Routes of infection, viremia, and liver disease in blood donors found to have hepatitis C virus infection

Impact of COVID-19 fear on Hepatitis C management

Background/Aim: Hepatitis C virus (HCV) infection, a major cause of cirrhosis worldwide, is the most common cause of cirrhosis and hepatocellular carcinoma in Turkey. Today, HCV infection can be treated effectively and safely using direct-acting antiviral drugs, and therefore, the World Health Organization has announced elimination targets by 2030. During the pandemic, many social and personal restrictions were applied for fear of increasing the prevalence of coronavirus disease 2019 (COVID-19) infection. Here we investigate the effects of these restrictions on managing HCV infection in internal medicine departments that deal with both infections. Methods: Patients who applied to the internal medicine departments of our hospital and tested for anti-HCV between 11 March 2020 and 09 April 2022, which was the time interval when official restrictions were applied in Turkey during the COVID-19 pandemic, were included in the study. Patients who were not tested for anti-HCV were excluded from the study. The study was planned as a retrospective cohort study, and patients’ files tested for anti-HCV were scanned. Anti-HCV positivity, HCV RNA PCR testing, and treatment status in HCV RNA-positive patients were evaluated. Results: During the official pandemic period when social restrictions were applied, anti-HCV positivity was revealed in 400 (1.9%) of 21,501 patients for whom anti-HCV tests were performed in internal medicine departments. HCV RNA was not tested in 64 of 400 patients with positive anti-HCV test (16%), and 83 (24.7%) of 336 patients tested for HCV RNA were found to be positive. It was determined that 17 (20.5%) of the HCV RNA-positive patients did not receive antiviral treatment. Conclusion: In studies conducted in Turkey in the pre-pandemic period, it was determined that HCV RNA was not tested in approximately half of the anti-HCV-positive patients, while this rate was found to be only 16% during the pandemic period. This can be explained by the fact that patients infected with the COVID-19 virus were mostly followed-up by internal medicine clinics, where the awareness of viral hepatitis was high. It was determined that 20.5% of the patients with positive HCV RNA PCR tests remained untreated. This finding suggested that the social and personal restrictions applied during the pandemic led to patient follow-up and treatment disruptions.

Gender differences in risk exposures for acute hepatitis C infection in Taiwan: a nationwide case-control study

BACKGROUND

In Taiwan, medical providers are required to report all acute hepatitis C (AHC) patients to National Notifiable Disease Surveillance System (NNDSS). Identifying factors associated with AHC may inform the strategies to prevent the spread of hepatitis C virus (HCV). We used the national surveillance data to assess gender difference in risk factors associated with AHC in Taiwan and propose control measures in at-risk groups.

METHODS

We conducted a nationwide case-control study using data from NNDSS and AHC case investigation questionnaires, for the period of March 6, 2014-December 31, 2016. Cases were AHC confirmed in NNDSS; controls were reported AHC with negative HCV nucleic acid test and negative serum anti-HCV antibody. We used bivariate analysis to identify characteristics and risk exposures for AHC and conducted gender stratified analyses.

RESULTS

We identified 602 AHC cases (66.9% males, median age 48 years) and 90 controls. Older age, male gender (OR: 1.85, 95% CI: 1.18-2.90), history of viral hepatitis (OR: 7.93, 95% CI:1.91-32.88), history of sexually transmitted infections (OR: 21.02, 95% CI: 2.90-152.43), and having healthcare-associated risk exposures (OR: 2.02, 95% CI: 1.25-3.25) were associated with AHC. Stratified analyses showed receiving intravenous infusion, history of hepatitis B, syphilis, and human immunodeficiency virus infection were risk factors for male AHC; receiving hemodialysis was risk factor for females.

CONCLUSIONS

Our study demonstrates risk factors for AHC in Taiwan with gender difference. Proper infection control practices in healthcare settings and interventions targeting male patients with HIV and other STIs, remain crucial to prevent individuals from AHC.

Implementation of a controlled human infection model for evaluation of HCV vaccine candidates

Hepatitis C virus (HCV) remains a major global health concern. Directly acting antiviral (DAA) drugs have transformed the treatment of HCV. However, it has become clear that, without an effective HCV vaccine, it will not be possible to meet the World Health Organization targets of HCV viral elimination. Promising new vaccine technologies that generate high magnitude antiviral T and B cell immune responses and significant new funding have recently become available, stimulating the HCV vaccine pipeline. In the absence of an immune competent animal model for HCV, the major block in evaluating new HCV vaccine candidates will be the assessment of vaccine efficacy in humans. The development of a controlled human infection model (CHIM) for HCV could overcome this block, enabling the head-to-head assessment of vaccine candidates. The availability of highly effective DAA means that a CHIM for HCV is possible for the first time. In this review, we highlight the challenges and issues with currently available strategies to assess HCV vaccine efficacy including HCV "at-risk" cohorts and animal models. We describe the development of CHIM in other infections that are increasingly utilized by trialists and explore the ethical and safety concerns specific for an HCV CHIM. Finally, we propose an HCV CHIM study design including the selection of volunteers, the development of an infectious inoculum, the evaluation of host immune and viral parameters, and the definition of study end points for use in an HCV CHIM. Importantly, the study design (including number of volunteers required, cost, duration of study, and risk to volunteers) varies significantly depending on the proposed mechanism of action (sterilizing/rapid viral clearance vs. delayed viral clearance) of the vaccine under evaluation. We conclude that an HCV CHIM is now realistic, that safety and ethical concerns can be addressed with the right study design, and that, without an HCV CHIM, it is difficult to envisage how the development of an HCV vaccine will be possible.

Drugs of Abuse and Their Impact on Viral Pathogenesis

Commonly misused substances such as alcohol, cocaine, heroin, methamphetamine, and opioids suppress immune responses and may impact viral pathogenesis. In recent years, illicit use of opioids has fueled outbreaks of several viral pathogens, including the human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV). This review focuses on the myriad of mechanisms by which drugs of abuse impact viral replication and disease progression. Virus–drug interactions can accelerate viral disease progression and lead to increased risk of virus transmission.

From hepatitis A to E: A critical review of viral hepatitis

Viral infections affecting the liver have had an important impact on humanity, as they have led to significant morbidity and mortality in patients with acute and chronic infections. Once an unknown etiology, the discovery of the viral agents triggered interest of the scientific community to establish the pathogenesis and diagnostic modalities to identify the affected population. With the rapid scientific and technological advances in the last centuries, controlling and even curing the infections became a possibility, with a large focus on preventive medicine through vaccination. Hence, a comprehensive understanding of hepatitis A, B, C, D and E is required by primary care physicians and gastroenterologists to provide care to these patients. The review article describes the epidemiology, pathogenesis, clinical presentation, diagnostic tools and current medication regimens, with a focus on upcoming treatment options and the role of liver transplantation.

Hepatitis C-Positive Donors in Cardiac Transplantation: Problems and Opportunities

PURPOSE OF REVIEW

With the growing need for donor hearts and longer transplant waiting lists, there is a growing interest in expanding the donor pool by reconsidering previously excluded donor candidates. There has been an increase in solid organ availability due to drug overdose deaths in the setting of the recent opioid epidemic. However, these donors often have transmissible infections such as hepatitis C. In this review, we discuss the challenges associated with heart transplantation from hepatitis C-infected donors as well as the recent advancements that are making the use of these organs possible.

RECENT FINDINGS

With the introduction and widespread use of nucleic acid testing (NAT), the ability to distinguish viremic donors and those that have cleared the virus has become a reality. In addition, with the emergence of direct antiviral agents, there is an increase in data showing the short-term outcomes and success of hepatitis C treatment for recipients of viremic donor hearts. As techniques to distinguish donor hepatitis C infection status and successful treatments emerge, the percentage of accepted hepatitis C donor hearts is increasing. A number of studies showing success with hepatitis C organ transplants present a promising new avenue for organ procurement essential to meet the increasing demand for donor hearts.

Preparation, stability and commutability of candidate reference materials for lactate dehydrogenase (LDH)

BACKGROUND

Lactate dehydrogenase (LDH) is a key enzyme that functions as a marker of cell damage. Its activity can be measured by a variety of laboratory methods. To eliminate inter-method bias and enhance equivalence among different measurement procedures, LDH detection needs to be standardized.

METHODS

Optimized sequences coding for lactate dehydrogenase subunit A (LDH-A) and subunit B (LDH-B) were synthesized and cloned into the pRSFDuet vector, and then the constructed 6His-LDHA-pRSFDuet, 6His-LDHB-pRSFDuet, and 6His-LDHA-LDHB-pRSFDuet plasmids were transformed into Escherichia coli BL21 (DE3) for expression. The enzyme activity and specific activity of recombinant LDHs were detected. Electrophoresis of LDH isoenzymes was performed. The stability of recombinant LDHs and serum LDH was evaluated. Commutability of recombinant LDH-B was studied by the IFCC reference method and six routine methods.

RESULTS

Three plasmids were constructed and three highly concentrated recombinant LDH isoenzymes were obtained. The specific activities of LDH-A, LDH-AB, and LDH-B were 18.08 U/mg, 21.74 U/mg, and 14.18 U/mg, respectively. There was a desirable linear correlation between the activities of recombinant LDH isoenzymes and their protein concentrations. Electrophoresis of LDH isoenzymes showed that the recombinant LDH-B corresponded to LDH1 and it demonstrated good stability at 4 °C and 25 °C for 5 weeks. LDH-B formulations in saline-bovine serum albumin solution and human serum matrix were commutable for six routine methods.

CONCLUSION

Human recombinant LDH-B has great potential to become an improved and less expensive standard or reference material in external quality assessment for clinical LDH measurement.

Assessing routes of hepatitis C transmission in HIV-infected men who have sex with men using single genome sequencing

The epidemic of hepatitis C virus (HCV) infection among HIV-infected men who have sex with men (MSM) is in its second decade, but the routes of transmission remain poorly understood. We hypothesized that by pairing single genome sequencing (SGS), to enumerate infecting HCV genomes (viruses), with detailed sexual and drug histories, we could gain insight into the routes of transmission among MSM. We used SGS to analyze blood specimens from eight HIV-infected MSM who had 10 episodes of acute (seronegative) or early HCV infections. Seven of eight men reported condomless receptive anal intercourse (CRAI), six with rectal exposure to semen, and all eight denied rectal trauma or bleeding. Of the 10 HCV infections, eight resulted from transmission of a single virus; one infection resulted from transmission of either one or a few (three or four) closely-related viruses; and one infection resulted from transmission of >10 distinct viruses. The participant infected by >10 viruses reported sharing injection equipment for methamphetamine during sex. Two other participants also injected methamphetamine during sex but they did not share injection equipment and were infected by a single virus. Conclusions: Most HCV infections of HIV-infected MSM without a history of either rectal trauma or bleeding or shared injection equipment were caused by a single virus. Intra-rectal exposure to semen during CRAI is therefore likely sufficient for HCV transmission among MSM. Conversely, rectal trauma or bleeding or shared injection equipment are not necessary for HCV transmission among MSM. These results help clarify routes of HCV transmission among MSM and can therefore help guide the design of much-needed behavioral and other interventions to prevent HCV transmission among MSM.

Range of Normal Serum Aminotransferase Levels in Liver Transplant Recipients

Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) are used to monitor liver transplant recipients (LTR) but the reference range and context of its use is not well defined. We aimed to determine the healthy ranges in LTR without chronic liver disease.

METHODS

One hundred and three LTR without chronic liver disease based on serology, transient elastography with controlled attenuated parameter, and ultrasound were included. A healthy range of aminotransferases was set to 95th percentile. An updated normal aminotransferase range was used to detect recurrence in post-liver transplantation (LT) with hepatitis C virus (HCV) and nonalcoholic fatty liver disease (NAFLD).

RESULTS

The normal ALT and AST range was 0 to 57 and 0 to 54 IU/L, respectively, in LTR and was not affected by age, sex, obesity, or choice of immunosuppressant. The diagnostic performance of serum ALT and AST to detect recurrence of NAFLD by a controlled attenuated parameter was poor with area under the receiver operating characteristic curve of 0.573 (95% confidence interval 0.493, 0.655; P = .08) and 0.537 (0.456, 0.618; P = .4), respectively. In contrast, the diagnostic performance of ALT and AST to detect recurrence of HCV after LT was 0.906 (0.868, 0.944; P < .001) and 0.925 (0.890, 0.959; P < .001), respectively.

CONCLUSION

The updated aminotransferase range in LTR is higher than the general population and accurate for detecting recurrent HCV, but not NAFLD.

Is there a risk of transfusion-transmissible infections after percutaneous needle treatments in blood donors? A systematic review and meta-analysis

BACKGROUND AND OBJECTIVES

The donor medical questionnaire identifies a blood donor's history of known blood safety risks. Current Australian, Canadian, European and USA legislation temporarily defers blood donors who received different percutaneous needle treatments (i.e. tattooing, acupuncture and piercing) from blood donation. This systematic review aimed to scientifically underpin these deferrals by identifying the best available evidence on the association between percutaneous needle treatments and the risk of transfusion-transmissible infections (TTIs).

MATERIALS AND METHODS

Studies from three databases investigating the link between percutaneous needle treatments and TTIs (HBV, HCV and HIV infection) in blood donors were retained and assessed on eligibility by two reviewers independently. The association between percutaneous needle treatments and TTIs was expressed by conducting meta-analyses and calculating pooled effect measures (odds ratios (ORs) and 95% CIs). The GRADE methodology (Grades of Recommendation, Assessment, Development and Evaluation) was used to assess the quality of evidence.

RESULTS

We identified 1242 references and finally included 21 observational studies. Twenty studies assessed the link between percutaneous needle treatments and HCV infection and found that blood donors receiving these treatments had an increased risk of HCV infection (tattooing: pooled OR 5·28, 95% CI [4·33, 6·44], P < 0·00001 (low-quality evidence); acupuncture: pooled OR 1·56, 95% CI [1·17, 2·08], P = 0·03 (very low-quality evidence); and piercing: pooled OR 3·25, 95% CI [1·68, 6·30], P = 0·0005 (low-quality evidence)).

CONCLUSION

Percutaneous needle treatments may be associated with an increased HCV infection risk. Further high-quality studies are required to formulate stronger evidence-based recommendations on percutaneous needle treatments as a blood donor deferral criterion.

Difficulty of acute hepatitis C diagnosis in a hospitalised patient

The hepatitis C virus (HCV) causes acute hepatitis C and is commonly detected via HCV antibody testing. However, delayed seroconversion of HCV antibodies and non-specific symptoms may hinder the diagnosis of this disease. A 71-year-old woman developed acute hepatitis while hospitalised for back pain. An HCV antibody test was negative, and she had no risk factors for hepatitis C. She was referred to our hospital for further evaluation. The HCV antibody test was repeated 16 days after the initial test; owing to a positive result, she was diagnosed with acute hepatitis C. Several months thereafter, the HCV spontaneously cleared. When diagnosing an HCV infection, the time at which the testing is performed needs to coincide with the time at which HCV antibody seroconversion occurs. Timely diagnosis of an HCV infection allows appropriate treatment during the acute phase which may prevent disease progression to the chronic phase.

Hepatitis C: clinical and biological features related to different forms of cocaine use

INTRODUCTION

Hepatitis C virus (HCV) infection is related with several liver diseases such as cirrhosis and hepatocellular carcinomas, leading to more than 0.5 million deaths every year and to a great global burden. It is known that injection drug users show a high prevalence of HCV infection, being considered a risk group for this disease. Cocaine users seem to be in greater risk than other drug users, and several hypotheses for this association are being studied.

AIM

To review data on HCV infection in cocaine users, taking into consideration the relevance of the different routes of drug administration and other risk behaviors.

METHODS

This was a narrative review performed in the main scientific databases.

RESULTS AND CONCLUSION

Data suggest that cocaine use could be associated with HCV infection due to the specificities of cocaine consumption pattern, even in those subjects who do not inject drugs, in addition to other risky behaviors, such as tattooing and unprotected sex. Injectable cocaine users seem to be more susceptible to contamination than users who do not inject drugs. However, evidence is pointing to the possibility of infection by sharing drug paraphernalia other than syringes. Moreover, specific immune system impairments caused by cocaine use are also being linked with HCV infection susceptibility, persistence and increased pathological effects.

The Role of the Signal-to-Cutoff Ratio in Automated Anti-HCV Chemiluminescent Immunoassays by Referring to the Nucleic Acid Amplification Test and the Recombinant Immunoblot Assay

Background

Following discontinuation of the recombinant immunoblot assay (RIBA), the only available supplementary test for the detection of hepatitis C virus (HCV) is the nucleic acid amplification test (NAAT). However, the NAAT does not adequately detect past HCV. Consequently, it is hard to distinguish between past HCV infection and biological false positivity with an anti-HCV result alone. We assessed the diagnostic performance of two immunoassays: the ARCHITECT anti-HCV chemiluminescent microparticle immunoassay (CMIA; Abbott Diagnostics, Wiesbaden, Germany) and the Access HCV Ab PLUS chemiluminescent immunoassay (CIA; Bio-Rad, Marnes-la-Coquette, France). We also explored an optimized algorithm to determine the anti-HCV results.

Methods

We tested 126,919 patients and 44,556 individuals who underwent a medical checkup. RIBA and NAAT were conducted for samples that tested anti-HCV-positive using CMIA and CIA. We assessed the optimal signal-to-cutoff (S/CO) ratio in HCV-positive samples.

Results

In total, 1,035 blood samples tested anti-HCV-positive. Of these, RIBA was positive in 512, indeterminate in 160, and negative in 363 samples. One hundred sixty-five samples were NAAT-positive. Diagnostic sensitivity and positive predictive value (PPV) were 96.7% and 52.1%, respectively, for CMIA, and 94.7% and 72.3%, respectively, for CIA. The optimal S/CO ratio was 5.2 for CMIA and 2.6 for CIA at 95% PPV. In total, 286 samples tested positive in CMIA and 444 in CIA, while 443 samples tested positive in both assays.

Conclusions

It is hard to determine anti-HCV positivity based on the S/CO ratio alone. However, this study elucidated the role of the S/CO ratio by using the NAAT and RIBA.

Hepatitis C virus antibodies are absent among high risk group of health care workers in Damascus Hospital

BACKGROUND AND STUDY AIMS

Liver disease caused by hepatitis C virus (HCV) is one of the most serious health issues worldwide. The prevalence of HCV among health care workers (HCWs) is higher than normal population. Our aim is to determine the seroprevalence of HCV among this high-risk group in Damascus Hospital, Syria in 2016.

SUBJECTS AND METHODS

During March 2016, anonymous testing for HCV was offered to 150 residents and physicians from different departments (Surgery, otolaryngology, gastroenterology, anaesthesiology and laboratory) in Damascus Hospital using fourth-generation enzyme-linked immunosorbent assay (ELISA). In addition, each participant was interviewed and answered a comprehensive questionnaire which includes questions on potential hazards, risk factors and the level of awareness about the disease and its ways of transmission.

RESULTS

Surprisingly, all samples tested negative for anti-HCV antibodies, though many participants were already exposed to many risk factors especially as HCWs.

CONCLUSION

HCV is not a main issue regarding its prevalence among HCWs in Damascus Hospital. Nevertheless, it is still necessary to develop a mandatory well-organized program to increase the awareness among HCWs and develop stricter prevention policies especially about bloodborne diseases transmitted occupationally.

Epidemiology and risk factors for hepatitis C virus infection in a high-prevalence population

To understand increasing rates of hepatitis C virus (HCV) infection in Tennessee, we conducted testing, risk factor analysis and a nested case-control study among persons who use drugs. During June-October 2016, HCV testing with risk factor assessment was conducted in sexually transmitted disease clinics, family planning clinics and an addiction treatment facility in eastern Tennessee; data were analysed by using multivariable logistic regression. A nested case-control study was conducted to assess drug-using risks and behaviours among persons who reported intranasal or injection drug use (IDU). Of 4753 persons tested, 397 (8.4%) were HCV-antibody positive. HCV infection was significantly associated with a history of both intranasal and IDU (adjusted odds ratio (aOR) 35.4, 95% confidence interval (CI) 24.1-51.9), IDU alone (aOR 52.7, CI 25.3-109.9), intranasal drug use alone (aOR 2.6, CI 1.8-3.9) and incarceration (aOR 2.7, CI 2.0-3.8). By 4 October 2016, 574 persons with a reported history of drug use; 63 (11%) were interviewed further. Of 31 persons who used both intranasal and injection drugs, 26 (84%) reported previous intranasal drug use, occurring 1-18 years (median 5.5 years) before their first IDU. Our findings provide evidence that reported IDU, intranasal drug use and incarceration are independent indicators of risk for past or present HCV infection in the study population.

Recognition criteria for occupational cancers in relation to hepatitis B virus and hepatitis C virus in Korea

The goal of this study was to review the scientific basis for the recognition of occupational cancer, in relation to hepatitis viral infections in Korea. Most Hepatitis B virus (HBV) infections in Korea occur as vertical infections, but these are decreasing rapidly due to vaccination. Hepatitis C virus (HCV) is known to be transmitted through parenteral routes, but the transmission route is often unclear. Most occupational infections of hepatitis virus involve accidental injuries of medical institution workers while using virus-contaminated medical devices. Many cohort studies and case-control studies have consistently reported that HBV and HCV infection increases the risk of hepatocellular carcinoma (HCC) and the strength of this association is high. Non-Hodgkin’s lymphoma appears to be associated with HCV. Cholangiocarcinoma, pancreatic cancer, leukemia, and thyroid cancer are considered to be less related or unrelated to epidemiological causation. There are no uniform international specific criteria for occupational cancer caused through occupational exposure to a hepatitis virus. In establishing appropriate standards applicable to Korea, there should be sufficient consideration of latency, virus exposure levels and frequency, and other cancers, apart from HCC.

In conclusion, we recommend keeping the current specific criteria. However, if a worker is injured at work when using a sharp medical device, and HBV and HCV viral infections are confirmed through serologic tests; if the worker is diagnosed as having a chronic HBV or HCV infection, a subsequent HCC (or Non-Hodgkin’s lymphoma following chronic HCV infection) can then be considered highly related to the worker’s occupation.

The risk of venous thromboembolism in patients with hepatitis C

Some studies suggest that patients with hepatitis C virus (HCV) infection have an increased risk of deep venous thrombosis (DVT) and pulmonary embolism (PE). Unfortunately, available data on this association are contrasting. A systematic review and meta-analysis of literature studies was performed to evaluate the risk of venous thromboembolism (VTE) associated with HCV. Studies reporting on VTE risk associated with HCV were systematically searched in the PubMed, Web of Science, Scopus and EMBASE databases. Six studies (10 data-sets) showed a significantly increased VTE risk in 100,364 HCV patients as compared with 8,471,176 uninfected controls (odds ratio [OR]: 1.900; 95 % confidence interval [CI]: 1.406, 2.570; p<0.0001). These results were confirmed when specifically considering the risk of DVT (6 studies, OR: 1.918; 95 %CI: 1.351, 2.723; p<0.0001), whereas a trend towards an increased risk of PE was documented in HCV patients (4 studies, OR: 1.811; 95 %CI: 0.895, 3.663; p=0.099). The increased VTE risk associated with HCV infection was consistently confirmed when analysing four studies reporting adjusted risk estimates (OR: 1.876; 95 %CI: 1.326, 2.654; P<0.0001), and after excluding studies specifically enrolling populations exposed to transient risk factors for VTE (4 studies, OR: 1.493; 95 %CI: 1.167, 1.910; p=0.001). Meta-regression models suggested that age and male gender may significantly impact on the risk of VTE associated with HCV-positivity. Results of our metaanalysis suggest that HCV-infected subjects may exhibit an increased risk of VTE. However, further high quality studies are needed to extend and confirm our findings.

Supplementary Material to this article is available online at www.thrombosis-online.com.

Effectiveness and cost-effectiveness of nationwide campaigns for awareness and case finding of hepatitis C targeted at people who inject drugs and the general population in the Netherlands

BACKGROUND

Hepatitis C virus infection (HCV) is a serious, but underdiagnosed disease that can generally be treated successfully. Therefore, a nationwide HCV awareness campaign was implemented in the Netherlands targeting people who inject drugs (PWID) in addiction care ('PWID intervention') and high-risk groups in the general population ('public intervention'). The objective of this study is to assess the effectiveness and cost-effectiveness of the interventions used in this campaign.

METHODS

For the 'PWID' intervention, all addiction care centres in the Netherlands provided proactive individual HCV consultation and testing. The 'public intervention' consisted of health education through mass media and instruction of health care professionals. A Markov chain model was used to estimate incremental cost-effectiveness ratios (ICER, cost per QALY gained). We included a 'DAA treatment' scenario to estimate the effect of these treatment strategies on cost-effectiveness.

RESULTS

The 'PWID intervention' identified 257 additional HCV-carriers. The ICER was €9056 (95% CI: €6043-€13,523) when compared to 'no intervention'. The 'public intervention' identified 38 additional HCV-carriers. The ICER was €18,421 (95% CI: €7376-€25,490,119) when compared to 'no intervention'. Probabilistic sensitivity analysis showed that the probability that the 'PWID intervention' was cost-effective was 100%. It also showed a probability of 34% that the 'public intervention' did not exceed the Dutch threshold for cost-effectiveness (€20,000). New treatment regimens are likely to improve cost-effectiveness of this strategy.

CONCLUSION

In a nationwide HCV awareness and case finding campaign, the intervention targeting PWID was effective and cost-effective. An intervention targeting risk groups in the general population showed only a modest effect and is therefore less likely to be cost-effective.

Sharing of Snorting Straws and Hepatitis C Virus Infection in Pregnant Women

OBJECTIVE

To evaluate possible modes of hepatitis C virus (HCV) acquisition in pregnant women found to be HCV-infected in the prenatal period and to assess transmission risk factors.

METHODS

This was a prospective cohort study conducted from March 2014 through June 2015 involving the distribution of an anonymous survey to HCV-infected pregnant women that assessed for numerous modes of potential HCV transmission involving, intravenous drug use, blood transfusion, organ transplant, sexual contact, tattoos, and snorting drugs with a straw. Participants were drawn from our institutional obstetric high-risk clinic. Statistical analysis involved simple percentages and χ comparisons where appropriate; P<.05 was considered significant. To test biologic plausibility, snorting utensils confiscated by law enforcement authorities from patients not in this study were tested for the presence of human blood.

RESULTS

A total of 189 HCV-infected pregnant patients completed the survey, and no approached patients declined. Of these, 136 (72%, 95% confidence interval [CI] 65-78%) admitted to intravenous drug use, of whom 89 (65%, 95% CI 57-73%) reported sharing needles. Of the 178 (94%, 95% CI 90-97%) who admitted snorting drugs, 164 (92%, 95% CI 87-96%) reported sharing straws. The difference between the proportion reporting sharing of snorting utensils compared with the proportion sharing intravenous drug use utensils was significant (P<.001). Twenty-nine patients (15%, 95% CI 11-21%) reported snorting drugs and sharing straws but denied any other risk factor except sexual contact. Of the 54 straws confiscated by law enforcement authorities, 13 (24%, 95% CI 13-38%) tested positive for the presence of human blood.

CONCLUSION

Sharing snorting utensils (straws) in noninjection drug use may be an additional risk factor for HCV and other virus transmission.

Threshold value of LIAISON XL anti-HCV screening assay predicting positive immunoblotting results

Some international guidelines recommend evaluating the need to confirm positive anti-hepatitis C virus (HCV) antibody screening results by means of a more specific antibody or molecular biology test on the basis of a screening threshold value (such as the sample signal/cut-off ratio) that can predict the positivity of additional antibody testing in at least 95% of cases. The aim of this study was to determine the threshold value of the DiaSorin LIAISON XL chemiluminescence test. Two hundred and twenty-eight routine laboratory samples that were chemiluminescence positive for anti-HCV antibodies but had different signal/cut-off ratios were assayed using immunoblotting, which indicated that 155 (68.0%) were positive, 40 (17.5%) were negative, and 33 (14.5%) were indeterminate. When the samples were divided on the basis of their signal/cut-off ratios, 95.5% of the samples with a ratio of ≥3.5 were positive as against 74.1% of the positive or indeterminate samples with a ratio of <3.5. Statistical analysis using Youden's index and a receiver operating characteristic curve showed that the optimum cut-off value was 3.65. These findings indicate that, when using the LIAISON XL system for anti-HCV antibody screening, a signal/cut-off ratio of ≥3.65 makes further confirmatory tests unnecessary.

Prevalence and trends of hepatitis B virus, Hepatitis C virus, Human immunodeficiency virus 1, 2 and syphilis infections among blood donors in a regional transfusion center in Punjab, India: A 3 years study

Background:

Accurate estimates of the risk of transfusion-transmitted infectious diseases are essential for monitoring the safety of blood supply and evaluating the potential effects of new screening tests.

Objective:

The aim was to determine changes over time in blood donor population infection rates of hepatitis B virus (HBV), hepatitis C virus (HCV), human immunodeficiency virus (HIV-1, 2) and syphilis.

Materials and Methods:

Changes in rates of HBV, HCV, HIV-1, 2, and syphilis infections were evaluated by comparing yearly prevalence rates for blood donors over 3 years, that is, between January 1, 2012 and December 31, 2014. Serological tests were done according to the standard operating procedures and manufacturer's instructions and included the following: tests for hepatitis B surface antigen; antibodies to HCV and HIV-1, 2 and rapid plasma reagin test for syphilis.

Results:

Nearly 2.54 of the total screened blood donors were reactive for one of the four transfusion transmitted infections (TTIs) with higher prevalence in replacement (3%) than voluntary donors (2.3%) and in male (2.54%) than female (2.3%) donors. TTI tend to be more (54.7%) in younger population of 18–30 years. HCV infection is the most common of all TTI (50%).

Conclusion:

The rising prevalence rates of HIV; HBV; HCV and syphilis among different groups suggests that blood transfusion is still very unsafe in this community and emphasis should be laid on donor education and donor self-exclusion, implementation of strict donor screening criteria, pre-donation counseling, and more sensitive screening methods. Furthermore, donors with a history of sexually transmitted infections should be totally excluded from all donations.

Circulating let-7 levels in plasma and extracellular vesicles correlate with hepatic fibrosis progression in chronic hepatitis C

The goal of this study was to determine whether an association exists between circulating microRNA (miRNA) levels and disease progression in chronic hepatitis C (CHC), whether plasma or extracellular vesicles (EVs) were optimal for miRNA measurement and their correlation with hepatic miRNA expression, and the mechanistic plausibility of this association. We studied 130 CHC patients prospectively followed over several decades. A comprehensive miRNA profile in plasma using microarray with 2578 probe sets showed 323 miRNAs differentially expressed between healthy individuals and CHC patients, but only six that distinguished patients with mild versus severe chronic hepatitis. Eventually, let-7a/7c/7d-5p and miR-122-5p were identified as candidate predictors of disease progression. Cross-sectional analyses at the time of initial liver biopsy showed that reduced levels of let-7a/7c/7d-5p (let-7s) in plasma were correlated with advanced histological hepatic fibrosis stage and other fibrotic markers, whereas miR-122-5p levels in plasma were positively correlated with inflammatory activity, but not fibrosis. Measuring let-7s levels in EVs was not superior to intact plasma for discriminating significant hepatic fibrosis. Longitudinal analyses in 60 patients with paired liver biopsies showed that let-7s levels in plasma markedly declined over time in parallel with fibrosis progression. However, circulating let-7s levels did not parallel those in the liver.

CONCLUSION

Of all miRNAs screened, the let-7 family showed the best correlation with hepatic fibrosis in CHC. A single determination of let-7s levels in plasma did not have superior predictive value for significant hepatic fibrosis compared with that of fibrosis-4 index, but the rate of let-7s decline in paired longitudinal samples correlated well with fibrosis progression. Pathway analysis suggested that low levels of let-7 may influence hepatic fibrogenesis through activation of transforming growth factor β signaling in hepatic stellate cells. (Hepatology 2016;64:732-745).

Peromyscus as a model system for human hepatitis C: An opportunity to advance our understanding of a complex host parasite system

Worldwide, there are 185 million people infected with hepatitis C virus and approximately 350,000 people die each year from hepatitis C associated liver diseases. Human hepatitis C research has been hampered by the lack of an appropriate in vivo model system. Most of the in vivo research has been conducted on chimpanzees, which is complicated by ethical concerns, small sample sizes, high costs, and genetic heterogeneity. The house mouse system has led to greater understanding of a wide variety of human pathogens, but it is unreasonable to expect Mus musculus to be a good model system for every human pathogen. Alternative animal models can be developed in these cases. Ferrets (influenza), cotton rats (human respiratory virus), and woodchucks (hepatitis B) are all alternative models that have led to a greater understanding of human pathogens. Rodent models are tractable, genetically amenable and inbred and outbred strains can provide homogeneity in results. Recently, a rodent homolog of hepatitis C was discovered and isolated from the liver of a Peromyscus maniculatus. This represents the first small mammal (mouse) model system for human hepatitis C and it offers great potential to contribute to our understanding and ultimately aid in our efforts to combat this serious public health concern. Peromyscus are available commercially and can be used to inform questions about the origin, transmission, persistence, pathology, and rational treatment of hepatitis C. Here, we provide a disease ecologist's overview of this new virus and some suggestions for useful future experiments.

The Natural History of Hepatit is C Viral Infection: Clinical Evaluation and Monitoring

Hepatitis C virus (HCV) infection is one of the most common causes of chronic liver disease in the world and represents a substantial burden on global health systems and individual patient wellbeing. Routine screening for HCV in certain high-risk populations is appropriate. HCV can cause both an acute and chronic hepatitis, and manifests as a variety of hepatic and extrahepatic symptoms, largely influenced by a combination of host and viral factors. It can be difficult to predict clinical outcomes in individual cases. In those who suffer a chronic infection, progression to cirrhosis carries the risk of decompensation and hepatocellular carcinoma. The natural history of HCV infection and our understanding of risk factors that are predictive of disease progression are discussed.

The risk of coronary artery disease and cerebrovascular disease in patients with hepatitis C: A systematic review and meta-analysis

BACKGROUND/OBJECTIVES

Some studies suggest that patients with hepatitis C virus (HCV) infection have an increased risk of coronary artery disease (CAD) and cerebrovascular disease. Unfortunately, available data on this association are widely variable. We have performed a systematic review and meta-analysis of literature to evaluate the risk of cardio-cerebrovascular disease (CCD) associated with HCV.

METHODS

Studies reporting on CCD risk associated with HCV were systematically searched in the PubMed, Web of Science, Scopus and EMBASE databases.

RESULTS

Twenty-seven studies (34 data-sets) showed a significantly increased CCD risk in 297,613 HCV patients as compared with 557,814 uninfected controls (OR: 1.428; 95% CI: 1.214, 1.681). These results were confirmed when separately considering the risk of CAD (20 studies, OR: 1.382; 95% CI: 1.103, 1.732) and of cerebrovascular disease (13 studies, OR: 1.485; 95% CI: 1.079, 2.044). Similar results were confirmed when analyzing 21 studies reporting adjusted risk estimates (OR: 1.448; 95% CI: 1.218, 1.722) and when, after excluding studies defining CAD as positive angiographic or electrocardiographic evidence, we specifically included the 17 studies reporting on acute CCD-related events (OR: 1.357; 95% CI: 1.103, 1.670). Moreover, 4 studies evaluating CCD-related deaths showed a higher risk in HCV patients than controls (OR: 1.772; 95% CI: 1.448, 2.168; P<0.0001). Meta-regression models suggested a direct association between prevalence of cirrhosis and difference in CCD risk between HCV patients and controls.

CONCLUSIONS

Results of our large meta-analysis suggest that HCV-infected subjects experience an increased risk of CCD. This should be considered to plan specific cardiovascular prevention strategies in this clinical setting.

Seroprevalence and Correlates of Hepatitis C Virus Infection in Secondary School Children in Enugu, Nigeria

BACKGROUND

Although children comprise a small fraction of the burden of hepatitis C virus (HCV) infections, which is a major global health challenge, a significant number of them develop chronic HCV infection and are at risk of its complications.

AIM

The aim of the current study was to determine the prevalence and associated factors of HCV infection in school children in Enugu urban.

SUBJECTS AND METHODS

This was a cross-sectional seroepidemiological study involving children aged 10-18 years selected using multistage systematic sampling in Enugu metropolis, Southeast Nigeria. The anti-HCV was tested using a 3(rd) generation enzyme-linked immunosorbent assay. Data were analyzed using SPSS Version 16.0 with the level of significance set at P < 0.05.

RESULTS

Four hundred and twenty children were selected and screened comprising 210 (50.0%) males and females. The seroprevalence of anti-HCV was 4 (1.0%). Three (75%) out of the four positive cases for the anti-HCV were females while one was a male giving a male to female ratio of 0.3-1. Traditional scarifications/tattoos were the putative risk factors observed to be significantly associated with anti-HCV seropositivity.

CONCLUSION

This study has demonstrated an anti-HCV seroprevalence of 1.0% among children aged 10-18 years in Enugu with traditional scarification as the predominant associated risk factor. Proper health education including school health education and promotion of behavioral change among the public on the practice of safe scarifications/tattoos should be encouraged in our setting.

Evaluation of a novel commercial quaternary ammonium compound for eradication of Mycobacteria, HCV and HBV in Egypt

Endoscopes are a common source of outbreaks of healthcare-associated infections. It is therefore important to identify high-level disinfectants capable of eliminating or killing all vegetative bacteria, mycobacteria, and viruses. Aldehydebased disinfectants are most commonly used in clinical practice but resistance has recently been detected and side effects associated with these disinfectants are well documented. In this study, we evaluated Virusolve+® EDS, a novel quaternary ammonium compound formulation supplied by Amity international, against Mycobacterium bovis (ATCC-27289), hepatitis C virus (HCV)-positive serum and hepatitis B surface antigen-positive serum. We also compared its efficacy against Cidex® (glutaraldehyde 2%), an aldehyde-based disinfectant. M. bovis showed no growth after 10 weeks with either Virusolve+® or Cidex®. Virusolve+® achieved a 10(4)- fold reduction in the initial 10(6) HCV load under clean conditions (without red blood cells) for 20 min, whereas Cidex® achieved this reduction under clean and dirty conditions (without and with red blood cells, respectively) after both 10 and 20 min. Both Virusolve+® and Cidex® were able to eradicate hepatitis B virus (HBV) infectivity under clean conditions after 10 and 20 min, whereas under dirty conditions they were only able to eradicate virus infectivity after 20 min. Virusolve+® EDS when compared with Cidex® showed equal mycobactericidal activity completely eradicating M. bovis. However, both showed comparable virucidal activity against HBV, which was more effective under clean conditions, emphasizing the importance of the cleaning step in endoscope reprocessing. Cidex® was more effective at eradicating HCV under dirty conditions after a short contact time.

Natural History of Hepatitis C

Hepatitis C infection is a common cause of cirrhosis and indication for liver transplantation in the United States. The incidence of chronic hepatitis C has been declining, but rates of cirrhosis and hepatocellular carcinoma are projected to increase. The outcome of chronic hepatitis C is variable. It is estimated that 20% to 25% will develop cirrhosis over a 25-year to 30-year period. The rate of disease progression is influenced by many host, viral, and environmental factors. Few can be modified.

Transmission of Hepatitis B and C Virus Infection Through Body Piercing: A Systematic Review and Meta-Analysis

Hepatitis B and hepatitis C are 2 types of potentially life-threatening liver diseases with high infection rate. Body piercing represents a progressively popular sociocultural phenomenon which is also a potential exposure approach for hepatitis B virus (HBV) and hepatitis C virus (HCV). Conclusions from those researches with statistically risk assessment of body piercing on HBV and HCV transmission are contradictory.Systematically analyze the association between body piercing and the risk of transmitting hepatitis B virus and hepatitis C virus for general population. Make evidence-based recommendations to the current practice and wake up public awareness of this health-threatening behavior.Comprehensive and high sensitivity search strategies were performed to exhaustively search related studies before 15 January 2015 (MEDLINE, EMBASE, WANFANG, CNKI datasets for published literatures, and Google and Google scholars for related grey articles). Two authors identified relevant studies for the review, abstracted data, and assessed literature quality independently and critically according to the selection criteria and quality assessment standard. Odds ratio (OR) and corresponding 95% confidence interval (CI) were used to estimate risk of HBV and HCV infection in relation to body piercing status. Subgroup analysis and sensitivity analysis were conducted to examine the source of heterogeneity and test the robust of the results.A total of 40 studies were included in this systematic review (10 for Hep-B, 26 for Hep-C, 4 for both Hep-B and Hep-C), the pooled OR (95% CI) for the association between body piercing and transmission of HBV/HCV is 1.80 (1.18, 2.75) and 1.83 (1.27, 2.64), respectively. Subgroup analysis suggested that highest risk of body piercing related to hepatitis C infection was for former soccer and veterans with OR of 4.63 (2.65, 8.10), while strongest association between body piercing and hepatitis B was for samples derived from students/community with OR of 2.40 (1.44, 4.02).The current systematic review and meta-analysis suggests that body piercing is significantly associated with the transmission of HBV as well as HCV, having body piercing probably can increase the risk of getting infected. Evidence from this study strongly recommends that comprehensive and effective programs should be established to provide safer piercing practice.

Prevalence of the hepatitis C virus among University employees in São Paulo, Southeastern Brazil: predictive factors and geoprocessing spatial analysis

BACKGROUND

There are limited studies on the prevalence and risk factors associated with hepatitis C virus (HCV) infection. Objective Identify the prevalence and risk factors for HCV infection in university employees of the state of São Paulo, Brazil.

METHODS

Digital serological tests for anti-HCV have been performed in 3153 volunteers. For the application of digital testing was necessary to withdraw a drop of blood through a needlestick. The positive cases were performed for genotyping and RNA. Chi-square and Fisher's exact test were used, with P-value <0.05 indicating statistical significance. Univariate and multivariate logistic regression were also used.

RESULTS

Prevalence of anti-HCV was 0.7%. The risk factors associated with HCV infection were: age >40 years, blood transfusion, injectable drugs, inhalable drugs (InDU), injectable Gluconergam®, glass syringes, tattoos, hemodialysis and sexual promiscuity. Age (P=0.01, OR 5.6, CI 1.4 to 22.8), InDU (P<0.0001, OR=96.8, CI 24.1 to 388.2), Gluconergam® (P=0.0009, OR=44.4, CI 4.7 to 412.7) and hemodialysis (P=0.0004, OR=90.1, CI 7.5 - 407.1) were independent predictors. Spatial analysis of the prevalence with socioeconomic indices, Gross Domestic Product and Human Development Index by the geoprocessing technique showed no positive correlation.

CONCLUSIONS

The prevalence of HCV infection was 0.7%. The independent risk factors for HCV infection were age, InDU, Gluconergan® and hemodialysis. There was no spatial correlation of HCV prevalence with local economic factors.

Establishing a sample-to cut-off ratio for lab-diagnosis of hepatitis C virus in Indian context

INTRODUCTION

Lab-diagnosis of hepatitis C virus (HCV) is based on detecting specific antibodies by enzyme immuno-assay (EIA) or chemiluminescence immuno-assay (CIA). Center for Disease Control reported that signal-to-cut-off (s/co) ratios in anti-HCV antibody tests like EIA/CIA can be used to predict the probable result of supplemental test; above a certain s/co value it is most likely to be true-HCV positive result and below that certain s/co it is most likely to be false-positive result. A prospective study was undertaken in patients in tertiary care setting for establishing this "certain" s/co value.

MATERIALS AND METHODS

The study was carried out in consecutive patients requiring HCV testing for screening/diagnosis and medical management. These samples were tested for anti-HCV on CIA (VITROS(®) Anti-HCV assay, Ortho-Clinical Diagnostics, New Jersey) for calculating s/co value. The supplemental nucleic acid test used was polymerase chain reaction (PCR) (Abbott). PCR test results were used to define true negatives, false negatives, true positives, and false positives. Performance of different putative s/co ratios versus PCR was measured using sensitivity, specificity, positive predictive value and negative predictive value and most appropriate s/co was considered on basis of highest specificity at sensitivity of at least 95%.

RESULTS

An s/co ratio of ≥6 worked out to be over 95% sensitive and almost 92% specific in 438 consecutive patient samples tested.

CONCLUSION

The s/co ratio of six can be used for lab-diagnosis of HCV infection; those with s/co higher than six can be diagnosed to have HCV infection without any need for supplemental assays.

HIV Infection Status as a Predictor of Hepatitis C Virus RNA Testing in Primary Care

INTRODUCTION

Receipt of hepatitis C virus (HCV) RNA testing following a positive HCV antibody (anti-HCV+) test result to establish current infection is a quality indicator for HCV-related care. This study examines HIV infection status as a predictor of HCV RNA test receipt after an anti-HCV+ result in the primary care setting.

METHODS

Electronic medical records of anti-HCV+ patients from a multisite retrospective study of patients aged ≥18 years who utilized one or more primary care outpatient services during 2005-2010 were analyzed in 2014. A multivariable logistic regression model examined the independent relationships between patient characteristics and receipt of HCV RNA testing.

RESULTS

Among 1,115 anti-HCV+ patients, 133 (11.9%) were also HIV-positive. Of these, 77.4% (n=103) underwent HCV RNA testing to determine current infection status. By contrast, 66.7% (n=654/980) of anti-HCV+ patients who were HIV-negative received HCV RNA testing. Following multivariable adjustment, the odds of receiving HCV RNA testing were higher among anti-HCV+ patients who were also HIV-positive (AOR=1.9, 95% CI=1.2, 3.0), compared with their HIV-negative counterparts. Elevated alanine aminotransferase level was also associated with receipt of HCV RNA testing (AOR=1.9, 95% CI=1.4, 2.4). Black race was associated with decreased odds of receiving HCV RNA testing (AOR=0.7, 95% CI=0.5, 1.0).

CONCLUSIONS

HIV infection status is independently associated with the likelihood of receiving HCV RNA testing following an anti-HCV+ result. One quarter of anti-HCV+ patients who were also HIV-positive and one third of their HIV-negative counterparts, respectively, did not receive testing to establish active HCV infection, which is imperative for appropriate care and treatment.

Seroprevalence of hepatitis C and factors associated with this in crack users

OBJECTIVE

to investigate the seroprevalence of hepatitis C in crack users in Piauí.

METHOD

seroepidemiological survey, undertaken in the Psycho-Social Care Centers for Drugs and Alcohol (CAPS AD) in Piauí in the period December 2011 to May 2012. A questionnaire was administered and blood samples were collected for serological research. Fisher's exact test and the Mann-Whitney test were used, with a level of significance of (p<0.05).

RESULTS

the prevalence of Anti-HCV was 05 (1.4%) and 04 (1.1%) for the RNA-HCV. There was a statistically significant association between hepatitis C (serological marker RNA-HCV) and age, being resident at home, length of use of crack, interruption of the use of crack, and the habit of sharing the crack pipes.

CONCLUSION

the findings support the need to implement health policies aimed at crack users, due to the accelerated process of physical and psychological deterioration to which these are subject.

A complete molecular biology assay for hepatitis C virus detection, quantification and genotyping

INTRODUCTION

Molecular biology procedures to detect, genotype and quantify hepatitis C virus (HCV) RNA in clinical samples have been extensively described. Routine commercial methods for each specific purpose (detection, quantification and genotyping) are also available, all of which are typically based on polymerase chain reaction (PCR) targeting the HCV 5' untranslated region (5'UTR). This study was performed to develop and validate a complete serial laboratory assay that combines real-time nested reverse transcription-polymerase chain reaction (RT-PCR) and restriction fragment length polymorphism (RFLP) techniques for the complete molecular analysis of HCV (detection, genotyping and viral load) in clinical samples.

METHODS

Published HCV sequences were compared to select specific primers, probe and restriction enzyme sites. An original real-time nested RT-PCR-RFLP assay was then developed and validated to detect, genotype and quantify HCV in plasma samples.

RESULTS

The real-time nested RT-PCR data were linear and reproducible for HCV analysis in clinical samples. High correlations (> 0.97) were observed between samples with different viral loads and the corresponding read cycle (Ct - Cycle threshold), and this part of the assay had a wide dynamic range of analysis. Additionally, HCV genotypes 1, 2 and 3 were successfully distinguished using the RFLP method.

CONCLUSIONS

A complete serial molecular assay was developed and validated for HCV detection, quantification and genotyping.

Hepatitis C in African Americans

The care of hepatitis C virus (HCV) in African Americans represents an opportunity to address a major health disparity in medicine. In all facets of HCV infection, African Americans are inexplicably affected, including in the prevalence of the virus, which is higher among them compared with most of the racial and ethnic groups. Ironically, although fibrosis rates may be slow, hepatocellular carcinoma and mortality rates appear to be higher among African Americans. Sustained viral response (SVR) rates have historically significantly trailed behind Caucasians. The reasons for this gap in SVR are related to both viral and host factors. Moreover, low enrollment rates in clinical trials hamper the study of the efficacy of anti-viral therapy. Nevertheless, the gap in SVR between African Americans and Caucasians may be narrowing with the use of direct-acting agents. Gastroenterologists, hepatologists, primary care physicians, and other health-care providers need to address modifiable risk factors that affect the natural history, as well as treatment outcomes, for HCV among African Americans. Efforts need to be made to improve awareness among health-care providers to address the differences in screening and referral patterns for African Americans.

Comparison of hepatitis C virus testing strategies: birth cohort versus elevated alanine aminotransferase levels

BACKGROUND

Hepatitis C virus (HCV) infection is unidentified in an estimated 40%-85% of infected adults. Surveillance and modeling data have found significant increases in HCV-associated morbidity and mortality.

PURPOSE

To compare two HCV antibody (anti-HCV) testing strategies based on (1) elevated alanine aminotransferase levels (ALT) and (2) a birth cohort approach for people born during 1945-1965.

METHODS

Data from 19,055 adults aged 20-70 years who completed the National Health and Nutrition Examination Survey in 1999-2008 were analyzed in 2013. Two independent models were evaluated, based on membership in the 1945-1965 birth cohort or elevated ALT, to compare the number of identified anti-HCV-positive (anti-HCV+) individuals; proportion of total identified cases; and the number of people that would be tested using either strategy.

RESULTS

The prevalence of anti-HCV among adults aged 20-70 years was estimated at 2.0% (95% CI=1.8%, 2.3%), representing about 3.6 million people. The birth cohort strategy would result in testing about 85.4 million people and identifying nearly 2.8 million anti-HCV+ people with a sensitivity of 76.6%. The ALT strategy would test about 21.5 million adults and identify approximately 1.8 million anti-HCV+ people with a sensitivity of 50.0%. Implementing both strategies concurrently would identify 87.3% of anti-HCV+ adults.

CONCLUSIONS

The birth cohort strategy, which is recommended by both the CDC and the U.S. Preventive Services Task Force, would identify 1 million more anti-HCV+ people than the elevated ALT approach. Concurrent implementation would identify an even larger number of individuals ever infected.

Role of IL28B for chronic hepatitis C treatment toward personalized medicine

Genome-wide association studies recently revealed that certain interleukin-28B (IL28B) polymorphisms are strongly associated with responses to pegylated interferon (PEG-IFN) and ribavirin (RBV) therapy in patients chronically infected with hepatitis C virus (HCV) genotype 1, as well as with spontaneous clearance of HCV. Subsequent reports revealed that IL28B genotypes also affect treatment efficacy in chronic infection with other HCV genotypes. Furthermore, there have been several reports that implicate IL28B genotypes in inflammatory status, progression of fibrosis and adverse clinical outcomes in chronic hepatitis C (CHC). Therapy of CHC recently entered a new era with the deployment of direct-acting antivirals. These include nonstructural 3/4A protease inhibitors which have shown promise in combination with PEG-IFN/RBV in several clinical trials. IFN-free therapy is expected to be useful especially in IFN-resistant patients and may become the standard of care in the future. Several clinical trials have revealed an association between IL28B genotype and treatment efficacy in triple therapy or IFN-free regimens. On the other hand the mechanism of the effect of IL28B on HCV infection has not yet been elucidated. Recently, it was shown that the polymorphism of IFN-lambda 4 (IFNL4) is in high linkage disequilibrium with that of near IL28B, and more strongly associated with spontaneous or treatment-induced HCV clearance than IL28B genotypes, especially in individuals of African ancestry. This finding provides new insights into the genetic regulation of HCV clearance and its clinical management. IL28B genotyping will be also useful for personalized CHC treatment in the forthcoming era of direct-acting antivirals.

Hepatitis C virus infection: the new global epidemic

Hepatitis C virus infects an estimated 170 million people worldwide. It is a major cause of liver cirrhosis, end-stage liver disease and hepatocellular carcinoma. It is also a leading cause of liver transplant in the USA. The virus is primarily transmitted parenterally, but there is significant mother-to-child transmission. Partly due to the virus's genetic diversity, it evades the host immune response and it has been difficult to identify candidate vaccines. However, significant advances have been made in the treatment of chronic hepatitis C virus infection. Currently, the combination of pegylated interferon-alpha and ribavirin is the standard treatment for chronic hepatitis C virus infection, and leads to long-term eradication of the virus in approximately 54% of people. Treatment response is dependent on the infecting genotype, with 76 to 80% of those with genotypes 2 and 3, but only approximately 40% with genotype 1 or 4 achieving a sustained virologic response. Since treatment is expensive and associated with significant adverse effects, more effective strategies for the prevention of transmission are needed, especially in resource-limited countries, where the burden of disease is the highest.

Hepatitis C virus infection in HIV-infected patients

The hepatitis C virus (HCV) is a spherical enveloped RNA virus of the Flaviviridae family, classified within the Hepacivirus genus. Since its discovery in 1989, HCV has been recognized as a major cause of chronic hepatitis and hepatic fibrosis that progresses in some patients to cirrhosis and hepatocellular carcinoma. In the United States, approximately 4 million people have been infected with HCV, and 10,000 HCVrelated deaths occur each year. Due to shared routes of transmission, HCV and HIV co-infection are common, affecting approximately one third of all HIV-infected persons in the United States. In addition, HIV co-infection is associated with higher HCV RNA viral load and a more rapid progression of HCV-related liver disease, leading to an increased risk of cirrhosis. HCV infection may also impact the course and management of HIV disease, particularly by increasing the risk of antiretroviral drug-induced hepatotoxicity. Thus, chronic HCV infection acts as an opportunistic disease in HIV-infected persons because the incidence of infection is increased and the natural history of HCV infection is accelerated in co-infected persons. Strategies to prevent primary HCV infection and to modify the progression of HCV-related liver disease are urgently needed among HIV/HCV co-infected individuals.

HCV transmission in industrialized countries and resource-constrained areas

HCV is a blood-borne virus transmitted by percutaneous exposure to infected blood or blood-derived body fluids. The main routes of transmission are blood transfusions, medical procedures and injection drug use. In industrialized countries, HCV transmission through blood transfusions has been virtually eliminated and iatrogenic transmission occurs only sporadically during local breaches of infection control procedures. As most new cases originate from injection drug use, harm-reduction programmes (including opiate substitution, needle exchange and health education) can greatly reduce HCV transmission. Currently, the main approach to reduce the HCV disease burden is by increasing awareness of both the public and health-care providers to hepatitis C, enhancing screening opportunities and treatment of the infected population. In resource-limited countries, the priority is reducing transmission through blood transfusions and invasive medical procedures. This approach requires training of health-care providers and also structural changes and financial investments in countries where antibody screening, disposable materials and effective sterilization procedures are not routinely available. In these countries, reducing the HCV burden has been hampered by limited access to treatment, largely owing to the cost of drugs. Access to treatment is moving up on the agenda of international and non-governmental organizations in conjunction with the future availability of highly efficacious oral drug regimens.

Alanine aminotransferase-old biomarker and new concept: a review

Measurement of serum alanine aminotransferase (ALT) is a common, readily available, and inexpensive laboratory assay in clinical practice. ALT activity is not only measured to detect liver disease, but also to monitor overall health. ALT activity is influenced by various factors, including viral hepatitis, alcohol consumption, and medication. Recently, the impact of metabolic abnormalities on ALT variation has raised concern due to the worldwide obesity epidemic. The normal ranges for ALT have been updated and validated considering the metabolic covariates in the various ethnic districts. The interaction between metabolic and demographic factors on ALT variation has also been discussed in previous studies. In addition, an extremely low ALT value might reflect the process of aging, and frailty in older adults has been raised as another clinically significant feature of this enzyme, to be followed with additional epidemiologic investigation. Timely updated, comprehensive, and systematic introduction of ALT activity is necessary to aid clinicians make better use of this enzyme.