Public health challenges in hepatitis C virus infection

Use of injected heroin and risk of hepatitis C in three cities in Colombia

INTRODUCTION

Hepatitis C is one of the most neglected diseases by governments internationally.

OBJECTIVE

Identify the prevalence of hepatitis C and associated injection drug users in three cities of factors Colombia.

METHODS

Cross-sectional study of 668 injecting drug users recruited through respondent-driven sampling, inquired about demographic characteristics and risk behaviors. Laboratory testing was used on filter paper and cases of hepatitis C viral load tests with RNA were confirmed. Hepatitis C prevalence and associated factors was estimated with Chi-square test statistics and reasons for crude and adjusted prevalence were calculated using logistic regression.

RESULTS

The prevalence of hepatitis C was 17.5% and were found as factors that increase the prevalence of hepatitis: having HIV, injecting another person carrying the virus dose used was sharing a syringe, injected with a syringe and consume marijuana. As a factor that reduces the prevalence, purchase syringes in drug stores or other stores.

CONCLUSION

This research evidence established consumption of drugs by injection , and the presence of hepatitis C in social networks of IDUs and highlights the importance of developing interventions for harm reduction and prevention of hepatitis C in this population these three cities.

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.

Low dose ribavirin has been effective in the treatment of incapacitating muco-cutaneous extrahepatic manifestations in patients with hepatitis C with contraindication or no access for approved antiviral treatment

BACKGROUND AND STUDY AIMS

Chronic hepatitis C virus (HCV) is a major public health problem and represents a common cause of chronic liver disease worldwide. The Egyptian Demographic Health Survey (EDHS) has estimated HCV prevalence in Egypt to be 14.7%. HCV can affect multiple organ systems and cause a variety of extrahepatic manifestations. Most of extrahepatic manifestations affect the skin and mucous membranes; such as lichen planus (LP), psoriasis, and leucocytoclastic vasculitis. The treatment of extrahepatic manifestations has been disappointing in patients not indicated for interferon with no access for the new costly all oral treatments.

PATIENTS AND METHODS

In 2014, thirty Egyptian patients with incapacitating mucocutaneous extrahepatic manifestations due to chronic HCV infection, not indicated for interferon, have been randomised into two groups; group I treated with ribavirin (5-10mg/kg daily divided into 2 doses), and group II treated with local steroids for 3months. Patients were followed up for 3months. Dermatology life quality index score has been measured before and after treatment for all patients.

RESULTS

A significant improvement of mucocutaneous lesions has been accomplished in group I in comparison to group II (p<0.01). All lesions in group I showed a significant improvement except psoriasis (p>0.05). A significant improvement of dermatology life quality index score has been found in patients in group I when compared to group II (p<0.05).

CONCLUSION

We conclude that low dose ribavirin was effective in the treatment of incapacitating mucocutaneous extrahepatic manifestations of chronic HCV infection in patients with contraindication or no access to the approved antiviral treatments.

Hepatitis C infection in hemodialysis patients in Iran: a systematic review

Hemodialysis (HD) patients are recognized as one of the high-risk groups for hepatitis C virus (HCV) infection. The prevalence of HCV infection varies widely between 5.5% and 24% among different Iranian populations. Preventive programs for reducing HCV infection prevalence in these patients require accurate information. In the present study, we estimated HCV infection prevalence in Iranian HD patients. In this systematic review, we collected all published and unpublished documents related to HCV infection prevalence in Iranian HD patients from April 2001 to March 2008. We selected descriptive/analytic cross-sectional studies/surveys that have sufficiently declared objectives, a proper sampling method with identical and valid measurement instruments for all study subjects, and proper analysis methods regarding sampling design and demographic adjustments. We used a meta-analysis method to calculate nationwide prevalence estimation. Eighteen studies from 12 provinces (consisting 49.02% of the Iranian total population) reported the prevalence of HCV infection in Iranian HD patients. The HCV infection prevalence in Iranian HD patients is 7.61% (95% confidence interval: 6.06-9.16%) with the recombinant immunoblot assay method. Iran is among countries with low HCV infection prevalence in HD patients.

Injecting drug users' understanding of hepatitis C

This cross-sectional survey examined IDUs' understanding of HCV, their knowledge of virus transmission, clinical markers, symptoms and treatment. IDUs were recruited through and interviewed at a range of settings in inner-city, suburban and regional sites of New South Wales, Australia; 149 IDUs were recruited. Recent HCV testing was reported by 74% of participants, but a number of IDUs were confused about the results of the various tests, e.g. 19% of participants who stated they had HCV believed they could not infect others or were immune. Significant gaps in IDUs' knowledge of HCV were uncovered with respect to transmission risks (48% believed HCV could be contracted from re-using one's own, unshared needle), symptoms and clinical markers (42% believed HCV antibodies gave protection against HCV infection), and treatment. Findings warrant further development of, and research into, strategies to improve IDUs' understanding of HCV.

Harm reduction, hepatitis C and opioid pharmacotherapy: an opportunity for integrated hepatitis C virus-specific harm reduction

While harm reduction advocates, policy makers and practitioners have a right to be proud of the impact of interventions such as needle and syringe programmes on HIV risk, we can be less sanguine about the ongoing high levels of HCV transmission among injecting drug users (IDUs) and the expanding burden of hepatitis C virus (HCV)-related liver disease. In this Harm Reduction Digest Drs Byrne and Hallinan from the Redfern Clinic and Dr Dore from the National Centre in HIV Epidemiology and Clinical Research offer a model of integrated HCV prevention and treatment services within the setting of opioid pharmacotherapy. In their experience, this common-sense approach provides an opportunity to reduce the burden of HCV and improve overall patient management. They believe that the key elements of a HCV-specific harm reduction model include: regular HCV testing; clinical assessment and determination of need for HCV treatment referral; use of broader HCV treatment inclusion criteria; and flexibility in opioid pharmacotherapy dosing. In an environment when our macro harm reduction interventions seem to have, at best, modest impact on HCV transmission, good clinical practice may be our most effective strategy against the HCV epidemic. This paper provides some practical suggestions as to how this can be done.

Patterns of drug use among a sample of drug users and injecting drug users attending a General Practice in Iran

AIM

This study aimed to examine drug use, drug treatment history and risk behaviour among a sample of Iranian drug users seeking treatment through a general practice clinic in Iran.

METHODS

Review of medical records and an intake questionnaire at a large general practice in Marvdasht, Iran, with a special interest in drug dependence treatment. Records from a random sample of injecting drug users (IDU), non-injecting drug users (DU) and non-drug using patients were examined.

RESULTS

292 records were reviewed (34% IDU, 31% DU and 35% non-drug users). Eighty-three percent were males; all females were non-drug users. The mean age of the sample was 30 years. Of the IDU sample, 67% reported sharing a needle or syringe, 19% of these had done so in prison. Of those who had ever used drugs, being 'tired' of drug use was the most common reason for seeking help (34%). Mean age of first drug use was 20 years. The first drugs most commonly used were opium (72%), heroin (13%) and hashish/ other cannabinoids (13%). Three quarters reported having previously attempted to cease their drug use. IDU were more likely than DU to report having ever been imprisoned (41% vs 7%) and 41% to have used drugs in prison.

CONCLUSION

This study has shown that there is a need for general practice clinics in Iran to treat drug users including those who inject and that a substantial proportion of those who inject have shared needles and syringes, placing them at risk of BBVI such as HIV and hepatitis C. The expansion of services for drug users in Iran such as needle and syringe programs and pharmacotherapies are likely to be effective in reducing the harms associated with opium use and heroin injection.

Initiation to heroin injecting among heroin users in Sydney, Australia: cross sectional survey

BACKGROUND: Heroin injection is associated with health and social problems including hepatitis C virus (HCV) transmission. Few studies have examined the circumstances surrounding initiation to heroin injecting, especially current users initiating others. The current study aimed to examine the age of first heroin use and injection; administration route of first heroin use; relationship to initiator; the initiation of others among a group of heroin users; and to examine these factors in relation to HCV status and risk. METHOD: Heroin users in Sydney were recruited through needle and syringe programs, a methadone clinic and snowballing. Participants were interviewed about their own initiation to heroin use, blood-borne virus risk and knowledge, and whether they had initiated others to heroin injecting. Information on HCV status was collected via self-report. Data was analysed using univariate and multivariate statistical techniques for Normally distributed continuous and categorical data. RESULTS: The study recruited 399 heroin users, with a mean age of 31 years, 63% were male, 77% reported heroin as their primary drug and 59% were HCV positive (self-report). Mean age at first heroin use and injection was 19 and 21 years, respectively. The majority of heroin users commenced heroin use via injecting (65%), younger users (<25 years, 25-30 years) were less likely than older users (>30 years) to commence heroin use parenterally. Participants were initiated to injection mainly by friends (63%). Thirty-seven percent reported initiating others to heroin injection, but few factors were related to this behaviour. Those with longer heroin using careers were more likely to report initiating others to heroin injection, but were no more likely to have done so in the preceding 12 months. Participants who had initiated others were more likely to have shared injecting equipment (12 vs 23%), but were no more likely to be HCV positive (self-report) than those who did not. CONCLUSION: Interventions to prevent heroin users initiating others to injecting are necessary. Peer groups may be well positioned to implement such interventions.

Human immunodeficiency virus (HIV) and hepatitis C virus (HCV) in a Northern Alberta population

OBJECTIVE

To describe the demographics and estimate the prevalence of hepatitis C virus (HCV) in a cohort of Human Immunodeficiency Virus (HIV) positive patients in Northern Alberta.

METHODS

A cross-sectional (prevalence) study was performed on a cohort of HIV-positive patients. HCV testing was not widely available until December 1989, and the more sensitive, second generation immunoassay was not available until 1992. To reduce the effect of testing bias, we restricted consideration of HCV status to patients first seen January 1, 1992 onward.

RESULTS

Forty-four percent of patients in the whole cohort were tested for HCV (564/1,276) and 62% (505/809) of patients entered since January 1, 1992 were tested for HCV. During the period January 1, 1992-December 31, 1999, the prevalence of HCV in our cohort of northern Alberta HIV-positive patients was at least 37.9% (307/809) and was 60.8% (307/505) among those who were tested for HCV in 1992 or later. The mean age of the co-infected group was 33.6 years, 66.1% were male, 91.2% were injection drug users (IDUs), 56.8% were Caucasian, and 40.0% were Aboriginal. A statistically significant difference was found between the HCV-negative cohort, the HCV co-infected cohort, and the HCV-untested cohort for the following variables: risk behaviour, gender, ethnic status, death, occurrence of an AIDS-defining illness (p < 00.0001), and mean baseline CD4 cell count (p = 0.002).

CONCLUSION

A high proportion of the HIV-infected IDUs was co-infected with HCV. Compared to the HCV-negative group, the co-infected group appears to have had less advanced HIV disease. This is likely a reflection of more recent HIV infection in the HCV co-infected group.

Molecular epidemiology of hepatitis B and C virus infections in Asia

The present paper provides a review of the current literature regarding the molecular-based epidemiology of hepatitis B virus (HBV) and hepatitis C virus (HCV), which are very important viruses underlying the etiology of blood-borne infectious diseases worldwide. Particularly, both HBV and HCV are widespread on the Asian continent and are associated with acute and chronic liver diseases, including hepatocellular carcinoma. HBV has been classified into genotypes A through G and shown to have a distinct geographic distribution. In Asia, genotypes B and C of HBV prevail, and genotype C has been shown to cause more serious liver disease than genotype B. High prevalence of HBV mutants with various forms, such as the pre-S mutant, basal core promoter mutant, YMDD motif mutant and vaccine escape mutant, were seen in Asia and these were found to be related to the severity of liver disease and sensitivity to therapy. HCV has also been classified into multiple genotypes and associated with geographic distribution. HCV genotype 1 is less sensitive to interferon therapy and may be associated with the presence of more serious liver disease than the other genotypes. Data on the relation among the HBV/HCV genotypes, their pathogenicity in chronic liver diseases including hepatocellular carcinoma and their effect on therapy are awaited with great interest, especially in Asia, which is an endemic region of blood-borne hepatitis viruses.

Ultrastructure characteristics of HCV infected human trophoblast cells in culture

AIM: To investigate whether the cultured trophoblastic cells can be infected with hepatitis C virus (HCV) and observe the ultrastructural features of infected cells.

METHODS: Human placentae were digested with trypsin and then centrifuged with percoll density gradient to obtain trophoblastic cells, and then incubated in HCV positive serum. The HCV RNA in HCV infected syncytiotroblasts was quantitated with RT-PCR. Ultrastructural characteristics of infected syncytiotroblasts were observed with transmission electron microscope.

RESULTS: HCV RNA was detected in supernatant of the cultured medium during 40 day periods of incubation. The antibody of HCV NS5 was observed around the nucleus with confocal microscope. The Ultrastructure of infected throphotoblast cells differed obviously from that of normal cells, and manifested with hyperplasia of lysosomes and rough endoplasmic, appearance of vacuoles and virus-like particles, and decreased lipid droplets.

CONCLUSION: Trophoblastic cells could be infected by HCV, and the cellular ultrastructure changed dramatically following infection of HCV.

Hepatitis D virus genotypes in intravenous drug users in taiwan: decreasing prevalence and lack of correlation with hepatitis B virus genotypes

Of 368 hepatitis B virus (HBV)-infected intravenous drug users, 144 (39%) were positive for antibody to hepatitis D virus (anti-HDV). Anti-HDV-positive HBV carriers had a lower rate of positivity for HBV DNA than did anti-HDV-negative carriers (52 versus 73%, respectively). From 1986 to 1997, the average rate of decrease in the prevalence of HDV infection in this population was 4.7%/year.

Detection of HCV RNA in saliva of patients with hepatitis C virus infection by using a highly sensitive test

Hepatitis C virus (HCV) is transmitted primarily by direct percutaneous exposures to blood. Since HCV RNA has been found in saliva, it has been suggested that saliva might also be a source of infection. HCV RNA in saliva from plasma HCV RNA positive patients was tested by a highly sensitive PCR method. HCV RNA was detected in 32 out of 61 saliva specimens (52.4%). No correlation was found between the presence of HCV in saliva and age, sex, identified risk factors for HCV infection, time lapsed since the diagnosis, transaminases and alkaline phosphatase values and stimulated salivary flow. A statistically significant relation between plasma HCV RNA viral load and saliva HCV RNA detection was observed (P<0.001). In conclusion, HCV RNA is often present in saliva of HCV infected patients, with plasma viral load being the only known predictable factor. Further studies on salivary HCV RNA are needed.

Hepatic Encephalopathy

A characteristic feature of the neuropsychiatric changes in hepatic encephalopathy (HE) is the potential for a complete recovery in the majority of patients. In this review, we limit our discussion to HE in individuals with chronic liver disease. The optimal approach to the management of HE includes the following elements. Provide standard supportive therapy for patients with an altered mental status. This is the mainstay of therapy in the majority of clinical situations and includes administration of parenteral fluids and nutrition, care of vascular and bladder catheters, control of self-injurious activities, and instituting aspiration precautions. Rule out or control concomitant causes of encephalopathy. The diagnosis of HE has positive and negative criteria, and ruling out other causes of change in mental status is an essential component of the diagnosis. Identify and correct the precipitating factors of HE. In the majority of patients with HE, a clearly defined precipitating factor usually is identified, and the reversal or control of these factors is a key step in management. Institute gut-cleansing and ammonia-lowering measures. These measures are based on clinical and pathogenic characteristics of HE and are aimed at neutralizing the putative encephalogenic toxins (namely ammonia).