Specific recognition of the HIV-1 genomic RNA by the Gag precursor

During assembly of HIV-1 particles in infected cells, the viral Pr55(Gag) protein (or Gag precursor) must select the viral genomic RNA (gRNA) from a variety of cellular and viral spliced RNAs. However, there is no consensus on how Pr55(Gag) achieves this selection. Here, by using RNA binding and footprinting assays, we demonstrate that the primary Pr55(Gag) binding site on the gRNA consists of the internal loop and the lower part of stem-loop 1 (SL1), the upper part of which initiates gRNA dimerization. A double regulation ensures specific binding of Pr55(Gag) to the gRNA despite the fact that SL1 is also present in spliced viral RNAs. The region upstream of SL1, which is present in all HIV-1 RNAs, prevents binding to SL1, but this negative effect is counteracted by sequences downstream of SL4, which are unique to the gRNA.

HIV-1 Pr55Gag binds genomic and spliced RNAs with different affinity and stoichiometry

The HIV-1 Pr55^Gag precursor specifically selects genomic RNA (gRNA) from a large variety of cellular and spliced viral RNAs (svRNAs), however the molecular mechanisms of this selective recognition remains poorly understood. To gain better understanding of this process, we analyzed the interactions between Pr55^Gag and a large panel of viral RNA (vRNA) fragments encompassing the main packaging signal (Psi) and its flanking regions by fluorescence spectroscopy. We showed that the gRNA harbors a high affinity binding site which is absent from svRNA species, suggesting that this site might be crucial for selecting the HIV-1 genome. Our stoichiometry analysis of protein/RNA complexes revealed that few copies of Pr55^Gag specifically associate with the 5' region of the gRNA. Besides, we found that gRNA dimerization significantly impacts Pr55^Gag binding, and we confirmed that the internal loop of stem-loop 1 (SL1) in Psi is crucial for specific interaction with Pr55^Gag. Our analysis of gRNA fragments of different length supports the existence of a long-range tertiary interaction involving sequences upstream and downstream of the Psi region. This long-range interaction might promote optimal exposure of SL1 for efficient Pr55^Gag recognition. Altogether, our results shed light on the molecular mechanisms allowing the specific selection of gRNA by Pr55^Gag among a variety of svRNAs, all harboring SL1 in their first common exon.

A comprehensive hepatitis C virus risk factors meta-analysis (1989-2013): do they differ in Egypt?

BACKGROUND & AIMS

The prevention and control of HCV infection is complex and challenging in terms of describing risk factors and modes of transmission. This meta-analysis was conducted to summarize the best available data on HCV risk factors worldwide and in Egypt.

METHODS

Through exhaustive literature searches (1989-2013) of HCV risk factors, 357 original eligible articles were included in this study.

RESULTS

The highest detected risk was intravenous drug users (IDUs) (OR = 9.6) followed by HIV infection (OR = 4.9), having an IDU partner (OR = 4.1), HBV infection (OR = 3.5), Caesarean section (CS) (OR = 3.35), blood transfusion (OR = 3.2) and having an HCV+ partner (OR = 3). Organ transplantation, hospital admission, haemodialysis and having a sexually transmitted infection carry 2.96, 2.4, 2.18 and 2 risks of having HCV respectively. Other significant risk factors included poor education, older age, sharing sharp or blunt objects, MSM, tattooing, hijama, body piercing, minor operations and medical procedures. Some risks showed a decrease over the previous decade, including blood transfusion, organ transplantation, IDUs, IDU partner and CS. Others showed rising risks, including having an HCV+ partner, MSM and suffering from STI. In Egypt, male gender, rural residence, acupuncture and receiving parenteral antischistosomal treatment were significant risks, while neither HIV nor HBV were found to carry a risk of HCV infection.

CONCLUSION

Blood transfusion, organ transplantation, CS, IDUs, haemodialysis, minor operations and medical procedures are established risk factors. Attention and urgent intervention should be given to the sexual route of transmission, as well as that through minor operations and medical procedures.

Multidomain Convergence of Argonaute during RISC Assembly Correlates with the Formation of Internal Water Clusters

Despite the relevance of Argonaute proteins in RNA silencing, little is known about the structural steps of small RNA loading to form RNA-induced silencing complexes (RISCs). We report the 1.9 Å crystal structure of human Argonaute4 with guide RNA. Comparison with the previously determined apo structure of Neurospora crassa QDE2 revealed that the PIWI domain has two subdomains. Binding of guide RNA fastens the subdomains, thereby rearranging the active-site residues and increasing the affinity for TNRC6 proteins. We also identified two water pockets beneath the nucleic acid-binding channel that appeared to stabilize the mature RISC. Indeed, mutating the water-pocket residues of Argonaute2 and Argonaute4 compromised RISC assembly. Simulations predict that internal water molecules are exchangeable with the bulk solvent but always occupy specific positions at the domain interfaces. These results suggest that after guide RNA-driven conformational changes, water-mediated hydrogen-bonding networks tie together the converged domains to complete the functional RISC structure.

Attributes of HIV infection over decades (1982-2018): A systematic review and meta-analysis

Understanding the risk factors for HIV infection is the foundation of successful preventive strategies, which must bundle sociocultural, behavioural and biomedical interventions to halt disease transmission. We aimed in this study to provide a pooled estimation of HIV risk factors and trace changes across decades in order to drive consensus and accurate assessment of disease transmission risk. We comprehensively searched PubMed, ISI Web of Knowledge, Medline, EMBASE, ScienceDirect, Ovid, EBSCO, Google Scholar and the Egyptian Universities Library Consortium from October to December 2018. Two independent reviewers extracted data from eligible studies. Funnel plots were inspected to identify publication bias. Heterogeneity across studies was checked using the Q and I² statistics. The results were reported based on the pooled odds ratio (pOR) with 95% CI using a random-effects model. Meta-analysis of HIV risk factors revealed a superior role for risky sexual practices (unprotected vaginal/anal sex), injecting drug use (IDU), sharing needles, sexually transmitted infections (STIs), child sexual abuse and vertical transmissions. Trends across decades (1982-1999 and 2000-2018, respectively) showed rising evidence for prostitution [pOR (95% CI)= 2.3 (1.12-4.68) versus 2.69 (1.67-4.32)] and men who have sex with men (MSM) [pOR (95% CI)= 2.28 (1.64-3.17) versus 3.67 (1.88-7.17)], while transmission through IDU [pOR (95% CI)= 3.42 (2.28-5.12) versus 2.16 (1.74-2.70)], alcoholism [pOR (95% CI)= 2.35 (0.73-7.59) versus 1.71(1.08-2.72)], and sharing syringes [pOR (95% CI)= 6.10 (2.57-14.5) versus 2.70 (2.01-6.35)] showed notable decline. Harm reduction programs and condom use have been recognized as chief HIV prevention strategies, while male circumcision contributed a partial role. Collectively, sexual risk factors continue to be a key driver of the global HIV epidemic. Persistent and emerging risk factors identified in our analysis should constitute the forefront targets of HIV prevention programmes to accelerate efforts towards HIV elimination.

A multifaceted risk model of brucellosis at the human-animal interface in Egypt

Brucellosis is a highly contagious zoonosis affecting humans and a wide range of domesticated and wild animal species. An important element for effective disease containment is to improve knowledge, attitudes and practices (KAP) of afflicted communities. This study aimed to assess the KAP related to brucellosis at the human-animal interface in an endemic area of Egypt and to identify the risk factors for human infection. A matched case-control study was conducted at the central fever hospitals located in six governorates in northern Egypt. Face-to-face interviews with cases and controls were conducted using a structured questionnaire. In total, 40.7% of the participants owned farm animals in their households. The overall mean practice score regarding animal husbandry, processing and consumption of milk and dairy products were significantly lower among cases compared with controls (-12.7 ± 18.1 vs. 0.68 ± 14.2, respectively; p < .001). Perceived barriers for notification of animal infection/abortion were predominate among cases and positively correlated with participants' education. The predictors of having brucellosis infection were consumption of unpasteurized milk or raw dairy products and practicing animal husbandry. Applying protective measures against infection significantly reduced its risk. A model predicting risk factors for brucellosis among those who own animal showed that frequent abortions per animal increased the chance for brucellosis infection among human cases by 50-fold (95% CI: 8.8-276.9), whereas the use of protective measures in animal care reduced the odds (OR = 0.11 [95% CI: 0.03-0.45]). In conclusion, consumption of unprocessed dairy products was equally important as contact with infected/aborted animals as major risk factors for Brucella spp. infection among humans in Egypt. There is poor knowledge, negative attitudes and risky behaviours among villagers which can perpetuate the risk of brucellosis transmission at the human-animal interface. This supports the need for integrating health education into the national brucellosis control programme.

Manganese-dependent microRNA trimming by 3'→5' exonucleases generates 14-nucleotide or shorter tiny RNAs

MicroRNAs (miRNAs) are about 22-nucleotide (nt) noncoding RNAs forming the effector complexes with Argonaute (AGO) proteins to repress gene expression. Although tiny RNAs (tyRNAs) shorter than 19 nt have been found to bind to plant and vertebrate AGOs, their biogenesis remains a long-standing question. Here, our in vivo and in vitro studies show several 3'→5' exonucleases, such as interferon-stimulated gene 20 kDa (ISG20), three prime repair exonuclease 1 (TREX1), and ERI1 (enhanced RNAi, also known as 3'hExo), capable of trimming AGO-associated full-length miRNAs to 14-nt or shorter tyRNAs. Their guide trimming occurs in a manganese-dependent manner but independently of the guide sequence and the loaded four human AGO paralogs. We also show that ISG20-mediated guide trimming makes Argonaute3 (AGO3) a slicer. Given the high Mn²⁺ concentrations in stressed cells, virus-infected cells, and neurodegeneration, our study sheds light on the roles of the Mn²⁺-dependent exonucleases in remodeling gene silencing.

Fibrocytes Differ from Macrophages but Can Be Infected with HIV-1

Fibrocytes (fibroblastic leukocytes) are recently identified as unique hematopoietic cells with features of both macrophages and fibroblasts. Fibrocytes are known to contribute to the remodeling or fibrosis of various injured tissues. However, their role in viral infection is not fully understood. In this study, we show that differentiated fibrocytes are phenotypically distinguishable from macrophages but can be infected with HIV-1. Importantly, fibrocytes exhibited persistently infected cell-like phenotypes, the degree of which was more apparent than macrophages. The infected fibrocytes produced replication-competent HIV-1, but expressed HIV-1 mRNA at low levels and strongly resisted HIV-1-induced cell death, which enabled them to support an extremely long-term HIV-1 production at low but steady levels. More importantly, our results suggested that fibrocytes were susceptible to HIV-1 regardless of their differentiation state, in contrast to the fact that monocytes become susceptible to HIV-1 after the differentiation into macrophages. Our findings indicate that fibrocytes are the previously unreported HIV-1 host cells, and they suggest the importance of considering fibrocytes as one of the long-lived persistently infected cells for curing HIV-1.

Asthma action plan for proactive bronchial asthma self-management in adults: a randomized controlled trial

Background

Written personalized asthma action plans are recommended as part of patient education and self-management.

Objectives

To enable asthmatic adults to proactively self-manage bronchial asthma and sustain asthma quiescent status through utilization of the Asthma Action Plan (AAP), and to establish a feasible asthmatic/care taker-health care provider communication.

Design

Randomized controlled trial with cluster sampling by pulmonologists.

Setting and participants

The study comprised 320 chronic asthmatic patients attending the chest department at the main health insurance hospital in Alexandria that were randomly allocated as the intervention group (AAIG; n=160) that received standard care and intervention by the AAP and a control group (AACG; n=160) that received the routine standard of care. Data were collected through an interviewing questionnaire. The study continued over a 6-month period and passed into three phase stations. During the preparatory phase the health care provider managed to explain, fill and simplify the use of the Arabic version of the AAP, to explain the correct utilization of the weekly follow-up form and to emphasize the weekly communication/visit with the health care provider (HCP) to update their weekly follow-up records. Follow-up was done on the 90th and 180th days from the launch of the study, respectively. The study asthmatics were subjected to history-taking of their asthma symptoms, signs and triggers, and a review of their medical/peak expiratory flow records, as well as his/her daily activity and exercise.

Results

The AAIG experienced superiority of the average of the green zone days ('doing well') with significantly more episodes of early asthma flare-up self-management concomitant with prominent fewer emergency department visits, hospitalization, admission at the ICU, private health facility, and days of sickness leaves and absenteeism. A preponderance of the high and medium adherence levels to asthma medications, avoidance of asthma triggers and smoking was achieved by the AAIG.

Conclusions

AAP was the basis for effective patient-health care provider communication and patient real time asthma flare-up self-management to achieve and sustain better asthma control in asthmatic adults.

Real-life results of sofosbuvir based therapy in chronic hepatitis C -naïve and -experienced patients in Egypt

BACKGROUND

More than ten million Egyptians are infected with HCV. Every one of them is going to infect about three to four persons every year. Treating those patients is a matter of national security. A dramatic improvement in hepatitis C virus (HCV) infection treatment was achieved in the last five years. A new era of direct-acting antivirals is now dawning in Egypt.

OBJECTIVE(S)

We share in this report our clinical experience in treating chronic HCV Egyptian patients with Sofosbuvir based regimens to evaluate its safety and efficacy on real life practical ground.

METHODS

A total of 205 chronic HCV patients (195 naive and 15 experienced) were enrolled in the study. Patient were treated with Sofosbuvir+Ribavirin 24 weeks as standard of care. Two interferon eligible patients were treated with PEG-INF+ Sofosbuvir+Ribavirin for 12 weeks. The primary efficacy endpoint was the proportion of patients with sustained virologic response at 24 weeks after cessation of therapy.

RESULTS

The overall response rate was 97.1%. Sustained virological response rate did not differ among treatment-naive patients and patients with previous history of IFN-based therapy. Portal hypertension, prediabetes, and lack of early virologic response were predictors of non response. No clinically significant treatment-emergent adverse effects were noted. No treatment discontinuation was encountered.

CONCLUSION

In the real-life setting, Sofosbuvir based regimens for 24 weeks has established an efficacious and well tolerated treatment in naïve and experienced patients with chronic HCV genotype 4 infection; although shorter treatment durations may be possible. However, patient follow up should extent to at least 6 months post-treatment and verifying viral load on yearly basis is warranted to track any late relapse.

Assessment of oxidative stress among refueling workers in an Egyptian setting

BACKGROUND

Unlike developing countries, in Egypt, gasoline is dispensed at dedicated stations by gasoline filling workers. This leads to high levels of exposure to the aromatic compounds in gasoline [principally benzene, toluene, ethyl benzene, and xylene (BTEX)] with the consequences of adverse health effects including oxidative stress.

OBJECTIVE(S)

To assess oxidative stress and trace metal levels among Egyptian gas filling workers.

METHODS

A cross-sectional study was conducted among 50 gasoline filling station workers (exposed group) and a matched group of 50 clerical workers (non-exposed group). Trace metal levels (Cu, Zn, Fe, and Mn) and the activities of the antioxidant enzymes superoxide dismutase (SOD) and glutathione peroxidase (GPx) were measured in sera of all enrolled participants using atomic absorption spectroscopy. BTEX levels were assessed in the environment of the studied gas filling stations using the MIRAN IR system.

RESULTS

All the measured trace metal levels and antioxidant enzyme activities were significantly lower among the exposed workers than among the non-exposed workers. All trace metals decreased significantly in relation to SOD activity among the exposed workers, whereas only Zn and Cu decreased in relation to SOD and GPx activity among the non-exposed workers. The exposed workers did not comply with the use of the required personal protective equipment (PPE) to avoid the dangerous effects of BTEX exposure. Among BTEX components, benzene exceeded the allowable Egyptian TLV in the studied gasoline stations (110.4 mg/m3 versus 1.6 mg/m3, respectively). The hygienic effect (HE) of the BTEX pollutant mixture exceeded the allowed borderline HE in Egypt although it did not show a significant correlation with different oxidative stress biomarkers and trace metals.

CONCLUSION

Exposure to BTEX at gasoline filling stations lowers the levels of antioxidant enzyme activities and trace metals due to the strong hygienic effect of BTEX. Individual protection using the proper PPE should therefore be enforced. Research assessing the need of providing refueling workers with supplements of necessary trace metals and antioxidants is warranted.

Adapting a Prediction Rule for Metabolic Syndrome Risk Assessment Suitable for Developing Countries

Background: Metabolic syndrome (MetS) is a cluster of cardiometabolic disturbances that increases the risk of cardiovascular diseases (CVD) and type 2 diabetes mellitus (DM). The early identification of high-risk individuals is the key for halting these conditions. The world is facing a growing epidemic MetS although the magnitude in Egypt is unknown. Objectives: To describe MetS and its determinants among apparently healthy individuals residing in urban and rural communities in Egypt and to establish a model for MetS prediction. Methods: A cross-sectional study was conducted with 270 adults from rural and urban districts in Alexandria, Egypt. Participants were clinically evaluated and interviewed for sociodemographic and lifestyle factors and dietary habits. MetS was defined according to the harmonized criteria set by the AHA/NHLBI. The risk of ischemic heart diseases (IHDs), DM and fatty liver were assessed using validated risk prediction charts. A multiple risk model for predicting MetS was developed, and its performance was compared. Results: In total, 57.8% of the study population met the criteria for MetS and were at high risk for developing IHD, DM, and fatty liver. Silent CVD risk factors were identified in 20.4% of the participants. In our proposed multivariate logistic regression model, the predictors of MetS were obesity [OR (95% CI) = 16.3 (6.03-44.0)], morbid obesity [OR (95% CI) = 21.7 (5.3-88.0)], not working [OR (95% CI) = 2.05 (1.1-3.8)], and having a family history of chronic diseases [OR (95% CI) = 4.38 (2.23-8.61)]. Consumption of caffeine once per week protected against MetS by 27.8-fold. The derived prediction rule was accurate in predicting MetS, fatty liver, high risk of DM, and, to a lesser extent, a 10-year lifetime risk of IHD. Conclusion: Central obesity and sedentary lifestyles are accountable for the rising rates of MetS in our society. Interventions are needed to minimize the potential predisposition of the Egyptian population to cardiometabolic diseases.

Risk Factors Associated with Parasitic Infection Among Municipality Solid-Waste Workers in an Egyptian Community

Solid-waste management is associated with several health hazards, particularly parasitic infection. The objective of the study was to determine the association between risk factors and the occurrence of intestinal parasitic infections (potentially pathogenic) among municipal waste collectors in Alexandria, Egypt. A cross-sectional survey was conducted in the main municipality company in Alexandria. A total of 346 municipality solid-waste workers (MSWWs) was interviewed using an in-depth questionnaire. The type of parasitic infections among waste handlers was determined using formol-ether concentration and modified Ziehl-Neelsen technique. About half of the workers were infected with parasites. The profile of parasitic infection revealed 12 parasitic species. These were comprised of the following helminths: Schistosoma mansoni (13.3%), Enterobius vermicularis (1.7%), Ascaris lumbricoides (1.4%), and Hymenolepis nana ova (0.6%). Among protozoa were pathogenic Entamoeba histolytica (3.2%), Giardia intestinalis (2.9%), nonpathogenic protozoa such as Entamoeba coli (1.7%), and potentially pathogenic or opportunistic ones as Cryptosporidium (23.4%), Microsporidia (20.25%), Cyclospora (2.0%), Blastocystis hominis (1.7%), and Cystoisospora belli (1.2%). About 1.4% of MSWWs have pediculosis and phthiriasis in their scalp and eyelashes respectively. Risk factors for infection were associated with direct exposure to solid fecal waste (odds ratio [OR] = 1.8, confidence interval [CI] = 1.1-3.0) and occupational activities that allowed for direct exposure to solid fecal waste (OR = 2.3, CI = 1.4-4.0). Logistic regression model has revealed that educational level and residence were the factors that contribute to parasitic infection among MSWWs (P < 0.05). MSWWs are at high risk of acquiring parasitic infections. Data of the present study highlighted the need for greater biomonitoring of MSWWs and the improvement of environmental conditions and health care in such marginalized communities to prevent parasitic infection and associated morbidities.

SARS-CoV-2 Transmission Channels: A Review of the Literature

BACKGROUND The novel coronavirus SARS-CoV-2 is responsible for the current global pandemic. There is a concerted effort within the global scientifi c community to identify (and thereby potentially mitigate) the possible modes of transmission through which the virus spreads throughout populations. OBJECTIVE Summarize the ways in which SARS-CoV-2 is transmitted and provide scientifi c support for the prevention and control of COVID-19. EVIDENCE AQUISITION We conducted an extensive literature search using electronic databases for scientifi c articles addressing SARSCoV-2 transmission published from December 28, 2019 through July 31, 2020. We retrieved 805 articles, but only 302 were included and discussed in this review. The report captured relevant studies investigating three main areas: 1) viral survival, 2) transmission period and transmissibility, and 3) routes of viral spread. DEVELOPMENT Currently available evidence indicates that SARSCoV-2 seems to have variable stability in different environments and is very sensitive to oxidants, such as chlorine. Temperature and humidity are important factors infl uencing viral survival and transmission. SARSCoV-2 may be transmitted from person to person through several different routes. The basic mechanisms of SARS-CoV-2 transmission person-to-person contact through respiratory droplets, or via indirect contact. Aerosolized transmission is likely the dominant route for the spread of SARS-CoV-2, particularly in healthcare facilities. Although SARS-CoV-2 has been detected in non-respiratory specimens, including stool, blood and breast milk, their role in transmission remains uncertain. A complicating factor in disease control is viral transmission by asymptomatic individuals and through what would otherwise be understood as innocuous human activities. CONCLUSIONS This article provides a review of the published research regarding human-to-human transmission of SARS-CoV-2 and insights into developing effective control strategies to stop viral propagation. KEYWORDS COVID-19, SARS-CoV-2, transmission, pandemics, microbial viability.

Validation of EGCRISC for Chronic Hepatitis C Infection Screening and Risk Assessment in the Egyptian Population

Chronic HCV infection, a highly endemic disease in Egypt, is usually asymptomatic for decades after infection. Prediction questionnaire tool was proofed to be a valuable, feasible and efficient instrument for the screening of several diseases. We previously developed an Egyptian HCV risk screening tool (EGCRISC). This study aims to validate/modify EGCRISC. A cross-sectional study testing 4579 individuals by EGCRISC as well as ELISA/PCR was performed. The sample was a stratified cluster sampling from urban and rural areas in Upper and Lower Egypt using a proportional allocation technique. The degree of agreement and positive and negative posttest probabilities were calculated. ROC curve was done and the cutoff points were customized for best performance. The total score was further classified into three levels according to the risk load. The mean age of the participants was 41.1±12.2 in whom HCV prevalence was 8.6%. EGCRISC, particularly after modifying the cutoff points, has a good discriminating ability. The degree of agreement was at least 68.1% and the positive posttest probability ranged from 5% to 37.2% whereas the negative posttest probability was in the range 1% to 17%. We conclude that EGCRISC is a valid tool that can potentially screen for HCV infection risk in Egypt and could diminish the demand for mass serologic screening in those apparently at minimal risk. Extensive use of electronic and self- or interviewer-administered risk-based screening strategy may simplify and promote overall screening and detection of HCV dissimilar communities.

Clinico-epidemiological profile of fever of unknown origin in an Egyptian setting: A hospital-based study (2009-2010)

INTRODUCTION

Fever of unknown origin (FUO) is one of the most challenging diagnostic dilemmas in the field of infectious diseases and tropical medicine. Clinicians should use the frequency distribution of disorders causing FUO to guide their diagnostic approach in patients with prolonged, unexplained fevers meeting the definition of FUO.

METHODOLOGY

The present study was undertaken to examine the etiologies, clinico-epidemiologic profile, and prognosis of classical FUO in patients reporting to the Alexandria Fever Hospital in Egypt. Records of 979 patients admitted to the fever hospital (from January 2009 to January 2010) and diagnosed as having FUO were examined carefully. FUO was defined as three outpatient visits or three days in the hospital without elucidation of cause of fever.

RESULTS

A total of 979 cases (57.0% males and 43.0% females), with ages ranging from 0.2 to 90 years, were investigated. The mean duration of fever before hospitalization was 31 ± 10 days. The etiology of FUO was delineated in 97% of cases, and only 3% remained undiagnosed. Diagnoses were grouped into five major categories. Infectious causes of FUO were strongly associated with better outcome (73.7% improved). Smoking, contact with animals or birds, drug addiction, and HIV seropositivity were important risk factors associated with infections.

CONCLUSIONS

Infections are the most common cause of FUO, followed by collagen vascular diseases, in our region. A three-step diagnostic work-up approach is recommended to be applied in Egypt in order to improve the quality of medical service provided to FUO patients.

Effectiveness of hepatitis B vaccination in chronic HCV patients after successful generic direct acting antiviral therapy: significance of isolated hepatitis B core antibodies

OBJECTIVE

Previous reports show conflicting results regarding hepatitis B virus (HBV) vaccine efficacy in Hepatitis C virus (HCV) infected individuals and in those with isolated hepatitis B core antibodies (HBcAb). We aimed to evaluate the effectiveness of HBV vaccine and identify possible factors that may contribute to hyporesponsivness in HCV-treated patients, including those with isolated HBcAb.

METHODS

We conducted a prospective study with 118 enrolled chronic HCV patients who followed a 12-week regimen of direct acting antivirals (DAAs) and were evaluated for HBV serological markers. Eventually, 98 received appropriate HBV vaccination and were assessed for response.

RESULTS

A total of 57.1% were vaccine responders although only 5.1% achieved a seroprotective level of HBsAb titre. The response rate was significantly lower among treated HCV patients with isolated HBcAb [2 (5.6%) vs. 40 (64.5%) respectively]. On multivariate analysis, advanced age [OR (95% CI) = 1.09 (1.02-1.17)] and presence of isolated HbcAb [OR (95% CI) = 39.59 (7.98-196.63)] were predictors of vaccine non-response. In our cost-effectiveness models, the cost of HBV serological screening was less than the nationally adopted non-screening approach. A model ratifying reinforced vaccination in non-responder HBcAb seropositive HCV patients would incur extra cost.

CONCLUSION

Hyporesponsiveness to the HBV vaccination is frequent in chronic HCV patients even after achieving SVR following DAAs. Although there is no consensus on the clinical management of patients with isolated HBcAb, our cost-effectiveness options may support decision-making for better clinical benefit and proper health investments.

Insulin resistance as a predictor of early virologic response to HCV therapy among chronic HCV Egyptian patients

Prior assessment of insulin resistance by HOMA-IR is emerging as an important milestone in the treatment of patients with chronic hepatitis C. This cost-effective tool is recommended to individualize treatment duration, or to exclude those with low insulin sensitivity from being treated until ameliorating their state of insulin resistance (IR). The present work aims to elucidate further the effect IR state on early viral kinetic response to Chronic hepatitis C virus (HCV) therapy and the impact of HCV treatment and viral eradication on insulin sensitivity. Insulin sensitivity was assessed using the HOMA-IR method. All enrolled patients were treated with a dual therapy (pegylated interferon-alpha plus ribavirin) for 48 weeks and evaluated using qRT-PCR for early virologic response as well as the impact of treatment on insulin sensitivity throughout the early period of therapy. Of a total 392 chronic HCV cases, early virologic response was achieved by 318 (81.1%). IR was detected in 241 (61.5%) chronic HCV patient of which 73.4% responded to treatment. Early virologic response among patients with > 2.18 HOMA-IR value were significantly lower than those with HOMA-IR values ≤2.18 (P < 0.0001). IR was significantly associated with high baseline BMI. Steatosis and fibrosis correlated with IR but neither independently predicted early virologic response. Pretreatment IR < 2.18, low fasting blood glucose, low and intermediate HCV viral load, normal BMI, and non-smoking were independent factors associated with early virologic response. IR interferes with early virologic response to the antiviral care. Clinical application of pretreatment HOMA-IR assessment could help in predicting early treatment outcome and thus enable treatment regimens to be optimized and individually tailored.

Toward a simple risk assessment screening tool for HCV infection in Egypt

Asymptomatic patients with HCV infection identified through screening program could benefit not only from treatment but also from other interventions such as counseling to maintain health and avoid risk behaviors. This might prevent the spread of infection and result in significant public health benefits. However, mass screening would quickly deplete resources. This work aims to develop a brief HCV risk assessment questionnaire that inquires initially about a wide range of risk factors found to be potentially associated with HCV infection in order to identify the few most significant questions that could be quickly used to facilitate cost-effective HCV case-finding in the general population in Egypt. An exhaustive literature search was done to include all reported HCV risk factors that were pooled in a 65 item questionnaire. After an initial pilot study, a case-control study was performed that included 1,024 cases and 1,046 controls. In a multivariable model, a list of independent risk factors were found to be significant predictors for being HCV seropositive among two age strata (<45 and >45 years) for each gender. A simplified model that assigned values of the odds ratio as a weight for each factor present predicted HCV infection with high diagnostic accuracy. Attaining the defined cut-off value of the total risk score enhances the effectiveness of screening. HCV risk factors in the Egyptian population vary by age and gender. An accurate prediction screening tool can be used to identify those at high risk who may benefit most from HCV serologic testing. These results are to be further validated in a large scale cross-sectional study to assess the wider use of this tool. J. Med. Virol. 88:1767-1775, 2016. © 2016 Wiley Periodicals, Inc.

Validation of a Non-Laboratory Based Screening Tool for Predicting Non-Alcoholic Fatty Liver Disease in an Egyptian Setting

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is a common chronic liver disorder in more than 20% of the general population worldwide.  Several combinations of non-invasive factors and scoring models were investigated as indicators of NAFLD. This study aimed to validate and adapt an established fatty liver score, which allows the identification of NAFLD based on routinely available clinical and laboratory data.

MATERIALS AND METHODS

The study cohort comprised 190 adults seeking health check-up at the out-patient clinic of a tertiary care hospital in Alexandria, Egypt. Anthropometric, clinical, and laboratory data were recorded and the status of fatty liver was diagnosed by abdominal ultrasound. A logistic regression model was built to determine the predictors of NAFLD. The performance of the derived risk scores was compared to other existing models.

RESULTS

Obesity (60.0%), metabolic syndrome (42.6%), and NAFLD (56.8%) were predominant features among the study population. Smoking [OR (95% CI) = 4.4 (0.9-21.4)], obesity [OR (95% CI) = 4.0 (1.7-9.7)], hypertension [OR (95% CI) = 2.4 (1.03-5.5)], elevated serum total cholesterol [OR (95% CI) = 4.8 (1.8-13.1)], triglycerides [OR (95% CI) = 11.8 (2.3-661.02)], and ALT [OR (95% CI) = 4.8 (1.8-13.1)] were multivariate predictors of NAFLD. A NAFLD screening questionnaire with values applicable for Egyptians was adapted from an existing model after validation. A total score ≥7 was suggestive of NAFLD [AUC = 0.810 (0.749-0.871); sensitivity = 87.0%; specificity = 62.2%; PPV = 75.2%; NPV = 78.5%].

CONCLUSIONS

NAFLD can be sufficiently predicted among apparently healthy Egyptians by a tempted simple and non-invasive scoring index although external validation is warranted.

Seroprevalence of HBV among Egyptian municipal solid waste workers

Background

Municipal solid waste workers (MSWWs) are potentially exposed to diverse hazards that are not merely a consequence of their occupation. Of particular concern are infectious diseases. The endemicity of hepatitis B virus (HBV) infection in Egypt suggests the possibility of disease transmission in MSWWs from improperly disposed hazardous materials found in the solid waste stream. To date, such transmission has not adequately been epidemiologically studied in Egypt.

Objective

To explore the seroprevalence of HBV among MSWWs in Egypt.

Methods

We conducted a descriptive cross-sectional study that included 1467 MSWWs recruited from the main municipality company in Alexandria, Egypt, in February 2018. The enrolled participants were categorized into two occupational groups (exposed; n = 1361 and non-exposed; n = 115) on the basis of their direct exposure to solid waste. The study procedure involved interviews using a predesigned questionnaire that covered general demographic information. Blood samples from all participants were tested for the hepatitis B surface antigen (HBsAg), a marker of active HBV infection, using a third-generation enzyme linked immunosorbent assay (ELISA).

Results

All MSWWs were male and had a mean age of 39.8 (±7.9) years. The majority were urban residents (72.8%) and engaged in solid waste collection (63.8%) or sorting (13.6%). The overall seroprevalence of active HBV infection was 1.5%. In total, 3.8% of the workers received the compulsory HBV vaccine during their infancy, meaning approximately 96.2% of the participants were at risk for HBV infection. Evaluating the availability and use of personal protective equipment revealed that most of the workers were provided with and wore overalls but not safety shoes, protective gloves, face masks, or helmets.

Conclusion

The present work suggests the possible transmission of HBV in workers exposed to municipal solid waste. This result necessitates the initiation of prophylactic HBV immunizations and the consideration of safer techniques for waste management.

Oxidative stress and adverse cardiovascular effects among professional divers in Egypt

Professional divers are exposed to unique multifactorial hazards in their working environment and adverse cardiovascular effects such as ischemia, arrhythmia, stroke, and death are associated with professional diving. Cardiovascular events are aggravated by diving-induced oxidative stress and account for one-fourth of diving fatalities. This study aimed to measure oxidative and cardiovascular stress in a group of professional divers in Alexandria, Egypt using a panel of biomarkers. A comparative cross-sectional study was conducted between June 2017 and May 2018 at the General Naval Hospital in Alexandria. A total of 50 professional divers and a comparison group of 50 marine seafarers sharing similar maritime environments were enrolled in the study. Participants were clinically evaluated by electrocardiography (ECG) and plasma measurement of trace metals (Fe⁺, Cu⁺, and Zn⁺), electrolytes (Na⁺, K⁺, Ca⁺), and oxidative stress biomarkers (OSBMs; MDA, TAS, GST, GSH, GR, GPx, SOD, and CAT). Significant ECG abnormalities including short corrected QT interval, sinus bradycardia, left ventricular hypertrophy, early repolarization, first-degree heart block, and intraventricular conduction defect were identified among divers. Biochemical analyses revealed high mean levels of FBG [89.0 ± 12.46 vs. 100.5 ± 29.03 mg/dl], LDH-C [41.46 ± 4.01 vs. 39.34 ± 4.34 mg/dl], electrolyte imbalance [higher Na⁺ (9.44 ± 0.52 vs. 9.19 ± 0.60 mmol/L), and lower Ca⁺ (141.72 ± 3.53 and 143.26 ± 3.99 mmol/L)], disturbed trace metals [Fe⁺ and Zn⁺ (101.1 ± 38.17 vs. 147.6 ± 38.08 and 85.52 ± 27.37 vs. 116.6 ± 21.95 µm/dl, respectively), higher Cu+ (271.3 ± 75.01 vs. 100.8 ± 30.20 µm/dl)], and higher OSBMs (high MDA and reduced CAT, GPx, GSH, GR, and GST enzyme levels) among professional divers compared to the marine seafarers (t-test p < 0.05). Oxidative stress and trace metal imbalance are associated with the pathophysiology of cardiovascular disease; this association, together with electrophysiological changes of ECG may serve as biomarkers for cardiovascular risk assessment in diver periodic medical examinations.

How accurate is the diagnosis of rheumatic fever in Egypt? Data from the national rheumatic heart disease prevention and control program (2006-2018)

Rheumatic heart disease (RHD) as a chronic sequela of repeated episodes of acute rheumatic fever (ARF), remains a cause of cardiac morbidity in Egypt although it is given full attention through a national RHD prevention and control program. The present report reviews our experience with subjects presenting with ARF or its sequelae in a single RHD centre and describes the disease pattern over the last decade. A cross-sectional study was conducted in El-Mahalla RHD centre between 2006 and 2018. A total of 17014 individual were enrolled and evaluated. Diagnosis ARF was based on the 2015 revised Jones criteria and RHD was ruled in by echocardiography. The majority of the screened subjects were female (63.2%), in the age group 5-15 years (64.6%), rural residents (61.2%), had primary education (43.0%), and of low socioeconomic standard (50.2%). The total percentage of cases presenting with ARF sequelae was 29.3% [carditis/RHD (10.8%), rheumatic arthritis (Rh.A) (14.9%), and Sydenham's chorea (0.05%)]. Noticeably, 72% were free of any cardiac insult, of which 37.7% were victims of misdiagnoses made elsewhere by untrained practitioners who prescribed for them long term injectable long-acting penicillin [Benzathine Penicillin G (BPG)] without need. About 54% of the study cohort reported the occurrence of recurrent attacks of tonsillitis of which 65.2% underwent tonsillectomy. Among those who experienced tonsillectomy and/or received BPG in the past, 14.5% and 22.3% respectively had eventually developed RHD. Screening of family members of some RHD cases who needed cardiac surgery revealed 20.7% with undiagnosed ARF sequalae [RHD (56.0%) and Rh.A (52.2%)]. Upon the follow-up of RHD cases, 1.2% had improved, 98.4% were stable and 0.4% had their heart condition deteriorated. Misdiagnosis of ARF or its sequelae and poor compliance with BPG use may affect efforts being exerted to curtail the disease. Updating national guidelines, capacity building, and reliance on appropriate investigations should be emphasized. Since the genetic basis of RHD is literally confirmed, a family history of RHD warrants screening of all family members for early detection of the disease.

Sofosbuvir-/Daclatasvir-based therapy for chronic HCV and HCV/hepatitis B virus coinfected patients in Egypt

BACKGROUND

Dramatic advances in hepatitis C virus (HCV) treatment were witnessed with the introduction of direct-acting antivirals (DAAs). Generic DAAs with remarkable efficacy and good safety profiles are currently manufactured by local pharmaceutical companies in Egypt.

METHODS

In the real-world setting, of a total of 367 patients chronically infected with HCV, 289 (277 treatment-naïve and 12 treatment-experienced) patients were enrolled. Approximately 15% of the patients were coinfected with hepatitis B virus (HBV). Patients were treated with sofosbuvir+daclatasvir with or without ribavirin for 12 or 24 wk as the standard of care. HBV DNA levels were monitored throughout the study.

RESULTS

A sustained virologic response at 12 wk (SVR12) was achieved in 98.3% of the patients. All non-responders were treatment-naïve and the response rate among treatment-experienced patients was 100.0%. Elevated α-fetoprotein and treatment with sofosbuvir+daclatasvir+ribavirin for 6 mo were predictors of non-response (OR [95% CI] = 1.06 [1.02 to 1.1] and 15.9 [1.8 to 136.2]; p<0.05, respectively). No HBV reactivation was noticed throughout the treatment and follow-up periods in HCV/HBV coinfected patients.

CONCLUSION

The present real-world findings add to the evidence for the efficacy of generic DAAs for the treatment of patients infected with HCV. HBV reactivation is unlikely to occur in those coinfected with HBV. Although liver cirrhosis affected the outcome, pretreatment liver chemistry did not seem to correlate with the results of treatment.

A clinical rule for the prediction of meningitis in HIV patients in the era of combination antiretroviral therapy

BACKGROUND

The diagnosis of meningitis in HIV patients is challenging due to altered immune responses. Diagnostic scoring systems were recently proposed for use in research settings to help prompt and easy differential diagnosis. The objective of this study was to create a clinical prediction rule (CPR) for meningitis in HIV-infected patients and to address the enigma of differentiating bacterial (BM), TB (TBM) and cryptococcal (CCM) meningitis based on clinical features alone, which may be enhanced by easy-to-obtain laboratory testing.

METHODS

We retrospectively enrolled 352 HIV patients presenting with neurological manifestations suggesting meningitis over the last 18 y (2000-2018). Relevant clinical and laboratory information were retrieved from inpatient records. The features independently predicting meningitis or its different types in microbiologically proven meningitis cases were modelled by multivariate logistic regression to create a CPR in an exploratory data set. The performance of the meningitis diagnostic score was assessed and validated in a subset of retrospective data.

RESULTS

AIDS clinical stage, injecting drug use, jaundice and cryptococcal antigen seropositivity were equally important as classic meningitic symptoms in predicting meningitis. Arthralgia and elevated cerebrospinal fluid Lactate dehydrogenase (LDH) were strong predictors of BM. Patients with cryptococcal antigenemia had 25 times the probability of having CCM, whereas neurological deficits were highly suggestive of TBM.

CONCLUSION

The proposed CPRs have good diagnostic potential and would support decision-making in resource-poor settings.