[Risk factors for hepatitis C among injecting drug users in Oslo]

BACKGROUND

Hepatitis C virus (HCV) infection is common among injecting drug users. The aims of this study were to assess the prevalence of risk behaviour and its association with HCV infection.

MATERIAL AND METHODS

All users of the needle exchange program in Oslo, within a given time period, were eligible for inclusion in this cross-sectional study; 327 chose to participate. The users were asked about type of drug use and risk behaviour for HCV exposure in a structured interview. Sera were drawn and tested for anti HCV (EIA-3) and HCV RNA (in- house PCR).

RESULTS

The prevalence of HCV RNA was 51 % and 81 % had anti-HCV. A multivariate analysis revealed positive associations between anti-HCV positive status and age < 20 years at first injection, > 5 years of drug use, age > 34 years, sharing of syringes, injecting drug use while imprisoned, back-loading and use of heroin. One in five users with anti-HCV reported to never have shared syringes. However, sharing of drug paraphernalia other than needles was not associated with anti-HCV. Sharing of needles the last four weeks before the interview was more common among those living with a partner than those who lived alone.

INTERPRETATION

Most injecting drug users in Oslo have been exposed to HCV (anti HCV+) and half of them have developed chronic infection (HCV RNA+). HCV was associated with back-loading and sharing of syringes - especially during incarceration. Sharing of injection paraphernalia was not associated with being anti HCV positive.

[Hepatitis C--a health problem also in Norway]

BACKGROUND

Hepatitis C is a large global health problem; approximately 20 - 30 000 are infected in Norway. Hepatitis C-infection is often chronic and can progress into chronic liver disease, liver cirrhosis and hepatocellular carcinoma. The most important transmission route is through percutaneous exposure to infected blood. The aim of this article is to describe the clinical course, microbiological diagnostic approaches, therapy, prophylaxis and public health aspects of Hepatitis C infection.

MATERIAL AND METHODS

The paper is based on results from annual health examinations (conducted since 2001) of persons who abuse drugs intravenously in Oslo, from diagnostic work in a national reference laboratory for Hepatitis C and studies of literature (retrieved from Pubmed).

RESULTS AND INTERPRETATION

The prevalence of Hepatitis C varies by country and subgroup of patients. In Norway the prevalence is 0.13 % among new blood donors, 0.7 % among pregnant women, 0.55 % in the general adult population and approximately 70 % among persons who abuse drugs intravenously. Treatment with pegylated interferon and ribavirin induces sustained virological response in 80 % of patients with genotypes 2 and 3 and in 30 - 40 % of those with genotype 1.

Pegylated interferon alfa and ribavirin for 14 versus 24 weeks in patients with hepatitis C virus genotype 2 or 3 and rapid virological response

A recent nonrandomized pilot trial showed that hepatitis C virus (HCV) patients with genotype 2/3 and rapid virological response (RVR) had a 90% sustained virological response (SVR) rate after 14 weeks of treatment. We aimed to assess this concept in a randomized controlled trial. In the trial, 428 treatment-naïve HCV RNA-positive patients with genotype 2 or 3 were enrolled. Patients with RVR were randomized to 14 (group A) or 24 (group B) weeks of treatment. Patients were treated with pegylated interferon alpha-2b (1.5 microg/kg) subcutaneously weekly and ribavirin (800-1400 mg) orally daily. The noninferiority margin was set to be 10% between the two groups with a one-sided 2.5% significance level. RVR was obtained in 302 of 428 (71%), and 298 of these were randomized to group A (n = 148) or group B (n = 150). In the intention-to-treat analysis, SVR rates were 120 of 148 (81.1%) in group A and 136 of 150 (90.7%) in group B (difference, 9.6%; 95% confidence interval, 1.7-17.7). Among patients with an HCV RNA test 24 weeks after the end of treatment, 120 of 139 (86.3%) patients in group A achieved SVR compared with 136 of 146 (93.2%) in group B (difference, 6.9%; 95% confidence interval, -0.1 to +13.9).

CONCLUSION

We cannot formally claim that 14 weeks of treatment is noninferior to 24 weeks of treatment. However, the SVR rate after 14 weeks of treatment is high, and although longer treatment may give slightly better SVR, we believe economical savings and fewer side effects make it rational to treat patients with genotype 2 or 3 and RVR for only 14 weeks.

Predictors of compliance with psychological interventions offered in the community

BACKGROUND

This study sought to evaluate the acceptance of two brief psychological interventions for depressed individuals, contacted through a community survey, and to look for predictors of adherence at the patient level.

METHOD

The authors used data from the Outcomes of Depression International Network (ODIN) study, which included a randomized controlled trial in which depressed individuals from five European countries, and nine geographical areas were assigned to one of three groups: individual problem-solving treatment, group psychoeducation, or control group. In this analysis, we included all of the individuals who had been assigned to one of the psychological interventions. Compliance with intervention was defined in two different ways. Multiple logistic regression was used to see which variables might predict an individual's compliance with psychological treatment.

RESULTS

Psychological intervention was offered to 236 subjects. Treatment was completed by 128 subjects and not by 108 (compliance definition A). Three variables were found to have an effect on compliance A: the presence of a confidant, the use of antidepressant medication during the previous 6 months, and the previous use of any social or health services. On the other hand, 164 subjects had agreed to at least start the treatment, and 72 had not (compliance definition B). The three factors associated with compliance B were presence of a confidant, previous use of services, and the 'desire for change' score.

CONCLUSIONS

Social support and previous use of services are the main predictors of compliance with a psychological treatment in depressed individuals from the community. Implications for clinical practice and community programs are discussed.

Short-term therapy for patients with hepatitis C virus genotype 2 or 3 infection

In the past 10 years, progress has been made in the management of patients with chronic hepatitis C. A sustained virological response (SVR) is achieved in 80-85% of patients infected with hepatitis C virus (HCV) genotype 2 or 3 after 24 weeks of treatment with peginterferon-alpha and ribavirin. Treatment durations <24 weeks have been investigated to determine whether shorter-term therapy reduces adverse effects and costs compared with longer-term therapy without compromising efficacy. Three studies involving only patients with HCV genotype 2 or 3, with different baseline patient characteristics have shown that 12-16 weeks of treatment can be as effective as 24 weeks of treatment. In all three trials, undetectable HCV RNA 4 weeks after the start of treatment was defined as rapid virological response (RVR), and only patients with RVR stopped treatment early. In the first trial, 75% of patients treated with peginterferon-alpha-2b and ribavirin achieved RVR; these rapid responders achieved an SVR rate of 90% after 14 weeks of treatment. In the second trial, 63% of patients achieved RVR after 4 weeks of treatment with peginterferon-alpha-2b and ribavirin, and 85% of patients with RVR achieved SVR after 12 weeks of treatment. In comparison, 91% of patients with RVR treated for 24 weeks had SVR. In the third study, 93% of the total study population achieved RVR and were randomly assigned to 16 or 24 weeks of treatment with peginterferon-alpha-2a and ribavirin. Among patients with RVR, 85% in the group treated for 16 weeks and 80% in the group treated for 24 weeks achieved SVR. Among patients with HCV genotype 2 or 3, achieving an RVR to interferon-based treatment is common and a criterion to reduce the duration of treatment. In patients with genotype 2 and RVR, 12 weeks of therapy with peginterferon-alpha and ribavirin is recommended. For patients with genotype 3, a univocal recommendation on treatment duration cannot be made. However, ongoing trials will probably clarify this aspect.

Follow-up studies of treatment for hepatitis C virus infection among injection drug users

Physicians are reluctant to treat chronic hepatitis C virus (HCV) infection in active injection drug users (IDUs). An important reason for this is concern about reinfection after successful treatment. However, little is known about this apparent risk; because of lack of protective immunity, reinfection with HCV seems possible. Here, I discuss several cases of probable reinfection in IDUs, 2 of which occurred during or after successful treatment for HCV infection. In a Norwegian trial, 69 IDUs who had abstained from drug use for >or=6 months were treated for HCV infection; of these, 27 tested negative for HCV RNA at 6 months of follow-up (sustained virological response). At 5 years of follow-up, 9 (33%) of the 27 IDUs with sustained virological response had returned to drug use, but only 1 case of reinfection was observed. In another study, 395 subjects with sustained virological response were followed with yearly testing for HCV RNA. Although injection drug use was the route of HCV transmission in 40% of the subjects, only 7 (2%) experienced a late relapse of HCV infection. It has not been determined whether any of these cases were actual reinfections. Available data suggest that the rate of long-term response to treatment for HCV infection is excellent in IDUs.

Short-term treatment duration for HCV-2 and HCV-3 infected patients

BACKGROUND

We have shown that 12-14 weeks treatment is effective in HCV-2 or -3 patients with undetectable HCV-RNA after 4 weeks of therapy (rapid virologic response).

PATIENTS

To identify predictors of sustained virologic response, rapid virologic response and relapse following short treatment, we pooled data from the original Italian and Norwegian studies. Four hundreds and three patients were treated with PegIFN alpha-2b (1.0, n=281 or 1.5 microg/kg, n=122) and ribavirin (800-1200 mg) for 12-14 or 24 weeks, depending on negative or positive HCV-RNA at week 4.

RESULTS

Sustained virologic response differed between cases with and without rapid virologic response (85% versus 62%, P<0.0001), mild and severe fibrosis (83% versus 67%, P=0.004), and HCV-2 and -3 (81% versus 73%, P=0.05). In a regression model, RVR (odds ratio 3.49, confidence interval 1.73-5.36) and mild fibrosis (odds ratio 2.91, confidence interval 1.57-5.38) independently predicted sustained virologic response. Rapid virologic response was obtained in 274 (68%) patients, 163/242 (67%) HCV-2, and 111/161 (69%) HCV-3. Patients with RVR had more frequently mild fibrosis (70% versus 54%, P=0.03), and high PegIFN dose (78% versus 64%, P=0.005). In a regression model, mild fibrosis independently predicted rapid virologic response (odds ratio 1.87, confidence interval 1.10-3.16). In rapid virologic response patients, sustained virologic response was achieved in 85% of both HCV-2 and -3. Virologic relapse was observed in 10.6% rapid virologic response patients and was more frequent among those with low ALT (14% versus 2%, P=0.04).

CONCLUSION

In HCV-2 or -3, the HCV-RNA status after 4 weeks of therapy may guide treatment duration. HCV-2 and HCV-3 patients with severe fibrosis are less likely to experience both rapid virologic response and sustained virologic response, and more frequently relapse after a 12 or 14 weeks duration of antiviral therapy.

A rapid real-time PCR assay for determination of hepatitis C virus genotypes 1, 2 and 3a

The genotypes of hepatitis C virus (HCV) in serum of patients have been described as independent predictors of success of antiviral therapy. Therefore, different antiviral regimens have been proposed depending on the infecting HCV genotype. HCV strain is usually determined by polymerase chain reaction (PCR) amplification of genome followed by sequencing or by line-probe assays. We report a new one step real-time PCR assay for genotyping of HCV strains that are prevalent in patients in Norway. HCV types 1, 2 and 3a were genotyped unambiguously in 37 patient serum samples with 100% correlation to genotyping by nucleotide sequence analysis and line-probe assays. Genotyping could also be confirmed against an HCV genotype panel from the National Institute for Biological Standards and Control. This assay does not require manipulation of amplified PCR products, it involves very little hands on and analysis time. This assay can be used for rapid genotyping of HCV-RNA in infected patients to aid physicians decide suitability of patients for treatment and subsequent length of treatment.

Treatment with pegylated interferon and ribavarin in HCV infection with genotype 2 or 3 for 14 weeks: a pilot study

The aim of this study was to determine the efficacy of 14 weeks of treatment in patients infected with hepatitis C virus (HCV) genotype 2 or 3 who achieve early virological response (EVR). In a noncontrolled multicenter trial, 122 treatment-naive patients received 1.5 mug/kg pegylated interferon alfa-2b subcutaneously once weekly and 800 to 1,400 mg/d ribavirin based on body weight. Treatment was stopped at week 14 in patients with EVR, defined as undetectable HCV RNA at weeks 4 and 8. Patients without EVR were assigned to 24 weeks of treatment. The primary end point was sustained virological response (SVR), defined as undetectable HCV RNA 24 weeks after end of treatment. Among the 122 patients, 95 (78%) had EVR and received 14 weeks of treatment. The remaining 27 (22%) were treated for 24 weeks. SVR was obtained in 85 (90%) of 95 patients in the 14-week treatment group and 15 of (56%) 27 in the 24-week treatment group. Altogether, SVR was obtained in 100 of 122 patients (82%; 95% CI, 75%-89%). SVR after 14 weeks of treatment was achieved more frequently among genotype 3a patients with low viral load compared with high viral load (98% vs. 79%; P = .019). Logistic regression analysis showed that absence of bridging fibrosis/cirrhosis was the only independent predictor of SVR. In conclusion, patients with genotype 2 or 3 and EVR obtained a high SVR after 14 weeks of treatment. The results need to be confirmed in a randomized, controlled study before this treatment approach can be recommended, particularly for patients with genotype 3 and high viral load or severe fibrosis.

Health-related quality of life in active injecting drug users with and without chronic hepatitis C virus infection

This study assessed the effect of chronic hepatitis C virus (HCV) infection on the health-related quality of life (HRQOL) of injecting drug users, comparing the HRQOL of injecting drug users with and without chronic HCV infection. The study included 199 injecting drug users of more than 18 years of age who participated in a needle exchange program. Blood samples were tested for the presence of HCV RNA in serum with a polymerase chain reaction method. HRQOL was measured using the questionnaire SF-36, measuring HRQOL over the last 4 wk. The HCV RNA test was positive in 102 (51%) and negative in 97 (49%) subjects. The HRQOL scores of actively injecting drug users were markedly reduced compared to the population norm. However, we did not find poorer HRQOL in injecting drug users with chronic HCV infection than in injecting drug users without HCV infection. HCV RNA positive injecting drug users who were aware of the infection had lower HRQOL scores than those unaware of the infection in 4 of the 8 SF-36 dimensions (general health, physical functioning, physical role, and vitality). HCV RNA negative subjects, who believed they were infected, scored worse in one dimension (general health) compared to those who did not believe they were infected. In conclusion, chronic HCV infection per se did not negatively affect the HRQOL of active injecting drug users. Those who thought they were infected had a lower HRQOL scores than those who believed they were not infected.

Hepatitis C in the general adult population of Oslo: prevalence and clinical spectrum

BACKGROUND

The prevalence of hepatitis C (HCV) in Northern Europe has not been well described. This study aimed to estimate the prevalence and spectrum of hepatitis C infection in the general adult population of Oslo, Norway.

METHODS

The study was part of the Oslo Health Study 2000-2001 and included a random selection of individuals older than 30 years living in Oslo County. Sera from 11,456 participants were screened for anti-HCV (EIA-3), positive samples were confirmed (RIBA-3) and examined for HCV RNA (PCR). All anti-HCV positive patients were offered clinical evaluation. Routine biochemical liver tests were performed. Candidates for HCV treatment were asked to undergo a percutanous liver biopsy.

RESULTS

Among 11,456 participants HCV RNA was detected in 62 (0.5%) and HCV RNA with raised serum alanine aminotransferase (ALT) in 46 (0.4%). Anti-HCV was detected in 78 (0.7%) with a peak prevalence of 1.5% among subjects 40 and 45 years old. Being anti-HCV positive was associated with being unmarried, unemployed and having low education. Anti-HCV prevalence was higher among subjects with alcohol-related problems compared to those without (4.4% versus 0.6%, P < 0.001). It was also higher among smokers compared to non-smokers (2.0% versus 0.2%, P < 0.001). In 33 liver biopsies, bridging fibrosis was seen in 8 (24%) and cirrhosis in 1 (3%). The route of transmission was injecting drug use in 67%, transfusion in 6% and unknown in 27%.

CONCLUSION

In this population-based survey the prevalence of chronic hepatitis C was 0.5% and ALT was raised in 80% of those with chronic infection.

Thyroid dysfunction during treatment of chronic hepatitis C with interferon alpha: no association with either interferon dosage or efficacy of therapy

OBJECTIVES

Treatment of chronic hepatitis C with interferon-alpha (IFN-alpha) may induce thyroid disorders. We evaluated whether this risk is related to the dosage of IFN-alpha or the virological treatment response. Other possible risk factors as well as the evolution of the thyroid abnormalities were also studied.

METHODS

In this prospective trial (n=254), thyroid-stimulating hormone (TSH), free thyroxin (fT4) and thyroid peroxidase autoantibodies were measured before, during and after treatment for hepatitis C virus (HCV). The patients were randomized to either induction therapy [IFN-alpha 6 million units (MIU) daily for 4 weeks and 3 MIU 3/7 days for 22 weeks] or conventional therapy [IFN-alpha 3 MIU 3/7 days for 26 weeks]. In addition, all patients received ribavirin (1000 or 1200 mg) daily. Sustained virological response was defined as loss of detectable HCV RNA at 6 months follow-up. Thyroid dysfunction was defined as TSH level below or above the normal range (0.2-4.5 MIU L-1).

RESULTS

Biochemical thyroid dysfunction developed in 30 (11.8%) of 254 patients. Hypothyroidism (TSH > 4.5 MIU L-1) was seen in 20 and hyperthyroidism (TSH < 0.2 MIU L-1) in 10 patients. Nine of the 30 patients developed symptomatic thyroid disease and HCV treatment was discontinued because of thyroid dysfunction in three of these patients. Thyroid dysfunction occurred in 15 (11.7%) of 128 patients who received high-dose IFN-alpha induction therapy as compared with 15 (11.9%) of 126 patients who received conventional IFN-alpha therapy (P=0.96). Amongst 231 patients who completed all 6 months of HCV treatment, a sustained virological response was obtained in 19 (66%) of 29 with thyroid dysfunction and 109 (54%) of 202 without (P=0.24). By multivariate analysis female gender and Asian origin were independent predictors of developing biochemical thyroid dysfunction (P < 0.01).

CONCLUSION

Thyroid dysfunction occurred in 11.8% of patients treated for chronic hepatitis C with IFN-alpha and ribavirin. Neither the IFN-alpha dosage nor the virological response to treatment were related to the incidence of thyroid dysfunction.

Treatment of chronic hepatitis C in injecting drug users: 5 years' follow-up

AIM OF THE STUDY

To assess the long-term hepatitis C (HCV) treatment outcome in former injecting drug users (IDUs).

MATERIALS AND METHODS

A long-term follow-up of 27 former IDUs who had been successfully treated for chronic hepatitis C was performed. These patients represented all IDUs who had obtained a sustained virological response in a Norwegian HCV treatment trial. The patients had been treated with interferon-alpha alone or in combination with ribavirin. At 5 years' follow-up the 27 IDUs were retested for HCV RNA and risk behaviour for HCV transmission after treatment was assessed. In the control group all 18 non-IDUs who had obtained a sustained virological response in the same treatment trial were included.

RESULTS

At follow-up 13-82 months (median 64) after the end of treatment only one case of probable reinfection was seen among the 27 IUDs. No reoccurrence of HCV was observed in the control group. The IDU who was HCV RNA positive at follow-up had continued injecting drugs and reported frequent needle sharing. At follow-up HCV of genotype 1a was detected in contrast to genotype 1b before treatment indicating that this patient was reinfected with HCV. A return to injecting drug use occurred in 9 (33%) of 27 IDUs.

CONCLUSION

The long-term outcome of HCV treatment in former IDUs was excellent. Despite frequent reinitiation of drug injection all but 1 remained HCV RNA negative.

[Serious bacterial and fungal infections in intravenous drug addicts]

Invasive infections caused by bacteria and fungi are common complications of intravenous drug abuse. Various vital organs and structures may be affected, e.g. the cardiac valves, the larger arteries, the bones, the joints and the central nervous system. However, due to the high frequency of low-virulent microbes of skin and oral origin, the clinical picture may be atypical with subacute course and few focal signs and symptoms. The complexity of this problem is illustrated by eight cases of serious bacterial and fungal infections recently diagnosed at our hospitals. All patients were HIV negative intravenous heroin addicts. The clinical spectrum was wide and included skin abscesses, pyomyositis, spondylodiscitis, septic arthritis, costal osteomyelitis, infective endocarditis, recurrent bacteraemia, and multiple brain abscesses.

Outcomes of Depression International Network (ODIN). Background, methods and field trials. ODIN Group

BACKGROUND

ODIN aims (a) to provide data on the prevalence, risk factors and outcome of depressive disorders in rural and urban settings within the European Union (EU) based on an epidemiological sampling frame; and (b) to assess the impact of two psychological interventions on the outcome of depression and on service utilisation and costs.

METHOD

Five centres across the EU are participating in ODIN. The centres are linked electronically and members meet regularly for training and strategic reviews. Urban and rural areas have been identified in each centre. The sampling frame is of adults aged 18-64, identified via primary care databases or electoral registers. Potential cases of depressive disorders are identified using the Beck Depression Inventory SCAN II and other validated measures are used to assign caseness against DSM-IV and ICD-10 criteria; assess comorbidity, disability, genetic/familial susceptibility, psychosocial stressors, personality traits and cognitive factors; and utilisation of local health care services. A randomised controlled trial of individual problem-solving treatment and a group educational programme is undertaken for respondents identified as cases of depressive disorder individuals are followed-up at six and 12 months.

RESULTS AND CONCLUSIONS

ODIN has already stimulated the development of an effective international research partnership.