Changing epidemiology of parenterally transmitted viral hepatitis: results from the hepatitis surveillance system in Italy

Trends in chronic hepatitis B virus infection in Italy over a 10-year period: Clues from the nationwide PITER and MASTER cohorts toward elimination

OBJECTIVES

The study measures trends in the profile of patients with chronic hepatitis B virus linked to care in Italy.

METHODS

A cross-sectional, multicenter, observational cohort (PITER cohort) of consecutive patients with hepatitis B surface antigen (HBsAg) over the period 2019-2021 from 46 centers was evaluated. The reference was the MASTER cohort collected over the years 2012-2015. Standard statistical methods were used.

RESULTS

The PITER cohort enrolled 4583 patients, of whom 21.8% were non-Italian natives. Compared with those in MASTER, the patients were older and more often female. The prevalence of hepatitis B e antigen (HBeAg) declined (7.2% vs 12.3; P <0.0001) and that of anti-hepatitis D virus (HDV) remained stable (9.3% vs 8.3%). In both cohorts, about 25% of the patients had cirrhosis, and those in the PITER cohort were older. HBeAg-positive was 5.0% vs 12.6% (P <0.0001) and anti-HDV positive 24.8% vs 17.5% (P <0.0017). In the logistic model, the variables associated with cirrhosis were anti-HDV-positive (odds ratio = 10.08; confidence interval 7.63-13.43), age, sex, and body mass index; the likelihood of cirrhosis was reduced by 40% in the PITER cohort. Among non-Italians, 12.3% were HBeAg-positive (vs 23.4% in the MASTER cohort; P <0.0001), and 12.3% were anti-HDV-positive (vs 11.1%). Overall, the adherence to the European Association for the Study of the Liver recommendations for antiviral treatment increased over time.

CONCLUSION

Chronic hepatitis B virus infection appears to be in the process of becoming under control in Italy; however, HDV infection is still a health concern in patients with cirrhosis and in migrants.

Hepatitis C Virus Infection in Eastern Libya: Efforts Needed to Improve HCV Testing and Linkage to Care in the Resource-Limited Setting

Hepatitis C virus (HCV) is a significant public health problem, and the elimination of its infection by 2031 is a global goal. However, due to insufficient testing, lack of linkage to care (LTC) and treatment, Libya may be far from achieving this goal. This study aimed to explore HCV testing, the care and treatment of infected people, and to assess the burden of the infection among individuals who visited the main Medical Centre in Tobruk region, eastern Libya, for various medical and surgical conditions. A research team interviewed public health officials in Tobruk Medical Center, inspected available equipment, and obtained data available for people who were positive for antibodies to HCV (anti-HCV) as part of their routine pre-invasive procedures and pre-donation screening tests from January 2005 to April 2020. HCV antibody tests were positive for 612 cases out of 368,392 (0.17%). Of those who tested positive for anti-HCV antibodies, no one had followed up by RNA test for identifying individuals with chronic HCV infection, and there are no links to outpatient care and treatment. Our findings highlight the critical need for an up-to-date HCV diagnosis and linkage to care guidelines, which includes a follow-up RNA test for anti-HCV positive patients and early linkage to care for confirmed cases to accelerate the elimination of HCV infection from the community.

Hepatitis B virus recurrence after liver transplantation: An old tale or a clear and present danger?

Hepatitis B virus (HBV) recurrence after liver transplantation (LT) has been described more than 50 years ago. Similarly, to other clinical conditions, in which impairment of host immune defense favors viral replication, early reports described in details recurrence and reactivation of HBV in liver transplant recipients. The evidence of a possible, severe, clinical evolution of HBV reappearance in a significant percentage of these patients, allowed to consider, for some years, HBV positivity a contraindication for LT. Moving from the old to the new millennium this picture has changed dramatically. Several studies contributed to establish efficient prophylactic protocols for HBV recurrence and with the advent of more potent anti-viral drugs an increased control of infection was achieved in transplanted patients as well as in the general immune-competent HBV population. Success obtained in the last decade led some authors to the conclusion that HBV is now to consider just as a “mere nuisance”. However, with regard to HBV and LT, outstanding issues are still on the table: (1) A standard HBV prophylaxis protocol after transplant has not yet been clearly defined; (2) The evidence of HBV resistant strains to the most potent antiviral agents is claiming for a new generation of drugs; and (3) The possibility of prophylaxis withdrawal in some patients has been demonstrated, but reliable methods for their selection are still lacking. The evolution of LT for HBV is examined in detail in this review together with the description of the strategies adopted to prevent HBV recurrence and their pros and cons.

Low prevalence of hepatitis B and hepatitis C virus serum markers in a cohort of pregnant women from Southern Italy

BACKGROUND

Mother-to-child transmission is still considered a major factor in the spread of hepatitis viruses. Nevertheless, epidemiological data on hepatitis B virus (HBV) and hepatitis C virus (HCV) in reproductive-age women are limited even in areas like the South of Italy where both viruses had been widespread.

AIM

The aim of this study was to investigate the prevalence of HBV and HCV serum markers in a large cohort of pregnant women from Southern Italy.

METHODS

Data concerning 7558 pregnant women consecutively admitted to an Obstetric Division of a Sicilian University Hospital over a six-year period (January 2010-December 2015) were retrospectively collected from clinical notes.

RESULTS

Positivity for both HBV s-antigen (HBsAg) and antibodies to HCV (anti- HCV) was very low (0.5% and 0.2%, respectively). HBsAg prevalence was significantly higher in non-Italian than in Italian women (p<0.001). On the contrary, all the anti-HCV positive cases were of Italian origin. Age was not significantly different between positive and negative women.

CONCLUSION

These results confirm the dramatic decline of HBV and HCV prevalence that recently occurred in Southern Italy, and highlight the importance and cost-effectiveness of systematic HBV and HCV screening in childbearing age women in order to properly apply the available preventive measures and definitively eliminate the risk of vertical transmission for both viruses.

Re-examining blood donor deferral criteria relating to injecting drug use

BACKGROUND AND AIMS

Potential Australian blood donors are deferred indefinitely if they report a history of injecting drug use (IDU), or for 12 months if they report having engaged in sexual activity with someone who might have ever injected. Given incremental improvements in blood safety, this study sought to examine whether Australia's IDU-related eligibility criteria reflected current scientific evidence, were consistent with international best practice and, if current IDU-related policies were to be changed, how this should happen.

METHODS

An expert committee was formed to review relevant literature with a focus on issues including: the epidemiology of IDU in Australia and key transfusion-transmissible infections (TTIs) among Australian people who inject drugs (PWID); and, 'non-compliance' among PWID regarding IDU-related blood donation guidelines. International policies relating to blood donation and IDU were also reviewed. Modelling with available data estimated the risk of TTIs remaining undetected if the Blood Service's IDU-related guidelines were changed.

RESULTS

Very few (<1%) Australians engage in IDU, and IDU risk practices are reported by only a minority of PWID. However, the prevalence of HCV remains high among PWID, and IDU remains a key transmission route for various TTIs. Insufficient data were available to inform appropriate estimates of cessation and relapse among Australian PWID. Modelling findings indicated that the risk of not detecting HIV becomes greater than the reference group at a threshold of non-admission of being an active PWID of around 1.8% (0.5-5.1%). Excluding Japan, all Organisation for the Economic Co-operation and Development member countries permanently exclude individuals with a history of IDU from donating.

CONCLUSION

Numerous research gaps meant that the study's expert Review Committee was unable to recommend altering Australia's current IDU-related blood donation guidelines. However, having identified critical knowledge gaps and future areas of research, the review made important steps toward changing the criteria.

Time trends of chronic HBV infection over prior decades - A global analysis

BACKGROUND & AIMS

Information on trends in chronic hepatitis B virus (HBV) prevalence across countries is lacking. We studied changes in chronic HBV infection over previous decades by country, and assessed patterns of change between and within WHO-defined regions.

METHODS

Based on data from a published systematic review on chronic HBV, we applied a linear model on the logit scale to assess time trends in country-specific prevalence. Estimated HBsAg prevalence in 2000 and relative changes in prevalence over time were evaluated by country and region.

RESULTS

Sufficient data were available for 50 countries, mostly showing reductions in prevalence over time. Various degrees of heterogeneity were observed within regions, with a relatively homogenous pattern in the Eastern Mediterranean region with strong decreases in HBsAg prevalence. Europe showed a mixed pattern: higher and stable chronic HBsAg prevalence in Eastern, and constantly low prevalence in Western Europe. In Africa, some countries demonstrated no change in prevalence; increases were seen in Uganda (odds ratio 1.05 per year; 95% confidence interval 1.04-1.06), Nigeria (1.02; 1.02-1.02), Senegal (1.01; 1.01-1.02), and South Africa (1.02; 1.01-1.02). With some exceptions, country-patterns overlapped among countries of South East Asian and Western Pacific regions, characterized by low-medium HBsAg decreases, most prominent in China and Malaysia.

CONCLUSIONS

Most countries experienced decreases in HBsAg prevalence. Dynamics varied, even within regions; decreases occurred mostly before the direct effects of childhood vaccination may have manifested. These findings together with stable and increasing HBsAg prevalence in some countries of Africa and Eastern Europe indicate the need for further tailored country-specific prevention.

LAY SUMMARY

This study investigated time trends in prevalence of chronic HBV infection in 50 countries worldwide over the last decade, by estimating relative changes in prevalence. Results show decreases in chronic HBV infection in most countries; no changes or increases in prevalence are noted in some African countries. Reasons for time changes need to be investigated further; based on the results, various prevention measures have contributed to reductions, and further tailored HBV prevention is required to combat the disease on a global level.

Hepatitis C in the pediatric population: Transmission, natural history, treatment and liver transplantation

The number of children affected by the hepatitis C virus (HCV) in the United States is estimated to be between 23000 to 46000. The projected medical cost for children with HCV in the United States is upwards of 200 million over the next decade. The implementation of routine screening of blood supply has virtually eliminated transmission via transfusion and vertical transmission is now the most common mode of infection in children. Infections acquired during infancy are more likely to spontaneously resolve and fibrosis of the liver tends to increase with age suggesting slow progressive histologic injury. Anti-viral treatment may be warranted in children with persistently elevated liver enzymes or with significant fibrosis on liver biopsy. Current standard of care includes weekly pegylated interferon and ribavirin twice daily. Predictors of high sustained viral response include genotype 2 and 3 and low viral load in children with genotype 1 (< 600000 IU/mL). Triple therapy is associated with a significantly higher rate of sustained virologic response (> 90%). Only 34 pediatric patients were transplanted with hepatitis C between January 2008 and April 2013. The majority of pediatric patients were born prior to universal screening of blood products and, as of June 2013, there are only two pediatric patients awaiting liver transplantation for end-stage liver disease secondary to hepatitis C. Pediatric survival rates post-transplant are excellent but graft survival is noticeably reduced compared to adults (73.73% for pediatric patients at one year compared to 87.69% in adult patients). New safe potent, and all-oral effective antiviral therapies for recurrent HCV should help increase graft survival.

Epidemiology of acute and chronic hepatitis B and delta over the last 5 decades in Italy

The spread of hepatitis B virus (HBV) infection has gradually decreased in Italy in the last 5 decades as shown by the steady reduction in the incidence rates of acute hepatitis B, from 10/100000 inhabitants in 1984 to 0.85/100000 in 2012, and by the reduced prevalence of hepatitis B surface antigen (HBsAg)-positive cases among chronic hepatitis patients with different etiologies, from 60% in 1975 to about 10% in 2001. The prevalence of HBsAg chronic carriers in the general population also decreased from nearly 3% in the 1980s to 1% in 2010. Linked to HBV by its characteristics of defective virus, the hepatitis delta virus (HDV) has shown a similar epidemiological impact on the Italian population over time. The incidence of acute HDV infection decreased from 3.2/100000 inhabitants in 1987 to 0.8/100000 in 2010 and the prevalence of HDV infection in HBsAg chronic carriers decreased from 24% in 1990 to 8.5% in 2006. Before the beneficial effects of HBV mass vaccination introduced in 1991, the decreased endemicity of HBV and HDV infection in Italy paralleled the improvement in screening blood donations, the higher standard of living and impressive reduction in the birth rate associated with a marked reduction in the family size. A further contribution to the decline in HBV and HDV infections most probably came from the media campaigns to prevent the spread of human immunodeficiency virus infection by focusing the attention of the general population on the same routes of transmission of viral infections such as unsafe sexual intercourse and parenteral exposures of different kinds.

Hepatitis C virus genotype distribution in Egyptian diabetic patients: a preliminary study

BACKGROUND AND STUDY AIMS

There is controversy regarding whether a specific hepatitis C virus (HCV) genotype is associated with diabetes mellitus. This study aimed to investigate HCV genotype distribution in diabetics and its relation to some clinical and laboratory variables in HCV-positive diabetic versus non-diabetic Egyptians in East Delta.

PATIENTS AND METHODS

The study included 100 HCV-positive patients of which 66 were diabetic in addition to 35 healthy adults as a control group. Clinical assessment, laboratory measurements of plasma glucose, insulin, C-peptide, C-reactive protein (CRP), tumour necrosis factor-α (TNF-α) and liver functions (alanine aminotransferase (ALT), aspartate aminotransferase (AST) and gamma-glutamyltransferase (GGT)) as well as HCV genotype determination were done, and AST/platelet ratio index (APRI) and Homoeostasis Model of Assessment-Insulin Resistance (HOMA-IR) were calculated.

RESULTS

The main results were the presence of HCV genotype 3, in 31.8% of the diabetic group and in 26.5% of the non-diabetic group, while the remainder of cases had genotype 4, the predominant genotype in Egypt. This is the first report of the presence of HCV genotype 3 in about 30% of an Egyptian cohort. However, there was no significant difference in genotype distribution between both groups. Further, there were significantly higher values of HOMA-IR, insulin and C-peptide in HCV-positive groups in comparison to the control group, while TNF-α was significantly higher in the HCV-positive diabetic group. However, there were no significant differences between both genotypes regarding these parameters.

CONCLUSION

Although this study reveals for the first time the presence of HCV genotype 3 in a significant percentage of a group of Egyptian patients, where the majority were diabetic, the association between diabetes and certain HCV genotypes could not be confirmed on the basis of our findings. Hence, taking into consideration the impact of such a finding on the treatment decisions of those patients, further studies are warranted to explore these findings to a greater extent.

Hepatitis C in the elderly: a multicentre cross-sectional study by the Italian Association for the Study of the Liver

BACKGROUND

The prevalence of hepatitis C virus infection increases with advancing age, but elderly hepatitis C virus patients remain an understudied population.

AIM

To define the virological, epidemiological and clinical profiles of Italian outpatients aged 65 years and over infected by hepatitis C virus.

METHODS

We evaluated 1544 anti-hepatitis C virus positive patients aged ≥65 years referred to 34 Italian outpatient specialty clinics over a two-year period.

RESULTS

The study population included 1134 (73%) early elderly (65-74 years) and 410 (27%) late elderly patients (≥75 years). Late elderly subjects were less likely to have their virus genotyped, their viral load assessed or a histological evaluation of liver disease. Overall, 30% of patients had advanced liver disease whose prevalence increased with increasing age. In both age groups, about 40% of patients had normal transaminase levels. Excluding patients with past infection, 51% had not received any antiviral treatment and only 25% were treated after the age of 65. Late elderly patients, women and patients with advanced liver diseases had been less frequently treated. The main reason for exclusion from treatment was age followed by the presence of comorbid conditions.

CONCLUSIONS

Elderly hepatitis C virus patients referred to Italian specialty clinics have advanced and underestimated liver disease. Nevertheless, they are progressively understudied in parallel with increasing age.

Incidence analyses and space-time cluster detection of hepatitis C in Fujian Province of China from 2006 to 2010

BACKGROUND

There is limited epidemiologic information about the incidence of hepatitis C in China, and few studies have applied space-time scan statistic to detect clusters of hepatitis C and made adjustment for temporal trend and relative risk of regions.

METHODOLOGY AND PRINCIPAL FINDINGS

We analyzed the temporal changes and characteristics of incidence of hepatitis C in Fujian Province from 2006 through 2010. The discrete Poisson model of space-time scan statistic was chosen for cluster detection. Data on new cases of hepatitis C were obtained from the Center for Disease Control and Prevention of Fujian Province. Between 2006 and 2010, there was an annualized increase in the incidence of hepatitis C of 23.0 percent, from 928 cases (2.63 per 100,000 persons) to 2,180 cases (6.01 per 100,000 persons). The incidence among women increased more rapidly. The cumulative incidence showed that people who were over 60 years had the highest risk to suffer hepatitis C (52.51 per 100,000 persons), and women had lower risk compared to men (OR=0.69). Putian had the highest cumulative incidence among all the regions (86.95 per 100,000 persons). The most likely cluster was identified in Putian during March to August in 2009 without adjustment, but it shifted to three contiguous cities with a two-month duration after adjustment for temporal trend and relative risk of regions.

CONCLUSIONS/SIGNIFICANCE

The incidence of hepatitis C is increasing in Fujian Province, and women are at a more rapid pace. The space-time scan statistic is useful as a screening tool for clusters of hepatitis C, with adjustment for temporal trend and relative risk of regions recommended.

Identifying newly acquired cases of hepatitis C using surveillance: a literature review

Surveillance of newly acquired hepatitis C virus (HCV) infection is crucial for understanding the epidemiology of HCV and informing public health practice. However, monitoring such infections via surveillance systems is challenging because they are commonly asymptomatic. A literature review was conducted to identify methodologies used by HCV surveillance systems to identify newly acquired infections; relevant surveillance systems in 15 countries were identified. Surveillance systems used three main strategies to identify newly acquired infections: (1) asking physicians to classify cases; (2) identifying symptomatic cases or cases with elevated alanine aminotransferases; and (3) identifying cases with documented evidence of anti-HCV antibody seroconversion within a specific time-frame. Case-ascertainment methods varied with greater completeness of data in enhanced compared to passive surveillance systems. Automated systems that extract and link testing data from multiple laboratory and clinic databases may provide an opportunity for collecting testing histories for individuals that is less resource intensive than enhanced surveillance.

HBV and HCV infection in type 2 diabetes mellitus: a survey in three diabetes units in different Italian areas

Viral infections and the metabolic syndrome may coexist in several individuals, due to the large prevalence of obesity and type 2 diabetes mellitus (T2DM). Antiviral therapy has changed the natural history of chronic viral hepatitis, but viral infection may remain undiagnosed in the absence of systematic screening. We determined the prevalence of HBV and/or HCV infection in an Italian cohort with T2DM (859 consecutive patients, 413 females) in three Italian centers: Turin, Bologna, and Naples. Screening for viral disease was coupled with the determination of parameters of metabolic syndrome. Fourteen patients were HBsAg-positive, 51 anti-HCV with a prevalence of genotype-1 infection in 58% of cases. Thirty cases had newly diagnosed viral markers, only one-third had already-diagnosed liver disease, 16 were being followed-up by a Liver Unit, and 9 cases had received antiviral treatment. Patients with viral markers had higher liver enzyme levels in comparison with virus-negative patients (P < 0.0001), whereas the prevalence of the metabolic syndrome was similar in the 2 groups. A positive correlation between BMI and alanine aminostransferase levels was only present in virus-negative cases, where the probability of enzyme levels above the upper limit of normal increased by 5% for unit of increase in BMI (OR: 1.05; 95% CI: 1.003-1.100, P = 0.037). In conclusion, the prevalence of HBV and HCV is non-negligible in patients with T2DM, but these cases may long remain undiagnosed. Elevated liver enzymes might be frequently disregarded in diabetes Units and ascribed to metabolic syndrome, thus excluding T2DM patients from specific disease-modifying antiviral treatment for hepatitis.

Hepatitis B virus and sexual behavior in Rakai, Uganda

HIV and hepatitis B virus (HBV) co-infection poses important public health considerations in resource-limited settings. Demographic data and sera from adult participants of the Rakai Health Sciences Program Cohort in Southwestern Uganda were examined to determine HBV seroprevalence patterns in this area of high HIV endemicity prior to the introduction of anti-retroviral therapy. Commercially available EIAs were used to detect prevalent HBV infection (positive for HBV core antibody [anti-HBc] and/or positive HBV surface antigen [HBsAg]), and chronic infection (positive for HBsAg). Of 438 participants, 181 (41%) had prevalent HBV infection while 21 (5%) were infected chronically. Fourteen percent of participants were infected with HIV. Fifty three percent showed evidence of prevalent HBV infection compared to 40% among participants infected with HIV (P = 0.067). Seven percent of participants infected with HIV were HBsAg positive compared to 4% among participants not infected with HIV (P = 0.403). The prevalence of prevalent HBV infection was 55% in adults aged >50 years old, and 11% in persons under 20 years. In multivariable analysis, older age, HIV status, and serologic syphilis were significantly associated with prevalent HBV infection. Transfusion status and receipt of injections were not significantly associated with HBV infection. Contrary to expectations that HBV exposure in Uganda occurred chiefly during childhood, prevalent HBV infection was found to increase with age and was associated sexually transmitted diseases (HIV and syphilis.) Therefore vaccination against HBV, particularly susceptible adults with HIV or at risk of HIV/STDs should be a priority.

Health care risk factors among women and personal behaviours among men explain the high prevalence of hepatitis C virus infection in Karachi, Pakistan

To estimate the prevalence and identify factors associated with hepatitis C virus (HCV) infection among men and women in Karachi, Pakistan. We conducted a cross-sectional study of adult men and women in a peri-urban community of Karachi (Jam Kandah). Households were selected through systematic sampling from within all villages in the study area. All available adults within each household were interviewed about potential HCV risk factors. A blood specimen was collected to test for anti-HCV antibodies by enzyme immunoassay. We used generalized estimating equations while accounting for correlation of responses within villages to identify the factors associated with HCV infection. Of 1997 participants, 476 (23.8%) were anti-HCV positive. Overall, HCV infection was significantly associated with increasing age, ethnicity, and having received > or =2 blood transfusions, > or =3 hospitalizations, dental treatment and >5 injections among women. Among women, > or =2 blood transfusions [adjusted odds ratio (aOR) = 2.32], >5 injections during the past 6 months (aORs = 1.47), dental treatment (aOR = 1.31) and increasing age(aOR = 1.49), while among men, extramarital sexual intercourse (aOR = 2.77), at least once a week shave from barber (aOR = 5.04), > or =3 hospitalizations (aOR = 2.50) and increasing age (aOR = 1.28) were associated with HCV infection. A very high prevalence of HCV was found in the study population. Among women, unsafe health care practices, while among men extramarital sex, shaving from a barber and hospitalizations were associated with HCV infection. Efforts are needed to improve the safety of medical procedures to reduce the transmission of HCV in Pakistan [Corrections made in Summary after initial online publication.].

The global spread of hepatitis C virus 1a and 1b: a phylodynamic and phylogeographic analysis

BACKGROUND

Hepatitis C virus (HCV) is estimated to affect 130-180 million people worldwide. Although its origin is unknown, patterns of viral diversity suggest that HCV genotype 1 probably originated from West Africa. Previous attempts to estimate the spatiotemporal parameters of the virus, both globally and regionally, have suggested that epidemic HCV transmission began in 1900 and grew steadily until the late 1980s. However, epidemiological data suggest that the expansion of HCV may have occurred after the Second World War. The aim of our study was to elucidate the timescale and route of the global spread of HCV.

METHODS AND FINDINGS

We show that the rarely sequenced HCV region (E2P7NS2) is more informative for molecular epidemiology studies than the more commonly used NS5B region. We applied phylodynamic methods to a substantial set of new E2P7NS2 and NS5B sequences, together with all available global HCV sequences with information in both of these genomic regions, in order to estimate the timescale and nature of the global expansion of the most prevalent HCV subtypes, 1a and 1b. We showed that transmission of subtypes 1a and 1b "exploded" between 1940 and 1980, with the spread of 1b preceding that of 1a by at least 16 y (95% confidence interval 15-17). Phylogeographic analysis of all available NS5B sequences suggests that HCV subtypes 1a and 1b disseminated from the developed world to the developing countries.

CONCLUSIONS

The evolutionary rate of HCV appears faster than previously suggested. The global spread of HCV coincided with the widespread use of transfused blood and blood products and with the expansion of intravenous drug use but slowed prior to the wide implementation of anti-HCV screening. Differences in the transmission routes associated with subtypes 1a and 1b provide an explanation of the relatively earlier expansion of 1b. Our data show that the most plausible route of the HCV dispersal was from developed countries to the developing world. Please see later in the article for the Editors' Summary.

Acute hepatitis C: prevention and treatment

HCV can cause acute or chronic hepatitis and is a health problem all over the world. It is one of the leading causes of cirrhosis and hepatocellular carcinoma, and is a common indication for liver transplantation. Unrecognized patients with HCV infection may transmit the virus to uninfected people. The acute form of the disease leads to chronic hepatitis in the majority of cases. Since the success rate of treatment given in the chronic phase is much lower than that given in the acute phase, recognizing acute hepatitis is critical. Although HCV is less prevalent since 1990s in the Western world after improved blood-donor screening programs, needle-exchange facilities and education among intravenous drug users, it is still endemic in some regions, including African countries, Egypt, Taiwan, China and Japan. Acute HCV infection may be a challenge for the clinician; since it is often asymptomatic, detection and diagnosis are usually difficult. After an incubation period of 7 weeks (2-12 weeks), only a minority of patients (10-15%) report symptoms. The spontaneous clearance of the virus is more frequent primarily during the first 3 months of clinical onset of the disease, but may occur anytime during the 6 months of acute infection. This spontaneous resolution seems to be more frequent in symptomatic cases. Viremia persisting more than 6 months is accepted as chronic infection. The virus is transmitted more frequently through infected blood or body fluids. Detection of antibodies against HCV is not a reliable method of diagnosing acute HCV infection since the appearance of antibodies against HCV can be delayed in up to 30% of patients at the onset of symptoms. Thus, the diagnosis of acute hepatitis C relies on the qualitative detection of HCV RNA, which may appear as early as 1-2 weeks after exposure quickly followed by highly elevated alanine aminotransferase. After a follow-up period of 8-12 weeks for allowing spontaneous resolution, treatment should be initiated. Pegylated interferon monotherapy for 24 weeks seems effective, and the therapy can be individualized according to the characteristics of the patient.

Different evolutionary rates and epidemic growth of hepatitis B virus genotypes A and D

The epidemiological history of HBV genotypes A and D and subgenotypes A2 and D3 was studied on 132 isolates drawn between 1980 and 2005 from patients living in a homogenous geographical area. Evolutionary rates and divergence dates were estimated and HBV demographic history was reconstructed by using a statistical approach based on coalescent theory. The evolutionary rate of A2 was significantly lower than that of D3. The growth rate of D3 epidemic was significantly faster than that of A2; both subgenotypes showed a decreasing growth rate from the mid-1980s. Our data suggest that the important discrepancies observed in the evolutionary rates of HBV genotypes A and D may reflect different population dynamics of their epidemics. These results show the usefulness of phylodynamic studies in reconstructing the history of epidemics due to highly variable DNA viruses, and in evaluating the long-term efficacy of prophylactic measures.

An assessment of the effect of hepatitis B vaccine in decreasing the amount of hepatitis B disease in Italy

Background

Hepatitis B (HBV) infection is an important cause of morbidity and mortality and it is associated to a higher risk of chronic evolution in infected children. In Italy the anti-HBV vaccination was introduced in 1991 for newborn and twelve years old children. Our study aims to evaluate time trends of HBV incidence rates in order to provide an assessment of compulsory vaccination health impact.

Method

Data concerning HBV incidence rates coming from Acute Viral Hepatitis Integrated Epidemiological System (SEIEVA) were collected from 1985 to 2006. SEIEVA is the Italian surveillance national system that registers acute hepatitis cases. Time trends were analysed by joinpoint regression using Joinpoint Regression Program 3.3.1 according to Kim's method. A joinpoint represents the time point when a significant trend change is detected. Time changes are expressed in terms of the Expected Annual Percent Change (EAPC) with 95% confidence interval (95% CI).

Results

The joinpoint analysis showed statistically significant decreasing trends in all age groups. For the age group 0–14 EAPC was -39.0 (95% CI: -59.3; -8.4), in the period up to 1987, and -12.6 (95% CI: -16.0; -9.2) thereafter. EAPCs were -17.9 (95% CI: -18.7; -17.1) and -6.7 (95% CI: -8.0; -5.4) for 15–24 and ≥25 age groups, respectively. Nevertheless no joinpoints were found for age groups 15–24 and ≥25, whereas a joinpoint at year 1987, before compulsory vaccination, was highlighted in 0–14 age group. No joinpoint was observed after 1991.

Discussion

Our results suggest that the introduction of compulsory vaccination could have contribute partly in decreasing HBV incidence rates. Compulsory vaccination health impact should be better investigated in future studies to evaluate the need for changes in current vaccination strategy.

Acute hepatitis C: a systematic review

INTRODUCTION

The annual incidence of acute hepatitis C virus (HCV) has fallen in recent years, primarily because of effective blood screening efforts and increased education on the dangers of needle sharing. However, hepatitis C infection is still relatively frequent in certain populations. Most patients infected with HCV are unaware of their exposure and remain asymptomatic during the initial stages of the infection, making early diagnosis during the acute phase (first 6 months after infection) unlikely. While some of those infections will have a spontaneous resolution, the majority will progress to chronic HCV. We scanned the literature for predictors of spontaneous resolution and treatment during the acute stage of HCV to identify factors that would assist in treatment decision making.

METHODS

A medical literature search through MEDLINE was conducted using the keyword "acute hepatitis C" with a variety of keywords focused on (a) epidemiology, (b) natural history and outcome, (c) diagnosis, (d) mode of transmission, and (e) treatment.

RESULTS

There are no reliable predictors for spontaneous resolution of HCV infection and a significant percentage of individuals exposed to HCV develop persistent infections that progress to chronic liver disease. An intriguing approach is to treat acute HCV and prevent the development of chronic hepatitis. Several clinical trials showed that treatment of hepatitis C infection during the acute phase is associated with high sustained virological response (SVR) rates ranging between 75% and 100%. Although there is a prevailing consensus that intervention during the acute phase is associated with improved viral eradication, relevant clinical questions have remained unanswered by clinical trials. Optimization of therapy for acute hepatitis C infection and identification of predictors of SVR represent a real challenge.

CONCLUSION

With more than 170 million chronic hepatitis C patients worldwide and an increase in the related morbidity and mortality projected for the next decade, an improvement in our ability to diagnose and treat patients with acute hepatitis C would have a significant impact on the prevalence of chronic hepatitis and its associated complications particularly in countries with a high endemic background of the infection.

Monitoring SCCA-IgM complexes in serum predicts liver disease progression in patients with chronic hepatitis

About 30% of the patients with chronic hepatitis develop a progressive liver disease and one of the most intriguing issues is the detection of noninvasive markers for fibrosis stage and disease progression. High levels of squamous cell carcinoma antigen (SCCA)-immunoglobulin M (IgM) are detectable in hepatocellular carcinoma and their increase in cirrhotic patients can predict tumour development. As SCCA-IgM can also be detectable at low percentages in patients with chronic hepatitis, the aim of this study was to assess SCCA-IgM complexes in relation to disease outcome in this group of patients. An ELISA assay was used to determine the presence of SCCA-IgM in 188 patients with chronic hepatitis and in 100 controls. An additional serum sample was available after a median period of 6 years in 57 untreated patients: these patients were subdivided in group A, including eight patients with a fibrosis score increase > or =2 in a second liver biopsy and group B, including 49 patients without fibrosis progression during a similar follow up. SCCA-IgM complexes were detectable in 63 of 188 (33%) patients but in none of the controls. A significant increase of SCCA-IgM levels over time was observed in patients with fibrosis progression (mean +/- SD: 117 +/- 200 U/mL/year), but not in those without histologic deterioration (mean +/- SD: -8.8 +/- 31 U/mL/year, P < 0.0001). In conclusion, monitoring SCCA-IgM levels over time appears a useful approach to identify patients with chronic hepatitis at higher risk for cirrhosis development.

Estimating past hepatitis C infection risk from reported risk factor histories: implications for imputing age of infection and modeling fibrosis progression

Background

Chronic hepatitis C virus infection is prevalent and often causes hepatic fibrosis, which can progress to cirrhosis and cause liver cancer or liver failure. Study of fibrosis progression often relies on imputing the time of infection, often as the reported age of first injection drug use. We sought to examine the accuracy of such imputation and implications for modeling factors that influence progression rates.

Methods

We analyzed cross-sectional data on hepatitis C antibody status and reported risk factor histories from two large studies, the Women's Interagency HIV Study and the Urban Health Study, using modern survival analysis methods for current status data to model past infection risk year by year. We compared fitted distributions of past infection risk to reported age of first injection drug use.

Results

Although injection drug use appeared to be a very strong risk factor, models for both studies showed that many subjects had considerable probability of having been infected substantially before or after their reported age of first injection drug use. Persons reporting younger age of first injection drug use were more likely to have been infected after, and persons reporting older age of first injection drug use were more likely to have been infected before.

Conclusion

In cross-sectional studies of fibrosis progression where date of HCV infection is estimated from risk factor histories, modern methods such as multiple imputation should be used to account for the substantial uncertainty about when infection occurred. The models presented here can provide the inputs needed by such methods. Using reported age of first injection drug use as the time of infection in studies of fibrosis progression is likely to produce a spuriously strong association of younger age of infection with slower rate of progression.

Epidemiology of hepatitis C virus infection

Globally, hepatitis C virus (HCV) has infected an estimated 130 million people, most of whom are chronically infected. HCV-infected people serve as a reservoir for transmission to others and are at risk for developing chronic liver disease, cirrhosis, and primary hepatocellular carcinoma (HCC). It has been estimated that HCV accounts for 27% of cirrhosis and 25% of HCC worldwide. HCV infection has likely been endemic in many populations for centuries. However, the wave of increased HCV-related morbidity and mortality that we are now facing is the result of an unprecedented increase in the spread of HCV during the 20th century. Two 20th century events appear to be responsible for this increase; the widespread availability of injectable therapies and the illicit use of injectable drugs.

Epidemiology of hepatitis C virus infection

Globally, hepatitis C virus (HCV) has infected an estimated 130 million people, most of whom are chronically infected. HCV-infected people serve as a reservoir for transmission to others and are at risk for developing chronic liver disease, cirrhosis, and primary hepatocellular carcinoma (HCC). It has been estimated that HCV accounts for 27% of cirrhosis and 25% of HCC worldwide. HCV infection has likely been endemic in many populations for centuries. However, the wave of increased HCV-related morbidity and mortality that we are now facing is the result of an unprecedented increase in the spread of HCV during the 20^th century. Two 20^th century events appear to be responsible for this increase; the widespread availability of injectable therapies and the illicit use of injectable drugs.

Transmission of hepatitis C virus by blood transfusions and other medical procedures: a global review

Hepatitis C virus (HCV) is a leading cause of chronic blood-borne infection and chronic liver disease. The global epidemic of HCV infection emerged in the second half of the 20th century, and several lines of evidence indicate that it was primarily triggered and fed iatrogenically by the increasing use of parenteral therapies and blood transfusion. In developed countries, the rapid improvement of healthcare conditions and the introduction of anti-HCV screening for blood donors have led to a sharp decrease in the incidence of iatrogenic hepatitis C, but the epidemic continues to spread in developing countries, where the virus is still transmitted through unscreened blood transfusions and non-sterile injections. This article reviews the published literature concerning HCV transmission through blood transfusions and other unsafe medical procedures. Given the substantial difference in current disease transmission patterns between the northern and southern hemispheres, the situation in developed and developing countries is separately analysed.

Changing prevalence, clinical features, and outcome of acute hepatitis in Spain (1982-2003)

BACKGROUND

Diagnostic and preventive measures have contributed to a change in the epidemiology of acute hepatitis. The purpose of the present paper was to assess the changing prevalence of acute hepatitis from 1982 to 2003.

METHODS

Trends in the epidemiology, clinical findings, and outcome of acute viral hepatitis from 1982 to 2003 were examined. A total of 548 episodes of acute hepatitis diagnosed between 1982 and 2003, the clinical course of which was monitored up to the year 2003, were included. Annual changes as well as for the intervals 1982-1992 and 1993-2003 were compared.

RESULTS

Severe infections occurred in 1.3% of cases, with a mortality of 0.6%, with progression into chronicity in 25.1%. The annual incidences of acute hepatitis and the comparative intervals 1982-1992 and 1993-2003 showed a decline of parenterally -B, delta and C virus- transmitted infections, unchanged number of cases of acute hepatitis A, an increase in the number of cases of drug-induced hepatitis, increase in median ages, and a decrease in the proportion of hepatitis in injecting drug users. Ages of patients with hepatitis A tended to increase.

CONCLUSIONS

A decline of parenterally transmitted acute hepatitis was documented throughout a 22-year period, while the number of cases of hepatitis A was unchanged and that of drug-induced hepatitis increased. Evaluation of the current targeted hepatitis A vaccination approach and adequate pharmacovigilance measures are required in the near future.

Epidemiology of viral hepatitis and HIV co-infection

Worldwide, hepatitis B virus (HBV) accounts for an estimated 370 million chronic infections, hepatitis C virus (HCV) for an estimated 130 million, and HIV for an estimated 40 million. In HIV-infected persons, an estimated 2-4 million have chronic HBV co-infection and 4-5 million have HCV co-infection. HBV, HCV and HIV share common routes of transmission, but they differ in their prevalence by geographic region and the efficiency by which certain types of exposures transmit them. Among HIV-positive persons studied from Western Europe and the USA, chronic HBV infection has been found in 6-14% overall, including 4-6% of heterosexuals, 9-17% of men who have sex with men (MSM), and 7-10% of injection drug users. HCV infection has been found in 25-30% of HIV-positive persons overall; 72-95% of injection drug users, 1-12% of MSM and 9-27% of heterosexuals. The characteristics of HIV infected persons differ according to the co-infecting hepatitis virus, their epidemiologic patterns may change over time, and surveillance systems are needed to monitor their infection patterns in order to ensure that prevention measures are targeted appropriately.

Rapid quantification of semen hepatitis B virus DNA by real-time polymerase chain reaction

AIM: To examine the sensitivity and accuracy of real-time polymerase chain reaction (PCR) for the quantification of hepatitis B virus (HBV) DNA in semen.

METHODS: Hepatitis B viral DNA was isolated from HBV carriers’ semen and sera using phenol extraction method and QIAamp DNA blood mini kit (Qiagen, Germany). HBV DNA was detected by conventional PCR and quantified by TaqMan technology-based real-time PCR (quantitative polymerase chain reaction (qPCR)). The detection threshold was 200 copies of HBV DNA for conventional PCR and 10 copies of HBV DNA for real time PCR per reaction.

RESULTS: Both methods of phenol extraction and QIAamp DNA blood mini kit were suitable for isolating HBV DNA from semen. The value of the detection thresholds was 500 copies of HBV DNA per mL in the semen. The viral loads were 7.5 × 10⁷ and 1.67 × 10⁷ copies of HBV DNA per mL in two HBV infected patients’ sera, while 2.14 × 10⁵ and 3.02 × 10⁵ copies of HBV DNA per mL in the semen.

CONCLUSION: Real-time PCR is a more sensitive and accurate method to detect and quantify HBV DNA in the semen.

Global epidemiology of hepatitis C virus infection

Hepatitis C virus (HCV) is a major cause of liver disease worldwide and a potential cause of substantial morbidity and mortality in the future. The complexity and uncertainty related to the geographic distribution of HCV infection and chronic hepatitis C, determination of its associated risk factors, and evaluation of cofactors that accelerate its progression, underscore the difficulties in global prevention and control of HCV. Because there is no vaccine and no post-exposure prophylaxis for HCV, the focus of primary prevention efforts should be safer blood supply in the developing world, safe injection practices in health care and other settings, and decreasing the number of people who initiate injection drug use.

Correlation between histologic staging, hepatitis C virus genotypes and clinical features in HCV chronic hepatitis: evidence of a new pattern

Genome heterogeneity may be related to the wide variability of clinical and pathological features in hepatitis C virus (HCV)-related chronic liver disease. This paper addresses the possible association between HCV subtypes and clinical and histological features of chronically infected patients. Sixty-eight consecutive liver biopsies of chronic hepatitis constituted the basis of the study. HCV genotyping was performed on frozen tissue. Grading of necroinflammatory activity and staging of fibrosis were histologically assessed. Serologic HCV-RNA and liver function were assessed at the same time. All information was compared with clinical data including age, sex, HCV serology, and probable data and route of infection. Two cases were excluded as inadequate tissue was available. Five cases were negative to HCV-RNA in both serum and tissue. In 61 cases HCV RNA was present at the same time in serum and liver tissue. Forty-four patients were men (72%) and 17 (28%) were women. Two peaks of age were observed: 1 in the 4th decade of life, the 2nd in the 7th. The 2 groups had different HCV genotypes. Patients with genotypes 1b (mean age 50.7 years), 2c (mean age 61.3 years), and a subgroup of coinfections (mean age 60 years) were older than patients with genotypes 1a (mean age 35.5 years), 3 (mean age 36 years), and a subgroup of coinfections (mean age 33 years). Patients with genotypes 1b, 2, or 2c and a subgroup of coinfections more frequently had a history of blood transfusion and or surgical intervention dating up to 49 years previously. Patients with HCV 1a, 3, and a subgroup of coinfections frequently admitted a period of intravenous drug abuse. Patients with advanced liver disease, i.e., severe fibrosis and cirrhosis, showed the same 2 peaks of incidence: in the 4th and 7th decades of life, the first group mainly comprising patients with HCV types 1a and 3, the second, patients with HCV types 1b and 2c. Both these groups shared a clinical history of a long-standing infection. Two profiles of patients emerged. The largest group was composed of elderly patients, infected by HCV genotypes 1b or 2c, with a history of blood transfusion and/or surgery, presenting an advanced stage of liver disease (namely, severe fibrosis or cirrhosis). The second group was composed of younger patients, mainly in the 4th decade of life, infected by HCV types 3 or 1a, often presenting with chronic hepatitis in the stage of severe fibrosis or cirrhosis. The latter could be the profile of HCV infection in the near future.

Case fatality rate of acute viral hepatitis in Italy: 1995-2000. An update

BACKGROUND

Fulminant hepatic failure is the most serious complication of viral hepatitis. Although this event occurs rarely, it may be fatal.

AIMS

To evaluate the case fatality rate (several deaths divided by number of cases x 100) for each viral hepatitis type in Italy from 1995 to 2000.

PATIENTS

Acute hepatitis cases identified by the surveillance system for acute viral hepatitis, which covers approximately 58% of the Italian population.

RESULTS

Twenty-five deaths (0.1%) occurred among the 18 460 acute viral hepatitis cases observed from 1995 to 2000, a rate threefold lower than the 0.3% reported during the period 1985-1994. The highest case fatality rate (0.4%) was seen for acute hepatitis B (18 deaths among 4257 cases). Only one death (0.01%) occurred among the 11 063 acute hepatitis A cases and two deaths (0.1%) among the 1536 acute hepatitis C cases. No deaths were observed among the 309 acute hepatitis A cases superimposed on chronic HBsAg carriers and the 166 superimposed on chronic HCV carriers. Intravenous drug use (22.2% of cases) and other parenteral exposures (22.2% of cases) were the most frequent non-mutually exclusive sources of infection reported by subjects who died of acute hepatitis B.

CONCLUSIONS

Analysis of surveillance system data from 1995 to 2000 indicates that, in Italy, deaths due to acute viral hepatitis are rare, but most commonly observed with acute hepatitis B. There is no evidence that acute hepatitis A may be fatal in chronic HBsAg or HCV carriers. The overall better survival rate may probably reflect improvements in the treatment of fulminant hepatitis in the last few years in Italy.

Natural course of acute hepatitis C: a long-term prospective study

BACKGROUND

Acute hepatitis C has a high chronicity rate which appears to be significantly reduced by early antiviral treatment. However, it is unclear if all acutely infected patients should be treated, and when. In this prospective study, patients with a well-documented diagnosis of acute hepatitis C were evaluated to define the natural course, the rate of chronicity, and host and virus-related factors which might predict a self-limiting or chronic evolution requiring early antiviral treatment.

METHODS

From 1995 to 2000, 40 consecutive patients with a community-acquired AHC were enrolled. Liver tests, anti-hepatitis C virus antibodies and hepatitis C virus RNA levels were monitored. Median follow-up was 35 months (range 12-68).

RESULTS

A total of 24/40 patients had symptomatic disease including 20 with jaundice; 13/40 patients had prompt serum hepatitis C virus RNA clearance and ALT normalisation within 12 weeks; in 12/13 patients this pattern remained unchanged during follow-up. Overall, 27/40 patients remained hepatitis C virus RNA positive with fluctuating ALT levels. Older age and jaundice were predictive of resolution whereas there was no correlation with other host factors, viral genotype or viral load.

CONCLUSIONS

Our data demonstrate that spontaneous resolution can occur in about 30% of AHC patients. This favourable outcome rarely occurs in patients with anicteric AHC or in those with jaundice but with persistent viremia for more than 12 weeks from onset; early antiviral treatment for these patients may avoid or reduce chronicity.

Transmission of viral hepatitis by blood and blood derivatives: current risks, past heritage

For more than 40 years in the history of transfusion medicine, transmission of viral hepatitis from infected donors to recipients has been a frequent and serious adverse effect of the administration of blood components and plasma derivatives. This epidemic is now over, at least in developed and resource-rich countries. Hence, the attention of clinicians and investigators now focuses mainly on the measures to reduce the residual risk, on the possible emergence of novel or undiscovered agents causing post-transfusion hepatitis, and on the long-term outcome of patients who became infected more than ten years ago. The present article reviews these issues.