High rate of hepatitis C virus infection in an isolated community: persistent hyperendemicity or period-related phenomena?

Seroprevalence of Hepatitis C in Children Without Identifiable Risk-Factors: A Systematic Review and Meta-Analysis

OBJECTIVES

Hepatitis C virus (HCV) remains a major public health burden for >30 years since its discovery. It is estimated that >80 million people have been already infected. Direct-acting antiviral (DAA) treatment is now approved for young children over the age of 3 years. Treating children before the development of high-risk behaviors is optimal. Thus, assessing the current epidemiology of HCV in children becomes important and may promote awareness.

METHODS

Articles describing the prevalence of hepatitis C in children, were systematically reviewed. To assess HCV infection prevalence in the general population, studies discussing high-risk groups alone were excluded.

RESULTS

Data from 58 studies were analyzed. National data was scarce. An overall prevalence of HCV in children of 0.87% was found, ranging from 0.34% in Europe to 3.02% in Africa. Prevalence of viremic infection is important and data synthesis from available data indicated that HCV viremia was detected in 56.8% of children. The prevalence of HCV according to sex was described in 25 studies but no difference between sexes was detected. HCV prevalence was significantly higher in children older than 10 years (0.97%) when compared to those ages under 10 years old (0.75%, P < 0.001).

CONCLUSIONS

Considering probable underdiagnosis of HCV infection in children, this information reveals that prevalence is substantial. One may argue that future strategies aiming towards HCV elimination, may need to include antiviral treatment of pre-adolescent children as well.

The epidemiological profile of chronic hepatitis C with advanced hepatic fibrosis regarding virus genotype in Taiwan: A nationwide study

BACKGROUND/PURPOSE

This study aims at investigating the epidemiological profile of chronic hepatitis C (CHC) regarding hepatitis C virus (HCV) genotype in Taiwan.

METHODS

A total of 29,087 CHC patients with advanced fibrosis who received direct-acting antivirals (DAAs) therapy under Taiwan's National Health Insurance (NHI) during 2017-2018 were recruited. The HCV genotype distribution and its association with patients' demographic factors including age, gender, and geographical areas were examined.

RESULTS

The most common genotypes were 1b (59.5%) and 2 (30.1%) with characteristics of older age (mean ± standard deviation (SD): 66.5 ± 10.7 years and 67.3 ± 10.9 years) and female gender predominant (57.1% and 59.4%), which were associated with iatrogenic infection decades ago. Most of patients with genotype 1a (5.9%) and 6 (3.7%) infection were relatively younger (59.2 ± 12.0 years and 60.0 ± 13.8 years) and male gender predominant (59.1% and 61.1%), except Liujia and Liuying districts in southern Taiwan. The youngest group (53.2 ± 11.8 years) and most male gender predominant (74.3%) was genotype 3 (0.37%). These genotypes with characteristics of being younger and male gender predominant were highly related to injection drug use in recent years. The number of genotype 4 patients were extremely rare (n = 25) and efficacy of genotype-4-specific-DAA was significantly poorer than non-genotype-4-specific DAA (P value = 0.0411).

CONCLUSION

The significant differences in demographic characteristics among CHC patients with different HCV genotypes found in this study suggest HCV genotype was highly associated with transmission pattern and may be used as a reference for HCV control.

Geographic variation of genotype 6 hepatitis C virus infection in an endemic area of southern Taiwan

Taiwan is a hepatitis C virus (HCV) endemic country with geographic variation of prevalence and main genotypes(GTs) are 1 b and 2a. We recently reported high GT6 prevalence in Tainan of southern Taiwan. To clarify this special genotype as a local endemic disease and its geographic variation, the prevalence rates of HCV GTs of 37 districts of Tainan were analyzed. A total of 3040 patients with HCV viremia were enrolled. The prevalence rates of HCV GT 1a, 1 b, 2, 3, 4, 6 and mixed types were 3.9%, 31.6%, 45.9%, 0.6%, 0.2%, 17.1% and 0.5% respectively. GT6 prevalence showed marked variation from 0 to 39.2%. Four districts with GT6 prevalence >30% are located between Jishui and Zengwen rivers. Preliminary subtyping data were 6 g/a/w. This geographic variation with spatial restriction by two rivers with 6 g/w is suggestive of local endemic infection of preexisting GT 6 HCV for centuries.

Secular Trends and Geographic Maps of Hepatitis C Virus Infection among 4 Million Blood Donors in Taiwan from 1999 to 2017

The prevalence of hepatitis C virus (HCV) infection in Taiwan was approximately 4% a decade ago, much higher than the worldwide average. This study aimed to assess the HCV burden among 4 million voluntary blood donors after 2 decades of prevention and treatment policies. We retrieved screening results for anti‐HCV and HCV RNA from the Database for Evaluating Voluntary Taiwanese Eligible Donors. First‐time blood donors who donated blood after 1999 and repeat donors who donated blood more than once between 2013 and 2017 were included to estimate HCV prevalence and incidence, respectively. The Cox proportional hazards model was used to estimate hazard ratios. Geographic variation in HCV prevalence and incidence in 364 townships was also analyzed. The prevalence study included 3,656,598 first‐time donors. The overall crude prevalence of anti‐HCV decreased from 15.5 to 4.5 per 1,000 donors between 1999 and 2017. Younger birth cohorts had a significantly lower prevalence of anti‐HCV. The majority of townships (64.3%) in Taiwan showed a significantly decreased prevalence. The incidence study included 1,393,014 repeat donors followed for 3,436,607 person‐years. Ninety‐eight donors seroconverted to HCV RNA positivity, resulting in an HCV incidence of 2.9 per 100,000 person‐years. Donors living in townships where HCV RNA prevalence was greater than 2 per 1,000 had at least 2.5‐fold greater risk of new HCV infection. Conclusion: HCV prevalence in Taiwanese first‐time blood donors decreased by 71% in the last 2 decades. However, townships with higher HCV prevalence also showed higher HCV incidence and require more active intervention.

Changing seroprevalence of hepatitis C virus infection among HIV-positive patients in Taiwan

Objective

The study aimed to describe the evolution of the seroprevalence of hepatitis C virus (HCV) among human immunodeficiency virus (HIV)-positive patients included in two cohorts in Taiwan.

Methods

We retrospectively collected the information on demographic and clinical characteristics of 4,025 and 3,856 HIV-positive Taiwanese, who were aged 18 years or older at designated hospitals around Taiwan in 2004–2007, when an outbreak of HIV infection was occurring, and 2012–2016, when the outbreak was controlled with the implementation of harm reduction program, respectively. Comparisons of HCV seropositivity were made among different age and risk groups for HIV transmission between these two cohorts.

Results

The overall HCV seroprevalence of the 2004–2007 cohort and 2012–2016 cohort was 43.4% (1,288/2,974) and 18.6% (707/3,793), respectively (P<0.001). The HCV seroprevalence among injecting drug users (IDUs), though decreasing, was constantly high across the two cohorts, 96.4% and 94.0% (P = 0.02), respectively, and all age groups. In contrast, the corresponding figures among men who have sex with men (MSM) and heterosexuals in the two cohorts were 5.9% vs. 3.5% (P = 0.002) and 9.4% vs. 10.9% (P = 0.59), respectively. Among sexually transmitted HIV-positive patients, HCV seropositivity was significantly correlated with age (adjusted odds ratio [aOR], per 1-year increase, 1.03; 95% confidence interval [CI], 1.02–1.05) and a rapid plasma reagin (RPR) titer ≥1:8 (aOR, 1.58; 95% CI, 1.03–2.43) in a multivariate analysis including age, gender, route for HIV transmission, baseline CD4 count and plasma HIV RNA load, the presence of hepatitis B surface antigen, and an RPR titer ≥1:8. Compared with heterosexuals, the aOR for HCV seropositivity among MSM was 0.47 (95% CI, 0.31–0.72).

Conclusions

HCV seroprevalence among HIV-positive patients in Taiwan decreased with time, probably related to the inclusion of younger adults and more non-IDUs, and remained high among IDUs. HCV seropositivity was associated with age and an RPR titer ≥1:8 among patients who acquired HIV through sexual contact.

Sexual Dimorphic Metabolic Alterations in Hepatitis C Virus-infected Patients: A Community-Based Study in a Hepatitis B/Hepatitis C Virus Hyperendemic Area

The impact of sex on metabolic alterations in individuals with hepatitis B virus (HBV) or hepatitis C virus (HCV) infection remains elusive.A community-based study was performed to assess sex, age, body mass index, the lipid profile, blood pressure, glucose, alanine aminotransferase, HBV surface antigen (HBsAg), and HCV antibody levels, smoking and alcohol drinking habits, and cardiometabolic diseases, including diabetes, hypertension, cardiovascular events, and renal diseases. The HCV-RNA level and genotype were further assessed in HCV antibody-positive subjects, and the hepatitis B e antigen and HBV-DNA levels were further examined in HBsAg-positive subjects.Among the 10,959 adults enrolled, 1949 (17.8%) and 1536 (14.0%) were HBV and HCV-infected, respectively. Univariate and multivariate analyses showed that the lipid profile and hypertension were independently associated with HCV infection (95% confidence intervals of odds ratios [OR 95% CI]: total cholesterol [TC] = 0.508-0.677; triglycerides = 0.496-0.728; hypertension = 0.669-0.937), but not with HBV infection. Consistently, HCV, but not HBV infection, was negatively associated with the TC and triglyceride levels (OR 95% CI for TC: 0.450-0.601; triglycerides: 0.443-0.671). Generalized linear models revealed that HCV infection, sex, and age interactively affected the lipid profile (OR 95% CI TC = 1.189-1.385; triglycerides = 1.172-5.289). Age-stratification analysis showed that the lipid levels were lower in both the HCV-positive females aged ≥49 years (TC, P < 0.001; triglycerides, P = 0.001) and males of all ages (TC, P < 0.001; triglycerides, P < 0.001) compared with their sex and age-matched HCV-negative counterparts. HCV infection was associated with a higher body mass index (≥49 years, β = 0.405, P = 0.002) and increased rates of cardiovascular events (<49 years, OR 95% CI 1.23-9.566), diabetes (≥49 years, OR 95% CI 1.114-1.932), and renal diseases (≥49 years, OR 95% CI 1.23-9.55), and with a lower rate of hypertension (≥49 years, OR 95% CI 0.616-0.964) in the females, but not in the males, as determined by multivariate analyses.Only HCV infection was associated with metabolic alterations in this HBV/HCV-hyperendemic area. Females aged ≥49 years and males of all ages exhibited HCV-associated hypolipidemia. HCV-associated cardiometabolic diseases were evident only in the females. Sex dimorphism in HCV-associated metabolic complications warrants personalized follow-up of HCV-positive patients.

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.

Chronic hepatitis C increased the mortality rates of patients with hepatocellular carcinoma and diabetes mellitus in a triple hepatitis virus endemic community

BACKGROUND

To elucidate the factors associated with mortality rates among older subjects with hepatocellular carcinoma (HCC) and diabetes mellitus (DM) in a triple hepatitis B virus (HBV), hepatitis C virus (HCV) and hepatitis delta virus (HDV) endemic community.

METHODS

A total of 2,909 residents aged>or=45 years were screened for hepatitis B surface antigen (HBsAg), antibodies to HCV (anti-HCV) and alanine aminotransaminase (ALT) in 1997. Anti-HDV was detected in HBsAg-positive subjects. Those who expired from HCC and DM were identified from official mortality data sets (1997-2003). Survival was analyzed using the Kaplan-Meier survival curve with log-rank test and the Cox proportional hazard model.

RESULTS

Forty-one patients died of HCC and 25 of DM during the study period. Multivariate analysis indicated that age>or=65 years (hazard ratio 3.4; 95% confidence interval 1.8-6.4), HBsAg (3.3; 1.7-6.7), anti-HCV (3.8; 1.7-8.5) and ALT>or=40 IU/L (3.7; 1.9-7.0) were independent predictors of HCC mortality, while age>or=65 years (4.8; 2.1-11.0) and anti-HCV (4.2; 1.7-10.6) were two independent predictors of DM mortality. There were synergistic effects of dual viral infections for HCC, but not for DM mortality.

CONCLUSIONS

Old age and chronic HCV infection increase the risk of HCC and DM mortality. HBsAg and ALT levels are also risk factors for HCC mortality, but not DM. The synergistic effects of dual hepatitis viral infections are demonstrable and warrant further investigation.

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

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

Changing prevalence of hepatitis C virus infection among teenagers in an endemic area in Taiwan

Tzukuan Township in Taiwan has been reported to be an endemic area for hepatitis C virus (HCV) infection both in adults and adolescents. The maritime part of the township carries a higher prevalence than the non-maritime part and, as a consequence, several public education strategies have been introduced during the past decade. The current follow-up study aimed to clarify the changing prevalence of HCV infection among teenagers in the endemic maritime part of Tzukuan. In addition to viral hepatitis markers and biochemical profiles, we compared the epidemiological characteristics of 887 and 394 teenagers (aged 13-16 years) from the maritime part enrolled in 1995 and 2005, respectively. Compared with the results of surveillance in 1995, the prevalence of anti-HCV seropositivity (1.0% vs. 2.8%; P=0.045) and HCV RNA (0.5% vs. 2.3%; P=0.026) had decreased significantly by 2005. Transfusions and anti-HCV-positive families were the main risk factors amongst the 25 anti-HCV-positive teenagers in 1995, and became non-significant amongst the four anti-HCV-positive teenagers in 2005. In conclusion, the seroprevalence of HCV infection has significantly decreased after one decade of intervention among the teenage population in this endemic area.

Case-control study of risk factors associated with hepatitis C virus infection among pregnant women in hospitals of Karachi-Pakistan

OBJECTIVE

To identify risk factors for hepatitis C virus (HCV) infection among pregnant women seeking antenatal care in tertiary care hospitals of Karachi, Pakistan.

METHODS

We enrolled 119 cases and 238 controls. Cases were enzyme-linked immunosorbent assay (ELISA III) positive pregnant women for antibodies to HCV; controls were anti-HCV ELISA negative pregnant women.

RESULTS

The mean age of study subjects was 26 years (SD 5) ranging from 15 to 50 years. The mean number of pregnancies for cases was 4 (SD 3) and for controls was 3 (SD 2). Among cases an average number of injections in any month was 40%, history of hospitalization was 61% and household contact with jaundice or hepatitis was 35%. In the final multivariable logistic regression model, five or more gestations (aOR = 1.99; 95% CI = 1.08-3.33), > or =1 injection (aOR = 2.33; 95% CI = 1.38-3.91) per month, hospitalization (aOR = 1.78; 95% CI = 1.01-2.99) and household contact with jaundice/hepatitis (aOR = 3.32; 95% CI = 1.89-5.83) were independently associated with HCV.

CONCLUSION

Iatrogenic exposure (health care injections, hospitalizations and gestations) is the major risk factor for transmission of HCV among pregnant women.

Place of residence and distance to medical care influence the diagnosis of hepatitis C: a population-based study

BACKGROUND/AIMS

In France, geographic access to medical care may affect the diagnosis of hepatitis C. The aims of this study were to compare the detection rates of hepatitis C in urban and rural areas after adjusting for distance to medical care, and evaluating the impact of the place of residence on patients' clinical characteristics.

METHODS

Between 1994 and 2001, 1938 newly detected cases were recorded in a French population of 1,005,817 inhabitants. Age and sex-adjusted detection rates for 10(5) inhabitants were estimated for urban and rural areas and for classes of distance to the nearest practitioner.

RESULTS

Detection rates were lower in rural than in urban areas [14.1, (95CI: 12.5-15.7) versus 24.7, (95CI: 23.5-26.0)] and decreased as the distance to the general practitioner increased [27.0, (95CI: 25.5-28.4) versus 13.7, (95CI: 12.1-15.3) for a cutoff value of 1.5 km]. In multivariate analyses, detection rates were only influenced by the distance to general practitioner. Hepatocellular carcinoma at diagnosis was more frequent among rural than among urban patients (adjusted OR = 2.28, 95CI: 0.97-5.39, P = 0.059).

CONCLUSIONS

A poorer geographic access to care explained the lower detection of hepatitis C in rural areas. Hepatocellular carcinoma was more frequent in rural patients. It may result from later detection and/or involvement of environmental factors on hepatocarcinogenesis.

Combined Interferon and Ribavirin Therapy for Chronic Hepatitis C in Taiwan

Chronic hepatitis C virus (HCV) infection, including its sequelae, is an important healthcare problem in Taiwan. The seroprevalence of HCV infection in first-time blood donors in Taiwan is 1.2% and an estimated 2-5% in the general population, with a great geographic variation. Genotype 1b is the most prevalent HCV genotype in Taiwan, with a prevalence rate of 50-70%. An increasing incidence of hepatocellular carcinoma (HCC) is mainly attributed to HCV infection, while the declining role of HBV is observed in Taiwan. The seroprevalence of hepatitis B surface antigen among patients with HCC was 90% three decades ago, while recently, chronic HCV infection accounts for more than 30% of HCC patients in the National Taiwan University Hospital. With the advent of a combined conventional interferon (IFN)-alpha and ribavirin therapy, to which Taiwan has contributed in the early study phase, the sustained virological response rate has been greatly improved compared with IFN monotherapy. The sustained virological response rate in Taiwanese patients treated with the combination therapy for 6 months has reached up to 50-60%, which is higher than that reported in patients from the Western countries receiving a 12-month regimen. It is necessary to search for the underlying mechanisms for the better treatment outcome with IFN plus ribavirin combination therapy in Taiwanese patients. Whether long-term effects of IFN plus ribavirin therapy can reduce the incidence of HCC needs to be established.

Global epidemiology of hepatitis C virus infection

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

Hepatitis C‐associated cryoglobulinaemia presenting with refractory hypertensive crisis and acute pulmonary oedema

We report two elderly women who presented with hypertensive crisis and acute pulmonary oedema, which responded poorly to antihypertensive therapy. The patients were later diagnosed as having hepatitis C virus-related cryoglobulinaemia.

Risk factors for hepatitis C virus infection among blood donors in Georgia

BACKGROUND

Growing awareness about the importance of blood safety for controlling the transmission of hepatitis C virus (HCV) has helped to decrease the spread of this virus in many settings. This study was conducted in order to evaluate potential risk factors for HCV infection among blood donors in Georgia.

METHODS

The study population consisted of 553 blood donors in three major Georgian cities: Tbilisi, the capital city and Batumi and Poti, naval port cities. Risk factors were examined using a behavior questionnaire. All blood samples were initially tested using 3rd generation anti-HCV enzyme-linked immunosorbent assays and confirmed using recombinant immunoblot assays and nucleic acid testing.

RESULTS

Forty-three blood donors, 7.8%, were confirmed HCV positive. Significant risk factors included: drug injection ever (OR: 42; 95% CI: 3.2-550.7); history of hepatitis (OR: 25.9; 95% CI: 4.6-145.5); history of a previous surgical procedure (OR: 148.4; 95% CI: 26.9-817.4); blood transfusion (OR: 25.9; 95% CI: 3.2-210.9).

CONCLUSIONS

This study found a very high prevalence of HCV among blood donors in Georgia. The main risk factor for HCV infection in this population of blood donors was previous contact with contaminated blood or blood products. Reliable screening of donors and their blood is critical for controlling the further spread of HCV in Georgia.

[Sporadic transmission of hepatitis C in dental practice]

Percutaneous contact with contaminated blood is the principal mode of transmission of the hepatitis C virus (HCV). However, the diagnosis of infection in patients in whom no parenteral risk factor can be identified allows speculation on the existence of other routes of transmission. In the field of dentistry, the role of saliva has still not been defined as a potential vehicle for infection nor the role of dental treatment as a possible occult factor in the sporadic transmission of hepatitis C. HVC-RNA is detectable in the saliva of over 50% of patients with chronic hepatitis C. The infectivity of the HVC particles detected in the saliva has not been determined, though it may be deduced from epidemiological studies that their potential for transmission, if it exists, is extremely limited. There has been no documented case of HVC transmission in a dental clinic. Studies which propose a history of dental treatment as a risk factor for HVC infection have not achieved conclusive results. The age distribution of the prevalence of HVC could indicate that a risk of iatrogenic transmission existed in the past, before the systematic application of universal barriers. The transmission of HVC in dental clinics may be considered a very infrequent occurrence as long as the norms for the control of cross-infection are respected.

A higher than expected recovery rate from hepatitis C infection amongst adolescents: a community study in a hepatitis C-endemic township in Taiwan

This study investigated the prevalence of antibody to hepatitis C virus (anti-HCV), evaluated clinical manifestations of hepatitis C, and explored the risk factors amongst adolescents in an HCV-hyperendemic area in Taiwan. In December 1999, 713 students aged 13-16 years from Taishi township, in central Taiwan, were enrolled in a screening program for anti-HCV and alanine transaminase (ALT) status. Fourteen participants (M/F = 6/8) were positive for anti-HCV. Eight of the 14 later proved to be negative for HCV RNA, and they demonstrated relatively low sample rate/cut-off rate (S/CO) ratios (1.05-11.83) for anti-HCV tests. All HCV RNA negative cases had normal serum ALT levels. The other six (43%) seropositive students demonstrated HCV viraemia and greater S/CO ratios (25.66-77.49). Two of these six participants had elevated serum ALT levels. Compared to anti-HCV-negative subjects, anti-HCV-positive students exhibited significantly greater rates of exposure to one or more of the following: blood transfusion, tattooing, and earlobe piercing. This study group has a greater prevalence (2%) of anti-HCV than the general Taiwanese population at the same age. The study also reveals a lower rate (43%) of chronicity of HCV infection than that reported in the literature.

Risk of transmission of hepatitis B virus through childhood immunization in northwestern China

Transmission of bloodborne pathogens by means of unsafe injection practices is a significant public health problem in developing countries. Although the overall proportion for immunization is low among injections, unsafe immunization practices affect mostly infants, a population with an increased likelihood of becoming hepatitis B virus carriers. This study estimated the prevalence of unsafe injection among vaccinators working at the peripheral level in northwestern China and the risk of HBV infections among infant vaccinees, and analyzed factors contributing to the most prevalent unsafe practice: the reuse of a non-sterilized reusable syringe among infants. A knowledge-attitude-practice survey was conducted in which 180 peripheral vaccinators selected by multi-stage cluster sampling in each of four provinces and one autonomous region completed a self-administered questionnaire. The lack of observational data for assessing the validity of the self-reported practices made the study prone to systematic respondent bias that may have skewed the results towards underestimation of unsafe practices. The minimum estimate of the percentage of peripheral vaccinators reusing a syringe and/or needle without sterilization between infants was 7.2-55.0%, whereas the percentage of those disposing of used disposable syringes and needles inappropriately was 8.9-23.3% by province. According to a model-based estimate, the annual number of HBV infections among 100,000 fully immunized children due to unsafe immunization injection was at least 135-3120. An insufficient supply of syringes and the attitude to justify reuse were significantly associated with the unsafe reuse of a reusable syringe in most part of the area studied. Introduction of auto-disable syringes may contribute to curb the unsafe practices, but the development of safe collection and disposal procedures for used syringes and needles is prerequisite. Sufficient supply of equipment as well as training, supervision, and monitoring targeting specifically on the risk behaviors and concerned attitudes are essential for behavior changes among the vaccinators.

High rate of hepatitis C virus infection and predominance of genotype 4 among elderly inhabitants of a remote village of the rain forest of South Cameroon

To determine the prevalence of hepatitis C virus (HCV) infection and genotype distribution in a rural isolated area of Central Africa, plasma of 409 Bantous (mean age, 32 years; range, 2-78 years) living in a remote village of the rain forest of Southern Cameroon was screened for anti-HCV antibodies. HCV seropositive samples were also subjected to qualitative detection of viral RNA. HCV antibodies were detected in 70 (17.1%) individuals, 48 (68.8%) of whom had detectable viremia. The seroprevalence did not differ by gender (P = 0.37), but increased significantly with age (P < 0.05), with a strong increase in the oldest age groups. Indeed, nearly one-half (48%) of the adults >50 years old were HCV seropositive. The characterization of the viral genotypes indicated that most of the HCV strains were of genotype 4 (76%), while genotype 2 (16%), and 1 (8%) were marginally represented. The results suggest a cohort effect with an old, possibly iatrogenic, group exposure rather than a continuous exposure. A more in-depth population-based epidemiological study is needed to address this issue further.

Eight-year nationwide survival analysis in relatives of patients with hepatocellular carcinoma: role of viral infection

BACKGROUND

Families of patients with hepatocellular carcinoma (HCC) carry a high risk of developing HCC. We determine the number of fatalities in relatives of HCC patients during an 8-year period to understand the risk and cause of HCC in relatives of patients with HCC.

METHODS

From 1992 to 1997, 15 410 relatives of HCC patients in three generations were screened prospectively for HCC by ultrasonography, alpha-fetoprotein, liver biochemistry and viral markers. By using national citizen identification numbers, we searched the total fatalities in relatives of HCC patients between 1992 and 1999 from the national mortality data bank. The results were compared among different viral infection groups.

RESULTS

Of the relatives studied, 37.8% were hepatitis B s antigen (HBsAg) positive (+), 4.3% were anti-hepatitis C virus (HCV) (+) and 1.7% were both HBsAg (+) and anti-HCV (+). A total of 399 fatalities, including 139 because of HCC (34.8%), 37 because of liver diseases (9.3%), 88 because of other cancers (22.1%) and 135 because of other diseases (33.8%), were found. Relatives who were HBsAg (+) or anti-HCV (+)showed a lower cumulative survival than did relatives who were negative for both HBsAg and anti-HCV. Relatives with dual infection of hepatitis B and C virus showed the highest mortality due to HCC or terminal liver diseases.

CONCLUSIONS

Chronic viral infection rather than a hereditary factor is the main cause of a familial tendency for HCC. Dual infection of hepatitis B and C virus increases the risk of HCC or decompensated liver diseases.

Hepatitis C virus infection and genotypes among human immunodeficiency virus high-risk groups in Cameroon

Parenteral transmission of HCV is well established but other possible routes such as heterosexual transmission are still questioned. The Central African region is characterised by a high HCV endemicity without any evidence on the route of transmission. The information on HCV genotypes that circulate in this area is also limited and controversial. HIV infection is very frequent in this region and mostly acquired via the heterosexual route. The aim of this work was to investigate the trend of HCV infection and genotypes among HIV high-risk groups from Cameroon. Four hundred eighty-two patients including 229 tuberculosis clinic attendants, 184 sexually transmitted disease clinic attendants, and 69 HIV clinical suspects from another clinic were enrolled. All plasma samples were screened for antibodies to HCV and HCV RNA. Genotypes were assigned by sequencing a 5'UTR amplified fragment. The overall prevalence of HCV markers was 11.6% and a significant increasing trend with respect to age was observed. A proportion of 64.1% (34/53) of HCV antibody positive samples was viraemic. HCV RNA was found in 3 samples that were indeterminate in RIBA 3.0. One was negative in the antibody screening test and the two others were weakly positive. The data on HCV genotypes revealed that genotype 1 was involved in 57% of viraemias, genotype 2 in 24%, while genotypes 4 and 5a accounted for 16 and 3%, respectively. In contrary to the predominance of genotype 4 reported in some African countries and even the neighbouring countries, these data demonstrate clearly that HCV infection in Cameroon is dominated by genotypes 1 and 2. No association was found between the HCV markers and the presence of HIV infection. It is concluded, therefore, that the heterosexual route plays a minor role in HCV transmission in this country.

Hepatitis C in a ward for cystic fibrosis and diabetic patients: possible transmission by spring-loaded finger-stick devices for self-monitoring of capillary blood glucose

OBJECTIVE

To identify the routes of transmission in a nosocomial outbreak of hepatitis C virus (HCV) infection.

DESIGN

Epidemiological investigation, including screening for HCV of hospitalized patients, and a retrospective cohort study, review of hygiene and medical practices, and molecular comparison of HCV isolates.

SETTING

A specialized care unit for cystic fibrosis (CF) and diabetic patients at an acute-care facility in the south of France.

RESULTS

Of the 57 CF patients (age in 1995: 2-28 years), 38 (66.7%) were tested and 22 (57.9%) were anti-HCV positive. Eight (50%) of 16 patients with anti-HCV antibody tested by polymerase chain reaction were viremic. No patients had received blood products or had any history of intravenous drug use. All 18 (100%) patients with CF who had ever undergone self-monitoring of capillary blood glucose in the unit were anti-HCV positive, compared to 4 (20%) of 20 who had not (relative risk, 5.0; 95% confidence interval, 2.1-12.0). Seventy (39.5%) of the patients with diabetes were screened for anti-HCV; 12 (18.8%) tested positive, with 3 (25%) positive for HCV-RNA. Patients with diabetes had routine capillary blood glucose monitoring while hospitalized and shared with CF patients the same spring-triggered devices for capillary blood glucose monitoring. The disposable platform of the devices was not changed between patient use. All HCV isolates belonged to the type 1, subtype b, and phylogenetic analysis showed a close homology by sequencing of NS5b and E2/HVR regions.

CONCLUSION

As reported earlier for the hepatitis B virus, shared spring-triggered devices for capillary blood glucose monitoring by finger puncture may transmit HCV. Strict application of Standard Precautions procedures is warranted in any healthcare setting.

Persistent hyperendemicity of hepatitis C virus infection in Taiwan: the important role of iatrogenic risk factors

The purpose of this study was to investigate determinants of endemic hepatitis C virus (HCV) infection within communities in Taiwan. A two-phase study, including a seroprevalence survey and a prevalent case-control study at the first phase, which has been published previously, and a follow-up seroconversion determination and an incident case-control study during the second phase, was carried out to evaluate correlates of persistent endemic HCV infection. At the first phase, a total of 12,021 men and 1,819 women who were 30-64 years old and living in seven townships in Taiwan were tested for the seroprevalence of antibodies to HCV (anti-HCV). In addition, a prevalent case-control study involving 272 HCV-positive cases and 282 seronegative controls identified from the anti-HCV testing was conducted to investigate risk factors associated with HCV prevalence. During the second phase, a total of 2,728 men and 834 women who were seronegative at recruitment participated in the 1-year prospective study on anti-HCV seroconversion. Subsequently, an incident case-control study based on 39 seroconverters and 81 persistently seronegative controls were carried out to elucidate determinants of HCV seroconvertion. Antibodies to HCV were tested by the second-generation enzyme immunoassay. Information on risk factors of HCV infection was collected from subject interviews. The prevalence of anti-HCV consistently increased with age (range 2.9-5.4%), whereas no apparent age trend was observed for anti-HCV seroconversion rate (range 0.9-1.7%). A striking geographical variation in seroprevalence and seroconversion rates of anti-HCV was observed in the study townships. Furthermore, a significant geographical correlation between HCV seroprevalence and seroconversion rates was noted (r = 0.962, P = 0.001). From the results of both prevalent and incident case-control comparisons, medical injections were found to be the main mode to sustain the persistent endemic state of HCV infection within a community (odds ratios for prevalent and incident case-control studies were 2.5 (95% CI = 1.7-3.6) and 3.1 (95% CI = 1.4-7.1), respectively. The data indicate that the basis for HCV transmission has already been existed in study areas and the iatrogenic risk factor tended to be the major determinant for sustaining persistent endemicity within a community.

Risk factors of hepatitis C virus-related liver cirrhosis in young adults: positive family history of liver disease and transporter associated with antigen processing 2(TAP2)*0201 Allele

The aim of this study was to clinically characterize young patients with hepatitis-C-related cirrhosis. We compared 27 patients with liver cirrhosis (Group LC) who were anti-HCV positive, aged 40 years or less at the time of diagnosis, with 323 consecutive patients with HCV-related chronic hepatitis (Group CH) matched for age and gender. Furthermore, Group LC was divided into two arbitrary groups (29-35 years, n = 8 /36-40 years, n = 19), based on the age of patients at the time of diagnosis of liver cirrhosis. Patients' characteristics and family history were investigated, and the frequency of transporter associated with antigen processing 2 (TAP2) was determined. A family history of liver disease was present in 40.7% of Group LC but in 18.0% of Group CH (P < 0.05). The younger the age of diagnosis of cirrhosis in Group LC, the higher the frequency of a positive family history (29-35 years, 87.5%; 36-40 years, 21.1%, P < 0.05). The frequency of TAP2*0201 was significantly higher in young adult patients with HCV-related liver cirrhosis than in HCV carriers with normal ALT (P < 0.05), and tended to be higher than in uninfected normal subjects (P = 0.05). The cumulative survival rate of cirrhosis patients with family history of liver diseases was significantly lower than that of cirrhosis patients without such history (P < 0.05). Our findings suggest that a positive family history of liver disease and TAP2*0201 polymorphism may be risk factors for HCV-related liver cirrhosis in young adults.