in the world. Given that the burden of chronic liver disease is expected to rise owing to increasing rates of alcoholism, hepatitis B and C prevalence and obesity-related fatty liver disease, it is expected that the incidence of HCC will also increase in the foreseeable future. This article summarizes the international epidemiology, the risk factors and the pathogenesis of HCC, including the roles of viral hepatitis, toxins, such as alcohol and aflatoxin, and insulin resistance.

Evaluation of pooled screening for anti-HCV in two blood services set-ups

OBJECTIVE

Screening blood donations for anti-HCV is only partially performed in many developing countries due to the relatively high costs of testing. The screening expenditures can be reduced by testing donations in pools. This study evaluates the accuracy and feasibility of pooled screening procedure for anti-HCV in blood banks in Israel and the Palestinian Authority.

METHODS

The sensitivity and specificity of tests performed on pool sizes of 6-24 samples were compared to singleton immunoassay testing. All negative samples and those positive for anti-HCV were obtained from the routine work of Magen David Adom Blood Services in Israel and Shifa Hospital blood bank in Palestinian Authority. The experiments were run in parallel with different technologies.

RESULTS

The sensitivity of pooled-testing for anti-HCV by Magen David Adom was 94-97% for verified samples. In the Shifa Hospital, the sensitivity was estimated as 96-97% for non-verified samples. Cost-analysis showed benefits up to $2 per donation screened for anti-HCV in Shifa Hospital.

CONCLUSIONS

We recommend using manually created pools of up to 6 samples when testing for anti-HCV, but at the cost of 3% loss in sensitivity. Pooling can be considered, in countries which do not perform routine screening, due to their limited economic resources.

Accuracy of hepatitis C virus core antigen testing in pools among seroconverters

BACKGROUND

Screening blood units for hepatitis C virus (HCV) with nucleic acid testing (NAT) reduces the risk associated with the long "window period" (8-9 weeks) after HCV infection. The feasibility of adding the HCV core antigen assay in pools to the existing anti-HCV individual screening was examined as an alternative of NAT, for early detection of HCV.

STUDY DESIGN AND METHODS

Eighteen HCV seroconversion panels were tested for HCV antibodies, HCV antigen, and HCV RNA. Each sample was tested for HCV antigen individually and in pools of 3, 6, and 12. Statistical analyses included estimation of time until detection of the first positive HCV antigen bleed in each pool size, with a locally weighted regression (LOWESS) model. Sensitivity was calculated compared to NAT.

RESULTS

Detection of HCV antigen in individual samples and in pools of 3 and 6 significantly preceded the detection of antibodies by 63, 53, and 46 days, respectively. Although the sensitivity of the HCV antigen test decreased with the increase in pool size, the estimated overall sensitivity of the "two-stage" antigen and antibody screening (where NAT of individual samples was the gold standard) was not significantly different between individual and the different pool sizes.

CONCLUSION

Screening for HCV antigen in pools of 6 can be considered an efficient and easier-to-implement alternative to the costly NAT for identifying blood donors in the seroconversion period. It may offer a cost-effective approach in resource utilization in poor countries, that, after the implementation of HCV antibody testing, want to further improve blood safety.

Soluble egg antigen of Schistosoma Haematobium induces HCV replication in PBMC from patients with chronic HCV infection

BACKGROUND

This study was conducted to examine, in vitro , the effect of soluble egg antigen (SEA) of S. haematobium on intracellular HCV RNA load in peripheral mononuclear cells (PBMC) as well as on cell proliferation in patients with chronic HCV infection.

METHODS

PBMC from 26 patients with chronic HCV infection were cultured for 72 hours in presence and absence of 50 mug SEA/ml medium. Intracellular HCV RNA quantification of plus and minus strands was assessed before and after stimulation. PBMC from five healthy subjects were cultured for 7 days, flow cytometric analysis of DNA content was used to assess the mitogenic effect of SEA on PBMC proliferation compared to phytoheamaglutinine (PHA).

RESULTS

Quantification of the intracellular viral load showed increased copy number/cell of both or either viral strands after induction with SEA in 18 of 26 patients (69.2%) thus indicating stimulation of viral replication. Flow cytometric analysis showed that mean +/- S.D. of percent values of cell proliferation was induced from 3.2 +/- 1.5% in un-stimulated cells to 16.7 +/- 2.5 % and 16.84 +/- 1.7 % in cells stimulated with PHA and SEA respectively.

CONCLUSION

the present study supports earlier reports on SEA proliferative activity on PBMC and provides a strong evidence that the higher morbidity observed in patients co-infected with schistosomiasis and HCV is related, at least in part, to direct stimulation of viral replication by SEA.

Soluble egg antigen of Schistosoma Haematobium induces HCV replication in PBMC from patients with chronic HCV infection

BACKGROUND

This study was conducted to examine, in vitro , the effect of soluble egg antigen (SEA) of S. haematobium on intracellular HCV RNA load in peripheral mononuclear cells (PBMC) as well as on cell proliferation in patients with chronic HCV infection.

METHODS

PBMC from 26 patients with chronic HCV infection were cultured for 72 hours in presence and absence of 50 mug SEA/ml medium. Intracellular HCV RNA quantification of plus and minus strands was assessed before and after stimulation. PBMC from five healthy subjects were cultured for 7 days, flow cytometric analysis of DNA content was used to assess the mitogenic effect of SEA on PBMC proliferation compared to phytoheamaglutinine (PHA).

RESULTS

Quantification of the intracellular viral load showed increased copy number/cell of both or either viral strands after induction with SEA in 18 of 26 patients (69.2%) thus indicating stimulation of viral replication. Flow cytometric analysis showed that mean +/- S.D. of percent values of cell proliferation was induced from 3.2 +/- 1.5% in un-stimulated cells to 16.7 +/- 2.5 % and 16.84 +/- 1.7 % in cells stimulated with PHA and SEA respectively.

CONCLUSION

the present study supports earlier reports on SEA proliferative activity on PBMC and provides a strong evidence that the higher morbidity observed in patients co-infected with schistosomiasis and HCV is related, at least in part, to direct stimulation of viral replication by SEA.

Molecular epidemiology of hepatitis C virus (HCV) in Greece: temporal trends in HCV genotype-specific incidence and molecular characterization of genotype 4 isolates

This study aimed to estimate the overall HCV genotype distribution and to reconstruct the HCV genotype-specific incidence in Greece during the recent decades. It also focused at the identification of genotype 4 subtype variability in Greek isolates. A total of 1686 chronically infected HCV patients with detectable serum HCV RNA by RT-PCR, belonging to different risk groups were studied. Amplified products from the 5'-noncoding region were typed using a commercially available assay based on the reverse hybridization principle. The HCV genotype-specific incidence was estimated using a previously described back calculation method. HCV genotype 1 was the most prevalent (46.9%) followed by genotype 3 (28.1%), 4 (13.2%), 2 (6.9%) and 5 (0.4%). A high prevalence of genotype 1 (66.3%) in haemophilia patients was recorded whereas HCV genotype 3 was found mainly among patients infected by I.V. drug use (58.2%). Data on the temporal patterns of HCV genotype-specific incidence in Greece revealed a moderate increase (1.3-1.6 times) for genotypes 1 and 4, and a decrease (1.5 times) for genotype 2 from 1970 to 1990, whereas there was a sharp (13-fold) increase for genotype 3. The molecular characterization of 41 genotype 4 HCV isolates belonging to various risk groups revealed that, subtype 4a was the most frequently detected (78%). Phylogenetic comparison of the Greek 4a isolates with all HCV-4a isolates reported worldwide so far revealed a topology which does not discriminate Greek isolates from the others. HCV-4 does not represent a recent introduction in Greece.

Molecular evolutionary analyses implicate injection treatment for schistosomiasis in the initial hepatitis C epidemics in Japan

BACKGROUND/AIMS

The mortality due to hepatocellular carcinoma (HCC) has ranged widely in various areas of Japan since 30 years ago and the incidence was particularly high in once Schistosoma japonicum (Sj)-endemic areas. Our aim was to estimate the spread time of hepatitis C virus (HCV) infection in the past with possible relevance to a higher incidence of HCC in once Sj-endemic than Sj-nonendemic areas.

METHODS

During 2001, 131 strains of HCV-1b were obtained from patients in three previously Sj-endemic areas, as well as Sj-nonendemic areas in Japan and a cross-sectional study was conducted on them with molecular evolutionary analyses.

RESULTS

A phylogenetic tree reconstructed on HCV-1b sequences in the NS5B region disclosed 2 independent clusters for Sj-positive and -negative groups with a high bootstrap value. The estimated effective number of HCV-infections indicated a transition from quiescence to rapid exponential growth in the 1920s among patients with schistosomiasis, which is 20 years earlier than that among patients without schistosomiasis.

CONCLUSIONS

The estimated spread time in previously Sj-endemic areas in Japan coincides with injection treatment for Sj since 1921. A high incidence of HCC there would be attributed to a long duration of HCV infection since 1920s.

Phylogenetic analysis of hepatitis C virus isolates from Tunisian patients

There is little information on the epidemiology characterisation of HCV isolates in Tunisia. Previous report showed predominance of genotype 1b. In this study, 32 HCV isolates from genotypes 1a (n = 10), 1b (n = 14), 2 (n = 4), 3a (n = 3) and 4 (n = 1) were genotyped by sequencing and phylogenetic analysis on the non-structural 5b (NS5b) region. The isolates originated from 14 patients with chronic hepatitis, 10 haemophiliacs and eight healthy blood donors. NS5b sequence grouping was concordant with previous 5' untranslated region (5'UTR) genotyping results in 91% of cases. Most of the Tunisian isolates were closely related to the European ones, except for genotype 4 which seems to be related mostly to isolates from Egypt. Isolates from genotype 1a obtained from haemophiliacs showed distinct clustering and nucleic divergence from those obtained from non-haemophiliac patients, this underlines the particular mode of contamination of this group of patients.

Exponential spread of hepatitis C virus genotype 4a in Egypt

Hepatitis C virus (HCV) infects >10% of the general population in Egypt, in which intravenous injection with an antimony compound for endemic schistosomiasis in the past has been implicated. To simulate the epidemic history of HCV in Egypt, sera were obtained from 3608 blood donors at 13 governorates in or surrounding the Nile valley during 1999. The prevalence of antibody to HCV (anti-HCV) and genotypes was determined in them, and the molecular evolutionary analysis based on the neutral theory was applied to HCV isolates of genotype 4a, which is outstandingly prevalent in Egypt and indigenous there. Of 3608 sera, 317 (8.8%) were positive for anti-HCV. The molecular evolutionary analysis on 47 HCV genotype 4a isolates of carriers from various districts in Egypt indicated that the spread of HCV-4a would have increased exponentially during the 1940s through 1980 when oral medications became available. In conclusion, the estimated spread time is consistent with the duration of intravenous antimony campaigns in Egypt.

Analysis of T cell responses against hepatitis C virus genotype 4 in Egypt

BACKGROUND/AIMS

Hepatitis C virus (HCV) remains the most common cause of chronic liver disease in Egypt. Despite the high prevalence of HCV and Schistosoma mansoni (S. mansoni) in Egypt, the effect of co-infection on the immune response against HCV genotype 4a has not been extensively examined.

METHODS

We evaluated the HCV 4a-specific responses against the core and non-structural 5B proteins in chronic HCV with or without S. mansoni co-infection in 38 volunteers from Egypt.

RESULTS

HCV 4a-specific responses were detected in 8/15 and 13/23 individuals with HCV alone or with concomitant schistosomiasis, respectively. Despite the alteration in the Th1 cytokine profile caused by schistosomiasis, the overall immune response rate against HCV was not affected (P=0.11). Seven individuals demonstrated HCV-specific responses against conserved regions of the Core that were previously identified for genotypes 1, 2 and 3 despite differences in HLA class I distribution.

CONCLUSIONS

Egyptian patients infected with HCV genotype 4 can mount HCV-specific T cell responses, both CD4+ and CD8+ T cell-mediated, despite the prevalence of concomitant schistosomiasis. These findings suggest that S. mansoni co-infection may not represent a major obstacle to developing an HCV vaccine in this population.

The role of hepatitis C in hepatocellular carcinoma: a case control study among Egyptian patients

BACKGROUND

Egypt has one of the highest prevalence rates of hepatitis C virus (HCV) infection in the world; however, the risk and attribution related to HCV in Egyptian patients with hepatocellular carcinoma (HCC) remains unknown.

GOALS

The current study was undertaken to estimate the risk of HCC in relation to HCV in Egypt.

STUDY

Thirty-three patients with HCC and 35 healthy controls who had a similar socioeconomic status were prospectively enrolled at the University of Cairo National Cancer Institute.

RESULTS

Anti-HCV antibodies were present in 75.8% of the patients and in 42.9% of the controls (p = 0.01); hepatitis B surface antigen (HBsAg) was present in 15.2% of the patients and in 2.9% of the controls (p = 0.03). In addition, the sex-and age-adjusted odds ratio (OR) for anti-HCV antibodies was 5.1 (95% CI = 1.5-17.4) and for HBsAg was 13.2 (95% CI = 1.2-148.2). Concurrent Schistosoma mansoni and anti-HCV was associated with an OR of 10.3 (95% CI = 1.3-79.8), which was higher than that for anti-HCV (6.5; 95% CI = 1.6-26.6) and S. mansoni infection (0.2; 95% CI = 0.1-6.2) alone. Finally, we estimated the attributable fraction of HCC to HCV to be 64% in this study population and 48% in the general Egyptian population.

CONCLUSIONS

Both HCV and hepatitis B virus infection increase the risk of HCC in Egyptian patients, whereas isolated Schistosoma infection does not. Because of the very high prevalence rate of HCV in the general Egyptian population, it accounts for most HCC cases in Egypt.

Patients' perceptions of blood transfusion risks in Karachi, Pakistan

OBJECTIVE

To evaluate the understanding of and attitudes toward risks of blood transfusions among transfusion recipients in Karachi.

METHODS

One hundred forty-one transfusion recipients from 13 major Karachi hospitals were interviewed. Indications for transfusion were obtained by reviewing the patients' medical records.

RESULTS

The most common indications for transfusion were surgical complications (n = 77, 55%), anemia (n = 34, 24%), and generalized weakness (n = 15, 11%). Most recipients (n = 103, 80%) had never heard of viral hepatitis, and 44 (31%) had never heard of acquired immunodeficiency syndrome (AIDS). Ninety-four recipients (66%) believed that generalized weakness was a valid indication for blood transfusion. Sixty-nine recipients (49%) were not willing to pay an increased price for blood that was screened for blood-borne pathogens.

CONCLUSIONS

Blood recipients in Karachi are unaware of the risks of transfusions, and the reasons given by the ordering physician for many of the transfusions were not consistent with international guidelines. Steps to educate the public about the risks of transfusions and practitioners about the indications for transfusion could prevent blood-borne virus transmission in Karachi.

Hepatitis C virus (HCV) infection in a community in the Nile Delta: population description and HCV prevalence

This report describes a cross-sectional survey of the prevalence of antibodies to hepatitis C virus (anti-HCV) in a rural Egyptian community in the Nile Delta. One half of the village households were systematically selected and examined by questionnaire and testing sera for anti-HCV and HCV RNA. Blood samples were obtained from 3, 888 (75.4%) of 5,156 residents >/=5 years of age; an additional 111 samples were obtained from children younger than 5 years. Overall, 973 (24.3%) of 3,999 residents were anti-HCV-positive, and the age- and gender-adjusted seroprevalence was 23.7%. Anti-HCV prevalence increased sharply with age, from 9.3% in those 20 years of age and younger to >50% in those older than 35 years. Currently or previously married individuals were more likely to be seropositive than those never married, controlling for age (Mantel-Haenszel risk ratio = 1.8; 95% CI: 1.3, 2.6). Of the 905 anti-HCV-positive samples tested, 65% were also positive for HCV RNA. Active schistosomal infection was not associated with anti-HCV status; however, history of antischistosomal injection therapy (reported by 19% of anti-HCV positives) was a risk for anti-HCV (age-adjusted risk ratio = 1.3; 95% CI: 1.2, 1.5). This study, the largest community-based survey to date, supports earlier reports of high levels of anti-HCV among adults in rural areas of Egypt, although many of those who are seropositive will not have active liver disease. The large reservoir of HCV infection in the community provides an opportunity to investigate risk factors for transmission, the natural history of infection and effectiveness of preventive methodologies, and raises concern about the prospect of an increasing incidence of chronic liver disease in the coming decades.

Hepatitis C epidemiology

Hepatitis C virus infection occurs in all parts of the world. Infection is generally due to percutaneous exposures, though sexual and perinatal transmission may occur. While further study is needed to elucidate the biology of HCV transmission and develop vaccines for prevention, new HCV infections can be reduced by economic development and education regarding blood-borne infections.

[Detection of hepatitis C virus antibodies in a pool of 5 sera: their use in seroepidemiologic studies]

In order to evaluate the reduction in the cost of testing for antibodies against hepatitis C (EIA) by the pool method, we tested serum samples from a rural population and from patients in a hemodialysis program. Two thirds of the high risk groups were positive. Pooling reduced the reagent use by 80% in the rural population and by 13% in the hemodialysis patients. We conclude that pool testing reduces the cost of anti-HCV detection in low-risk groups.

Assay for hepatitis C virus in peripheral blood mononuclear cells enhances sensitivity of diagnosis and monitoring of HCV-associated hepatitis

Hepatitis C virus (HCV) is a major etiological factor in chronic hepatitis affecting up to 24% of blood donors in Egypt. Since fluctuating levels of HCV RNA loads, including undetectable values, have been frequently observed in sera of chronic hepatitis patients, this study was designed to assess the sensitivity of PCR amplification for the plus- and minus-RNA strands in peripheral blood mononuclear cells (PBMC) compared to single serum PCR assay. Since the latter test detects viremia in only 79.5% of seropositive cases, the highest sensitivity for HCV diagnosis was achieved (93.20% when applying the combined triple test including PCR amplification of plus-strand in serum, together with plus-strand in PBMC and minus-strand in PBMC. The results of this study indicate that the triple test provides significant information on extrahepatic replication of HCV in a sizable sample of seropositive subjects (429 cases) and improves the assessment of HCV viremia. The cost/effectiveness and speed were upgraded by using capillary/air rapid thermal cycler. The use of the triple assay in HCV diagnosis and post-therapy monitoring is recommended.

The relationship between hepatitis C virus and schistosomiasis: histopathologic evaluation of liver biopsy specimens

The reported high incidence of anti-HCV seropositivity in the Egyptian population seems surprising. Some suggest that schistosomiasis is the responsible factor, either by producing false positivity for HCV antibodies or by predisposing to actual HCV infection in some way. In an attempt to investigate this unclear relationship on a histological level, we performed a thorough semiquantitative morphological study of liver biopsy specimens from 44 anti-HCV-positive Egyptian patients with chronic liver disease. More than half of these patients (23) had serological evidence of schistosomiasis. The results have shown that all 44 liver biopsy specimens demonstrated the histopathological features known to be characteristic of chronic HCV hepatitis. Statistical analysis showed no significant difference between the schistosomal and nonschistosomal groups regarding the semiquantitative histological scores of these features. This study confirms the presence of definite HCV-induced hepatic pathology in all anti-HCV seropositive cases. More importantly, it shows the lack of enhancement of this pathology in the schistosomal patients.

The prevalence of hepatitis B and C infections among immigrants to a newly reclaimed area endemic for Schistosoma mansoni in Sinai, Egypt

Serology for hepatitis B and C markers was performed on a community-based random sample of 506 residents of an area recently reclaimed from the desert and endemic for Schistosoma mansoni. The mean age of the study subjects was (20 +/- 14), and 52% were males. The overall seroprevalence of hepatitis B (Anti-HBc and/or HBsAg) was 19.6%, hepatitis C (Anti-HCV) was 10.3%, while 5% were positive for both hepatitis B and C. A strong association was present with increasing age for both hepatitis B and C markers. However, there was no association with either sex, S. mansoni infection or schistosomal periportal fibrosis. Also HBV seropositivity was not associated with increased risk of HCV seropositivity. Anti-HCV seropositivity was significantly associated with previous parenteral treatment for schistosomiasis (OR = 7.9), and with history of previous surgery (OR = 3). Hepatitis B and C are major public health problems in this population. It is recommended to consolidate the Egyptian programme of infant hepatitis B vaccination, and to extend it to older children and high risk adult groups. There is also an urgent need to study more closely the epidemiology, natural history, risk factors and modes of transmission of hepatitis C.

Unexpected high prevalence of hepatitis C virus genotype 4 in Southern Spain

BACKGROUND/AIMS

A unusually high rate of HCV-infected individuals in whom the HCV genotype cannot be ascertained by means of single PCR and LIPA procedures has recently been reported in our area. The aim of the present study was to investigate the epidemiological, clinical and molecular characteristics of these patients.

METHODS

Cross-sectional study. Eighty anti-HCV-positive patients with chronic liver disease, 45 (56.25%) of them intravenous drug users, were included. HCV genotyping was carried out in all patients using commercial single PCR and LIPA procedures. Samples where no HCV RNA amplification and/or indeterminate HCV genotype were found were also tested by means of a nested PCR. HCV viral load was measured in all patients.

RESULTS

HCV genotyping was not achieved in 23 (28.75%) individuals. No amplification of HCV RNA was found in 19 of them, and in four other cases the LIPA procedure did not allow identification of a distinct HCV genotype. After the use of nested PCR+LIPA, it was found that the HCV genotype 4 was found in 11 of those 23 individuals (47.82%). Ten of these 11 HCV genotype 4-harboring individuals were intravenous drug users. The HCV viral load was lower in HCV genotype 4-harboring individuals than in those whom the genotypes 1, 2 or 3 were found (p<0.001).

CONCLUSIONS

A high rate of HCV genotype 4-harboring cases has been found among HCV-infected individuals in Southern Spain. Had only single PCR been used, these individuals could have been wrongly regarded as non-viremic.

Interferon therapy for chronic HCV hepatitis: trick or treat?

Chronic hepatitis caused by the hepatitis C virus (HCV) is a common condition that leads to cirrhosis and hepatocellular carcinoma. Current treatment with interferon is unsatisfactory, with a low percentage of patients who respond and uncertain high-term significance; in addition, it is associated with sometimes severe side effects. The increasing sophistication of molecular biology has enabled viral characteristics such as viral load, genotypes, and quasi-species to be identified, which may help predict a patient's response to interferon treatment. We suggest that interferon therapy for hepatitis C virus should be restricted to referral centers in the context of controlled trials.

Hepatitis C antibody prevalence in blood donors in different governorates in Egypt

Markers of hepatitis B virus (HBV) and hepatitis C virus (HCV) infections were sought in serum samples from 2644 blood donors in 24 of Egypt's 26 governorates. Of the 2644 samples, 656 (24.8%) were shown to contain anti-HCV immunoglobulin G antibody by Abbott second generation enzyme immunoassays (EIA). Of 85 EIA-positive samples tested by recombinant immunoblot assay, 72 (85%) were positive. HCV seroprevalence in the governorates ranged from zero to 38%; 15 governorates (62%) had an HCV antibody prevalence greater than 20%, and 6 (25%) greater than 30%. Governorates with higher sero-prevalences were located in the central and north-eastern Nile river delta, and south of Cairo in the Nile river valley. Subjects from areas in and adjoining the Sinai peninsula, in the eastern and western desert, and in southernmost Egypt, had the lowest prevalence of HCV antibody. The large urban governorates of Cairo and Alexandria had antibody prevalences of 19% and 11%, respectively. A total of 39.4% subjects had evidence of HBV infection (and-HBV core antigen total antibody). HCV infections were detected more frequently in donors with markers for HBV infections than in uninfected subjects (36% versus 18%, P < 0.001).