Hepatitis C virus among childbearing women in Scotland: prevalence, deprivation, and diagnosis

A rapid review of antenatal hepatitis C virus testing in the United Kingdom

BACKGROUND

The United Kingdom (UK) has committed to the World Health Organization's viral hepatitis elimination targets. New case finding strategies, such as antenatal testing, may be needed to achieve these targets. We conducted a rapid review to understand hepatitis C-specific antibody (anti-HCV) and HCV RNA test positivity in antenatal settings in the United Kingdom to inform guidance.

METHODS

Articles and conference abstracts published between January 2000 and June 2022 reporting anti-HCV testing in antenatal settings were identified through PubMed and Web of Science searches. Results were synthesised using a narrative approach.

RESULTS

The search identified 2,011 publications; 10 studies were included in the final synthesis. Seven studies used anonymous testing methods and three studies used universal opt-out testing. Anti-HCV test positivity ranged from 0.1 to 0.99%, with a median value of 0.38%. Five studies reported HCV RNA positivity, which ranged from 0.1 to 0.57% of the testing population, with a median value of 0.22%. One study reported cost effectiveness of HCV and found it to be cost effective at £9,139 per quality adjusted life years.

CONCLUSION

The relative contribution of universal opt-out antenatal testing for HCV should be reconsidered, as antenatal testing could play an important role in new case-finding and aid achieving elimination targets.

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.

Distance to treatment as a factor for loss to follow up of hepatitis C patients in North East England

BACKGROUND

A large proportion of the 200 000 HCV-infected individuals in the UK are undiagnosed or lost to follow-up. Engaging known infected individuals in treatment is essential for elimination.

METHODS

Using PHE surveillance data and HCV treatment registers from North East of England (NE) treatment centres for 1997-2016, we estimated the number of HCV cases not linked to treatment and the proportion with active infection. We compared distances of treated and untreated cases to treatment services, and assessed the effect of expanding HCV treatment into existing drug and alcohol treatment centres in the NEE on treatment accessibility.

RESULTS

The odds of being treated was associated with distance to treatment services. Confirmatory results for ~50% were not reported to PHE NE. Overall, 3385 patients reported to PHE NE had no record of treatment; we estimated 1621 of these may have been lost to follow-up after confirmation of active infection.

CONCLUSIONS

Poor access to healthcare services may contribute to under-diagnosis or loss to follow-up. Expanding HCV treatment delivery into NEE drug and alcohol treatment centres would improve the accessibility of treatment services to people infected with/at risk of HCV. This may increase the proportion receiving treatment and support progress towards elimination.

Epidemiology and natural history of hepatitis C virus infection

Hepatitis C virus (HCV) affects 130-210 million people worldwide and is one of the major risk factors for hepatocellular carcinoma. Globally, at least one third of hepatocellular carcinoma cases are attributed to HCV infection, and 350000 people died from HCV related diseases per year. There is a great geographical variation of HCV infection globally, with risk factors for the HCV infection differing in various countries. The progression of chronic hepatitis C to end-stage liver disease also varies in different study populations. A long-term follow-up cohort enrolling participants with asymptomatic HCV infection is essential for elucidating the natural history of HCV-caused hepatocellular carcinoma, and for exploring potential seromarkers that have high predictability for risk of hepatocellular carcinoma. However, prospective cohorts comprising individuals with HCV infection are still uncommon. The risk evaluation of viral load elevation and associated liver disease/cancer in HCV (REVEAL-HCV) study has followed a cohort of 1095 residents seropositive for antibodies against hepatitis C virus living in seven townships in Taiwan for more than fifteen years. Most of them have acquired HCV infection through iatrogenic transmission routes. As the participants in the REVEAL-HCV study rarely receive antiviral therapies, it provides a unique opportunity to study the natural history of chronic HCV infection. In this review, the prevalence, risk factors and natural history of HCV infection are comprehensively reviewed. The study cohort, data collection, and findings on liver disease progression of the REVEAL-HCV study are described.

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.

Improving access to treatment for patients with chronic hepatitis C through outreach

BACKGROUND

Chronic hepatitis C infection (HCV) is common in injecting drug users and is a major cause of liver disease. Antiviral treatment can 'cure' HCV, but is frequently associated with side effects and requires regular monitoring. Non-attendance at hospital appointments is frequent. To try and improve attendance and increase the number of current and previous injecting drug users treated we developed three outreach clinics.

OBJECTIVE

To review the outcome of patients referred to the outreach clinics.

METHODS

Retrospective service review of three clinics at drug treatment centres in Newcastle and Northumberland. Data was collected on attendance rates, patient demographics, treatment rates and outcomes.

RESULTS

141 referrals were received across the three sites with an overall attendance rate of 75% (106 patients, 79% men and median age 36), which compared favourably with that at our hospital (50%). All patients were on methadone/subutex. 45% were infected with Genotype 1 HCV. 10% were cirrhotic. To date, 30% have started treatment and 21% are waiting to start or are still in workup. 13% elected to delay treatment due to early stage disease and 11% were not ready for treatment on psychological or social grounds. Only 12% failed to attend follow up after initial assessment. To date, 24 patients have completed full courses of treatment with sustained viral response in 13 patients. Results are awaited for seven patients.

CONCLUSIONS

The development of outreach clinics for HCV in drug treatment centres can substantially improve clinic attendance and increase access to treatment in this marginalised group.

Dried blood spot samples: optimization of commercial EIAs for hepatitis C antibody detection and stability under different storage conditions

This study was undertaken to optimize and compare the efficiency of two commercial EIAs for anti-HCV detection (HCV Ab Radim, Pomezzia, Italy and ETI-AB-HCVK-4 DiaSorin, Vercelli, Italy), in dried blood spot (DBS) samples. The long-term stability of anti-HCV on DBS samples stored at three environmental conditions was also evaluated at: 2-8 °C, 20-25 °C, and -20 °C. Paired DBS and serum samples were obtained from individuals with or without anti-HCV. The type of elution buffer, sample and conjugate volume, sample incubation time and cut-off values were evaluated. For both EIAs, a larger sample volume was used, and the cut-off value determined by the manufacturer was employed for Radim EIA; however, ROC curve analysis was used for the DiaSorin EIA. The sensitivity and specificity of Radim EIA on DBS were 97.5% and 99.5%, respectively, and of DiaSorin EIA were 88.9% and 98.9%, respectively. Accurate results were obtained for a period of 117 days using DBS samples stored at all storage conditions, but storage at -20 °C resulted in the lowest variation among the absorbance values. Both EIAs demonstrated the same limit of detection (until dilution of 1:10(4) with estimated viral load of 3.1 × 10(-1) UI/ml), but the Radim EIA was associated with the best performance because a low coefficient of variation was observed in the repetition and reproducibility studies. In conclusion, commercial EIAs can be optimized for anti-HCV detection in DBS samples that are extremely stable at different conditions for more than 100 days.

Detection of hepatitis C virus RNA in dried blood spots

BACKGROUND

An estimated 130-170 million people worldwide are chronically infected with HCV.(1) In Europe the highest prevalence of HCV infections is in the IDU population.(2) As traditional HCV screening relies on the detection of HCV antibody or HCV RNA in blood, screening in high-risk groups such as IDU is difficult due to poor venous access caused by damaged veins.

OBJECTIVES

In this study DBS was evaluated as an alternative sample type to blood for the detection of HCV RNA.

STUDY DESIGN

The endpoint detection limit, inter-assay and intra-assay variability of the method were determined. The DBS method was compared to our routine frontline assay using a panel of paired DBS and blood samples. The effect of different storage temperatures and length of storage time on the stability of HCV RNA in DBS was also assessed.

RESULTS

The endpoint detection limit of the method based on results from mock DBS was 250 IU/ml. The method was shown to be precise and robust. The sensitivity and specificity of the method was found to be 100% and 95.8%, respectively. No significant variation in the stability of HCV RNA in DBS over a 1 year period at a range of different temperatures was observed.

CONCLUSIONS

A sensitive and stable method was developed for the detection of HCV RNA in DBS. Screening high-risk populations using DBS as a sample type may improve uptake of HCV testing by increasing opportunity for patients to be tested and consequently increasing access to treatment.

Identifying former injecting drug users infected with hepatitis C: an evaluation of a general practice-based case-finding intervention

BACKGROUND

In Scotland, a general practice-based case-finding initiative, to diagnose and refer hepatitis C virus (HCV) chronically infected former injecting drug users (IDUs), was evaluated.

METHODS

Testing was offered in eight Glasgow general practices in areas of high deprivation and high HCV and IDU prevalence to attendees aged 30-54 years with a history of IDU. Test uptake and diagnosis rates were compared with those in eight demographically similar control practices.

RESULTS

Of 422 eligible intervention practice attendees, 218 (52%) were offered an HCV test and, of these, 121 (56%) accepted. Poor venous access in 13 individuals prevented testing. Of 105 tested, 70% (74/105) were antibody positive of which 58% (43/74) were RNA positive by PCR. Of 43 chronically infected individuals identified in intervention practices, 22 (51%) had attended specialist care within 30 months of the study, while 9 (21%) had defaulted. In control practices, 8 (22%) of 36 individuals tested were antibody positive. Test uptake and case yield were approximately 3 and 10 times higher in intervention compared with control practices, respectively.

CONCLUSIONS

Targeted case-finding in primary care demonstrated higher test uptake and diagnosis rates; however, to optimize diagnosis and referral of chronically infected individuals, alternative means of testing (e.g. dried blood spots) and retention in specialist care (e.g. outreach services) must be explored.

Prevalence of hepatitis C virus antibody in newborn infants in southern California in 2003

The prevalence of hepatitis C virus (HCV) antibody in newborn infants in 3 counties in southern California in 2003 was found to be 2.5 per 1000 live births using dried blood spot testing. With advances in HCV antiviral therapy providing decreasing morbidity from chronic HCV infection, prenatal HCV screening to identify both mothers and at-risk infants should be reconsidered.

Guidance for clinical trials for children and adolescents with chronic hepatitis C

Most children with chronic hepatitis C are infected vertically, have a low natural seroconversion rate, and carry a lifetime risk of cirrhosis and cancer. Affected children are usually asymptomatic, and histological findings are mild with a low risk of progression, although 5% develop significant liver disease in childhood.The use of combination treatment with pegylated interferon-α and ribavirin has changed the outcome and prognosis for this disease, with approximately 60% of children achieving sustained viral clearance. Combination therapy is not ideal for children because pegylated interferon is administered subcutaneously, impairs growth velocity, and both interferon and ribavirin have significant adverse effects that affect compliance. In addition, approximately 50% of children infected with genotype 1 do not respond to therapy. Thus, additional treatment options are required including improvement in dosing, reduction in the length of treatment, and evaluation of new drugs, such as protease inhibitors, which could be more effective for patients infected with genotype 1.The primary goal of treatment is to eradicate the infection. The future clinical trial design should ensure that any new drugs demonstrate noninferiority to the present standard regimen in both children and adults. The measure for documenting substantial improvement above present therapy should be increased viral clearance rate or the same clearance rate, with a shorter duration of treatment and/or fewer adverse effects. We do not believe there is any need for a placebo arm because approved therapy is available and new treatments can be compared with present therapy.Safety measures should include the standard recommended laboratory investigations, growth parameters, quality-of-life or psychological measures, and a requirement for long-term follow-up for up to 5 years.

Dried blood spot for hepatitis C virus serology and molecular testing

We investigated the performance of dried blood spots (DBS) in hepatitis C virus (HCV) diagnosis using modified commercial tests. Paired DBS and serum samples were collected from 200 patients: 100 patients with anti-HCV antibodies (anti-HCV), including 62 patients with detectable serum HCV RNA, and 100 patients without anti-HCV. The DBS sample consisted of three drops of approximately 50 microL of whole blood applied to a paper card, which was then stored at -20 degrees C within 48 hours of collection. Using the Ortho HCV 3.0 enzyme-linked immunosorbent assay kit on DBS, we observed both a specificity and sensitivity of 99% in detecting anti-HCV. HCV RNA was detected on DBS in 60/62 (97%) patients with detectable serum HCV RNA, which was then successfully quantified in 55 samples (89%) using the Cobas TaqMan HCV test. A good correlation was observed between the DBS HCV RNA concentration and the serum level (r(2) = 0.95; P < 0.001). HCV genotyping was successfully performed on DBS samples, with a full concordance between the 14 paired DBS and serum samples (genotypes 1-4).

CONCLUSION

This study presents DBS as a reliable alternative to serum specimens for detecting anti-HCV, quantifying HCV RNA and genotyping HCV. DBS may increase the opportunities for HCV testing and treatment follow-up in hard-to-reach individuals.

Diagnosis of hepatitis C virus infection in Scotland's injecting drug user population

We estimated the extent of undiagnosed hepatitis C virus (HCV) infection in injecting drug users (IDUs) in Scotland. We used record-linkage to determine HCV diagnosis status for 41 062 current/former IDUs attending drug treatment and support services between 1 April 1995 and 31 March 2006; the extent of undiagnosed HCV infection was estimated by comparing the number HCV-diagnosed to the number HCV-infected (estimated from an unlinked anonymous testing survey of 2141 current/former IDUs). In all, 9145 IDUs (22%) were diagnosed HCV antibody-positive since first attendance at drug services (diagnosis rate of 33.6/1000 person-years, 95% CI 32.7-34.4). By 31 March 2006, of the 19 632 current/former IDUs who had attended drug services and were determined to be living with HCV, an estimated 58% (95% CI 45-62) had not been HCV-diagnosed. It is essential that the deployment of resources for identifying at-risk IDUs with a view to offering antiviral therapy is guided by evidence.

Management strategies for hepatitis C virus infection in children

Chronic hepatitis C virus (HCV) infection is a major cause of morbidity and mortality worldwide. Progression to cirrhosis and hepatocellular carcinoma occurs in 20% of infected adults. The natural history following childhood infection is less well defined, although cirrhosis in children is described. Since blood product screening for HCV infection was introduced in 1990, most children who acquire HCV do so by vertical transmission from an infected mother. Transmission to offspring occurs in approximately 5%. Most children with HCV infection are asymptomatic. Diagnosis is made by testing those at risk for HCV RNA by polymerase chain reaction (PCR) and HCV antibody (anti-HCV) by enzyme immunoassay (EIA). The clinical impact of HCV infection is assessed by monitoring symptoms and signs, blood testing of liver enzymes, ultrasound imaging, and by liver biopsy. Improved efficacy and tolerability of treatment strategies in adults have had a significant impact on the management of children with HCV infection. The emphasis is now on promoting awareness, early diagnosis, and treatment. Treatment strategies have evolved from monotherapy with interferon alfa (IFNalpha), to combination therapy with ribavirin. Pegylated IFNalpha is superior to conventional IFNalpha, and forms the basis of current recommendations. The genotype of HCV influences treatment efficacy. Treatment is generally well tolerated in children, although adverse effects are common. Preparation and support throughout treatment for the whole family is needed. A proportion of children with HCV infection have co-morbidity, including viral co-infection or hematologic disease. Although treatment may be contraindicated, risks and benefits must be considered before denying treatment. Anemia is more common in those with HIV co-infection, renal insufficiency, thalassemia, or cirrhosis, and may be aggravated by treatment. Children with thalassemia may have iron overload, and transfusion requirements may increase during treatment. Further refinements of combination therapy and development of new drugs are in progress. Vaccine candidates are undergoing phase I and II treatment trials.

Chronic hepatitis C in pregnancy

OBJECTIVE

To estimate outcomes, to determine whether appropriate follow-up was performed for pregnant patients with hepatitis C virus (HCV), and to show that maternal and neonatal complications would be higher in the HCV-positive group.

METHODS

We compared pregnant women from a drug dependence and treatment program who were HCV antibody-positive with those who were HCV antibody-negative using the University of New Mexico Perinatal Database. Maternal and neonatal outcomes were evaluated, including cholestasis of pregnancy, preterm birth, low birth weight, neonatal intensive care unit admissions, and neonatal methadone withdrawal. Variables were compared using Student t, Fisher exact, and chi(2) tests.

RESULTS

Among 351 pregnancies between January 2000 and 2006, 159 (53%) were HCV antibody reactive, 141 (47%) tested nonreactive, and 51 (15%) were not screened. Hepatitis C reactivity was more common among Hispanics. Cholestasis of pregnancy was increased in HCV antibody reactive (Ab+) pregnancies (10 of 159, 6.3% compared with 0 of 141, P=.002). Among women taking methadone, there was a significantly higher incidence of neonatal withdrawal (P=.001). This was significant in mothers on low (0-30 mg) and moderate (31-90 mg) methadone doses. Despite the high cure rate with intensive therapy, only 5.7% of HCV Ab+ mothers and 1.9% of their neonates received gastroenterology referrals.

CONCLUSION

In pregnant women involved in this drug treatment program, HCV reactivity was associated with Hispanic ethnicity, cholestasis of pregnancy, and increased neonatal methadone withdrawal regardless of maternal methadone dose. Gastroenterology consultation was inadequate.

[Clinical aspects of hepatitis C in women of child-bearing age]

It is difficult to define the optimal timing of antiviral treatment in women infected with viral hepatitis C, who have child-bearing potential. Antiviral treatment is strictly contraindicated during pregnancy and the breast-feeding period. Data are conflicting about the question of treatment with modern drugs (peginterferon and ribavirin) before or after pregnancy. The risk of vertical transmission from mother to child is estimated about 5%. The mother's viraemia seems to be the main transmission factor. There is a worse prognosis in nulliparous and postmenopausal women in the natural history of viral hepatitis C. Poor outcome in gestational age, maturity and Apgar score were not associated with hepatitis C virus infection. Combined treatment has frequent gynecological and other side effects. The timing of antiviral therapy in women in child-bearing period is recommended individually.

Socioeconomic context, distance to primary care and detection of hepatitis C: a French population-based study

Previous research suggests that hepatitis C detection is lower in rural than in urban areas and depends on geographic accessibility to care. To what extent differences in socioeconomic context could explain these disparities remains unknown. This study assessed the respective influence of the socioeconomic context and of the distance to primary care on the hepatitis C detection rates in a well-defined population of 1,005,817 inhabitants covered by a universal health insurance system in the Côte d'Or and the Doubs areas of France. The 1938 cases of hepatitis C newly diagnosed in the survey area between 1994 and 2001 were included. The patients' 'cantons' of residence were classified into six socioeconomic clusters according to 19 quantitative indicators. Age and sex-standardized hepatitis C detection rate ratios (DRR) for the six clusters were estimated and a multilevel Poisson model investigated whether detection rates varied across clusters after adjusting for distance to the nearest general practitioner. Standardized DRR (95% CI) were higher in both "lower-income urban" and "upper-income urban" clusters and lower in the following clusters: "outer suburb", "industrial rural" and economically "dynamic rural". Adjusting for distance to general practitioner reduced the rate difference between socioeconomic clusters: for a distance to general practitioner equalling 0km (practice in the municipality) and compared to the "upper-income urban" cluster, only the "lower-income urban" cluster had higher DRR. In the six clusters, detection rates decreased as the distance to general practitioner increased (DRR 0.89 95% CI 0.84-0.96 for a 1-km change) but the decrease was more marked in both urban clusters. In this population with good primary care affordability, geographic proximity to general practitioner, rather than socioeconomic context of neighborhood, appeared to be the main factor limiting hepatitis C detection.

Gauging acceptance of a hepatitis C test by family planning clinic attendees in Glasgow, UK

BACKGROUND

In the UK, pregnant women are not offered and recommended a hepatitis C virus (HCV) test because no effective intervention to prevent vertical transmission of HCV exists following conception. Mother-to-child transmission of HCV could, however, be reduced if infected women planning to have children underwent a course of therapy prior to conception.

OBJECTIVE

To determine what proportion of female family planning clinic (FPC) attendees would hypothetically accept an HCV test if they were offered it and to identify the factors associated with such a decision.

METHODS

Opportunistic sampling was used to recruit 1000 women attending FPCs in Glasgow during 2002/2003. Participants were asked to self-complete a brief questionnaire about HCV and testing.

RESULTS

Of 964 participants, 62% reported that they would accept an HCV test if it was offered in the family planning setting and 24% indicated that they were undecided. Only 4% of women reported that they would be offended if offered an HCV test. The highest rates of hypothetical acceptance of an HCV test were reported among those who had ever injected drugs (88%) and those who felt that they were at risk of being infected with HCV (84%). Women who were single [adjusted odds ratio (OR) 1.4, 95% CI 1.1-1.8] and who were of non-white ethnic origin (adjusted OR 2.5, 95% CI 1.0-6.2) were also significantly more inclined to hypothetically accept an HCV test.

CONCLUSION

Selective HCV testing to those women at high risk of HCV infection should be encouraged in the family planning setting.

Major decline of hepatitis C virus incidence rate over two decades in a cohort of drug users

Injecting drug users (DU) are at high risk for hepatitis C virus (HCV) and HIV infections. To examine the prevalence and incidence of these infections over a 20-year period (1985-2005), the authors evaluated 1276 DU from the Amsterdam Cohort Studies who had been tested prospectively for HIV infection and retrospectively for HCV infection. To compare HCV and HIV incidences, a smooth trend was assumed for both curves over calendar time. Risk factors for HCV seroconversion were determined using Poisson regression. Among ever-injecting DU, the prevalence of HCV antibodies was 84.5% at study entry, and 30.9% were co-infected with HIV. Their yearly HCV incidence dropped from 27.5/100 person years (PY) in the 1980s to 2/100 PY in recent years. In multivariate analyses, ever-injecting DU who currently injected and borrowed needles were at increased risk of HCV seroconversion (incidence rate ratio 29.9, 95% CI 12.6, 70.9) compared to ever-injecting DU who did not currently inject. The risk of HCV seroconversion decreased over calendar time. The HCV incidence in ever-injecting DU was on average 4.4 times the HIV incidence, a pattern seen over the entire study period. The simultaneous decline of both HCV and HIV incidence probably results from reduced risk behavior at the population level.

Caesarean section versus vaginal delivery for preventing mother to infant hepatitis C virus transmission

BACKGROUND

Observational studies have generally not provided evidence that delivery by caesarean section reduces perinatal hepatitis C virus (HCV) transmission. However, these studies have methodological weaknesses with potential for bias and their findings should be interpreted with caution.

OBJECTIVES

To assess the evidence from randomised controlled trials that a policy of delivery by planned caesarean section versus vaginal delivery reduces mother to infant HCV transmission.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (April 2006) and the Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, Issue 2).

SELECTION CRITERIA

Controlled trials using random or quasi-random participant allocation that compared a policy of planned elective caesarean section versus vaginal birth for mothers with HCV infection.

DATA COLLECTION AND ANALYSIS

We did not identify any randomised controlled trials.

MAIN RESULTS

We did not identify any randomised controlled trials.

AUTHORS' CONCLUSIONS

Currently, there is no evidence from randomised controlled trials upon which to base any practice recommendations regarding planned caesarean section versus vaginal delivery for preventing mother to infant hepatitis C virus transmission. In the absence of trial data, evidence to inform women and carers is only available from observational studies that are subject to biases. Systematic review of these studies is needed. There is a need to determine whether women and healthcare providers would support a large pragmatic randomised controlled trial to provide evidence regarding the benefits and harms of planned elective caesarean section versus planned vaginal birth for women with HCV infection.

Hepatitis C virus infection in Scotland: epidemiological review and public health challenges

INTRODUCTION

In 2004, Scotland's Health Minister stated that the hepatitis C virus (HCV) "is one of the most serious and significant public health risks of our generation".

METHODS

To appreciate the prevention and care challenges posed by HCV in Scotland, we reviewed all country-specific data on i) the prevalence of infection among different populations, ii) the numbers infected with HCV, and iii) the current and future HCV disease burden.

RESULTS

An estimated 1% of Scotland's population has HCV; 85-90% of those infected were injecting drug users (IDUs). Reductions in HCV prevalence among young IDUs during the early 1990s suggest that the incidence of HCV had decreased; since then, the absence of further reductions highlight that existing prevention measures are insufficient. Two-thirds of the estimated 37,500 chronically HCV-infected individuals in Scotland remain undiagnosed and two-thirds of this group are former IDUs. An estimated 9,000 former IDUs were living with either moderate or severe HCV disease in 2004; if the current uptake of antiviral therapy continues, this number was estimated to double by 2016. Approximately 1,200 HCV-infected IDUs had developed liver failure by 2004; this figure was predicted to increase to 3,200 by 2020.

CONCLUSIONS

Scotland faces three principal public health challenges: i) the prevention of HCV among current IDUs, ii) the diagnosis of HCV-infected persons, particularly those most in need of therapy to prevent severe HCV disease, and iii) the current and future provision of adequate resources to ensure that the movement of patients through the diagnostic and clinical care pathway is optimal.

Perinatal hepatitis C virus infection: diagnosis and management

Hepatitis C virus (HCV) infection in children is becoming an increasing challenge to health professionals. As our understanding of the disease evolves, so must our diagnostic and management strategies. In the 1990s, when HCV testing became available, children identified with HCV infection in the UK were mostly those who had required blood products, particularly those with haematological disorders. Acquiring knowledge of the natural history of HCV infection was confounded by the co-morbidity of iron overload, viral co-infection, and chemotherapy.

Hepatitis C virus infection among injecting drug users in Scotland: a review of prevalence and incidence data and the methods used to generate them

It is estimated that of 50,000 persons in Scotland (1% of the county's population), infected with the hepatitis C virus (HCV), around 90% injected drugs. This paper reviews data on the prevalence and incidence of HCV, and the methods used to generate such information, among injecting drug users (IDUs), in Scotland. The prevalence estimate for HCV among IDUs in Scotland as a whole (44% in 2000), is comparable with those observed in many European countries. Incidence rates ranged from 11.9 to 28.4/100 person-years. The data have shaped policy to prevent infection among IDUs and have informed predictions of the number of HCV-infected IDUs who will likely progress to, and require treatment and care for, severe HCV-related liver disease. Although harm reduction interventions, in particular needle and syringe exchanges and methadone maintenance therapy, reduced the transmission of HCV among IDUs during the early to mid-1990s, incidence in many parts of the country remains high. The prevention of HCV among IDUs continues to be one of Scotland's major public health challenges.

Commercial enzyme immunoassay adapted for the detection of antibodies to hepatitis C virus in dried blood spots

BACKGROUND

Dried blood spots (DBS) provide a convenient method for blood sample collection in many settings where the prevalence of infection with hepatitis C virus (HCV) is increasing. Consequently, HCV assays are required that produce reliable results using samples derived from DBS.

OBJECTIVES AND STUDY DESIGN

The optimum buffer for the elution of samples from DBS was selected and the performance of a commercial enzyme immunoassay (EIA) was evaluated using these DBS eluates and paired plasma samples.

RESULTS

DBS with paired plasma samples were compared using this modified commercial EIA, which was found to have an estimated sensitivity and specificity of approximately 100% for detecting anti-HCV antibodies in DBS.

CONCLUSION

A DBS-based assay for the detection of antibodies to HCV will prove valuable for collecting epidemiological data in the field or in under resourced settings.

Prior information in behavioral capture-recapture methods: demographic influences on drug injectors' propensity to be listed in data sources and their drug-related mortality

The authors present findings from a Bayesian analysis of Scotland's four primary capture-recapture data sources for 2000 that was carried out to estimate numbers of current injecting drug users by region (Greater Glasgow vs. elsewhere in Scotland), sex (male vs. female), and age group (15-34 years vs. > or =35 years). A secondary goal of the analysis was to obtain Bayesian estimates and credible intervals for the demographic influences on Scotland's drug-related death rate per 100 current injectors. Incorporation of informative priors altered the models with highest posterior probability. Expert opinion on how demography influenced Scottish drug injectors' propensity to be listed in different data sources was taken into account, along with external information about European injectors' drug-related death rates and male:female ratios. Higher drug-related mortality was confirmed in older drug injectors and those outside of Greater Glasgow. Female injectors' lower drug-related death rate was not sustained beyond 34 years of age. The authors recommend that demographic influences be accommodated in behavioral capture-recapture estimation, especially when it is a prelude to secondary analysis, such as the analysis of drug-related death rates presented here.

Modeling the current and future disease burden of hepatitis C among injection drug users in Scotland

Quantitative estimates of the current and future burden of hepatitis C virus (HCV) disease are required to plan a public health response to the HCV epidemic with regard to both prevention and treatment. A forward projection model was used to estimate the numbers of both current and former injecting drug users (IDUs) who acquired HCV and progressed to moderate and severe disease in Glasgow and Scotland during 1960-2030. The model was designed to synthesize information on the incidence and cessation of injecting drug use, the incidence of HCV infection among IDUs, the rate of HCV disease progression, and the annual number of IDUs developing HCV-related decompensated cirrhosis. During 2003, a total of 17,400 and 42,900 HCV-infected IDUs were estimated in Glasgow and Scotland, respectively; this compares with approximately 5,000 and 13,900 diagnosed, respectively, and 13,200 and 32,200 with chronic HCV, respectively. The number of IDUs developing HCV-related decompensated cirrhosis in Scotland is estimated to double between 2000 and 2020. As many as 16% and 27% of former IDUs in 2005 aged 30-39 and 40-49 years, respectively, were estimated to have moderate disease, which highlights the potential benefit of targeting HCV testing at former IDUs who belong to these age groups. In conclusion, the identification and treatment of a larger proportion of former IDUs with HCV disease and education about the importance of minimal alcohol consumption are needed to help achieve a greater impact on the future morbidity and mortality of this disease.

The management of HCV infected pregnant women and their children European paediatric HCV network

BACKGROUND/AIMS

As evidence accumulates relating to mother-to-child (vertical) transmission of hepatitis C virus (HCV), it is timely to draw up guidelines for the clinical management of HCV infected pregnant women and their children.

METHODS

A review of evidence from the European Paediatric HCV Network (EPHN) prospective study of HCV infected women and their children and other published studies. Meeting of EPHN clinical experts to reach a consensus on recommendations for management. Each recommendation was graded according to the level of evidence.

RESULTS/CONCLUSIONS

Although several risk factors for mother-to-child transmission have been identified, none are modifiable and there are currently no interventions available to prevent vertical transmission of HCV. Data on timing of loss of maternal antibodies and reliability of diagnostic tests inform the optimum follow-up schedule for confirmation or exclusion of infection in children born to HCV infected women. Based on the current evidence, routine antenatal screening for HCV should not be introduced and neither elective caesarean section nor avoidance of breastfeeding should be recommended to HCV infected women to prevent mother-to-child transmission of HCV. HCV/HIV co-infected women should follow existing HIV guidelines.

Hepatitis C in pregnancy

Hepatitis C is a worldwide health problem affecting men and women of all ages. In young pregnant women, however, the existence of hepatitis C presents a set of unique issues for the mother and the child. For the mother, therapeutic and medical decisions for hepatitis C are affected by pregnancy. For the child, transmission of hepatitis C from the mother can occur. Identification of risk factors for mother-to-child transmission and prevention of this transmission are the foremost concerns.