Hepatitis C virus, hepatitis B virus and human immunodeficiency virus infection in pregnant women in North-East Italy: a seroepidemiological study

Prevalence and Predominant Genotype of Hepatitis C Virus Infection and Associated Risk Factors among Pregnant Women in Iran

Objective

Knowledge regarding the prevalence and risk factors of hepatitis C virus (HCV) infection among pregnant women can give clue to health care providers regarding the appropriate management of HCV infection. Therefore, this study was conducted to determine the prevalence, genotypic pattern, and risk factors of HCV infection among pregnant women in the northern shores of the Persian Gulf, south of Iran.

Methods

From January 2018 to June 2019, serum samples were obtained from 1425 pregnant women, ages ranging from 14 to 46 years (28.1 ± 5.99). Serum samples were tested for detection of anti-HCV antibodies using an enzyme-linked immunosorbent assay (ELISA) (HCV Ab ELISA kit, Dia.Pro, Milan, Italy). Following the extraction of nucleic acid, the molecular evaluation of HCV infection was performed by seminested reverse transcriptase-polymerase chain reaction assay (RT-PCR), targeting the 5′ untranslated region (5′UTR) and core of HCV genome and sequencing.

Results

Of the 1425 pregnant women, 19 women (1.33%, 95% CI: 0.85%–2.07%) were positive for anti-HCV antibodies. The majority of HCV-seropositive women were in the third trimester of pregnancy, educated, and had a history of blood transfusion, abortion, surgery, or dentistry. Moreover, Arab and Fars pregnant women and those aged >39 years had the highest rate of HCV seroprevalence. Nevertheless, none of these variables were significantly associated with HCV seropositivity. In contrast, HCV seropositivity was associated with place of residency, so that residents of Khormuj city had significantly higher HCV seroprevalence compared to the residents of other cities (OR: 7.05; 95% CI: 1.75–28.39; P = 0.006). According to the molecular evaluation, 9 of the 19 HCV-seropositive pregnant women (47.37%) had HCV viremia with genotype 3a.

Conclusion

This study reports the HCV prevalence of 1.33% for anti-HCV antibodies and 0.63% for HCV RNA among pregnant women in the south of Iran. Considering the asymptomatic nature of chronic HCV infection and the fact that vertical transmission is possible in women with detectable viremia, therefore, screening of women before pregnancy is recommended to reduce the risk of HCV infection and its complications during pregnancy.

Hepatitis C Virus in Pregnancy: A Systematic Review of the Literature

OBJECTIVE

The aim of this study was to systematically review the literature to summarize recent demographic characteristics of hepatitis C virus (HCV) infection during pregnancy and the efficacy of risk-based versus universal screening.

STUDY DESIGN

PubMed, EMBASE, and Cochrane Library were searched to identify relevant studies. Studies that recognized hepatitis C as a primary or secondary outcome, with pregnant women as the population and written in English, were included. Studies were excluded if they were abstracts only, written in foreign language, or published prior to 1992. Two researchers independently screened all the studies by titles, abstracts, and full text. Conflicts were settled by a third researcher.

RESULTS

A total of 698 studies were identified with 78 fitting inclusion criteria. In total, 69 epidemiologic and 9 comparison studies were found. Identified risk factors for HCV infection include intravenous or illicit drug use, sexually transmitted coinfection, high-risk behaviors in the partners, high parity, and history of miscarriages or abortions. Demographic characteristics associated with HCV include non-Hispanic white race, American Indian or Alaskan Native ethnicity, and increasing age. Providers may fail to adequately screen for each risk factor, and up to two-thirds of women with a known risk factor are not screened under current guidelines. Finally, up to 27% of HCV+ women have no identifiable risk factors for infection.

CONCLUSION

There is evidence that risk-based screening fails to identify a large proportion of HCV positive women in pregnancy and that pregnant women with HCV risk factors and consistent with current screening guidelines fail to be tested. We urge for the adoption of universal screening to identify these women and offer treatment.

Hepatitis C Virus Infection in Pregnancy: An Update

Parenteral transmission is the major route of hepatitis C virus transmission in adults; however, vertical transmission is most common in children. There are several factors that have been shown to be associated with vertical transmission of hepatitis C virus, including hepatitis C virus RNA, human immunodeficiency virus coinfection, and peripheral blood mononuclear cell infection. As there is no effective vaccine to prevent hepatitis C virus infection, and there are no human data describing the safety of the new direct acting antiviral agents in pregnancy, the only preventive strategy for vertical transmission is to treat the hepatitis C virus infection before becoming pregnant. Direct acting antiviral agents are interferon-free, and many are also ribavirin-free. Based on animal studies, sofosbuvir plus ledipasvir may be the best safety profile during pregnancy for now; however, it is too early to recommend treating hepatitis C virus-infected pregnant women with these direct acting antiviral agents currently.

Seroprevalence of hepatitis B, hepatitis C, and HIV in pregnant women from Eastern Turkey

BACKGROUND/AIMS

The vertical transmission of hepatitis B virus, hepatitis C virus (HCV), and human immunodeficiency virus (HIV) infections are essential public health problems. In this study, we aimed to investigate the seroprevalence of the aforementioned infections among pregnant women.

MATERIALS AND METHODS

This study was done retrospectively on pregnant women who presented for antenatal follow-up and delivery between 2013 and 2016. Data were collected from the hospital's electronic health records and patient files. Blood samples were analyzed at the microbiology laboratory of the hospital. HBsAg, anti-HBs, anti-HCV, and anti-HIV titers were tested using the chemiluminescence enzyme immunoassay method (Architect, Abbott Laboratories, USA).

RESULTS

HBsAg and anti-HBs levels were tested in 35,295 pregnant women aged 18-45 years. The HBsAg and anti-HBs levels were positive in 425 (1.2%) and 9583 (27.7%) patients, respectively. From 2013 to 2016, the HBV carrier rates have continuously decreased from 1.4% to 0.8%, whereas the anti-HBs positivity has increased from 25.4% to 30.2%. Anti-HCV was detected in 6 of the 9709 (0.06%) patients. All the 7113 pregnant women screened for HIV showed negative results.

CONCLUSION

Hepatitis B carrier rates among pregnant women gradually decreased with a simultaneous increase in the immunity rates. HCV seroprevalence was low and HIV positivity was not encountered in the study population.

Infection with hepatitis B and C virus in Europe: a systematic review of prevalence and cost-effectiveness of screening

BACKGROUND

Treatment for chronic hepatitis B virus (HBV) and hepatitis C virus (HCV) infection is improving but not benefiting individuals unaware to be infected. To inform screening policies we assessed (1) the hepatitis B surface antigen (HBsAg) and anti-hepatitis C virus antibody (anti-HCV-Ab) prevalence for 34 European countries; and (2) the cost-effectiveness of screening for chronic HBV and HCV infection.

METHODS

We searched peer-reviewed literature for data on HBsAg and anti-HCV-Ab prevalence and cost-effectiveness of screening of the general population and five subgroups, and used data for people who inject drugs (PWID) and blood donors from two European organizations. Of 1759 and 468 papers found in the prevalence and cost-effectiveness searches respectively, we included 124 and 29 papers after assessing their quality. We used decision rules to calculate weighted prevalence estimates by country.

RESULTS

The HBsAg and anti-HCV-Ab prevalence in the general population ranged from 0.1%-5.6% and 0.4%-5.2% respectively, by country. For PWID, men who have sex with men and migrants, the prevalence of HBsAg and anti-HCV-Ab was higher than the prevalence in the general population in all but 3 countries. There is evidence that HCV screening of PWID and HBsAg screening of pregnant women and migrants is cost-effective.

CONCLUSION

The prevalence of chronic HBV and HCV infection varies widely between European countries. Anti-HCV-Ab screening of PWID and HBsAg screening of pregnant women and migrants have European public health priority. Cost-effectiveness analyses may need to take effect of antiviral treatment on preventing HBV and HCV transmission into account.

The impact of immigration and vaccination in reducing the incidence of hepatitis B in Catalonia (Spain)

BACKGROUND

The Hepatitis B virus (HBV) infection is a major cause of liver disease and liver cancer worldwide according to the World Health Organization. Following acute HBV infection, 1-5% of infected healthy adults and up to 90% of infected infants become chronic carriers and have an increased risk of cirrhosis and primary hepatocellular carcinoma. The aim of this study was to investigate the relationship between the reduction in acute hepatitis B incidence and the universal vaccination programme in preadolescents in Catalonia (Spain), taking population changes into account, and to construct a model to forecast the future incidence of cases that permits the best preventive strategy to be adopted.

METHODS

Reported acute hepatitis B incidence in Catalonia according to age, gender, vaccination coverage, percentage of immigrants and the year of report of cases was analysed. A statistical analysis was made using three models: generalized linear models (GLM) with Poisson or negative binomial distribution and a generalized additive model (GAM).

RESULTS

The higher the vaccination coverage, the lower the reported incidence of hepatitis B (p <0.01). In groups with vaccination coverage > 70%, the reduction in incidence was 2-fold higher than in groups with a coverage <70% (p <0.01). The increase in incidence was significantly-higher in groups with a high percentage of immigrants and more than 15% (p <0.01) in immigrant males of working age (19-49 years).

CONCLUSIONS

The results of the adjusted models in this study confirm that the global incidence of hepatitis B has declined in Catalonia after the introduction of the universal preadolescent vaccination programme, but the incidence increased in male immigrants of working age. Given the potential severity of hepatitis B for the health of individuals and for the community, universal vaccination programmes should continue and programmes in risk groups, especially immigrants, should be strengthened.

Evaluation of the compliance with the protocol for preventing perinatal hepatitis B infection in Italy

OBJECTIVE

To evaluate the compliance with the protocol for preventing perinatal hepatitis B infection in Italy, including HBsAg screening of pregnant women and immunization of newborns to infected mothers.

METHODS

Women consecutively delivering, over 6 months in 2008-2009, in public and private hospitals of 13 Italian regions were recruited. Data on socio-demographic characteristics, HBsAg prenatal screening and newborns immunization were collected.

RESULTS

17,260 pregnant women were enrolled. Of them 16,858 (97.7%) attended prenatal screening. Delivering in a public hospital and in hospitals located in South Italy were both independent predictors of non-adherence to HBsAg screening. Foreign pregnant women were also less likely to be screened. Overall, HBsAg prevalence was 0.86%; it was 0.4% for Italian women and 2.5% for foreign women. Differences in prevalence by country of origin and education were statistically significant. Of 138 newborns from HBsAg positive mothers 131 received passive/active immunization; 7 newborns received just vaccine.

CONCLUSION

In this study compliance with the protocol for preventing perinatal hepatitis B was very good. Further efforts are needed to improve adherence to prenatal screening in public hospitals, in hospital located in southern Italy and among foreign women. HBV spread in Italy is progressively declining, also involving immigrant population.

Estimating the incidence, prevalence and clinical burden of hepatitis C over time in Italy

Our objective was to estimate HCV clinical burden over time in Italy. A national age-specific HCV prevalence in 1995 was obtained from studies conducted in general population samples and intravenous drug users. Age profile of new HCV infections and trend of incidence since 1985 were derived from a database of reported acute HCV infections. These incidence and prevalence data were used to estimate HCV burden from 1950 to 2030 by mathematical modelling. Different rates of HCV related liver disease progression were tested to assess the robustness of estimates. It is estimated that HCV had a major spread in Italy in 1945-1969. HCV RNA-positive subjects peaked around 1970; their prevalence in 2005 was 3.2%, 58% of them being >65 y of age. The number of individuals with HCV related cirrhosis and that of HCV liver related deaths peaked in 1980-1985. In 2005, they were approximately 230,000 (range 150,000-240,000, according to lower or higher disease progression rates) and approximately 7,000 (range 2200-12,300), respectively: both will be halved by 2025. In conclusion, unlike other industrialized countries, the burden of clinically relevant HCV-positive cases in Italy is already on the decline and will further reduce in the future. This is due to differences in the age-specific prevalence, most of HCV-positive Italians currently being >65 y of age.

Seroepidemiology of hepatitis B virus infection in pregnant women in Catalonia (Spain)

BACKGROUND

In recent years there has been a substantial reduction in hepatitis B incidence as a result of routine vaccination of preadolescents and the selective vaccination of high risk groups and newborns of HBsAg+ mothers.

OBJECTIVES

To determine the prevalence of hepatitis B virus infection markers and of serologic markers of hepatitis B vaccination in a representative sample of pregnant women in Catalonia.

STUDY DESIGN

A representative sample was obtained by random cluster sampling (hospitals with maternity units) stratified by provinces. Anti-HBc, anti-HBs and HBsAg were determined using an ELISA test (Behring, Marburg, Germany). The crude and adjusted odds ratios for the sociodemographic variables analyzed were also calculated.

RESULTS

The global prevalence of carriers of HBsAg+ was 0.1% (95% CI 0.0-0.3), that of hepatitis B infection (anti-HBc+) was 5% (95% CI 3.9-6.1) and that of serologic markers of vaccination (anti-HBs+ and anti-HBc-) was 16.4% (95% CI 14.5-18.2) The prevalence of infection increased with age from 3.0% (15-19 years age group) to 14.8% (40-44 years age group). The prevalence of anti-HBc+ was higher in women born in Asia (27.6%) and Africa (18.8%) than in those born in Spain (3.7%), Europe (3.3%) and America (4.6%), with the differences being statistically significant.

CONCLUSIONS

The results of this study confirm the change in the pattern of endemicity of hepatitis B infection in pregnant women in Catalonia after the introduction of vaccination programmes. They also confirm the increasingly important role played by immigration in the epidemiology of hepatitis B.

Hepatitis A, B, and C infection in a community of sub-Saharan immigrants living in Verona (Italy)

BACKGROUND

In Italy, about 5% of the population is represented by immigrants. The epidemiology of hepatitis A virus (HAV), hepatitis B virus (HBV), and hepatitis C virus (HCV) infection in Africa is very different from Europe; the present study aimed to assess the seroprevalence of viral hepatitis infections in sub-Saharan African immigrants living in Verona.

METHODS

A total of 182 illegal immigrants were interviewed concerning sociodemographic characteristics and epidemiological information. Their serum was tested for anti-HAV [immunoglobulin (Ig) G and IgM], HBV (HBsAg, anti-HBs, anti-HBc, HBeAg, and anti-HBe), and HCV (anti-HCV) markers.

RESULTS

The immigrants (age: 3 mo-60 y) were mostly single and males, with a higher education; only 50% of them declared having a regular job. Anti-IgG HAV+ prevalence was 99.5% (100% HAV positivity in the younger age bracket). As for HBV, 67.6% (123) of the immigrants were naturally infected and 9.3% had chronic infection; 4.4% were anti-HBs+ isolated (vaccinated). For HBV infection (any HBV marker), a significant difference was only found for increasing age ( p < 0.01) and married people ( p < 0.001). A statistically significant prevalence of HBsAg was found among the unemployed ( p < 0.001) and those with a lower education ( p < 0.05). Five cases (2.7%) resulted in HCV+ with no reported specific risk factors and with no significantly different sociodemographic features; these people tended to report a low level of education and unemployment.

CONCLUSIONS

HAV and HBV positivity is higher than in the autochthonous population. While HAV positivity merely represents past infection, the high prevalence of HBsAg in immigrants and the presence of HBsAg/HBeAg in the same group may represent a risk for HBV transmission. The HCV positivity rate resulted similar to the prevalence of the Italian population.

Pregnancy complications associated with hepatitis C: data from a 2003-2005 Washington state birth cohort

OBJECTIVE

The objective of the study was to determine the effect of hepatitis C virus (HCV) on selected maternal and infant birth outcomes.

STUDY DESIGN

This population-based cohort study using Washington state birth records from 2003 to 2005 compared a cohort of pregnant women identified as HCV positive from birth certificate data (n = 506) to randomly selected HCV-negative mothers (n = 2022) and drug-using HCV-negative mothers (n = 1439).

RESULTS

Infants of HCV-positive mothers were more likely to be low birthweight (odds ratio [OR], 2.17; 95% confidence interval [CI] 1.24, 3.80), to be small for gestational age (OR, 1.46; 95% CI, 1.00, 2.13), to need assisted ventilation (OR, 2.37; 95% CI, 1.46, 3.85), and to require neonatal intensive car unit (NICU) admission (OR, 2.91; 95% CI, 1.86, 4.55). HCV-positive mothers with excess weight gain also had a greater risk of gestational diabetes (OR, 2.51; 95% CI, 1.04, 6.03). Compared with the drug-using cohort, NICU admission and the need for assisted ventilation remained associated with HCV.

CONCLUSION

HCV-positive pregnant women appear to be at risk for adverse neonatal and maternal outcomes.

Long-term course of chronic hepatitis C in children: from viral clearance to end-stage liver disease

BACKGROUND & AIMS

The natural course of chronic hepatitis C (CHC) in children is not well understood. The aim of this study was to assess the long-term course of CHC in a large sample of otherwise healthy children.

METHODS

From 1990 to 2005, 504 consecutive antihepatitis C virus (HCV)-positive children were enrolled at 12 centers of a national observatory and were followed up retrospectively/prospectively.

RESULTS

Putative exposure was perinatal in 283 (56.2%) cases, parenteral in 158 (31.3%), and unknown in 63 (12.5%). At baseline, 477 (94.6%) cases were HCV RNA seropositive, 118 (24.7%) of which were treated with standard interferon alpha. Ten years after putative exposure, the outcome in 359 HCV RNA-positive, untreated patients was (1) undetectable viremia in 27 (7.5%) (by Cox regression analysis, spontaneous viral clearance was independently predicted by genotype 3 [hazard ratio 6.44; 95% confidence interval: 2.7-15.5]) and (2) persistent viremia in 332 (92%) cases. Six of these 332 cases (1.8%) progressed to decompensated cirrhosis (mean age, 9.6 years). This latter group included 5 Italian children perinatally infected with genotype 1a (4 of the mothers were drug users). Thirty-three (27.9%) treated patients achieved a sustained virologic response.

CONCLUSIONS

Over the course of a decade, few children with chronic HCV infection cleared viremia spontaneously, and those who did were more likely to have genotype 3. Persistent viral replication led to end-stage liver disease in a small subgroup characterized by perinatal exposure, maternal drug use, and infection with HCV genotype 1a. Children with such features should be considered for early treatment.

Serological markers of selected sexually and blood transmitted infections in pregnant women and in newborns of HIV-positive mothers in the Slovak Republic

Aim of the study was to investigate serological markers of selected sexually and blood transmitted infections (HBV, HCV, CMV, and Treponema pallidum) in the group of pregnant women and in newborns of HIV-positive mothers in Slovakia. IgG antibodies to CMV were found in 78 of 97 women, from them in 6 of 7 HIV-positive and in 72 of 90 HIV-negative persons. Occurrence of HbsAg and HCV was significantly higher in the group of HIV-positive women (1/7 and 2/7) comparing to the HIV-negative one (4/90 and 0/92, respectively). Antibodies to T. pallidum were found only in one HIV-negative woman from 92 women tested. Five of seven children born to HIV-1 infected mothers were found HIV-1 negative, two children are still under control. Four of 7 newborns were found anti-CMV IgG positive. Although one woman, IDU, was confirmed HbsAg and anti-HCV positive, vertical transmission of HBV and HCV to her newborn was not observed by molecular-biological methods. Similarly, HCV antibodies were found in one more women and neither in her child HCV infection was confirmed. In no one of mother - child pair's antibodies to T. pallidum were observed. Due to these findings strong attention should be paid to health education and prophylaxis of mother to child HIV and other STIs transmission in Slovakia.

Adherence to the screening program for HBV infection in pregnant women delivering in Greece

Background

Hepatitis B infection (HBV) is a major Public Health Problem.

Perinatal transmission can be prevented with the identification of HBsAg(+) women and administration of immunoprophylaxis to their newborns. A national prevention programme for HBV with universal screening of pregnant women and vaccination of infants is in effect since 1998 in Greece.

Methods

To evaluate adherence to the national guidelines, all women delivering in Greece between 17–30/03/03 were included in the study. Trained health professionals completed a questionnaire on demographic data, prenatal or perinatal screening for HBsAg and the implementation of appropriate immunoprophylaxis.

Results

During the study period 3,760 women delivered. Prenatal screening for HBsAg was documented in 91.3%. Greek women were more likely to have had prenatal testing. HBsAg prevalence was 2.89% (95%CI 2.3–3.4%). Higher prevalence of HBV-infection was noted in immigrant women, especially those born in Albania (9.8%). Other risk factors associated with maternal HBsAg (+) included young maternal age and absence of prenatal testing. No prenatal or perinatal HBsAg testing was performed in 3.2% women. Delivering in public hospital and illiteracy were identifiable risk factors for never being tested. All newborns of identified HBsAg (+) mothers received appropriate immunoprophylaxis.

Conclusion

The prevalence of HBsAg in Greek pregnant women is low and comparable to other European countries. However, immigrant women composing almost 20% of our childbearing population, have significant higher prevalence rates. There are still women who never get tested. Universal vaccination against HBV at birth and reinforcement of perinatal testing of all women not prenatally tested should be discussed with Public Health Authorities.

Pregnant women as a sentinel population to target and implement hepatitis B virus (HBV) vaccine coverage: a three-year survey in Palermo, Sicily

Hepatitis B virus (HBV) vaccine coverage was assessed using serologic patterns of infection (HBsAg, anti HBc) and vaccine-induced immunity (isolated anti HBs) among 3318 pregnant women attending the Obstetrical Unit of the University Hospital in Palermo who were screened over 3 years (2001-2003). Three thousand and eight of them (90.6%) were born in Sicily, whereas 310 (9.4%) were immigrants from non-EU countries. The overall prevalence of HBsAg was 1.1%, and it was significantly higher among immigrant than indigenous women (4.2% versus 0.8%; OR 5.26; p < 0.0001). Serologic evidence of past HBV infection (anti HBc) also was significantly higher in immigrants than in Sicilian women (24.5% versus 5.2%, respectively). Women aged 17-21 in our study were in cohorts that had been targeted since 1991 for mandatory HBV vaccination at age 12. In this targeted age group, 74.2% of the Sicilian women had isolated anti HBs, compared to only 15.0% among immigrants. The results suggest the need to improve HBV immunization of Sicilian adolescents and especially to implement active surveillance and to launch an HBV immunization programme that targets immigrants to Sicily.

Oral lichen planus, hepatitis C virus, and HIV: No association in a cohort study from an area of high hepatitis C virus endemicity

OBJECTIVES

We sought to assess the age-specific prevalence of oral lichen planus (OLP) in Mediterranean patients with chronic hepatitis C virus (HCV) and to evaluate the features of OLP in relation to sex, smoking, HCV genotype, HIV-1 coinfection, and antiviral treatments.

METHODS

In all, 178 anti-HCV-positive adults (60 women and 118 men; age range 20-66 years) recruited from two cohorts (104 HIV-negative patients and 74 patients with HIV coinfection) underwent oral examination.

RESULTS

Overall prevalence of OLP was 2.8% (5 of 178) (male/female ratio 0.2; odds ratio=0.119; 95% confidence interval=0.013-1.106), only among HIV-negative participants, always in the reticular pattern, and in the adult age. HCV genotype, tobacco smoking, and treatment (interferon alfa/ribavirin) were not significantly associated to OLP.

CONCLUSIONS

Among HCV-infected patients, we found a low prevalence of OLP. The absence of OLP in HIV-coinfected patients suggests immunosuppression secondary to defective CD4 functions.

Seroprevalencia de anticuerpos frente a Treponema pallidum, Toxoplasma gondii, virus de la rubéola, virus de la hepatitis B y C y VIH en mujeres gestantes

INTRODUCTION

The prevalence of antibodies against Treponema pallidum, Toxoplasma gondii, rubella virus, hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV) was investigated in pregnant women.

METHODS

With the use of several serological methods in samples from women who had their first obstetric visit in 2001, we studied the prevalence of serum antibodies against T. pallidum, T. gondii, rubella virus, HBV and HCV in 2,929 pregnant women, and anti-HIV antibodies in the 1,349 women agreeing to this test.

RESULTS

Antibodies against T. pallidum were not detected in any case. HBsAg was found in 11 patients (0.4%), six of whom (54.5%) were not aware of their condition. The presence of anti-rubella antibodies was almost universal (99.95%). In the total population, 18.8% of patients had anti-T. gondii antibodies; only one had a serological profile suggesting acute toxoplasmosis. Among the 1,349 women studied, anti-HIV antibodies were detected in two intravenous drug abusers who were aware of their condition. Anti-HCV antibodies were found in 0.4% of the series, and 36.4% of the HCV-positive patients had no knowledge of their condition.

CONCLUSIONS

Active infection by T. pallidum in pregnant women in Spain is currently exceptional. The level of immunization against rubella virus is excellent. Seropositivity to T. gondii is lower than rates reported in earlier studies. The prevalence of HBsAg and anti-HCV antibodies is around 0.4%, and seropositive status is often discovered in routine serological studies performed during pregnancy. HIV seropositivity is low, and the pregnant women included in this study were aware of their condition.

Liver transplantation for chronic liver disease: advances and controversies in an era of organ shortages

Since liver transplantation was first performed in 1968 by Starzl et al, advances in case selection, liver surgery, anaesthetics, and immunotherapy have significantly increased the indications for and success of this operation. Liver transplantation is now a standard therapy for many end stage liver disorders as well as acute liver failure. However, while demand for cadaveric organ grafts has increased, in recent years the supply of organs has fallen. This review addresses current controversies resulting from this mismatch. In particular, methods for increasing graft availability and difficulties arising from transplantation in the context of alcohol related cirrhosis, primary liver tumours, and hepatitis C are reviewed. Together these three indications accounted for 42% of liver transplants performed for chronic liver disease in the UK in 2000. Ethical frameworks for making decisions on patients' suitability for liver transplantation have been developed in both the USA and the UK and these are also reviewed.

Viral load in HCV RNA-positive pregnant women

OBJECTIVES

The risk of hepatitis C virus (HCV) infection in the newborn is estimated to be around 5%, but becomes very high in the case of coinfection with HIV. One of the main factors associated with the vertical transmission of HCV is the viral load. Our objective was to investigate the behavior of HCV viral load during pregnancy in relation to HIV coinfection, liver enzymes, and vertical transmission.

METHODS

Three thousand seven hundred forty-eight women seen consecutively in their first trimester of pregnancy were screened for HCV infection. Sixty-five were found to be anti-HCV+/HCV RNA+ and were followed up with clinical and serological assessment (i.e., transaminases and quantitative polymerase chain reaction [PCR] for viral load) in their second and third trimesters and 6 months after delivery. All were anti-HIV and hepatitis B surface antigen negative. HCV RNA was 12.0+/-19.9 x 10(6) copies/ml in the first trimester and 10.9+/-13.3 x 10(6) in the second, but increased to 19.5+/-25.1 x 10(6) in the third trimester. Six months after delivery the viral load returned to the baseline levels; the changes in viral load did not reach any statistical significance, however. Transaminases tended toward a reduction from the baseline during the second and third trimesters, and then an increase in both AST and ALT was recorded 6 months after delivery. However, when the group whose AST/ALT were found abnormal at the first test was considered, no significant changes were recorded during the follow-up. The overall rate of vertical transmission was 4.6

CONCLUSIONS

With HCV+ mothers monitoring transaminases during pregnancy is unnecessary, and testing liver enzymes at the beginning of pregnancy is sufficient. Qualitative PCR should be done once during the pregnancy, but any staging of the liver disease should be taken after delivery. Quantitative PCR testing is expensive and pointless. Any decision for elective cesarean section in HCV RNA+ mothers should be confirmed by other studies.