Hepatitis C virus screening of high-risk patients in a community hospital emergency department: Retrospective review of patient characteristics and future implications

Background

Chronic hepatitis C virus infection (HCV) is a common infectious disease that affects more than 2.7 million people in the US. Because the emergency department (ED) can present an ideal opportunity to screen patients who may not otherwise get routine screening, we implemented a risk-based screening program for ED patients and established a system to facilitate linkage to care.

Methods and findings

A risk-based screening algorithm for HCV was programmed to trigger an alert in Epic electronic medical record system. Patients identified between August 2018 and April 2020 in the ED were tested for HCV antibody reflex to HCV RNA. Patients with a positive screening test were contacted for the confirmatory test result and to establish medical care for HCV treatment. Patient characteristics including age, sex, self-awareness of HCV infection, history of previous HCV treatment, history of opioids use, history of tobacco use, and types of insurance were obtained.

A total of 4,525 patients underwent a screening test, of whom 131 patients (2.90%) were HCV antibody positive and 43 patients (0.95%) were HCV RNA positive, indicating that only 33% of patients with positive screening test had chronic HCV infection. The rate of chronic infection was higher in males as compared to females (1.34% vs 0.60%, p = 0.01). Patients with history of opioid use or history of tobacco use were found to have a lower rate of spontaneous clearance than patients without each history (opioids: 48.6% vs 72.0%, p = 0.02; tobacco: 56.6% vs 80.5%, p = 0.01). Among 43 patients who were diagnosed with chronic hepatitis C, 26 were linked to a clinical setting that can address chronic HCV infection, with linkage to care rate of 60.5%. The most common barrier to this was inability to contact patients after discharge from the ED.

Conclusions

A streamlined EMR system for HCV screening and subsequent linkage to care from the ED can be successfully implemented. A retrospective review suggests that male sex is related to chronic HCV infection, and history of opioid use or history of tobacco use is related to lower HCV spontaneous clearance.

Hepatitis C Core-Antigen Testing from Dried Blood Spots

In order to expand hepatitis C virus (HCV) screening, a change in the diagnostic paradigm is warranted to improve accessibility and decrease costs, such as utilizing dried blood spot (DBS) collection. In our study, blood from 68 patients with chronic HCV infection was spotted onto DBS cards and stored at the following temperatures for one week: −80 °C, 4 °C, 21 °C, 37 °C, and alternating 37 °C and 4 °C; to assess whether temperature change during transportation would affect sensitivity. Sample was eluted from the DBS cards and tested for HCV antibodies (HCV-Ab) and HCV core antigen (core-Ag). HCV-Abs were detected from 68/68 DBS samples at −80 °C, 4 °C, 21 °C, and 67/68 at 37 °C and alternating 37 °C and 4 °C. Sensitivity of core-Ag was as follows: 94% (−80 °C), 94% (4 °C), 91% (21 °C), 93% (37 °C), and 93% (37 °C/4 °C). Not only did temperature not greatly affect sensitivity, but sensitivities are higher than previously reported, and support the use of this assay as an alternative to HCV RNA. We then completed a head-to-head comparison (n = 49) of venous versus capillary samples, and one versus two DBS. No difference in core-Ag sensitivity was observed by sample type, but there was an improvement when using two spots. We conclude that HCV-Abs and core-Ag testing from DBS cards has high diagnostic accuracy and could be considered as an alternative to HCV RNA in certain settings.

Identification of two novel anti-HCV E2 412-423 epitope antibodies by screening a Chinese-specific phage library

The hepatitis C virus (HCV) E2 412-423 linear epitope has been found to be highly conserved across multiple HCV genotypes. The antibodies against this epitope have broadly neutralizing activity. Considering the poor immunogenicity of the epitope in humans and significant diversity in the global distribution of HCV genotypes, the aim of this study was to construct an anti-HCV phage library by using a series of optimal strategies to screen novel broadly neutralizing antibodies from Chinese donors. mRNA was isolated from peripheral blood samples of 39 patients who were anti-HCV positive. A phage library was constructed by inserting a single-chain variable fragment (scFv) gene repertoire into the T7Select10-3b vector. A synthetic peptide representing the HCV E2 N-terminal 412-423 region was used as "bait" for bio-panning. The binding affinities of phage clones to the synthetic peptide were evaluated through peptide-ELISA. Two scFv clones (R3-19 and R4-85) showing the strongest binding affinities were selected. The complementarity-determining regions (CDRs) of these clones were aligned with those of other previously reported broadly neutralizing anti-HCV antibodies, and multiple conserved amino acid sites were found. The optimized procedures ensured that two novel scFv antibodies were isolated from a constructed phage library and showed specific binding to the poorly immunogenic HCV E2 412-423 linear epitope. Keywords: phage antibody library; hepatitis C virus; broadly neutralizing antibody; synthetic peptide.

Streamlining the screening cascade for active Hepatitis C in Russia: A cost-effectiveness analysis

OBJECTIVE

Screening for hepatitis C in Russia is a complex process that involves several visits and stepwise testing, limiting adherence and substantially reducing the yield in the identification of active infections. We aimed to evaluate the cost-effectiveness of different screening algorithms from a health system perspective.

METHODS

A decision analytic model was applied to a hypothetical adult population eligible to participate in a general screening program for hepatitis C in Russia. The standard pathway (I: Screen for anti-HCV antibodies followed by a nucleic acid test for HCV RNA on antibody positives) was compared to three alternatives (II: Screen for antibodies, a reflexed test for HCV antigen on antibody positives, and RNA on antigen negatives; III: Screen for antibodies, a reflexed test for HCV antigen on antibody positives; IV: Screen for antigen). Each strategy considered a cascade of events (referral, adherence, testing, diagnosis) that must occur for screening to be effective. The primary measure of effectiveness was the number of diagnosed active infections. Calculations followed a health system perspective with costs derived from 2017 reimbursement rates and a willingness-to-pay of 2,000RUB ($82) per diagnosed active infection. Model was tested with deterministic and probabilistic sensitivity analyses.

RESULTS

Non-adherence to screening stages reduced the capture rate of active infections in Strategy I from 79.0% to 40.6%. Strategies II, III, and IV were less affected and identified 69%, 67%, and 104% more infections. Average costs per diagnosed infection were decreased by 41% from 89,599RUB ($3,681) for I to 53,072RUB ($2,180), 53,004RUB ($2,177), and 59,633RUB ($2,450) for II, III, and IV, respectively. With a probability of 97%, Strategy III was most cost-effective with an incremental cost-effectiveness ratio vs. I of -1,373RUB (CI: -5,011RUB to -2,033RUB; $-56; CI: -$206 to -$84). Below a willingness-to-pay of 91,000RUB ($3,738), Strategy IV was not cost-effective. Sensitivity analyses confirmed the robustness of results.

CONCLUSIONS

Testing strategies for hepatitis C with HCV antigen on HCV antibody positive cases offer a streamlining opportunity for population screening programs. Those shall increase the chances for detecting active infections and are cost-effective over current practice in Russia.

The impact of hepatitis C viremia status on lung functions in chronic hepatitis c patients

Background

Previous trials have investigated the effect of hepatitis C on lung functions; however, the role of viral load levels is unclear. The aim of this study was to investigate the effect of HCV viremia status on lung functions.

Methods

This study was in 60 patients with chronic hepatitis C (CHC). Patients were classified into three groups (non-viremic, low-viremic and high-viremic) based on serum HCV RNA levels. Spirometric parameters (FEV1, FVC, FEV1/FVC) and the proportion of patients with spirometric abnormalities were compared between three groups.

Results

High-viremic and low-viremic patients showed a significantly higher prevalance of spirometric abnormality than observed in non-viremic patients (p=0.02). Moreover, there was a significant moderate correlation between viremia level and the percentage of spirometric abnormalities (Cramer's U value=0.452, p=0.002). High-viremic patients were 14.2 times more likely to exhibiting pulmonary dysfunction than non-viremic patients. Additionally, spirometric parameters FEV1 and FVC were significantly reduced in high-viremic and low-viremic patients compared to those in non-viremic patients (p=0.013 and p<0.001 respectively).

Conclusion

These results indicate that persistent HCV infection may be associated with reduced pulmonary functions, especially in patients with high viremia levels. Therefore, these patients should be carefully monitored for lung function.

Hepatitis C screening in the Emergency Department of a large hospital in southern Italy: results of a pilot study

Around 71 million people worldwide are chronically infected with hepatitis C. HCV prevalence among individuals born in the United States between 1945 and 1965 is estimated to be about 3%. In Italy, about 2% of the population is chronically infected with HCV. Since chronic HCV infection is often asymptomatic, many patients require access to medical care only in an advanced phase of the disease. The best strategy for bringing out hidden chronic HCV infection remains uncertain. The aim of the study was to evaluate the feasibility of an FDA-approved rapid salivary, point-of-care (POC) assay for anti-HCV, performed in patients aged between 45 and 80 years old who were referred to the emergency department of a large hospital in southern Italy and were all unaware of their HCV serostatus. In all, 966 patients were interviewed during the study period. Among them, 220 patients were enrolled. Notably, 25/588 (4%) reported to be anti-HCV positive. Of these, 19 were already being treated with direct-acting antivirals (DAA). Among the enrolled patients, two (0.9%) tested anti-HCV positive and 218 (99.1%) were negative at screening. Both patients with a positive test were male, below the age of 54, with a previous history of intravenous drug abuse, a low level of education, and who had had at least one experience of unprotected sex. We scheduled a visit for treatment evaluation for every positive patient who was not on treatment. Neither of the two de novo patients and 3/6 (50%) patients who were aware of their anti-HCV positivity came to the follow-up visit. Our study shows that a screening strategy for HCV infection in ED is feasible and that about 1% of patients attending the ED and who are unaware of their conditions are anti-HCV positive. Moreover, a non-negligible proportion of subjects, though aware of their condition, was not linked to any hepatologic center.

Evaluation of five rapid diagnostic tests for detection of antibodies to hepatitis C virus (HCV): A step towards scale-up of HCV screening efforts in India

Objectives

Hepatitis C virus (HCV) infection is a major contributor to morbidity and mortality worldwide. Early detection and curative treatment of HCV can reduce the risk of liver-related mortality and serve to prevent transmission of new infections. India is estimated to have about six million HCV infected individuals, most of whom are unaware of their infection status. Rapid diagnostic test kits (RDTs) could help identify HCV infected persons more expeditiously and thus availability of high performing, quality-assured RDTs is essential to scale-up HCV screening efforts. The present study was thus undertaken to evaluate the performance characteristics of five anti-HCV RDTs.

Methods

Five anti-HCV RDTs (Alere Truline, Flaviscreen, Advanced Quality, SD Bioline and OraQuick) were evaluated using two panels of known anti-HCV positive and negative samples; one characterized from Indian patient samples (n = 360) and other obtained from the US Centers for Disease Control and Prevention (CDC), Atlanta (n = 100). Sensitivity, specificity, inter-observer agreement, test validity and operational characteristics of RDTs were assessed.

Results

The combined sensitivities across both panels for Alere Truline, Flaviscreen, Advanced Quality, SD Bioline and OraQuick RDTs were 99.4% (95%CI-96.6%-99.9%), 86.2% (95%CI-79.8%-91.1%), 96.2% (95%CI-91.9%-98.6%), 99.4% (95%CI-96.6%-99.9%) and 99.4% (95%CI-96.6%-99.9%) respectively. The overall specificities across both panels for all RDTs were 99.7%. The inter-observer agreement was 100% for Alere Truline, SD Bioline and OraQuick, while it was 99.5% and 98.6% with Advanced Quality and Flavicheck respectively. Discordant results were significantly associated with human immunodeficiency virus (HIV) positivity for both Advanced Quality and Flavicheck (p<0.001).

Conclusion

The present evaluation demonstrated that Alere Truline, SD Bioline and OraQuick RDTs had sensitivity and specificity in accordance with the acceptance criteria of the Drug Controller General, India, the national regulatory authority, had excellent inter-observer agreement and superior operational characteristics. Our findings suggest that certain HCV RDTs perform well and can be a useful tool in screening of HCV infections expeditiously.

Novel and Simple Approach to Estimating the Actual Incidence of Blood and Body Fluid Exposure

BACKGROUND

There is no current way to determine the actual blood and body fluid exposure (BBFE) incidence in hospitals. We propose a simple, reliable, and widely available method for the accurate estimation of BBFE.

METHODS

Data for BBFE for healthcare workers between 2006 and 2015 at Osaka University Hospital were retrospectively extracted from the electronic records. Annual positivity of hepatitis C virus (HCV) antibody in the source individuals and overall patient population were calculated over time. We created an estimation formula focusing on the difference in HCV positivity between the source individuals and overall patient population for the actual number of BBFEs. A linear regression model was used to evaluate the temporal change in the reported and estimated BBFEs.

RESULTS

During the study period, 937 BBFEs were reported. HCV positivity between the post-BBFE cohort and overall patient population greatly differed; the incidence ratio ranged from 2.1 to 5.7. The linear regression model revealed that the reported BBFEs did not significantly change during the study period (the slope, 1.315 [95% confidence interval (C.I.): -0.849 to 3.480, p = 0.199]). The annual incidence ratio of the estimated and reported BBFEs significantly reduced over time (the slope, -0.287 [95% C.I.: -0.488 to -0.086, p = 0.011]), indicating that, although the reported number of BBFEs seemed unchanged, the estimated incidence decreased.

CONCLUSIONS

We propose a novel and simple approach to estimating the actual incidence of BBFEs in hospitals using the difference in HCV positivity between the post-BBFE cohort and overall patient population.

Hepatitis C: an Overview of Various Laboratory Assays with their Mode of Diagnostic Cooperation

BACKGROUND

This review describes in chronological order the different assays for hepatitis C virus (HCV) antibodies, for the core antigen and for the HCV-RNA.

METHODS

By ascending chronological order, the enzyme-linked immunosorbent assay (ELISA), rapid diagnostic tests (RDTs), HCV-Ab IgG avidity index (HCV AI), and Cy3-labeled microarray assay have been described for HCV antibodies in addition to ELISA for the total HCV core antigen (Ag).

RESULTS

The recombinant immunoblot assay (RIBA) is a confirmatory test for HCV-Ab in blood, which is no longer needed due to the use of the sensitive third and fourth generation ELISA in addition to HCV-RNA detection by the Reverse Transcriptase-Polymerase Chain Reaction (RT-PCR). ELISA and RIBA measure current and prior exposure to HCV infection, but cannot discriminate between the two. RT-PCR is performed after ELISA for the diagnosis of HCV infection whether acute, chronic, false positive or false negative ELISA.

CONCLUSIONS

The cooperation between ELISA and RT-PCR in the diagnosis of HCV infection has been tabulated and discussed. HCV genotyping and subtyping testing is essential in pre-treatment evaluation of the patients for setting valuable treatment strategies and in understanding the epidemiology of the virus.

Correlation between hepatitis C viral load and hepatitis C Core antigenaemia among Egyptians

Hepatitis C virus (HCV) infection is widespread in Egypt. This study compared HCV RNA with HCVcAg for the detection and quantification of viraemia among a sample of Egyptians. Sera from 80 suspected HCVpositive individuals were tested simultaneously for HCV-RNA load using real-time polymerase chain reaction (PCR) and HCVcAg level using ELISA. Of the 80 samples, 25% were HCV-RNA-negative. HCVcAg was detected in all samples: range 0.4-2462 ng/mL, mean 460 (SD 506) ng/mL. The sensitivity and specificity of HCVcAg were 96.7% and 90.9%, respectively. There was a significant correlation between serum HCV-RNA and HCVcAg levels (r = 0.4, P < 0.0001). HCV-RNA remains the gold standard for diagnosis of active HCV infection but HCVcAg can be used where PCR is not available.

Long-term follow-up of patients with spontaneous clearance of hepatitis C: does viral clearance mean cure?

Up to 40% of patients with hepatitis C virus (HCV) antibodies are negative for HCV RNA at initial evaluation. If there is a risk of viral re-activation, long term follow-up is required with attendant financial, psychological and medical implications. We investigated the risk of re-activation in the Irish anti-D cohort. Information was obtained from the national hepatitis C database which includes data on patients infected by anti-D immunoglobulin in two large outbreaks, 1977-9 and 1991-94. As part of a screening programme, starting in 1994, 64,907 females exposed to anti-D immunoglobulin were evaluated. Three hundred and forty-seven were found to be antibody positive but HCV RNA negative at initial assessment. 93% had subsequent RNA tests. There was no evidence of HCV recurrence in patients whose infection resolved spontaneously. It appears that two initial sequential negative results for HCV RNA are sufficient to confirm spontaneous viral clearance and probable cure of hepatitis C virus infection.

Hepatitis C Antibody Testing in a Commercially Insured Population, 2005-2014

INTRODUCTION

In the U.S., the burden of hepatitis C virus (HCV) infection and associated sequelae is substantial. HCV prevalence is highest among those born in 1945-1965 (Birth Cohort). Newly diagnosed infections are increasing in younger people concurrent with rising opioid/heroin use. The Centers for Disease Control and Prevention (2012) and U.S. Preventive Services Task Force (2013) recommend HCV testing for at-risk individuals and one-time testing for the Birth Cohort. This study describes national trends in HCV antibody testing from 2005 to 2014.

METHODS

Using commercial and Medicare supplemental insurance claims data, people were identified who were continuously enrolled for ≥2 years during the 10-year study period, without prior HCV diagnosis (N=190,926,299). Current Procedural Terminology codes identified 3,382,267 unique antibody tests. Temporal trends in annual testing were evaluated using the Cochran-Armitage test, and primary ICD-9-CM diagnosis codes used at the time of testing were described. Data were analyzed in 2015 and 2016.

RESULTS

Testing was highest among those aged 18-29 and 30-39 years, increasing by 123% (1.66% to 3.71%) and 108% (1.99% to 4.13%), respectively (p<0.0001). Among the Birth Cohort, there was a 136% increase in HCV antibody testing from 2005 to 2014, with a 91% increase from 1.71% in 2011 to 3.26% 2014 (p<0.0001).

CONCLUSIONS

Although the increased HCV antibody testing observed among the Birth Cohort from 2011 to 2014 likely reflects early adoption of updated national testing recommendations, overall testing remains low in this commercially insured population, indicating a clear need for improvement.

A practical overview of the treatment of chronic hepatitis C virus infection

BACKGROUND

Although hepatitis C virus (HCV) infection is associated with significant morbidity and mortality, OBJECTIVE: This article provides an overview for GPs on the principles involved in assessing and treating patients with chronic hepatitis C within a community setting.

DISCUSSION

Treatment with DAA medications listed on the PBS should be considered for all patients with chronic HCV infection. These regimens are well tolerated, highly efficacious and have all-oral administration. A thorough pre-treatment evaluation should be undertaken, and patients with cirrhosis, significant comorbidities or potential drug-drug interactions should be referred to a specialist. Successful eradication of HCV is characterised by undetectable HCV ribonucleic acid viral load on polymerase chain reaction testing 12 weeks after treatment completion, although antibodies to HCV may remain positive for the rest of the patient's life.

Impairment of Recent Thymic Emigrants in HCV Infection

Hepatitis C Virus (HCV) often has a more favorable course in younger patients. Considering the involution of the thymic function with age, we investigated the output of recent thymic emigrants (RTE) in HCV patients. To evaluate RTE, we used a competitive quantitative PCR in order to determine the percentages of cells with cj-T cell receptor excision circles (TREC). This study was performed in 14 HCV patients at diagnosis and before any anti-HCV treatment. The results obtained in this group were compared to those obtained in a group of age-matched controls. We found that in the 14 HCV patients naive for anti-HCV treatment the mean percentage of cj-TREC was 3%. We could not detect a correlation between the percentages of cj-TREC and age or patients' viremia. In contrast, in the 26 age-matched controls mean percentage of cj-TREC was 5.6% (P=0.01). Our study describes a novel immune defect in HCV patients. Additional studies are needed to get further insight in the possible role of TREC defect in the pathogenesis and prognosis of the disease.

Comparison of Angiographic Burden of Coronary Artery Disease in Patients With Versus Without Hepatitis C Infection

Hepatitis C virus (HCV) infection is thought to be associated with an increased risk of coronary heart disease (CHD) events, perhaps secondary to increased inflammation. We sought to examine the angiographic burden of coronary artery disease (CAD) in patients with HCV compared to HCV-negative patients. All consecutive HCV RNA-positive patients (n = 61) who underwent coronary angiography at the University of Arkansas for Medical Sciences from 2001 to 2013 were identified. A parallel group of HCV-negative controls (n = 61), matched for age, gender, and indication for coronary angiography served as control. Angiographic burden of CAD was assessed by computing Gensini scores. Statistical analysis was performed using SPSS 21.0. Patients with HCV had significantly lower levels of total and low-density lipoprotein cholesterol. Preangiographic use of aspirin and statin was significantly lower in the HCV cohort. Number of patients with obstructive CAD was less in HCV group (23% vs 39%, p <0.05). However, angiographic Gensini score was similar in both groups. There was no correlation between HCV RNA titers and Gensini score (p = 0.9, analysis of variance). In conclusion, patients with active HCV infection have similar angiographic CAD burden as HCV-negative patients. Furthermore, viral load does not appear to correlate with atherosclerosis burden. Patients with HCV have less-obstructive CAD and less-frequent use of aspirin and statins.

THE PERFORMANCE OF A RAPID TEST FOR ANTI-HCV SCREENING IN ORAL FLUIDS

Gingival crevicular fluid (GCF) and saliva samples provide advantages for screening or sero-prevalence studies on HCV using less invasive methods. The study aimed to evaluate the performance of a rapid test for HCV-antibodies (HCV-Ab) screening in oral fluids among high-risk individuals with chronic liver disease.

METHODS

Chronic liver disease patients attending at the Matei Bals National Instiute for Infectious Diseases were recruited for this study. Plasma, GCF and saliva samples (pair samples) were collected from each patient included in the study. Forty-three sample pairs were tested with Laboquick (Koroglu Medical Devices) rapid test and ELISA (DIA.PRO--Diagnostic Bio-probes) for the detection of anti-HCV antibodies.

RESULTS

Using rapid test, anti-HCV antibodies were detected in 36 GCFs (83.72%) and 24 saliva cases (55.8%) of infected subjects. For a better estimation of oral fluids positivity, the cut-off values were calculated following plotting the ROC curves (COV2). Comparing Laboquick and ELISA (COV2) data, matched results were noted in 95.3 % saliva samples and 93% GCF samples.

CONCLUSIONS

Oral fluids could be an alternative to blood for detection of HCV-positive subjects. Anti-HCV rapid test may be useful in routine dental medicine.

Hepatitis C polymerase chain reaction testing by GPs

BACKGROUND

Approximately 75% of patients exposed to the hepatitis C virus will become chronically infected. Polymerase chain reaction (PCR) testing more than 6 months after exposure is necessary to identify this group. This pilot study assessed the practical ap-plication of PCR testing in the general practice context.

METHODS

General practitioners of patients newly notified as positive for hepatitis C antibody between 1 August 2007 and 1 August 2012 were invited to participate. They completed a self-administered survey, recording details on the use of hepatitis C PCR testing in their patients.

RESULTS

The survey found that 16 patients (46%) did not undergo any PCR testing for hepatitis C. Of those who underwent PCR testing, 11 (58%) were positive on PCR testing but only six (55%) of those with a positive PCR test were retested 6 months later.

DISCUSSION

Appropriate use of PCR is necessary to identify patients with chronic hepatitis C and offer appropriate referral and treatment.

Epidemiology of hepatitis C viral infection in Faisalabad, Pakistan: a retrospective study (2010-2012)

BACKGROUND

Hepatitis viral infections are major health challenge leading to high morbidity and mortality worldwide.

OBJECTIVES

Although the magnitude of hepatitis in Pakistan has been well documented, information regarding the prevalence of hepatitis C virus (HCV) infection in Faisalabad, Pakistan is scarce. The present retrospective study was undertaken to determine the epidemiology of HCV in Faisalabad, Pakistan.

METHODS

Between May, 2010 and December, 2012, medical records of 39780 subjects visiting sexually transmitted infections (STIs) clinic, district headquarter (DHQ) hospital, Faisalabad, Pakistan were reviewed. Regression analysis was used to determine independent risk factors.

RESULTS

HCV prevalence was 21.99%. With mean age of 49.5 ± 2.7 years (range 27-63 years), majority (67.15%) of the individuals were male. Marital status and low literacy rates were associated with HCV (P<0.05). Reference to the potential risk factors, the injection drug use was the major mode (72.77%) of infection transmission. Age (OR 1.5, 95% CI 1.2-1.9), male gender (OR 1.2, 95% CI 0.9-1.6) and injection use (OR 1.9, 95% CI 1.0-2.7) were significantly associated with HCV.

CONCLUSIONS

Most important finding was higher HCV prevalence in Faisalabad region as compared to the previous assessments that demands an urgent need for preventive intervention strategies.

Hepatitis B, C virus co-infection and behavioral risks in HIV-positive patients in southern Iran

OBJECTIVE

To determine the risk factors and frequency of hepatitis B and C virus co-infections in human immunodeficiency virus-positive patients.

METHODS

The cross-sectional study was conducted at the Control of Diseases Centre of Kerman Medical University, southern Iran, between May and December 2011. Demographic features and history of high-risk behaviours were evaluated in 165 patients positive for human immunodeficiency virus. Third-generation hepatitis C virus antibody and hepatitis B surface antigen tests were performed by enzyme-linked immunosorbent assay method. SPSS 18 was used for statistical analysis.

RESULTS

Out of the 165 patients, 136 (82.4%) were male and 29 (17.6%) were female. The mean age of the subjects was 40.4 +/- 9 years. Positive hepatitis C antibody was found in 122 (73.9%) and positive hepatitis B surface antigen was present in 6 (3.6%). Frequency of all three viruses co-infection was 3 (1.8%). History of imprisonment (OR = 17.5; 95% CI: 7.1-43.1) and drug injection addiction (OR = 15.3; 95% CI: 6.4-36.1) were the most significant risk factors involved in hepatitis C virus co-infection.

CONCLUSION

Seroprevalence of hepatitis C virus and human immunodeficiency virus co-infection was high and it was strongly related to history of imprisonment and drug injection addiction.

[Recent developments in serologic and molecular diagnosis of hepatitis B and C]

The 2013 Update of the Croatian Guidelines for the Diagnosis and Treatment of Viral Hepatitis summarizes recent developments in the diagnosis of hepatitis B and C. Determination of HBsAg, anti-HBc and anti-HBs is the initial step in the diagnostic workup of acute and chronic hepatitis B. Other hepatitis B serologic markers should be analyzed in the second stage of the diagnostic workup in HBsAg and/or anti-HBc positive patients. A positive anti-HBc finding should be followed by HBV DNA quantification. HBsAg quantification is complimentary to the HBV DNA quantification and is used: (i) to differentiate between inactive HBsAg carriers and active chronic HBeAg-negative hepatitis B in patients with HBV DNA < 2000 IU/mL; and (ii) for treatment monitoring in patients with chronic hepatitis B receiving pegylated interferon-alpha. Real-time PCR remains the method of choice for detection and quantification of HBV DNA. The first step in HCV testing is determination of specific antibodies via screening assays, enzyme immunoassays or point-of-care assays. All persons with positive results of anti-HCV screening assays should be additionally tested for HCV RNA or presence of HCV viral capsid antigen. Confirmatory anti-HCV assays should be used as additional assays for confirmation of reactive results obtained by screening enzyme immunoassays in HCV RNA-negative persons only. Molecular assays with identical lower limit of detection (LLOD) and lower limit of quantification are recommended for monitoring of viral kinetics during chronic hepatitis C triple therapy. HCV resistance testing to protease inhibitors is not part of the recommended diagnostic monitoring of patients receiving triple therapy. HCV subtyping is currently not recommended as part of pretreatment diagnostic algorithm due to currently insufficient evidence on its clinical usefulness. IL-28 genotype is an important predictor of SVR in patients treated with a combination of interferon-alpha and ribavirin as well as in patients with HCV genotype 1 receiving triple therapy. IL-28B genotyping is recommended as part of pretreatment diagnostic workup in patients with chronic hepatitis C and is a particularly important parameter for recommending double versus triple therapy in treatment-naïve patients with chronic hepatitis C.

Human type 2 myeloid dendritic cells produce interferon-λ and amplify interferon-α in response to hepatitis C virus infection

BACKGROUND & AIMS

The type III interferons (IFN-λs: interleukin [IL]-28a, IL-28b, and IL-29) have important roles in hepatitis C virus (HCV) infection, but little is understood about what cells produce these cytokines or how production is activated. We investigated whether human immune cells recognize HCV-infected cells and respond by producing IFN-λ.

METHODS

We cultured healthy human peripheral blood mononuclear cells (PBMCs) with different populations of immune cells and Japanese fulminant hepatitis-1 (JFH-1) HCV-infected Huh7.5 (cell culture-derived HCV particles [HCVcc]/Huh7.5) cells.

RESULTS

Human PBMCs recognized HCVcc/Huh7.5 cells and responded by producing IFN-α, IFN-γ, and IFN-λ. A rare subset of myeloid dendritic cells (mDCs), which are blood DC antigen (BDCA)+ (also called mDC2 cells), were the major source of IL-28 and IL-29 production in response to HCVcc/Huh7.5 cells. Plasmacytoid DCs produced IFN-α, whereas natural killer and natural killer T cells were the main source of IFN-γ production in co-culture experiments. Of the endosomal Toll-like receptors (TLRs)3, 7, 8, and 9, only TLR3 or double-stranded HCV RNA induced production of IL-28 and IL-29 by mDC2s; endosomal maturation was required. Production of IFN-α and IFN-λ were linked-IFN-λ increased production of IFN-α by plasmacytoid DCs and IFN-α significantly increased production of IFN-λ.

CONCLUSIONS

mDC2s are a major source of IFN-λ production by PBMCs in response to HCVcc/Huh7.5 cells. mDC2s are activated through the TLR3 pathway, indicating that human DCs efficiently can initiate an immune response against HCV infection. IFN-λ therefore has an important role in HCV infection.

Association between chronic hepatitis C virus infection and high levels of circulating N-terminal pro-brain natriuretic peptide

The association between HCV infection and myocardial disorders remains unclear. This study aimed to assess whether or not HCV infection influences myocardial dysfunction by the use of NT-proBNP, a sensitive marker of myocardial dysfunction. A total of 198 participants [99 patients with chronic HCV infection (aged 46-68 years) and 99 anti-HCV-negative sex and age matched controls] were examined. Serum HCV-RNA level and HCV genotype were tested and liver biopsy was done only for the patient group. The NT-proBNP concentration of the HCV patients (mean 71.6 ± 79.1 pg/ml; median 46.0 pg/ml, range 5.0-400.0) was significantly higher than that of the controls (mean 39.8 ± 24.4 pg/ml; median 35.8 pg/ml, range 7.0-108.0) (P < 0.05). 20.0 % of the HCV patients and 0.6 % of the controls had high NT-proBNP (higher than 125 pg/ml; the single cut off point for patients under 75 years of age) (P < 0.05). Stepwise multiple regression analysis revealed that chronic HCV infection was independently correlated with NT-proBNP level after adjustment for parameters that might influence NT-proBNP (P = 0.005). Our data suggest that chronic HCV infection is associated with increased NT-proBNP, indicating that chronic HCV infection might induce myocardial dysfunction.

Cross-sectional, anonymous screening for asymptomatic HCV infection, immunity to HBV, and occult HBV infection among health care workers in Warsaw, Poland

INTRODUCTION AND OBJECTIVES

Epidemiological data on symptomatic HCV infection in Poland has shown that its prevalence among health care workers (HCWs) may exceed the prevalence notified among general population. Since such epidemiological situation would be similar to the increased prevalence of HBV infection among HCWs before anti-hepatitis B vaccine era, a seroprevalence study on HCV infection and immunity to HBV was performed in the group of volunteering HCWs.

MATERIAL AND METHODS

All the persons employed as HCWs in the two largest clinical hospitals in Warsaw were invited to participate in the study. They voluntarily gave a sample of blood for serological examination and were asked to fill-in a questionnaire containing questions relevant to the possible routes of infection, period of employment, and in part also to their life style. Both were done anonymously and in the unlinked manner. The activity of aminotransferases has also been determined in all the samples.

RESULTS

961 serum samples were collected from HCWs employed in both hospitals. Anti-HCV were detectable in 16 out of 961 sera (1.7%). HCV RNA was detected in 3 out of these 16 (19%) sera; in 2 serum samples genotype 2, in 1--genotype 1b HCV. Anti-HBs were detected in 943 out of 961 (98.1%) sera. Anti-HBc (total) were detectable in 151 out of 961 (15.7%) sera. Out of 151 sera with anti-HBc in 149 (98.7%) samples anti-HBs were also detected. HBV DNA was detected in 6 (4%) samples out of 151 sera containing anti-HBc. While the prevalence of asymptomatic HCV infection among HCWs is similar to that seen in general population in Poland, the 15.7% prevalence of anti-HBc exceeded almost three times the percentage found in another study.

CONCLUSIONS

Since vaccination of health care personnel against HBV is at present obligatory, a large percentage of anti-HBs positive persons indicates for a high rate of immune response to vaccination. However, it seems that the presence of anti-HBs may not always be taken as indicating for immunity to HBV, but in some persons it may mask occult HBV infection. Since a younger population is immune to HBV infection due to universal vaccination of newborns and catch-up vaccination program for teenagers, older generations of HCWs may constitute a risk group for occult HBV infection.

[Dependence of IgG titers specific to various hepatitis C virus proteins on features of chronic infection course]

AIM

Analysis of IgG titers that are specific to various hepatitis C proteins depending on features of chronic infection course.

MATERIALS AND METHODS

Qualitative analysis of levels of IgG specific to a number of hepatitis C virus proteins was performed in 30 patients and 30 virus carriers.

RESULTS

Significant differences between these HCV infection course variants by level of accumulation of all studied HCV antibody groups were detected. Low a-core and a-NS4 IgG, high a-NS3 and medium a-NS5 titers may be an indicator of HCV carriage. Medium and high a-core, medium a-NS3 and a-NS4 as well as higher a-NS5 titers indicate chronic hepatitis C.

CONCLUSION

The proposed method can be used for screening of chronic HCV infection course in the clinical practice.

Acute hepatitis C in Korea: different modes of infection, high rate of spontaneous recovery, and low rate of seroconversion

The epidemiology and clinical outcomes of acute hepatitis C are different geographically. This study aimed to investigate the mode of infection, clinical characteristics, and outcomes of acute hepatitis C in Korea. Forty-seven patients with acute hepatitis C were enrolled consecutively in a study conducted in seven medical centers. The patients with the mean age of 45.8 years had mostly mild symptoms. A healthcare-related procedure was the most common exposure history (42.5%): acupuncture (17%), surgery (10.6%), needle-stick injury (8.5%), and other medical procedures (6.4%). There was no case of intravenous drug use. Twenty-one patients (44.7%) recovered spontaneously. Among the 16 patients who received antiviral therapy (34%), all of the 12 evaluable patients had a sustained virologic response, while 10 patients (21.3%) who did not receive antiviral therapy progressed to chronic infection. The overall seroconversion rate of anti-HCV antibody was 61.7%. The patients who recovered spontaneously had significantly lower rate of seroconversion compared with the patients who did not clear spontaneously the infection. In conclusion, acute hepatitis C in Korea was related to various healthcare procedures, including acupuncture, characterized by high rates of spontaneous recovery and low rates of seroconversion, which may be associated with different modes of infection and ethnic differences. The characteristics of acute hepatitis C in Asian countries warrants further study.

Effect of hepatitis C virus on C-reactive protein and interleukin-6 in hemodialysis patients

INTRODUCTION

Patients with end-stage renal disease are at a high risk of hepatitis C virus (HCV) infections. These patients are on maintenance hemodialysis where they are exposed to dialysis fluid and dialysis membrane that generate an acute-phase response, which leads to inflammation, reflected in increased inflammatory markers like C-reactive protein (CRP) and interleukin-6 (IL-6). The aim of this study was to investigate levels of IL-6 and CRP in patients on hemodialysis and to determine effects of HCV on these markers.

MATERIALS AND METHODS

A total of 43 patients (39.5% men and 60.5% women; age range, 21 to 65 years) on maintenance hemodialysis for a period of at least 3 months were included. Twenty-four of them were HCV positive. Serum IL-6 and CRP were assessed in all patients.

RESULTS

Of HCV-positive patients, 11 (45.8%) had high levels of CRP, while 13 (54.2%) had low levels and increased levels of IL-6 (1064 ± 544.2 pg/mL, P = .19). Of 19 HCV-negative patients, 13 (68.4%) had high levels of CRP, while 6 (31.6%) had low levels, and all these patients had low levels of IL-6, as compared to HCV-positive patients. No significant correlation was observed between the levels of CRP or IL-6 and the duration of dialysis.

CONCLUSIONS

In our study, we found high serum IL-6 and CRP levels in HCV-positive hemodialysis patients, compared with HCV-negative ones. However, we failed to show the significance of these differences. More studies with large sample sizes and evaluation of the other inflammatory markers are warranted.

[Investigation of occult hepatitis B in HIV infected patients]

Due to their shared transmission route, hepatitis B virus (HBV) or hepatitis C virus (HCV) co-infections can be observed in human immunodeficiency virus (HIV)-infected cases and are associated with more severe clinical courses. The detection of HBV DNA despite HBV surface antigen (HBsAg) seronegativity is defined as occult HBV infections. According to the current seroepidemiological data, Turkey is classified as an intermediate HBV, low HIV endemic region. Occult HBV infections have previously been reported from Turkey but has not been investigated previously in HIV infected cohorts. The aim of this study was to identify occult HBV infections in HIV-infected persons. Twenty-eight HIV-positive cases followed-up at Hacettepe University Hospital, Infectious Diseases Unit were included in the study after informed consent. For the detection of HBsAg, anti-HBs and anti-HCV, commercial ELISA tests (Architect System, Abbott Diagnostics, USA) were employed. Absolute CD4+ and CD8+ T-cell counts were determined via flow cytometry. HIV viral load was calculated via COBAS TaqMan HIV-1 Real-time PCR (Roche Diagnostics, USA) and the presence of HBV DNA was evaluated via COBAS TaqMan HBV Real-time PCR (Roche Diagnostics, USA), in addition to a nested PCR assay targeting HBV S gene. The mean age of the study group was 43.2 (range between 27-65) years, 64.3% (18/28) of them were males and the mean duration of HIV infection was 4.2 (2-11) years. Mean CD4+ ve CD8+ T-cell counts were 414 ± 267 cells/mm3 and 854 ± 293 cells/mm3, respectively. Twenty-six (92.8%) cases were under highly-active anti-retroviral therapy at the time of the study, 88.5% of which included HBV-active drugs (lamivudine or tenofovir). HIV RNA were found negative in 11 (39.3%) patients, of those nine (81.8%) were the cases who treated with HBV-active antiretroviral therapy. HBsAg were negative in all of the 28 patients, while the positivity rates of anti-HBs and anti-HCV were 39.3% (11/28) and 3.6% (1/28), respectively. All samples were negative for HBV DNA via the commercial real-time PCR and in-house nested PCR assays. The absence of occult HBV in the study group may indicate the absence of occult HBV or suppression of viral replication due to the anti-retroviral therapy. In conclusion, further large-scale studies are required to fully understand the impact of occult HBV in HIV-infected patients in Turkey.

IL28B CC-genotype association with HLA-DQB1*0301 allele increases the prediction of spontaneous HCV RNA clearance in thalassaemic HCV-infected patients

BACKGROUND

A single nucleotide polymorphism (SNP), upstream of the IL28B gene has been recently associated with natural clearance of HCV. In a well-characterized cohort of patients with thalassaemia major exposed to the risk of acquiring HCV infection by blood transfusions, we aimed to replicate this finding and to evaluate whether combining the IL28B genotype and HLA class II alleles allow viral clearance to be accurately predicted.

METHODS

Of 168 patients, 130 with complete clinical history were included in the analysis. According with their HCV antibodies status 13 were defined HCV resistant, and 117 infected. Infected patients were subdivided, giving 49 with self-limiting and 68 with ongoing infection.

RESULTS

IL28B CC-genotype was observed in 32 patients with self-limiting and in 23 with ongoing infection (64% versus 34%; P=0.004). HLA DQB1*0301 allele was associated with viral clearance in 36 cases (73%; P<0.0001). Both DQB1*0301 and IL28B CC-genotype were found to be independent predictors of HCV clearance (OR=5.64, 95% CI 1.52-20.9 and OR=5.76, 95% CI 2.16-15.33, respectively). With the addition of DQB1*0301, the accuracy of the prediction increased from 63% to 69%.

CONCLUSIONS

In addition to IL28B CC-genotype, HLA DQB1*0301 helps in predicting natural clearance of HCV after acute infection.

HCV screening practices and prevalence in an MCO, 2000-2007

BACKGROUND/OBJECTIVE

The Centers for Disease Control and Prevention recommends routine screening for the hepatitis C virus antibody (anti- HCV) among persons most likely to be infected. Little is known about anti-HCV screening and prevalence in routine practice settings. We studied anti-HCV screening rates, anti-HCV positivity, and demographic and risk factors associated with increased likelihood of anti-HCV screening or positivity in a managed care organization (MCO).

METHODS

This was a retrospective observational study of 17-to-74-year-old MCO enrollees from 2000 to 2007 (N = 557,056; 1,949,499 enrollee years). The primary outcome measures were likelihood of anti-HCV screening and HCV positivity (both in the total population and among those screened). Independent variables were: birth cohort, gender, HCV risk factors, and socioeconomic status (SES) and race of residents' neighborhoods. Likelihood of each outcome as a function of the independent variables was estimated using logistic regression.

RESULTS

Over the 8-year period, 4.31% of the total population received anti-HCV screening; 0.22% had a positive HCV result. Among those screened, HCV positivity was 5.15%. HCV screening and positivity rates increased over time. Both likelihood of HCV screening and HCV positivity were highest (P <0.05) among persons born during 1945-1964, males, those with HCV risk factors, and residents of neighborhoods of lower SES or with higher percentages of African Americans.

CONCLUSIONS

Although HCV screening and detection improved in this MCO over an 8-year period, anti-HCV screening was lower than expected. Many persons at risk for HCV remained unscreened. Strategies for improving anti-HCV screening in routine practice are recommended for patients at increased risk.

Evaluation of a rapid, point-of-care test device for the diagnosis of hepatitis C infection

BACKGROUND

Despite considerable evolution in the quality of laboratory-based testing for detection of HCV, the availability of rapid, point-of-care tests may increase diagnoses by increasing opportunities for testing outside of traditional laboratory settings.

OBJECTIVES

We evaluated the performance of a new, rapid HCV test that can be used with venous blood, finger stick blood, serum, plasma, or oral fluid and compared it to FDA-approved laboratory methods.

STUDY DESIGN

HCV positive subjects as well as subjects at low risk for HCV were tested with the rapid test using all 5 specimen types and results compared to FDA-approved laboratory methods. In addition, performance was assessed in commercially available seroconversion panels.

RESULTS

Sensitivity and specificity of the rapid test was equivalent to laboratory EIA and performance was comparable across all 5 specimen types.

CONCLUSIONS

The OraQuick HCV Rapid Antibody Test appears suitable as an aid in the diagnosis of HCV infection.

Immunohistochemical detection of hepatitis C virus (genotype 4) in B-cell NHL in an Egyptian population: correlation with serum HCV-RNA

BACKGROUND AND AIM

Retrospective evaluation of hepatitis C virus (HCV) prevalence in lymphoma tissues has important applications in clarifying the contribution of viral factors to the pathogenesis. Trials for detection of HCV at the cellular level in lymphoma tissues are, so far, minimal with unsatisfactory results. We aimed to study the detection and localization of HCV in the tissues of B-cell non-Hodgkin lymphoma (NHL) patients.

DESIGN

We performed immunohistochemistry to detect the HCV nonstructural 3 protein in paraffin-embedded tissue specimens of B-cell NHL patients, in 39 serum HCV-RNA positive samples and 35 serum HCV-RNA negative samples as controls. The serum analysis was carried out for HCV antibodies using enzyme-linked immunoassay and for HCV-RNA using reverse transcription-polymerase chain reaction. Reverse transcription-polymerase chain reaction was used to detect the HCV-RNA in tissues in immunohistochemically positive cases. We correlated the results with the clinicopathologic characteristics of the patients.

RESULTS

A diffuse cytoplasmic immunohistochemical staining for HCV in the lymphoid cells was detected in 8 of 39 serum positive cases (20.5%), all of which were genotype 4, which is the most prevalent HCV genotype in Egypt. Only 2 out of 35 serum negative control samples showed positive staining and in 1 of them HCV-RNA was detected in tissue. No significant correlation was detected between HCV positive cases and the clinicopathologic features of the patients.

CONCLUSIONS

Immunohistochemical detection of HCV proteins in lymphoma tissues supports a potential role of viral replication in lymphomagenesis. The low number of cases showing expression of viral proteins may represent a low viral load in lymphoid tissue and/or restriction of HCV protein expression to certain subtypes of B-cell NHL. Immunohistochemistry can be used as a complementary tool for specific HCV detection in the paraffin-embedded material of lymphoma tissues not suitable for RNA analysis.

Coinfection by human immunodeficiency virus, hepatitis B virus and hepatitis C virus in injecting drug users

Detection of hepatitis B surface antigen (HBsAg), anti hepatitis C virus (HCV) antibody and anti human immunodeficiency virus (HIV) antibody was carried out in serum samples from 250 injecting drug users (IDUs) from a deaddiction centre, Shalom, in Churachanpur district, Manipur during the period of August-October, 2002. One hundred and forty-nine (59.6%) IDUs were positive for HIV antibody, 226 (90.4%) were positive for anti HCV antibody and 27 (10.8%) were positive for HBsAg. There was coinfection of HIV, hepatitis B virus (HBV) and HCV in 15 (6%) of the IDUs. The coinfection of HBV and HCV was found in 12 cases (4.8%) and coinfection of HIV and HCV was found in 131 cases (52.4%). HIV and HCV were the highest among the coinfection of IDUs. The IDUs were in sexually active age group with a risk of infection to their sexual partner.

Detection of neutralizing antibodies with HCV pseudoparticles (HCVpp)

Infectious HCV pseudoparticles (HCVpp) can be assembled by display of unmodified and functional HCV glycoproteins on retroviral and lentiviral core particles. HCVpp have been shown to mimic the early infection steps of parental HCV. The presence of a marker gene packaged within these HCV pseudoparticles allows reliable and fast determination of infectivity mediated by the HCV glycoproteins. With this highly flexible system, E1E2 from a broad range of HCV strains can be investigated, including autologous HCV strains from patients' virus, and it has allowed careful investigation of the humoral response to HCV.

Re-treatment of patients with hepatitis C who failed to respond (nonresponders) to previous treatment

The aim of four-year follow up study was evaluation of re-treatment efficacy of antiviral therapy in patients with hepatitis C who failed to respond (non responders) to previous therapy. Study enrolled 29 patients, aged 21-59 with HCV infection (15 had HCV genotype 1, and 14 had HCV non-genotype1), who previously were treated with unmodified interferon alfa (conventional interferon) 2a or 2b 5 MIU TIW plus ribavirin (1000-1200 mg/day) and who failed under this therapy. Study subjects were randomized into two groups: in group I were included 17 patients--relapsers (patient in whom HCV RNA becomes undetectable on treatment and is undetectable at the end of therapy, but is detected again after discontinuation of treatment). Group II was composed of 12 patients: 4 were non responders (patient in whom HCV RNA levels remain stable on treatment), 4--partial responders (HCV RNA levels decline by >2 logs, but never become undetectable during treatment) and 4--breakthrough non responders (HCV RNA become undetectable during treatment, but before-treatment termination again become detectable). The diagnosis of HCV infection was made based on detection of HCV antibodies by ELISA and confirmed by RIBA. Detection of HCV RNA (qualitative) and HCV RNA Viral load--by Real time PCR technique (COBAS TaqMan Test). HCV genotypes were detected by INNO-Lipa method. In group I--rapid virological response (RVR) was observed in 10 (58%) patients, early viral response (EVR) in 12 patients (70%). Among them 9 (52%) patients remained HCV RNA undetectable by the end of treatment. After 6 months sustained viral response (SVR) was received in 7 (41%) patients from group I. In group II--RVR was observed in 5 (41%), EVR in 6 (50%) patients. Among them 5 (41%) patients remained HCV RNA undetectable by the end of treatment. After 6 months Sustained Viral Response was received in 3 (25%) patients. Re-treatment with pegylated interferon and ribavirin in patients with hepatitis C who failed to responds to previous treatment was effective in relapsers. Re-treatment in non responders, partial responders and breakthrough non responders was less effective (especially in non responders). Re-treatment effectiveness was higher in HCV genotype non 1 patients in comparison with HCV genotype 1. Thus re-treatment will be considered for relapsers. For making decision on re-treatment for other nonresponders, severity of disease (advance disease) should be considered.

Viral hepatitis C

Hepatitis C is caused by the hepatitis C virus (HCV) infection. According to World Health Organization data, 3% of the world population (approximately 170 million people) is infected with HCV; in Poland there are over 700,000. Over 70% of those infected manifest no symptoms in the acute phase of the disease, and in about 70-80% the acute phase progresses into a chronic form. Patients with symptoms in the acute phase of HCV infection most commonly present with unspecific signs and symptoms that may develop in other viral liver infections, e.g. malaise, fatigue, abdominal pain, mild hepato- and splenomegaly and arthralgia. These symptoms usually persist for 2 to 12 weeks. In the chronic phase a subset of patients complain of malaise, nausea, abdominal pain and itching. With time, chronic hepatitis C may develop into liver cirrhosis. The basic diagnostic methods in HCV infection involve determination of anti-HCV antibodies using the ELISA immunoassay and examination of HCV-RNA with the RT-PCR method. The current treatment of HCV infection involves administration of pegylated interferon a and ribavirin over a period of 48 weeks in HCV-1 genotype infection, and 24 weeks for HCV-2 and 3 genotypes. Effectiveness of therapy depends on the HCV genotype. HCV elimination can be achieved in 78% of patients with HCV-2 and 3 genotypes, and in 55% of patients with HCV-1 genotype.

Immunochemical localization of protein kinase Calpha in the biopsies of human hepatocellular carcinoma

The purpose of this study was to elucidate the protein kinase C (PKC) alpha distribution in human hepatocellular carcinoma (HCC). The histoimmunopathologic technique was used to determine the localization and expression of PKCalpha in HCC biopsies. The HCC tissues were classified as cytosolic type (PKCalpha deposited in the cytoplasm in > 50% of cells) and membranous type for the remaining ones. There was a significant association of the membranous type with non-hepatitis C virus (HCV) infected patients. Moreover, the expression of PKCalpha in this type was significantly higher in HCC cells than that in the adjacent non-tumor liver cells. The result indicated that PKCalpha may play an important role in carcinogenesis of HCC patients with HBV infection and/or non-HCV infection.

[Seroprevalence of the infection and risk factors of hepatitis B and C in healthy military personnel]

OBJECTIVE

Determine the prevalence of infections by the hepatitis B (HBV) and C (HCV) viruses and the risk factors associated with their acquisition in clinically healthy military personnel.

METHOD

Correlational and analytic transversal study. The population was made up of active, clinically healthy military personnel from the Peruvian Air Force that volunteered for a screening program between October and December 2007. The HBsAg and anti-HBc markers of HBV and the anti-HCV marker of HVC were evaluated.

RESULTS

Of the 3,343 military personnel studied, 93.2% (3,116) were male and 6.8% (227) were female, with an average age of 38.9+/-8.6 years (range: 18 to 60 years old), mostly non-commissioned officers (79.5%). An HBsAg prevalence of 0.33% was found, with an anti-HBc prevalence of 0.58%, while the prevalence of anti-HCV was 0.21%. The risk factor associated with active infection by HBV (HBsAG) was risky sexual behavior (OR: 8.3; IC 95%:1.6-42.4 and p=0.01). On the hand, for the past infection by HBV (anti-HBc), the associated risk factors were risky sexual behavior (OR: 6.3; IC 95%:1.7-23.4 and p=0.006) and tattoos (OR: 5.5; IC 95%:1.2-25.8 and p=0.031). No association was found between the risk factors studied and seropositivity by HCV.

CONCLUSIONS

We found a low prevalence of the serological markers of infection by hepatitis B and C viruses in active military personnel. The risk factors associated with infection by HBV were risky sexual conduct and the use of tattoos. There was no risk factor found to be associated with infection by HCV in this population.

Hepatitis C virus infection in Nigerians with diabetes mellitus

BACKGROUND/AIMS

Studies from mainly Caucasian populations have shown epidemiological evidence of an association between diabetes mellitus and Hepatitis C virus (HCV) infection. The aim of this study was to determine whether any such association exists in a blackAfrican population with diabetes mellitus.

METHOD

This was a cross sectional study of consecutive diabetic patients seen at the diabetes clinic of the University of Nigeria Teaching Hospital Enugu, Nigeria between September 1, 2004 and April 30, 2005. Patients who underwent upper gastrointestinal endoscopy during the same period for dyspeptic symptoms were used as controls after matching for age and sex. Structured questionnaire on risk factors for HCV infection was administered to the participants. Blood test for HCV antibodies was carried out on the diabetic patients as well as the control subjects.

RESULTS

Out of 191 diabetic patients, 27(14.1%) were HCV antibody positive compared to the control group in which 5 out of 134 (3.7%) subjects had HCV antibodies (p = 0.0046).

CONCLUSION

Hepatitis C virus infection is more common in Nigerian patients with diabetes mellitus than in control subjects. The nature of the association between diabetes mellitus and HCV infection remains to be elucidated.

Heat shock protein A1B 1267 polymorphism is highly associated with risk and prognosis of hepatocellular carcinoma: a case-control study

We conducted a case-control study to elucidate the role of heat shock protein A1B (HSPA1B) 1267 single nucleotide polymorphism (SNP) on the risk and prognosis of hepatocellular carcinoma (HCC). Subjects enrolled included 150 pairs of sex- and age-matched HCC patients and unrelated controls. Genomic DNA was typed for HSPA1B1267 SNP using polymerase chain reaction with restriction fragment length polymorphism. The frequencies of the HSPA1B P2/P2 genotype and the HSPA1B P2 allele in HCC patients were higher than in unrelated controls (each p = 0.0001). Multivariate analysis identified the following independent risk factors for HCC: HSPA1B P1/P2 genotype (odds ratio [OR], 2.34; 95% confidence interval [CI], 1.07-5.11), HSPA1B P2/P2 genotype (OR, 12.06; 95% CI, 4.43-32.79), hepatitis B surface antigen (HBsAg) (OR, 25.95; 95% CI, 11.88-56.68), and antibodies to hepatitis C virus (anti-HCV) (OR, 70.43; 95% CI, 21.89-226.64). There was an additive interaction between HSPA1B P2 allele carriers and the presence of either HBsAg (synergy index = 2.48) or anti-HCV (synergy index = 1.52). However, as HSPA1B1267 SNP is a silent mutation, it is a surrogate genetic marker for increasing risk of HCC. Our findings indicate that patients with chronic hepatitis B/hepatitis C virus infection who harbor this SNP represent a high-risk group for HCC. They should receive more intensive surveillance for early detection of HCC. Moreover, patients with the HSPA1B P2 allele had significantly longer survival (p = 0.002).The limitations of this study include the unknown functional significance of the HSPA1B1267 polymorphism, the relatively small sample size, the fact that this was not a prospective study of cases and controls, and the questionable generalizability of the findings given the specific ethnic composition of the population studied.

Differences in long-term outcome and prognostic factors according to viral status in patients with hepatocellular carcinoma treated by surgery

Long-term postoperative survival and prognostic factors were examined retrospectively in patients with hepatocellular carcinoma (HCC) with serum hepatitis B surface antigen (HBsAg) or hepatitis C antibody (HCVAb) and in those without virus infection. Subjects were 265 consecutive HCC patients treated surgically at one institution during the period 1990 to 2006. Postoperative survival was analyzed and compared between HBsAg-positive (B-HCC), HCVAb-positive (C-HCC), and hepatitis B- and C-negative (NBNC-HCC) patients. Prognostic factors for overall and recurrence-free survival were also analyzed. Overall and recurrence-free survival rates were significantly higher in the NBNC-HCC group than in the C-HCC group. Significant prognostic factors for overall survival identified by univariate and multivariate analyses were age, serum alkaline phosphatase (ALP) level, tumor multiplicity, portal vein invasion (Vp), hepatic vein invasion (Vv), and operative blood loss in the B-HCC group; serum albumin level, ALP level, tumor size, and Vv in the C-HCC group; and tumor multiplicity in the NBNC-HCC group. Significant factors for recurrence-free survival were age, ALP level, tumor multiplicity, Vp, and operation time in the B-HCC group; ALP level, prothrombin time, tumor size, Vv, and width of the surgical margin in the C-HCC group; and age, tumor size, tumor multiplicity, and Vp in the NBNC-HCC group. Thus, postoperative survival and prognostic factors in cases of HCC differ according to the presence of serologic viral markers.

[Control of viral hepatitis in Lithuanian hemodialysis centers in 1997-2001]

Hemodialysis patients are a high-risk group for hepatitis B and C virus infections. The aim of the study was to evaluate the prevalence of B and C viral hepatitis, level of its control among patients on hemodialysis. In December of 1997, 1998, 1999, 2000, 2001 we visited all hemodialysis centers of Lithuania and gathered information about these infections in patients on hemodialysis. Eleven percent (11.4%) of all hemodialysis patients were not examined for HB(s)Ag and 15.2% for anti-HCV, 67.3%--for anti-HB(s) and 57.7% for anti-HBc in 2001. The number of examined patients for the markers of hepatitis had increased in 2001 in comparison with 1997. The same number of hemodialysis patients with HB(s)Ag was found in each year of study (14% in 1997, 14.4% in 2001). We observed the decrease in percentage of anti-HCV positive patients from 23% in 1998 till 15.4% (p<0.01) in 2001. Only 10.6% hepatitis B virus vaccinated patients was registered in 2001 and this percentage increased if compared to 6.3% in 1999. About (1/4) of anti-HB(c) positive patients were HB(s)Ag positive in 2000-2001. Chronic hepatitis B could be diagnosed for them. The duration of hemodialysis of HB(s)Ag and anti-HCV positive patients was longer compared to HB(s)Ag and anti-HCV negative patients (p<0.001).

Outcome of screening for hepatitis C virus infection based on risk factors

OBJECTIVES

Screening for hepatitis C virus (HCV) infection in individuals at increased risk is currently recommended by most, but not all, health authorities. This study identifies outcomes of individuals diagnosed through a screening program targeting high-risk patients.

METHODS

Veterans presenting for care in VA facilities are assessed for HCV risk factors by a questionnaire. Those with a risk factor are offered anti-HCV testing. Between October 1998 and May 2004, 25,701 patients were assessed and 8,471 patients had a risk factor for HCV. Patients diagnosed through the screening program were assessed per study protocol.

RESULTS

The prevalence of a positive HCV antibody in veterans who identified a risk factor was 7.3% (95% CI 6.6-8.0%). Among those diagnosed through the screening program (N = 260), 47% had chronic hepatitis C. Among patients with chronic HCV, 18% had evidence of advanced liver disease (stage III/IV on biopsy or clinical cirrhosis) while 34% had persistently normal alanine aminotransferase (ALT). Two-thirds of individuals who underwent liver biopsy had minimal or no fibrosis. About half (47%) of the screen-detected patients with chronic HCV were treatment candidates. Forty-four percent were not immediate candidates secondary to medical or psychiatric comorbidities or active substance abuse. Twenty-two patients (8%) had died after a median follow-up of 911 days. Two were liver-related deaths.

CONCLUSION

Screening for hepatitis C in persons at high risk can lead to early identification of individuals at risk for progressive liver disease who may benefit from antiviral therapy and counseling to reduce HCV-related liver injury.

Viral clearance or persistence after acute hepatitis C infection: interim results from a prospective study

OBJECTIVE

Hepatitis C virus infection (HCV) has a high rate of chronic evolution; however, the underlying mechanisms remain to be elucidated. We investigated natural clinical, virological, and immunological course of acute HCV infection in order to identify possible prognostic factors of spontaneous resolution and to gain more understanding of early characteristics responsible for viral clearance or persistence.

MATERIALS AND METHODS

Eight patients with acute symptomatic hepatitis C were prospectively followed up for more than 6 months (range, 8-14 months). None of the individuals received antiviral therapy during the study period. We analyzed biochemical, virological, and immunological parameters of these patients detected at different time-points of the follow-up. Plasma HCV RNA was quantitated using TaqMan real-time polymerase chain reaction. Virus-specific CD4(+) T cells were enumerated by interferon-gamma (IFN-gamma) ELISpot assay.

RESULTS

Two of eight individuals resolved HCV spontaneously, while the remaining patients developed chronic HCV infection. HCV RNA became undetectable within 14 days of the study, followed by a rapid alanine aminotransferase normalization in patients with resolved infection. On the contrary, chronically infected subjects demonstrated persistent viremia or intermittently undetectable HCV-RNA, accompanied by polyphasic alanine aminotransferase profile throughout the study. Patients with self-limited hepatitis C displayed the strongest virus-specific CD4(+) T (IFN-gamma) cell reactivity within the first weeks of the follow-up, while persistently infected subjects initially showed a weak antiviral CD4(+) T (IFN-gamma) cell response.

CONCLUSIONS

In most cases, acute hepatitis C progresses to chronic disease. Viral clearance within the first month after clinical presentation accompanied by monophasic alanine aminotransferase profile could predict recovery. Early and strong CD4(+)/Th1 immune response against HCV might play an important role in the disease resolution.

The epidemiology and virology of hepatitis C virus genotype 5 in central France

BACKGROUND

We previously reported high prevalence of hepatitis C virus genotype 5a (HCV 5) (14%) in Central France.

AIM

To identify the risk factors associated with HCV5 infection and to characterize local HCV5 lineages.

METHOD

A case-control study and phylogenetic analysis were conducted.

RESULTS

In all, 131 HCV5 and 343 HCV non 5 infected patients were enrolled. No HCV5 patient was born in sub-Saharan Africa and only two were injection drug user. HCV5 contamination was associated with living in a rural area called Vic le Comte (VLC) in non-transfused patients (OR = 17.7), with transfusion in patients living outside VLC (OR = 3.8) and with receiving injections in patients from VLC (OR = 3.1). More than 80% of the patients from outside VLC were contaminated by transfusion and those from VLC mainly by an iatrogenic factor - injections performed before 1972 by the local physician. Phylogenetic analysis of HCV5 isolates evidenced no distinct genetic cluster, but close relationships between the isolates of spouse pairs and between blood donors and recipients.

CONCLUSIONS

Our results suggest that HCV5 spread in our district by iatrogenic route before 1972 and then via transfusion to the whole district. Collaborative studies are underway to study viral sequences from different parts of Africa and Europe to estimate the origin of our HCV 5a strains.

Hepatitis C virus infection and the dialysis patient

Hepatitis C virus (HCV) remains common in patients undergoing regular dialysis and is an important cause of liver disease in this population both during dialysis and after renal transplantation (RT). Anti-HCV screening of blood products has almost eliminated posttransfusion HCV infection but acquisition of HCV continues to occur in dialysis patients because of nosocomial spread. The natural history of HCV in dialysis population is not completely understood though recent data show that HCV infection has a detrimental role on survival of chronic dialysis patients. Several clinical trials have suggested that the response rate to conventional interferon (IFN) is higher in dialysis patients than those with normal kidney function but tolerance is lower. There are only limited data about pegylated IFN alone or in association with ribavirin for hepatitis C in dialysis population. IFN remains contraindicated post-RT because of concern about precipitating graft dysfunction; however, preliminary evidence shows the durability of sustained response to antiviral therapy pre-RT after renal transplant. Successful pretransplant therapy is associated with several benefits after RT including reduced incidence of posttransplant diabetes mellitus and de novo glomerulonephritis in HCV-infected recipients.

Routine practice HCV infection screening with saliva samples: multicentric study in an intravenous drug user population

OBJECTIVE

The purpose of this randomized multicentric study was to evaluate the diagnostic contribution of screening for HCV infection on saliva samples in day-to-day practice in the intravenous drug-user (IVDU) population.

METHODS

Between January and May 2004, 274 presumably HCV-negative IVDU were screened for HCV infection in 15 centers in France (median age 29 years). After centralized randomization, screening tests were performed on blood samples (arm A) or saliva samples (arm B). Screening tests were performed in 78 subjects (28%) had never been screened before and in 196 subjects (72%) who had had a negative HCV screening test on average 12 months prior to the beginning of the study. In the event of a positive saliva test for anti-HCV Ab, a serum test for anti-HCV Ab was performed. In the event of a positive serum test for anti-HCV Ab, PCR was performed on serum to measure HCV-RNA.

RESULTS

Fourteen individuals were positive for HCV RNA (7 in each arm). Six of these cases had not been detected before. In eight cases, the median time between the last negative screening test and study inclusion was 11 months (range 6-94 months).

CONCLUSIONS

Viremia tests were positive in 5% percent of the target population, although one-third of the individuals in arm A (blood samples) were not tested. The saliva test may be a useful alternative in the event of refusal of a blood test or when poor venous conditions compromise venous puncture. A confirmatory blood test still remains difficult to obtain in nearly half of patients.