High seroprevalence of hepatitis C infection among risk groups in Egypt

Cognitive impairment in children with chronic Hepatitis C Virus: Case control study

Hepatitis C virus (HCV) infection is the most common cause of chronic liver disease of infectious etiology in children. This study aims to compare cognitive impairment, and psychological status of treatment-naïve HCV children with control group. Treatment-naïve children with HCV and an equal control group of children of matched age and gender were recruited. Assessment included measures of children's cognitive functioning, behavior, depression and anxiety as well as laboratory investigations and liver biopsy. Overall 102 children of both genders were recruited; the majority was from rural areas and from middle social class. Their age ranged from 7 to 17 years old. Only 6.9% reported positive family history of Psychiatric disorders while 35.3% reported current Psychiatric disorder. The most frequent diagnosis in the sample was depression (16.7%). Depression scores correlated negatively with liver biopsy activity (p = 0.024) and positively with WBCS (p = 0.0024). Anxiety scores correlated positively with WBCS (p = 0.017). Verbal IQ, performance IQ and total IQ correlated with the social class and with the liver biopsy activity. Also it was found that higher depression scores can predict lower verbal IQ. Depression, social class and liver Inflammation are predictors of cognitive impairment in children with HCV.

Egypt's Ambitious Strategy to Eliminate Hepatitis C Virus: A Case Study

A national hepatitis C virus elimination strategy rooted in mass screening and treatment can be effective in many middle-income countries. A strong public health infrastructure, political commitment, and technological advances are essential to such initiatives.

Introduction:

Chronic hepatitis C virus (HCV) infection is a major public health problem in many low- and middle-income countries. In 2015, Egypt's HCV infection prevalence of 7% among adults was among the highest in the world and accounted for 7.6% of the country's mortality. In 2014, Egypt embarked on an aggressive screening and treatment program that evolved into a national strategy to eliminate HCV as a public health threat by 2021.

Methods:

In this qualitative case study, we analyzed Egypt's HCV control strategy using the Kingdon framework to understand how the problem, policy, and political streams merged to create an opportunity to achieve an ambitious elimination goal. We describe key aspects of the implementation, identify lessons learned, and provide recommendations for other low- and middle-income countries aiming to eliminate HCV.

Results:

Between 2014 and 2020, Egypt screened more than 50 million and treated more than 4 million residents for HCV. Five key elements contributed to Egypt's successful HCV elimination program: (1) sufficient and reliable epidemiologic data to quantify and monitor public health threats; (2) a robust public health care infrastructure; (3) inclusive care that reached all sectors of society; (4) political commitment to public health through increased health care spending and a comprehensive long-term national control strategy; and (5) innovative scientific research and use of information technology.

Conclusion:

Egypt conducted a successful HCV screening program that covered more than 50 million residents and treated more than 4 million. It is poised to be the first country in the world to eliminate HCV within its borders. The lessons learned from this experience can inform the elimination plans of other low- and middle-income countries with high HCV burden.

HCV and HEV: two players in an Egyptian village, a study of prevalence, incidence, and co-infection

The highest recorded hepatitis C virus (HCV) prevalence worldwide is in Egypt. A high prevalence of hepatitis E virus (HEV) in chronic liver disease has been reported. The aim of this study was to study prevalence, incidence, and outcome of HCV infection in an Egyptian Nile Delta village and the relation between HEV infection and HCV-related chronic hepatic affection. This prospective cohort study included 2085 Nagreej village residents. Mass HCV screening was conducted and testing for HEV antibodies among HCV-infected patients performed. The annual incidence of HCV was recorded. Five hundred five (24.22%) of the tested villagers were positive for HCV RNA. Prevalence escalated with age and male sex. The main recorded risk factors were a history of surgery, dental procedures, hospitalization, blood transfusion, and antischistosomal treatment. HEV IgG antibody was positive in 71.4% of individuals with chronic HCV and 96.1% with advanced liver disease (cirrhosis ± hepatocellular carcinoma (HCC)). After 1 year, 29 of the 1390 HCV Ab negative villagers had a positive HCV PCR, placing an annual incidence of new HCV infections at 2.09%. The Egyptian HCV prevalence remains high with infection particularly among the elderly. The annual incidence in a small Nile Delta village is 2.086%. HCV-HEV co-infection may lead to a worse prognosis among Egyptians with chronic liver disease.

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

OBJECTIVES

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Individual-level key associations and modes of exposure for hepatitis C virus infection in the Middle East and North Africa: a systematic synthesis

PURPOSE

To identify, map, and synthesize the individual-level key associations and modes of exposure for hepatitis C virus (HCV) infection in the Middle East and North Africa (MENA), the most affected region by HCV.

METHODS

Source of data was the MENA HCV Epidemiology Synthesis Project database, populated through systematic literature searches. Risk factors determined to be statistically significant after adjustment for confounders were extracted and categorized into key associations or modes of exposure.

RESULTS

In total, 329 risk factors were identified from 109 articles in 14 of 24 MENA countries. Among key associations, age was most frequently reported (n = 39; 34.2%), followed by other infections/diseases (n = 20; 17.5%), and incarceration (n = 17; 14.9%). Among modes of exposure, health care-related exposures were most frequently reported (n = 127; 59.5%), followed by injecting drug use exposures (n = 45; 20.9%), community-related exposures (n = 34; 15.8%), and sexual-related exposures (n = 8; 3.7%). Blood transfusion, hemodialysis, surgical and other medical procedures, dental work, and medical injections were identified as key health care-related exposures.

CONCLUSIONS

Health care appears to be the primary driver of prevalent (and possibly incident) infections in MENA, followed by injecting drug use. HCV screening should target the identified modes of exposure. Commitment to prevention should be an integral component of HCV response to achieve HCV elimination by 2030, with focus on strengthening infection control in health care facilities, improving injection safety and blood screening, and expanding harm reduction services for people who inject drugs.

Characterizing hepatitis C virus epidemiology in Egypt: systematic reviews, meta-analyses, and meta-regressions

Egypt is the most affected nation by hepatitis C virus (HCV) and needs a comprehensive characterization of HCV epidemiology to inform the scale-up of treatment and prevention programs. Systematic reviews, meta-analyses, and meta-regressions were conducted. A total of 25 incidence, 259 prevalence, and 47 genotype studies were identified. Incidence and prevalence levels were high across all populations. Genotype 4 accounted for 94.1% of infections with a relative Shannon Diversity Index of only 14.4%. Pooled mean HCV prevalence was estimated at 11.9% (95% CI = 11.1–12.6%) among the general population, 55.6% (95% CI = 49.4–61.7%) among populations at high risk, 14.3% (95% CI = 10.3–18.8%) among populations at intermediate risk, 56.0% (95% CI = 50.4–61.6%) among populations with liver-related conditions, and 35.0% (95% CI = 27.3–43.1%) among special clinical populations. Mean HCV viremic rate was estimated at 66.7% (95% CI = 61.7–71.5%). Meta-regression indicated 6% lower odds for HCV prevalence for each one-year increment in publication year (AOR = 0.94; 95% CI = 0.92–0.96). HCV prevalence is high with evidence for ongoing transmission mainly through healthcare. Genotype diversity is low with genotype 4 dominance. Two-thirds of antibody-positive Egyptians are chronically infected and need treatment. Clinical populations should be prioritized for screening. Despite the large-scale epidemic, prevalence appears to be declining rapidly consistent with a contracting epidemic.

Epidemiology of hepatitis C virus among hemodialysis patients in the Middle East and North Africa: systematic syntheses, meta-analyses, and meta-regressions

We aimed to investigate hepatitis C virus (HCV) epidemiology among hemodialysis (HD) patients in the Middle East and North Africa (MENA). Our data source was an HCV biological measures database populated through systematic literature searches. Descriptive epidemiologic syntheses, effects meta-analyses and meta-regressions, and genotype analyses were conducted. We analyzed 289 studies, including 106 463 HD patients. HCV incidence ranged between 0 and 100% as seroconversion risk, and between 0 and 14·7 per 1000 person-years as incidence rate. The regional pooled mean estimate was 29·2% (95% CI: 25·6–32·8%) for HCV antibody positive prevalence and 63·0% (95% CI: 55·4–70·3%) for the viremic rate. Region within MENA, country income group, and year of data collection were associated with HCV prevalence; year of data collection adjusted odds ratio was 0·92 (95% CI: 0·90–0·95). Genotype diversity varied across countries with four genotypes documented regionally: genotype 1 (39·3%), genotype 2 (5·7%), genotype 3 (29·6%), and genotype 4 (25·4%). Our findings showed that one-third of HD patients are HCV antibody positive and one-fifth are chronic carriers and can transmit the infection. However, HCV prevalence is declining. In context of growing HD patient population and increasing HCV treatment availability, it is critical to improve standards of infection control in dialysis and expand treatment coverage.

Hepatitis C in Egypt - past, present, and future

Hepatitis C viral infection is endemic in Egypt with the highest prevalence rate in the world. It is widely accepted that the implementation of mass population antischistosomal treatment involving administration of tartar emetic injections (from 1950s to 1980s) led to widespread infection. What is less well known, however, is that these schemes were implemented by the Egyptian Ministry of Health on the advice of the World Health Organization. There has been a spectrum of treatments to target the public health disaster represented by the hepatitis C problem in Egypt: from the use of PEGylated interferon to the recent use of direct acting antiviral drugs. Some new treatments have shown >90% efficacy. However, cost is a key barrier to access these new medicines. This is coupled with a growing population, limited resources, and a lack of infection control practices which means Egypt still faces significant disease control issues today.

Risky exposures and national estimate of HCV seroprevalence among school children in urban Egypt

Hepatitis C virus (HCV) is a significant cause of morbidity and mortality all over the world, particularly in Egypt. Limited data are available concerning the national seroprevalence and the possible modes of transmission of HCV in the pediatric age group. The aim of this study was to obtain a better estimate of the national hepatitis C seroprevalence and the possible risky exposures among healthy school children in Alexandria; the second biggest city in Egypt. HCV knowledge and counseling for school children were also investigated. A total of 500 school children, age between 6 and 15 years were evaluated for HCV seropositivity and interviewed for potential disease risk factors. The seropositivity for Anti-HCV Ab was 2.8 %. About 71.4 % of seropositive children were 10-15 years old. Urban residence, chronic disease, male circumcision and invasive procedures were detected as significant risk factors for acquiring HCV infection among the studied children. The level of awareness of hepatitis C among school children was very low (3.6 %) and was correlated with the age and educational level. HCV infection continues to occur in children and is frequently unrecognized. This mandates immediate intervention and robust control strategies in the settings of exposure combined with health education programs to limit further HCV spread.

Elevated serum α-fetoprotein levels in patients with chronic hepatitis C virus genotype 4: not the end of the story

BACKGROUND AND AIM

Elevated serum α-fetoprotein (AFP) is not uncommonly seen among patients with chronic hepatitis C. This study aimed to identify clinical characteristics, histological characteristics, and biochemical markers associated with increased serum AFP levels in hepatitis C virus genotype 4-infected patients with no evidence of hepatocellular carcinoma and to determine the effect of lifestyle modification on these parameters.

METHODS

The study included 447 chronic hepatitis C patients with no evidence of hepatocellular carcinoma and 100 healthy controls. They underwent liver biopsies, homeostasis model assessment-insulin resistance (HOMA-IR), measurement of serum insulin, leptin, adiponectin, tumor necrosis factor-α, and interleukin-6 levels by an enzyme-linked immunosorbent assay, and assessment of AFP levels. Eighty patients with HOMA-IR greater than 3 received prospective longitudinal lifestyle intervention.

RESULTS

In a multivariate analysis, platelet count less than 140×10/cm, a mean platelet volume of at least 9.5 fl, a neutrophil-lymphocyte ratio (NLR) of at least 2, an aspartate transaminase level of at least 55 IU/l, a γ-glutamyl transpeptidase level of at least 40 IU/l, an albumin level of up to 3.8 g/dl, HOMA-IR greater than 3, a leptin level of at least 10 pg/ml, an iron level of at least 165 μg/dl, a ferritin level of at level 175 ng/ml, and hepatic fibrosis F3-F4 were found to be independently associated with elevated AFP levels. The lifestyle intervention significantly improved BMI, platelet indices, NLR, γ-glutamyl transpeptidase, leptin, leptin/adiponectin ratio, tumor necrosis factor-α, interleukin-6, HOMA-IR, and AFP levels.

CONCLUSION

Elevated insulin resistance, leptin, serum iron, ferritin, mean platelet volume, NLR, and advanced fibrosis, as well as decreased platelet count and serum albumin, are independently associated with an elevated AFP level. Lifestyle modification can improve (reduce) insulin resistance, leptin, leptin/adiponectin ratio, platelet count and their indices, NLR, and AFP level.

A cross-sectional household cluster serosurvey of hepatitis C virus antibodies in an urban slum of Cairo, Egypt in 2004

Background

Hepatitis C Virus (HCV) continues to be a burden to the Egyptian population and its economy. Despite all efforts, the prevalence of infection continues to be one of the highest in the world. The high national prevalence has been attributed to unintentional, nosocomial spread during an anti-schistosomiasis campaign conducted in the 1970’s, but that does not fully explain the persistent infection rates. Work is needed to further clarify risk associations. A serosurvey was performed in Manshiet Nasser, a slum in Cairo sometimes referred to as Mokattem Hills where a primary occupation is garbage collection and sorting, to characterize potential risk factors for infection.

Methods

Following a detailed mapping and census of the area, a cluster sampling was performed and demographic and risk behavior data and a blood sample were collected from subjects older than 6 months. Blood samples were tested using 4^th generation anti-HCV EIA kit.

Results

The slum was estimated to house 45,000 residents. Blood samples were obtained from 2169 subjects. The age adjusted anti-HCV seroprevalence was 9.1 %. Participants with HCV antibodies were more likely to be male, heads of households, subjects without formal education, and those with a lower standard of living. After adjustment of all prevalence ratios (aPR) for age, the following risk factors were significantly associated with higher risk of HCV infection: Garbage collection (aPR 1.5), history of blood transfusion (aPR 2.0), tattooing (aPR 1.4), history of schistosomiasis (aPR 1.5), and use of traditional latrines (aPR 2.0) or pits for sanitation (aPR 1.3). The results of the multivariate analysis indicated that age (p < 0.01), history of schistosomiasis (p < 0.05), garbage sorting (p = 0.05), blood transfusions (<0.001), and the use of traditional latrines for sanitation (p < 0.01) were significantly associated with infection.

Conclusion

While HCV prevalence among those over 30 could be attributed to anti-schistosomiasis injections, the prevalence in younger age indicates ongoing transmission. Although specific behavioral risks were not identified, HCV infection appears to be an occupational hazard of garbage collection and sorting in this environment. Given the large reservoir of HCV infection in the population, further effort needs to be made to identify and mitigate new infections.

Hepatitis C screening beyond CDC guidelines in an Egyptian immigrant community

BACKGROUND & AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

Association between Schistosomiasis mansoni and hepatitis C: systematic review

OBJECTIVE

To perform a systematic review of the prevalence of the HCV/ S. mansoni co-infection and associated factors in Schistosoma mansoni -infected populations.

METHODS

The bibliographic search was carried out using the Medline, Lilacs, SciELO, Cochrane Library and Ibecs databases. The criteria for the studies' selection and the extraction data were based on systematic review methods. Forty five studies were found, with nine being excluded in a first screening. Thirteen articles were used for data extraction.

RESULTS

The HCV infection rates in schistosomiasis populations range from 1% in Ethiopia to 50% in Egypt. Several studies had poorly defined methodologies, even in areas characterized by an association between hepatitis C and schistosomiasis, such as Brazil and Egypt, which meant conclusions were inconsistent. HCV infection rates in schistosomotic populations were heterogeneous and risk factors for acquiring the virus varied widely.

CONCLUSIONS

Despite the limitations, this review may help to identify regions with higher rates of hepatitis C and schistosomiasis association. However, more studies are necessary for the development of public health policies on prevention and control of both diseases.

Hepatitis C Virus NS5B Sequence-Based Genotyping Analysis of Patients From the Sharkia Governorate, Egypt

BACKGROUND

Chronic hepatitis C virus infection and its sequela are major health problems facing the Egyptian community. The high prevalence and spread rates of the disease require serious actions to stop or decrease these rates. Determination of HCV genotypes and subgenotypes adds significant knowledge about the epidemiology of the disease, and provides an added value in the decision making process of what strategy to follow and what therapy response to expect. The molecular epidemiology and genetic variability of HCV variants circulating in Egypt still need further analysis.

OBJECTIVES

The study was held to evaluate the genotype and subgenotype of the hepatitis c virus circulating in Sharkia as one of the large governorates of Egypt, which was not included in any study for genotyping of the virus before.

PATIENTS AND METHODS

The HCV molecular epidemiology in Sharkia governorate was studied using direct sequencing and further phylogenetic analysis of a partial NS5B region of the HCV genome from 63 patients. HCV genotype and subtype were successfully determined in 62 out of 63 patients.

RESULTS

The highest prevalent genotype was genotype 4a, which was found in 57 patients (92%) followed by 2 isolates (3%) with genotype 4o, 2 strains (3%) with genotype 1g and one isolate (2%) with genotype 4n.

CONCLUSIONS

This molecular epidemiology study revealed high prevalence of HCV genotype 4, subtype 4a among Egyptian patients residing in Sharkia governorate, Egypt.

The state of hepatitis B and C in the Mediterranean and Balkan countries: report from a summit conference

The burden of disease due to chronic viral hepatitis constitutes a global threat. In many Balkan and Mediterranean countries, the disease burden due to viral hepatitis remains largely unrecognized, including in high-risk groups and migrants, because of a lack of reliable epidemiological data, suggesting the need for better and targeted surveillance for public health gains. In many countries, the burden of chronic liver disease due to hepatitis B and C is increasing due to ageing of unvaccinated populations and migration, and a probable increase in drug injecting. Targeted vaccination strategies for hepatitis B virus (HBV) among risk groups and harm reduction interventions at adequate scale and coverage for injecting drug users are needed. Transmission of HBV and hepatitis C virus (HCV) in healthcare settings and a higher prevalence of HBV and HCV among recipients of blood and blood products in the Balkan and North African countries highlight the need to implement and monitor universal precautions in these settings and use voluntary, nonremunerated, repeat donors. Progress in drug discovery has improved outcomes of treatment for both HBV and HCV, although access is limited by the high costs of these drugs and resources available for health care. Egypt, with the highest burden of hepatitis C in the world, provides treatment through its National Control Strategy. Addressing the burden of viral hepatitis in the Balkan and Mediterranean regions will require national commitments in the form of strategic plans, financial and human resources, normative guidance and technical support from regional agencies and research.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The comparison of chronic hepatitis C treatment outcome between intravenous drug users and non-intravenous drug users

Despite the fact that the majority of prevalent and incident cases of HCV are associated with intravenous drug use (IVDU), these patients have largely been excluded from HCV care. The aim of this study was to examine the treatment outcome of chronic hepatitis C in IVDUs compared to non-IVDUs.

PATIENTS AND METHODS

Patients with chronic hepatitis C (CHC) who initiated and completed combination antiviral therapy with pegilated interferon and ribavirin, at the Hepatology Department of the University Hospital for Infectious and Tropical Diseases in Belgrade, were retrospectively analyzed. The study included a series of 254 patients of which 100 (39.4%) were former IVDU.

RESULTS

Sustained virological response (SVR) was recorded in a total of 172 patients (67.7%). The analyses of the favorable treatment outcome, regarding particular viral genotypes, revealed that among those with genotype 1 and/or 4, including patients with genotype 1 recombinants with genotype 3, SVR was achieved in 114 (63.3%), while it was almost equally distributed between subgroups of former IVDU and all others (P=0.079). Among patients infected with HCV genotypes 2 and/or 3 the SVR rate was as high as 86.6%.

CONCLUSION

IVDU with CHC infection should be treated with standard combination antiviral therapy for CHC, since the success rate is equal or even better than in non-IVDU patients.

Hepatitis C, hepatitis B and HIV infection among Egyptian prisoners: seroprevalence, risk factors and related chronic liver diseases

BACKGROUND AND AIM

Prisons in Egypt do not currently screen for blood-borne viruses, and there are no statistics concerning the prevalence of hepatitis C virus, hepatitis B virus or human immunodeficiency virus among prisoners. This study was performed to detect the prevalence of antibodies against hepatitis C, hepatitis B core and human immunodeficiency virus among Egyptian prisoners.

METHODS

The study was conducted in an Egyptian prison. The prisoners voluntarily completed a risk factor questionnaire and provided blood specimens for testing for antibodies against hepatitis C virus, hepatitis B virus core antigen and human immunodeficiency virus. Positive results were confirmed by the detecting HCV RNA via polymerase chain reaction. Multivariate regression analysis was performed to determine the factors that were independently associated with positive HCV serology.

RESULTS

Five hundred resident prisoners were screened. The prevalence of hepatitis C virus antibodies was 15.8% (79/500), and viremia was confirmed by PCR in 77.2% (61/79) of the antibody-positive prisoners. The prevalence of antibodies to hepatitis B core antigen was 9.8% (49/500), and 1.2% (6/500) of prisoners were dually infected with HBV and HCV. Antibodies to human immunodeficiency virus were not detected in any of the prisoners. The best predictor for hepatitis C and hepatitis B infection was a history of intravenous drug use (P<0.011 for HBV and P<0.001 for HCV), a period of >10 years spent in prison (P<0.052 for HBV and P<0.021 for HCV) and shared toiletries (P<0.059 for HBV and P<0.002 for HCV).

CONCLUSION

Hepatitis C and hepatitis B virus infections constitute an important public health problem in prisons. Public health strategies to prevent morbidity and mortality from these infections should include hepatitis B vaccination, HCV testing, counseling and medical management of infected prisoners.

Noninvasive assessment of hepatic fibrosis in Egyptian patients with chronic hepatitis C virus infection

AIM: To evaluate the accuracy of specific biochemical markers for the assessment of hepatic fibrosis in patients with chronic hepatitis C virus (HCV) infection.

METHODS: One hundred and fifty-four patients with chronic HCV infection were included in this study; 124 patients were non-cirrhotic, and 30 were cirrhotic. The following measurements were obtained in all patients: serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), albumin, total bilirubin, prothrombin time and concentration, complete blood count, hepatitis B surface antigen (HBsAg), HCVAb, HCV-RNA by quantitative polymerase chain reaction, abdominal ultrasound and ultrasonic-guided liver biopsy. The following ratios, scores and indices were calculated and compared with the results of the histopathological examination: AST/ALT ratio (AAR), age platelet index (API), AST to platelet ratio index (APRI), cirrhosis discriminating score (CDS), Pohl score, Göteborg University Cirrhosis Index (GUCI).

RESULTS: AAR, APRI, API and GUCI demonstrated good diagnostic accuracy of liver cirrhosis (80.5%, 79.2%, 76.6% and 80.5%, respectively); P values were: < 0.01, < 0.05, < 0.001 and < 0.001, respectively. Among the studied parameters, AAR and GUCI gave the highest diagnostic accuracy (80.5%) with cutoff values of 1.2 and 1.5, respectively. APRI, API and GUCI were significantly correlated with the stage of fibrosis (P < 0.001) and the grade of activity (P < 0.001, < 0.001 and < 0.005, respectively), while CDS only correlated significantly with the stage of fibrosis (P < 0.001) and not with the degree of activity (P > 0.05). In addition, we found significant correlations for the AAR, APRI, API, GUCI and Pohl score between the non-cirrhotic (F0, F1, F2, F3) and cirrhotic (F4) groups (P values: < 0.001, < 0.05, < 0.001, < 0.001 and < 0.005, respectively; CDS did not demonstrate significant correlation (P > 0.05).

CONCLUSION: The use of AAR, APRI, API, GUCI and Pohl score measurements may decrease the need for liver biopsies in diagnosing cirrhosis, especially in Egypt, where resources are limited.

Can we consider the right hepatic lobe size/albumin ratio a noninvasive predictor of oesophageal varices in hepatitis C virus-related liver cirrhotic Egyptian patients?

BACKGROUND

The current guidelines recommend the screening of all cirrhotic patients by endoscopy, but repeated endoscopic examinations are unpleasant for patients and have a high cost impact and burden on endoscopic units. The aim of this study is to evaluate the optimal liver lobe size/albumin ratio and to compare this ratio with spleen size, platelet count and platelet count/spleen diameter ratio as potential noninvasive predictors of oesophageal varices in hepatitis C virus (HCV)-related liver cirrhosis in Egyptian patients.

METHODS

This prospective study included one hundred patients with HCV-related liver cirrhosis. All studied subjects underwent a detailed clinical examination, biochemical workup, upper gastrointestinal endoscopy and abdominal ultrasound. The platelet count/spleen diameter ratio and the right liver lobe/albumin concentration ratio for all patients were calculated.

RESULTS

The 4 predictors demonstrated a high statistically significant correlation with the presence and grade of oesophageal varices (P values<0.001). The platelet count/spleen diameter ratio had the highest accuracy, followed by the right liver lobe/albumin concentration ratio, spleen size and then platelet count.

CONCLUSION

The use of the studied noninvasive predictors, especially the platelet count/spleen diameter ratio and the right liver lobe/albumin concentration ratio, can help physicians by restricting the use of endoscopic screening only to patients presenting a high probability of oesophageal varices. This is especially useful in clinical settings where resources are limited and endoscopic facilities are not present in all areas. Such is the case in Egypt, where there is a large number of patients who require oesophageal screening for oesophageal varices.

Hepatitis C virus infection among healthy Egyptian children: prevalence and risk factors

The aim of this study was to estimate the prevalence and identify the risk factors of hepatitis C virus (HCV) infection among healthy Egyptian children. A representative random sample of 500 children, age between 6 and 15 years, was selected from 10 schools in Alexandria, Egypt. A questionnaire was used to collect demographic data and potential risk factors, while blood samples were collected and analyzed for antibodies to HCV (anti-HCV). Positive sera were further confirmed by HCV-RNA. HCV seroprevalence of 5.8% was found, with HCV viraemia in 75% of the studied children. The prevalence of anti-HCV increased with age from 0% in children aged 6-7 years to 16% in those of 15 years old. It was also shown that history of previous blood transfusion (odds ratio[OR] = 34.8, 95% CI=4.39-272.95), intravenous injections (OR=4.68, 1.89-11.59), surgical intervention (OR=5.64, 2.55-12.52), dental treatment (OR = 6.81, 2.64-17.39), injection (OR=2.29, 1.08-4.89) and circumcision for boys by informal health care providers (OR=2.6, 1.0-6.73), age above 10 years (OR=6.83, 2.44-19.07), very low socioeconomic class (OR=5.92, 1.3-25.2) and rural area residence (OR=2.49,1.61-5.29) are the most significant risk factors for HCV infection. Adjusting for all other risk factors by multivariate logistic regression analysis, it has been shown that blood transfusion, surgical procedures, dental treatment, and age above 10 years are still significant risk factors associated with anti-HCV (P<0.05). The current study reveals the extremely high HCV seroprevalence among Egyptian children. This mandates immediate preventive strategies to limit further HCV spread.

Hepatitis C virus infection in a population with high incidence of type 2 diabetes: impact on diabetes complications

A growing number of reports suggest a connection between hepatitis C virus (HCV) infection and type 2 diabetes (T2D). However, the association of HCV infection with diabetes-related complications has not yet been clarified. The aim of this study was to determine the prevalence of HCV infection in T2D-patients in Kuwait which has a high incidence of type 2 diabetes, and to investigate the association between HCV viremia and diabetes-related complications. A total of 438 patients with T2D (325 Kuwaitis and 113 Egyptians), and 440 control subjects, were enrolled for this study. HCV infection was assessed by testing for serum HCV-specific antibodies, and by detection of HCV RNA. HCV viral load and hemoglobin A1c (HbA1c) levels were assessed in patients with and without diabetes complications. Thirty one (7%) out of 438 T2D-patients had evidence of HCV infection compared to 4 (1%) out of 440 control adults (p<0.0001). The prevalence of HCV infection in Kuwaiti and Egyptian T2D-patients was 3% and 18%, respectively. Most of the HCV sequences detected in T2D patients and control subjects were of genotype 4. The HbA1c levels in T2D-patients with HCV viremia were significantly higher than those in HCV-negative patients. HCV viremia, female sex, age, family history of diabetes were found to be independent risk factors for diabetes complications. The results suggest that T2D-patients in Kuwait have higher prevalence of HCV infection than controls, and that HCV viremia is associated with diabetes-related complications.

A systematic review of hepatitis C virus epidemiology in Asia, Australia and Egypt

BACKGROUND

The hepatitis C pandemic has been systematically studied and characterized in North America and Europe, but this important public health problem has not received equivalent attention in other regions.

AIM

The objective of this systematic review was to characterize hepatitis C virus (HCV) epidemiology in selected countries of Asia, Australia and Egypt, i.e. in a geographical area inhabited by over 40% of the global population.

METHODOLOGY

Data references were identified through indexed journals and non-indexed sources. In this work, 7770 articles were reviewed and 690 were selected based on their relevance.

RESULTS

We estimated that 49.3-64.0 million adults in Asia, Australia and Egypt are anti-HCV positive. China alone has more HCV infections than all of Europe or the Americas. While most countries had prevalence rates from 1 to 2% we documented several with relatively high prevalence rates, including Egypt (15%), Pakistan (4.7%) and Taiwan (4.4%). Nosocomial infection, blood transfusion (before screening) and injection drug use were identified as common risk factors in the region. Genotype 1 was common in Australia, China, Taiwan and other countries in North Asia, while genotype 6 was found in Vietnam and other Southeast Asian countries. In India and Pakistan genotype 3 was predominant, while genotype 4 was found in Middle Eastern countries such as Egypt, Saudi Arabia and Syria.

CONCLUSION

We recommend implementation of surveillance systems to guide effective public health policy that may lead to the eventual curtailment of the spread of this pandemic infection.

Epidemiologic risk factors of hepatocellular carcinoma in a rural region of Egypt

BACKGROUND

Hepatocellular carcinoma (HCC) is a major health problem worldwide, including Egypt. In the recent past, HCC has become the second most prevalent cancer among men in Egypt. Since HCC has not been well studied in the rural population of Egypt, this case-control study was conducted to investigate the epidemiologic risk factors of HCC in the predominantly rural region of Gharbiah, Egypt.

METHODS

A total of 150 cases and 150 controls matched to cases on age (±5 years) and sex were recruited from the Gharbiah Cancer Society and Tanta Cancer Center. Exposure data were collected by an interviewer-administered standardized questionnaire about epidemiologic, occupational, medical and family history of HCC. Conditional logistic regression was utilized to calculate unadjusted and adjusted odds ratios (ORs) and 95% confidence intervals (CI). The effect modification of HCC risk between viral infection and environmental risk factors was also assessed.

RESULTS

Being an industrial worker was an independent risk for developing HCC (OR 3.54, 95% CI 1.18, 10.63) after adjusting for viral infection, schistosomiasis and tobacco smoking. High relative risk of HCC was observed among HCV-infected individuals who were farmers (OR 9.60, 95% CI 3.72, 24.76), industrial workers (OR 12.90, 95% CI 4.33, 38.43) or active smokers (OR 5.95, 95% CI 2.20, 16.08).

CONCLUSION

Occupational exposure may play an important role in the development of HCC. Farming, industrial exposures and cigarette smoking may increase the risk of HCC among HCV-seropositive individuals. Future research focusing on mechanisms of occupational exposures among HCV patients in this population is needed.

Pattern of hepatitis virus infection among pregnant women and their newborns at the Women's Health Center of Assiut University, Upper Egypt

OBJECTIVE

To determine the prevalence, risk factors, and rate of vertical transmission of HBV and/or HCV infection among pregnant women in Upper Egypt, and assess the preventive efficacy of administering hepatitis B immunoglobulin and vaccine to newborns on their carrier status at 8 months.

METHODS

Five hundred pregnant women were screened for HCV and HBV serum markers by enzyme-linked immunoassay. Those testing positive had their status confirmed by polymerase chain reaction and their levels of liver enzymes and interferon gamma were evaluated. The newborns of HBV-positive women received hepatitis B immunoglobulin and vaccine and were followed up to assess the rates of vertical transmission and carrier status among the newborns.

RESULTS

Of the 500 pregnant women, 6.4% were HCV positive, 4.0% were HBV positive, and 1.0% were both. The vertical transmission rate was 3.1% for HCV, 30.0% for HBV, and 20.0% for a combined infection. The carrier rate of the infants at the end of their eighth month was 10.8% for those with HCV and 8% for those with HBV.

CONCLUSION

Infection with HBV and/or HCV is highly prevalent among pregnant women in Upper Egypt. The rate of vertical transmission was also high. Administering hepatitis B vaccine and immunoglobulin resulted in a 92% reduction in carrier status among newborns.

Genetic variability of hepatitis C virus in South Egypt and its possible clinical implication

Egypt is one of the countries with very high rates of hepatitis C virus (HCV) related morbidity and mortality. However, little is known about geographical and clinical differences in genetic variability of HCV in Egypt. Using direct sequencing and phylogenetic analysis of partial core/E1 and NS5B regions of the HCV genome, HCV genotype/subtype was determined in 129 HCV-infected patients residing in three governates in south Egypt: Assuit, Sohag, and Qena. According to clinical stage of infection, patients were categorized into four groups: asymptomatic carriers, n = 16; chronic hepatitis C patients, n = 36; liver cirrhosis, n = 54; and hepatocellular carcinoma (HCC), n = 23. Genotype 4a was detected in 80.6%, whereas 1g, 4l, 4n, 4o, 4f, and 4m were identified in 7.7%, 4.7%, 3.9%, 1.6%, 0.8%, and 0.8% of cases, respectively. The prevalence of 4a differed regionally; from 88.5% (in Sohag) to 64% (in Assuit, P = 0.002). Genotypes 4l and 4n had a higher prevalence in Assuit (12.8%, 10.3%) than Sohag (0%, 0%; P < or = 0.011). Difference in clinical features of determined genotypes/subtypes was observed; more carriers of non-4a variants (4l and 4n, 4f, or 4m) had chronic hepatitis compared to carriers of 4a (53.3% vs. 23.1%, P = 0.025), while more patients with 4a had liver cirrhosis (45.2% vs. 13.3%, P = 0.023). Two HCV-4o strains were isolated in this study, both from patients with HCC. In conclusion, geographical diversity of HCV was revealed in this study in southern Egypt. A further case-control study is required to confirm the trends of differential pathogenicity of HCV subtypes, indicated by this study.

High prevalence of occult hepatitis B in hepatitis C-infected Egyptian children with haematological disorders and malignancies

OBJECTIVE

This study investigates the prevalence of occult hepatitis B virus (HBV) in children and adolescents with haematological diseases with or without hepatitis C virus (HCV) infection.

METHODS

Forty-nine children with haematological disorders (median age 11.4 years) and 51 with haematological malignancies (median age 8 years) were enrolled. Sera were tested for HCV antibodies, HCV-RNA [nested reverse transcriptase polymerase chain reaction (PCR)], HBV markers (HBsAg, anti-HBcAb IgM and total, HBeAg) and HBV-DNA (nested PCR for s, c and x regions).

RESULTS

Anti-HCV was detected among 40/49 (81.6%) children with haematological disorders (24/49; 49% HCV-RNA positive) and 9/51 (17.6%) children with malignancies (12/51; 23.5% HCV-RNA positive). HBV-DNA was positive among 38%; positive c region in 33% (15/49 and 18/51 children with haematological disorders and malignancies respectively), s region in four leukaemics and x region in one leukaemic. Twenty-one patients had occult HBV infection; one (2.6%) was HBeAg positive, four (19%) total HBcAb positive, 20 (95.2%) c region HBV-DNA positive and one was s region positive (1/21; 4.8%). HCV-RNA was the significant predictor for occult HBV (P<0.05), with an increased frequency of HBV-DNA in the HBsAg negative (HCV-RNA positive) (63.2%) compared with patients negative for HCV-RNA (25%) (P=0.009).

CONCLUSION

Occult HBV infection is not uncommon in transfused immunocompromised children with chronic HCV infection. Nucleic acid amplification should be considered in screening donors as post-transfusion hepatitis B viraemia may be substantial.

Prevalence of transfusion transmitted virus (TTV) genotypes among HCC patients in Qaluobia governorate

Background

Transfusion Transmitted virus (TTV) is a novel single-stranded DNA virus that was identified in patients with post-transfusion hepatitis of non-A-G type. Clinical significance of TTV infection was analyzed in Egyptian hepatocellular carcinoma (HCC) patients. The present study attempted to clarify these issues in Egypt, particularly in Qaluobia governorate, a country known for its high endemicity of liver disease and hepatotropic viruses.

Methods

TTV are determined in the serum of 60 samples obtained from HCC and liver cirrhosis (LC) patients and 30 healthy individuals. TTV DNA is amplified by nested-PCR with TTV-specific mixed primers derived from the conserved open reading frame 1 (ORF1) region followed by digestion with restriction enzyme. Using the enzymes HaeIII, DraI, EcoRI and PstI, we are able to distinguish between the four TTV genotypes.

Results

The positive rate of TTV detection was 46.7%, 40% and 36.7% among HCC, LC patients and healthy individuals respectively. The more prevalence genotype was detected in the positive serum samples was genotype 1 (35.7%) in HCC patients, (50%) in LC and (63.3%) in healthy individuals, Genotype 5 (21.4%), (25.5%) and (18.2%) in HCC, LC and healthy individuals respectively.

Discussion

This study indicates that TTV is commonly present in adult patients with HCC and LC as well as healthy individuals. The most prevalence TTV genotype is genotype 1. It seems that the infection neither contribute to the severity of liver disease no to the causation of HCC.

Survey of Hepatitis Markers Among Donors in the State of Qatar

A total of 78,428 blood units collected by the Blood Donor Unit, Hamad Medical Corporation, Doha, from the multinational donors of Qatar (28,622 Qatari nationals donors and 49,806 Non-Qatari donors) in the period January 1994 to Dececember 2001 were screened for hepatitis markers. About 10,382 units (13.2%) were discarded because of positivity for one or more hepatitis markers; 769 units (0.9%) were positive for hepatitis-B surface antigen (HBsAg), 8516 units (10.9%) were positive for hepatitis-B core antibodies (HBcAb) and 1097 units (1.39%) were positive for hepatitis C (HCV) antibodies. There was no significant difference between the rate of positivity for HBcAb and HBsAg in indigenous Qataris and Non-Qataris despite a slightly higher rate ofpositivity for HCV antibodies in the Non-Qatari group. An outstanding finding was the significantly high rate of positivity for HCV antibodies in Egyptian donations (11.2%), which accounted for 31.2% of all discards for the Non-Qatari group. As the Blood Donor Unit at HMC is the only blood collection center in Qatar it is assumed that the results could be representative of the country as a whole.

Assessment of hepatic fibrosis in pediatric cases with hepatitis C virus in Egypt

AIM: To assess hepatic fibrosis and factors associated with its progression in children with HCV infection.

METHODS: At the Hepatology Unit, Cairo University Children’s Hospital, a single liver biopsy was performed to 43 children with HCV infection after an informed consent between 1998-2004. Their mean age at liver biopsy was 8.67 ± 4.3 years.

RESULTS: Among the 43 patients’ biopsies, 12 (27.9%) were having no fibrosis, 20 (46.5%) mild fibrosis and 11 (25.6%) moderate to severe fibrosis. The median time for development of fibrosis was estimated to be 5.5 years. Developing fibrosis was significantly associated with shorter duration from first detected ALT elevation to biopsy (12 mo vs 1.2 mo, P = 0.015) and having higher levels of direct serum bilirubin (0.3 mg/dL vs 0.5 mg/dL, P = 0.048). No association was found between fibrosis stage and the presence of co-morbid conditions (P = 0.33).

CONCLUSION: Hepatic fibrosis was present in 72.1% of children with HCV infection. The development of fibrosis was associated with higher levels of direct serum bilirubin. There was no significant association between fibrosis and age, duration of infection, risk factors, co-morbid conditions and most biochemical parameters.

Prevalence and risk factors of asymptomatic hepatitis C virus infection in Egyptian children

AIM: To identify the prevalence, risk factors and manifestations of asymptomatic hepatitis C virus (HCV) infection in Egyptian children.

METHODS: Children at the age of 1-9 years were screened for HCV antibodies and alanine aminotransferase (ALT) levels. Every child with elevated ALT and/or detectable HCV antibodies was tested for HCV RNA by RT-PCR and compared with two negative controls for risk factors and signs and symptoms of liver disease.

RESULTS: We screened 1042 children, six of them had elevated ALT, negative HCV antibody and positive RNA, likely representing acute hepatitis C cases. Fifteen children were HCV seropositive, 5 of them were HCV RNA positive. Asymptomatic HCV infection was present in 2.02% (positive results for either HCV antibodies or HCV-RNA or both). Symptoms such as diarrhea, abdominal pain, history of fatigue and school absence because of illness and risk factors such as dental care were significantly more common among HCV positive cases than among controls. None of the HCV positive children was diagnosed as having signs of advanced liver disease upon clinical or ultrasonographic examination.

CONCLUSION: Asymptomatic HCV infection is detectable in 2.02% Egyptian children.

Necrolytic acral erythema in Egyptian patients with hepatitis C virus infection

BACKGROUND

Necrolytic acral erythema (NAE) is a distinctive skin lesion that was first described in 1996 with only few cases being reported, mostly from Egypt. It is unique in its acral distribution and exclusive association with hepatitis C virus (HCV) infection.

METHODS

Twenty-three patients (mean age 41.7 +/- 11.5 years; M:F 10:13) with clinical features consistent with NAE were enrolled in a 3-year period. Five of those were known HCV-infected individuals and 18 were referred by the dermatologist for evaluation and HCV screening. Liver function tests, serum zinc, hepatitis B markers, HCV antibodies and HCV-RNA were tested. All patients were subjected to skin biopsy examination; five lesional biopsies were selected for electron microscopic examination and capillary endothelium was scanned for hepatitis C viral particles. An additional five patients were subjected to detection of HCV-RNA in their skin biopsies by polymerase chain reaction. All patients received oral zinc sulfate supplementation while interferon-alpha therapy combined with ribavirin was available for four patients.

RESULTS

Most NAE patients were adults (91.3%) and the skin lesions were predominantly chronic (78.3%), with affection of the dorsa of toes and/or feet in all cases. Skin biopsies showed hyperkeratosis, psoriasiform epidermis and upper epidermal necrosis. Electron microscope examination demonstrated clumped tonofilaments in the keratinocytes, yet HCV-RNA could not be detected in the skin lesions of examined cases. Interferon-alpha combined with ribavirin caused regression of skin lesions in three patients and complete clearance in one patient. Some improvement was induced by oral zinc administration.

CONCLUSION

Necrolytic acral erythema is considered to be a cutaneous marker for HCV infection. The majority of patients are diagnosed by dermatologists. Therefore, improved awareness of this cutaneous lesion should prompt early diagnosis and treatment of HCV, which should in turn cure the lesion and prevent progression of liver disease.

Liver disease in Egypt: hepatitis C superseded schistosomiasis as a result of iatrogenic and biological factors

In Egypt, schistosomiasis was traditionally the most important public health problem and infection with Schistosoma mansoni the major cause of liver disease. From the 1950s until the 1980s, the Egyptian Ministry of Health (MOH) undertook large control campaigns using intravenous tartar emetic, the standard treatment for schistosomiasis, as community-wide therapy. This commendable effort to control a major health problem unfortunately established a very large reservoir of hepatitis C virus (HCV) in the country. By the mid-1980s, the effective oral drug, praziquantel, replaced tartar emetic a s treatment f o r schistosomiasis in the entire country. This both reduced schistosomal transmission and disease and interrupted the "occult" HCV epidemic. It was evident when diagnostic serology became available in the 1990s that HCV had replaced schistosomiasis as the predominant cause of chronic liver disease. Epidemiological studies reported a high prevalence and incidence of HCV, particutarly within families in rural areas endemic for schistosomiasis. Clinical studies showed 70% to 90% of patients with chronic hepatitis, cirrhosis, or hepatocellular carcinoma had HCV infections. Co-infections with schistosomiasis caused more severe liver disease than infection with HCV alone. Schistosomiasis was reported to cause an imbalance in HCV-specific T-cell responses leading to increased viral load, a higher probability of HCV chronicity, and more rapid progression of complications in co-infected persons. As complications of HCV usually occur after 20 years of infection, the peak impact of the Egyptian outbreak has not yet occurred. Efforts have been initiated by the Egyptian MOH to prevent new infections and complications of HCV in the estimated 6 million infected persons.

Prevalence of and risk factors for hepatitis C in rural pregnant Egyptian women

Prevalence and risk factors for hepatitis C virus (HCV) infection were studied in 2,587 pregnant women from three rural Egyptian villages in the Nile Delta being admitted to a prospective cohort study of maternal-infant transmission; 408 (15.8%) had antibodies to HCV (anti-HCV) and 279 (10.8%) also had HCV-RNA. Fewer than 1% gave a history of jaundice or liver disease. Risk factors for anti-HCV included increasing age, low socioeconomic status and a history of blood transfusion or injection therapy for schistosomiasis. Sub-analyses after stratification of subjects by village revealed risks associated with specific venues for medical care, having a previous delivery attended by a traditional birth assistant (TBA), receiving medical care in a temporary clinic located in a mosque, overnight admission to a private doctor's clinic, and circumcision by a TBA or a 'health barber'. Our results suggest HCV causes very little detected illness in young adult Egyptian women and some sources of HCV transmission in rural Egypt in the past were associated with the provision of medical care and varied by location. Prevention should be focused on providing appropriate resources and health education should be given to formal and informal health care providers and should be sufficiently broad to adjust for local variations in exposures.

Viral etiology of hepatocellular carcinoma and HCV genotypes in Taiwan

Etiologic variations of hepatocellular carcinoma (HCC) exist in different geographic areas of the world. Hepatitis B virus infection is associated with HCC. However, hepatitis C virus (HCV) infection plays an increasingly more important role in the development of HCC and is associated with more than 30% of HCC in Taiwan. The prevalence of HCV infection and HCV genotypes vary in different geographic areas. The prevalence of HCV genotype 1b (HCV-1b) was around 50-70% in Taiwan and even varied in different townships. In addition to host factors, HCV genotypes may be associated with the development of HCC. In our study, the prevalence of HCV-1b in patients with HCC was significantly higher than in those with liver cirrhosis and chronic hepatitis; multivariate analysis revealed that the disease severity was significantly correlated with age and HCV-1b. Furthermore, HCV-1b was associated with a lower response rate to interferon (IFN) therapy than HCV-2. Our study has demonstrated that mutations in the IFN sensitivity-determining region, spanning nucleotides 2,209-2,248 in the NS5A region, correlate with the sustained virological response to combination therapy with IFN and ribavirin in patients with chronic HCV-1b infection in Taiwan. A third-generation enzyme immunoassay for antibody to HCV can be used to predict viremia and monitor the virological response.