Spatial epidemiology of hepatitis C virus infection in Egypt: analyses and implications

The role of high-risk geographies in the perpetuation of the HIV epidemic in rural South Africa: A spatial molecular epidemiology study

In this study, we hypothesize that HIV geographical clusters (geospatial areas with significantly higher numbers of HIV positive individuals) can behave as the highly connected nodes in the transmission network. Using data come from one of the most comprehensive demographic surveillance systems in Africa, we found that more than 70% of the HIV transmission links identified were directly connected to an HIV geographical cluster located in a peri-urban area. Moreover, we identified a single central large community of highly connected nodes located within the HIV cluster. This module was composed by nodes highly connected among them, forming a central structure of the network that was also connected with the small sparser modules located outside of the HIV geographical cluster. Our study supports the evidence of the high level of connectivity between HIV geographical high-risk populations and the entire community.

Community-Based Screening for Hepatitis B and C Infectivity Using Two Quantitative Antigens to Identify Endemic Townships

Screening and linkage to care are essential to achieve viral hepatitis elimination before 2030. The accurate identification of endemic areas is important for controlling diseases with geographic aggregation. Viral activity drives prognosis of chronic hepatitis B and hepatitis C virus infection. This screening was conducted in Chiayi County from 2018–2019. All residents aged 30 years or older were invited to participate in quantitative HBsAg (qHBsAg) and HCV Ag screening. Among the 4010 participants (male:female = 1630:2380), the prevalence of qHBsAg and HCV Ag was 9.9% (396/4010) and 4.1% (163/4010), respectively. High-prevalence townships were identified, three for qHBsAg > 15% and two for HCV Ag > 10%. The age-specific prevalence of qHBsAg was distributed in an inverse U-shape with a peak (16.0%, 68/424) for subjects in their 40 s; for HCV, prevalence increased with age. Concentrations of qHBsAg < 200 IU/mL were found in 54% (214/396) of carriers. The rate of oral antiviral treatment for HCV was 75.5% (114/151), with subjects younger than 75 years tending to undergo treatment (85.6% vs. 57.4%, p < 0.001). QHBsAg and HCV Ag core antigens can reflect the concentration of the viral load, which serves as a feasible screening tool. Using quantitative antigen screening for hepatitis B and C in community-based screening, two hyperendemic townships were identified from an endemic county.

Current situation of viral hepatitis in Egypt

An estimated 8-10 million people suffer from viral hepatitis in Egypt. Hepatitis A virus (HAV) and hepatitis E virus (HEV) are the major causes of viral hepatitis in Egypt as 50% or more of the Egyptian population are already exposed to HAV infection by the age of 15. In addition, over 60% of the Egyptian population test seropositive for anti-HEV in the first decade of life. HEV mainly causes self-limiting hepatitis; however, cases of fulminant hepatitis and liver failure were reported in Egypt. Hepatitis B virus (HBV), hepatitis C virus (HCV), and hepatitis D virus (HDV) are the main causes of chronic hepatitis, liver cirrhosis, and liver cancer (hepatocellular carcinoma [HCC]) in Egypt. Globally, Egypt had the highest age-standardized death rate due to cirrhosis from 1990 to 2017. The prevalence rate of HBV (1.3%-1.5%) has declined after national infantile immunization. Coinfection of HBV patients with HDV is common in Egypt because HDV antibodies (IgG) vary in range from 8.3% to 43% among total HBV patients. After the conduction of multiple national programs to control HCV infection, a lower rate of HCV prevalence (4.6%) was recently reported. Data about the incidence of HCV after treatment with direct antiviral agents (DAAs) are lacking. An HCC incidence of 29/1000/year in cirrhotic patients after DAA treatment is reported. A higher rate of infiltrative pattern among HCC patients after DAA treatment is also recognized. Viral hepatitis is one of the major public health concerns in Egypt that needs more attention and funding from health policymakers.

Occult hepatitis C virus infection in patients with malignant lymphoproliferative disorders

Despite the link between HCV and malignant lymphoproliferative disorders has been established, the association between occult hepatitis C virus infection and malignant lymphoproliferative disorders remains obscure. The present study intended to identify the possible association between occult HCV infection and malignant lymphoproliferative disorders. Newly diagnosed patients with LPDs were screened for the presence of HCV-RNA in both plasma and PBMCs. PBMCs of the subjects were also, examined by transmission and immuno-electron microscopy. LPD patients showed a high percentage of HCV infection (71.9%): OCI-HCV (37.5%) and HCV (34.38%). Meanwhile, 28.13% of LPD patients did not show any evidence of HCV infection. Ultrastructural examination of PBMCs revealed the presence of intracytoplasmic vacuoles enclosing viral like particles, which were less prominent in occult HCV patients. The possibility of occult HCV should be considered in patients with LPDs which can be helpful in the management of the treatment protocol in order to set up a balance between the control of the tumor progression and minimizing post chemotherapy complications related to HCV infection.

Characterizing the historical role of parenteral antischistosomal therapy in hepatitis C virus transmission in Egypt

Background

Egypt is the nation most affected by hepatitis C virus (HCV) infection, following an epidemic of historic proportions. We aimed to characterize the epidemic’s historical evolution and to delineate the role of parenteral antischistosomal therapy (PAT) campaigns in transmission.

Methods

A mathematical model was constructed and analysed in order to understand HCV-transmission dynamics. The model was fitted to Egypt’s Demographic and Health Survey data and to a systematic database of HCV-prevalence data.

Results

The incidence rate peaked in 1966 at 15.7 infections per 1000 person-years—a period of time that coincides with the PAT campaigns—and rapidly declined thereafter, beginning the mid-1990s. The annual number of new infections peaked in 1993 at 581 200 (with rapid demographic growth), leading to a high-incidence-cohort effect, and declined to 67 800 by 2018. The number of individuals ever infected (1950–2018) was 16.4 million, with HCV prevalence peaking in 1979. The number of individuals ever exposed to PAT was 8.3 million; however, of these individuals, 7.3 million were alive in 1980 and only 3.5 million alive in 2018. The number of individuals ever infected due to PAT exposure was 963 900, with 850 200 individuals alive in 1980 and only 389 800 alive in 2018. The proportion of PAT-attributed prevalent infections peaked at 19.9% in 1972, declining to 5.5% by 2018.

Conclusions

PAT campaigns played an important role in HCV transmission, yet explain only 6% of infections—they appear to be a manifestation, rather than a cause, of the epidemic. A possible driver of the epidemic could be the mass expansion of inadequate-quality healthcare during PAT campaigns and subsequent decades. Despite a historic toll, the epidemic has been rapidly diminishing since the mid-1990s.

Body mass index (BMI) and alpha-fetoprotein (AFP) level correlate with the severity of HCV-induced fibrosis in a cohort of Egyptian patients with chronic HCV

Background

Viral hepatitis is the seventh leading cause of mortality globally, and half of this mortality is attributed to hepatitis C virus (HCV). Egypt has the highest HCV prevalence worldwide, with an estimated 14.7% of the population being HCV-positive. HCV infection is the primary cause of liver fibrosis, cirrhosis, and hepatocellular carcinoma. Liver fibrosis varies in severity during chronic HCV infection, and 10–20% of chronic hepatitis C (CHC) patients with severe fibrosis develop cirrhosis. The goal of this work was to assess the clinico-demographic predictors of severity of HCV-induced fibrosis in a cohort of Egyptian patients.

Results

A cohort of Egyptian patients with chronic HCV genotype 4a infection showed significant association between severe fibrosis stages and obesity, represented by a higher body mass index (BMI), low albumin level, high alpha-fetoprotein (AFP) level, low thyroid-stimulating hormone (TSH) level, and high alkaline phosphatase (ALP) level. Multivariate analysis delineated BMI, TSH, and ALP as independent significant variables that could predict the risk of fibrosis severity in HCV infections.

Conclusion

This study argues in favor of using the biomarker profile of CHC patients infected with HCV genotype 4a to identify patients at higher risk of developing severe fibrosis, which is a necessary first step towards precision medicine via patient stratification.

A prospective study in hepatitis C virus treatment-naïve patients showing rheumatologic extra-hepatic manifestations of hepatitis C with associated risk factors: efficacy and safety using sofosbuvir-based direct antiviral therapy

Background

To study the most common rheumatologic manifestations of hepatitis C viral (HCV) infection in Egyptian patients and associated risk factors with assessment the effect of current therapies on these manifestations. A prospective study was carried out to HCV patients attending the tropical medicine department referred to rheumatology department, over a year. A total of 204 hepatitis C virus treatment-naïve patients aged 21–71 years old suffering from rheumatologic manifestations were recruited, and history taking, general and musculoskeletal examination, laboratory and serological investigations, imaging, and liver fibrosis findings were assessed: baseline, end of treatment, and 12 weeks later, either sofosbuvir/ribavirin or sofosbuvir/simeprevir regimens and through three consecutive visits: joint activity and functional scores were taken.

Results

Common observed rheumatologic manifestations were fibromyalgia (74.5%), arthralgia (73.5%), Raynaud’s phenomenon (54.9%), peripheral neuropathy (29.4%),chronic fatigue syndrome and purpura (24.5%), arthritis (16.7%), Sicca symptoms and skin ulcers (9.8%), and vasculitic CNS involvement (5.9%), mostly seen in females. VAS and FAS scales have improved across visits (p value < 0.001) with lowered number and percentage of arthralgia (tender joint counts), arthritis (swollen joint counts), improvement of fibromyalgia, purpura, peripheral neuropathy, anemia, and thrombocytopenia (p < 0.001). Common reported risk factors were barber shaving (52 %), dental procedures (44.1%), and surgical interventions (36.3%). Non-reactive cases shown by HCV-PCR response increased at the end of study reaching 62%. The percent of improvement was significantly higher in patients receiving sofosbuvir/simeprevir regimen (100%) versus sofosbuvir/ribavirin (58.2%).

Conclusion

Direct antiviral drugs seem to improve the rheumatic extra-hepatic manifestations of HCV patients and lowering viremia level especially sofosbuvir/simeprevir regimen in hepatitis C treatment-naïve patients.

A multimethod approach for county-scale geospatial analysis of emerging infectious diseases: a cross-sectional case study of COVID-19 incidence in Germany

Background

As of 13 July 2020, 12.9 million COVID-19 cases have been reported worldwide. Prior studies have demonstrated that local socioeconomic and built environment characteristics may significantly contribute to viral transmission and incidence rates, thereby accounting for some of the spatial variation observed. Due to uncertainties, non-linearities, and multiple interaction effects observed in the associations between COVID-19 incidence and socioeconomic, infrastructural, and built environment characteristics, we present a structured multimethod approach for analysing cross-sectional incidence data within in an Exploratory Spatial Data Analysis (ESDA) framework at the NUTS3 (county) scale.

Methods

By sequentially conducting a geospatial analysis, an heuristic geographical interpretation, a Bayesian machine learning analysis, and parameterising a Generalised Additive Model (GAM), we assessed associations between incidence rates and 368 independent variables describing geographical patterns, socioeconomic risk factors, infrastructure, and features of the build environment. A spatial trend analysis and Local Indicators of Spatial Autocorrelation were used to characterise the geography of age-adjusted COVID-19 incidence rates across Germany, followed by iterative modelling using Bayesian Additive Regression Trees (BART) to identify and measure candidate explanatory variables. Partial dependence plots were derived to quantify and contextualise BART model results, followed by the parameterisation of a GAM to assess correlations.

Results

A strong south-to-north gradient of COVID-19 incidence was identified, facilitating an empirical classification of the study area into two epidemic subregions. All preliminary and final models indicated that location, densities of the built environment, and socioeconomic variables were important predictors of incidence rates in Germany. The top ten predictor variables’ partial dependence exhibited multiple non-linearities in the relationships between key predictor variables and COVID-19 incidence rates. The BART, partial dependence, and GAM results indicate that the strongest predictors of COVID-19 incidence at the county scale were related to community interconnectedness, geographical location, transportation infrastructure, and labour market structure.

Conclusions

The multimethod ESDA approach provided unique insights into spatial and aspatial non-stationarities of COVID-19 incidence in Germany. BART and GAM modelling indicated that geographical configuration, built environment densities, socioeconomic characteristics, and infrastructure all exhibit associations with COVID-19 incidence in Germany when assessed at the county scale. The results suggest that measures to implement social distancing and reduce unnecessary travel may be important methods for reducing contagion, and the authors call for further research to investigate the observed associations to inform prevention and control policy.

Key associations for hepatitis C virus genotypes in the Middle East and North Africa

This study aimed to investigate the epidemiology of hepatitis C virus (HCV) genotypes in the Middle East and North Africa (MENA) through an analytical and quantitative meta-regression methodology. For the most common genotypes 1, 3, and 4, country/subregion explained more than 77% of the variation in the distribution of each genotype. Genotype 1 was common across MENA, and was more present in high-risk clinical populations than in the general population. Genotype 3 was much more present in Afghanistan, Iran, and Pakistan than the rest of countries, and was associated with transmission through injecting drug use. Genotype 4 was broadly disseminated in Egypt in all populations, with overall limited presence elsewhere. While genotype 2 was more present in high-risk clinical populations and people who inject drugs, most of the variation in its distribution remained unexplained. Genotypes 5, 6, and 7 had low or no presence in MENA, limiting the epidemiological inferences that could be drawn. To sum up, geography is the principal determinant of HCV genotype distribution. Genotype 1 is associated with transmission through high-risk clinical procedures, while genotype 3 is associated with injecting drug use. These findings demonstrate the power of such analytical approach, which if extended to other regions and globally, can yield relevant epidemiological inferences.

Hepatitis C Virus Infection in Populations With Liver-Related Diseases in the Middle East and North Africa

We investigated hepatitis C virus (HCV) epidemiology in populations with liver‐related diseases (LRDs) in the Middle East and North Africa. The data source was standardized databases of HCV measures populated through systematic reviews. Random‐effects meta‐analyses and meta‐regressions were performed, and genotype diversity was assessed. Analyses were based on 252 HCV antibody prevalence measures, eight viremic rate measures, and 30 genotype measures on 132,358 subjects. Pooled mean prevalence in LRD populations was 58.8% (95% confidence interval [CI], 51.5%‐66.0%) in Egypt and 55.8% (95% CI, 49.1%‐62.4%) in Pakistan; these values were higher than in other countries, which had a pooled prevalence of only 15.6% (95% CI, 12.4%‐19.0%). Mean prevalence was highest in patients with hepatocellular carcinoma at 56.9% (95% CI, 50.2%‐63.5%) and those with cirrhosis at 50.4% (95% CI, 40.8%‐60.0%). Type of LRD population and country were the strongest predictors of prevalence, explaining 48.6% of the variation. No evidence for prevalence decline was found, but there was strong evidence for prevalence increase in Pakistan. A strong, positive association was identified between prevalence in the general population and that in LRD populations; the Pearson correlation coefficient ranged between 0.605 and 0.862. The pooled mean viremic rate was 75.5% (95% CI, 61.0%‐87.6%). Genotype 4 was most common (44.2%), followed by genotype 3 (34.5%), genotype 1 (17.0%), genotype 2 (3.5%), genotype 6 (0.5%), and genotype 5 (0.3%). Conclusion: HCV appears to play a dominant role in liver diseases in Egypt and Pakistan and has a growing role in Pakistan. Testing and treatment of LRD populations are essential to reduce disease burden and transmission and to reach HCV elimination by 2030.

Characterization of the hepatitis C virus epidemic in Pakistan

Background

With one in every 20 Pakistanis already infected, Pakistan has the second largest number of hepatitis C virus (HCV) infections globally. The aim of this study was to present a quantitative and analytical characterization of the HCV epidemic in Pakistan.

Methods

A standardized database of HCV antibody incidence and prevalence and HCV genotypes in all subpopulations was systematically assembled. Random-effects meta-analyses and random-effects meta-regressions were performed. Shannon Diversity Index was calculated to determine genotype diversity.

Results

The database included two incidence, 309 prevalence, and 48 genotype measures. Pooled mean HCV prevalence ranged between 7.0% (95% confidence interval (CI): 5.8–8.3%) in Sindh and 0.9% (95% CI: 0.1–2.4%) in Federally Administered Tribal Areas (F.A.T.A). Estimated number of chronically-infected persons ranged between 4.2 million in Punjab and 0.03 million in F.A.T.A. HCV prevalence was stable over time [adjusted odds ratio (AOR) of 1.0 (95% CI: 1.0–1.0)]. Population classification was the strongest predictor of HCV prevalence, explaining 51.8% of prevalence variation. Relative to the general population, HCV prevalence was higher in people who inject drugs [AOR of 23.8 (95% CI: 13.0–43.6)], populations with liver-related conditions [AOR of 22.3 (95% CI: 15.7–31.6)], and high-risk clinical populations [AOR of 7.8 (95% CI: 4.8–12.7)]. Low genotype diversity was observed (Shannon diversity index of 0.67 out of 1.95; 34.5%). There were only minor differences in genotype diversity by province, with genotype 3 being most common in all provinces.

Conclusion

Pakistan’s HCV epidemic shows homogeneity across the provinces, and over time. HCV prevalence is strikingly persistent at high level, with no evidence for a decline over the last three decades. Scale up of HCV treatment and prevention is urgently needed.

Electronic supplementary material

The online version of this article (10.1186/s12879-019-4403-7) contains supplementary material, which is available to authorized users.

Geospatial epidemiology of hepatitis C infection in Egypt 2017 by governorate

Background

Geographic Information Systems (GIS) and spatial epidemiological methods may provide a basis for disease investigation through which hotspots and disease determinants can be identified. Applying these methods for hepatitis C virus (HCV) in Egypt would support a more effective strategy to control its transmission. Therefore, this study used GIS software to draw one of the first HCV maps in Egypt elucidating and analyzing geographical and epidemiological differences in HCV distribution within the country.

Methods

A cross-sectional survey of 21 governorates (n = 12169, 8080 rural, 3733 urban and 356 slums areas) was completed. All participants were interviewed regarding potential exposures to HCV. Third generation ELISA was used to test serum for HCV antibody. Quantitative real-time RT-PCR was used to test anti-HCV positive subjects for HCV-RNA.

Results

The participants ranged in age from 14-90 years. Overall, anti-HCV sero-prevalence was 14.8%. The prevalence of HCV-RNA, was 9.5%. Proportionally, 65.8% of anti-HCV positives were positive for HCV-RNA. The map of Egyptian governorates highlighted the darkest spot of HCV infection in Menoufeya (37.8%) followed by Beni Suef (29.2%) and Minya (28.6%). Anti-HCV prevalence was higher among males and logistic regression models revealed a strong independent association with increasing age, rural residence and parenteral anti-schistosomal therapy.

Conclusions

Rural residences and HCV hotspots should be prioritized for HCV prevention programs. The unique age distribution first shown in this study shows that the older age groups (≥60 years old) constitutes a considerable reservoir of infection and must not be neglected.

Treatment as prevention for hepatitis C virus in Pakistan: mathematical modelling projections

OBJECTIVE

Direct-acting antivirals have opened an opportunity for controlling hepatitis C virus (HCV) infection in Pakistan, where 10% of the global infection burden is found. We aimed to evaluate the implications of five treatment programme scenarios for HCV treatment as prevention (HCV-TasP) in Pakistan.

DESIGN

An age-structured mathematical model was used to evaluate programme impact using epidemiological and programme indicators.

SETTING

Total Pakistan population.

PARTICIPANTS

Total Pakistan HCV-infected population.

INTERVENTIONS

HCV treatment programme scenarios from 2018 up to 2030.

RESULTS

By 2030 across the five HCV-TasP scenarios, 0.6-7.3 million treatments were administered, treatment coverage reached between 3.7% and 98.7%, prevalence of chronic infection reached 2.4%-0.03%, incidence reduction ranged between 41% and 99%, program-attributed reduction in incidence rate ranged between 7.2% and 98.5% and number of averted infections ranged between 126 221 and 750 547. Annual incidence rate reduction in the first decade of the programme was around 6%-18%. Number of treatments needed to prevent one new infection ranged between 4.7-9.8, at a drug cost of about US$900. Cost of the programme by 2030, in the most ambitious elimination scenario, reached US$708 million. Stipulated WHO target for 2030 cannot be accomplished without scaling up treatment to 490 000 per year, and maintaining it for a decade.

CONCLUSION

HCV-TasP is a highly impactful and potent approach to control Pakistan's HCV epidemic and achieve elimination by 2030.

Tolerability and effectiveness of generic direct-acting antiviral drugs in eradication of hepatitis C genotype 4 among Egyptian patients

BACKGROUND

We investigated tolerability and effectiveness of generic, less expensive direct antiviral drugs in the treatment of hepatitis C virus genotype 4 (HCV GT-4) in an Egyptian cohort.

PATIENTS AND METHODS

Retrospectively, we analysed data from 648 patients with HCV GT4 attending Alexandria Main University Hospital from January 2016 to May 2017 [488 treatment naïve/160 treatment-experienced/288 with chronic hepatitis/360 with cirrhosis]. Patients received generic sofosbuvir/ledipasvir (n = 168, treatment naïve = 136, treatment-experienced = 32) or sofosbuvir/daclatasvir (n = 480, treatment naïve = 352, treatment-experienced = 128) ± ribavirin. We assessed sustained virologic response 12 weeks after treatment, non-response, relapse, treatment discontinuation and drug adverse reactions.

RESULTS

An overall sustained virologic response 12 weeks after treatment was achieved in 97.8%, non-response in 0.6%, relapse in 0.3% and discontinuation of treatment in 1.3% of patients. Sofosbuvir/ledipasvir ± ribavirin regimen attained an overall sustained virologic response 12 weeks after treatment in 96.4% of patients (100% of treatment-experienced vs 95.6% of treatment naïve, P = 0.28), vs 98.3% for sofosbuvir/daclatasvir ± ribavirin regimen (100% of treatment-experienced vs 97.7% of treatment naïve, P = 0.08). No severe drug adverse events or deaths were reported except anaemia due to ribavirin.

CONCLUSION

Generic direct antiviral drugs used in treating Egyptian patients with HCV GT-4 demonstrated equal potency, safety and tolerability compared to original brands, with low cost which would help to provide treatment to a larger scale of patients.

Who to Test for Hepatitis C Virus in the Middle East and North Africa?: Pooled Analyses of 2,500 Prevalence Measures, Including 49 Million Tests

Expanding hepatitis C virus (HCV) treatment coverage is challenged by limited testing and diagnosis. This study assessed the risk of exposure, for the Middle East and North Africa, by population, yields of testing, and program efficiency of testing strategies. A standardized and systematically assembled database of 2,542 HCV antibody prevalence studies on 49 million individuals was analyzed. Random effects meta-analyses were conducted to estimate pooled measures for risk of exposure, risk ratio (RR) of exposure, and yields of testing. Program expansion path curves were calculated to assess program efficiency. Countries clustered into two patterns: generalized versus concentrated epidemics. In generalized epidemics (Egypt and Pakistan) relative to general populations, RR of exposure was 6.8 for people who inject drugs (PWID), 6.7 for populations with liver conditions, and 5.0 for populations with high-risk health care exposures. In concentrated epidemics (remaining countries), corresponding RRs were 97.2, 45.1, and 22.2, respectively. In generalized epidemics, the number of tests needed to identify a chronic infection was 2.5 for PWID, 2.4 for populations with liver conditions, 2.7 for populations with high-risk health care exposures, and 14.2 for general populations. In concentrated epidemics, corresponding numbers were 2.8, 8.6, 5.1, and 222.2, respectively. Program expansion path curves demonstrated major gains in program efficiency by targeting specific populations. Risk of exposure varies immensely by population and shows a distinctive hierarchy, particularly in concentrated epidemics. Testing strategies can be much more efficient through population prioritization by risk of exposure. General population testing is not programmatically efficient in concentrated epidemics.

Applying core theory and spatial analysis to identify hepatitis C virus infection "core areas" in British Columbia, Canada

"Core areas" of transmission for bacterial sexually transmitted infections have been identified. However, it is unclear whether core areas apply to viral infections, such as hepatitis C virus (HCV). We used geographic mapping and spatial analysis to identify distinct core areas of HCV infection in British Columbia (BC) using the BC Hepatitis Testers Cohort (BC-HTC), 1990-2013. The BC-HTC includes all BC residents tested for HCV (~1.5 million; 1990-2013). Core HCV infection areas were identified spatially and temporally for five time periods (1990-1993, 1994-1998, 1999-2003, 2004-2008 and 2009-2013) through thematic mapping, Kernel Density Estimation, Hotspot analysis and cluster analysis at the Census dissemination area level in ArcGIS and SatScan. HCV infection core areas were consistently identified. HCV core areas expanded from the downtown of major cities in different regions of BC (Metro Vancouver, Vancouver Island, and Northern BC; 1990-1998), to smaller cities in Metro Vancouver and Interior BC (2000 onwards). Statistically significant clusters, or hotspots, were also observed for downtown Vancouver, Northern BC (Prince George) and Vancouver Island from 1990 to 2008 with expansion to other urban areas in Metro Vancouver from 1990-2013. Statistically significant clusters persisted after adjustment for injection drug use, number of HCV tests, age, sex, material and social deprivation. Persistence of areas with high HCV diagnoses rates in Vancouver and Prince George supports the theory of core areas of HCV transmission. Identification of core areas can inform prevention, care and treatment programme interventions and evaluate their impact over time.

The epidemiology of hepatitis C virus in Central Asia: Systematic review, meta-analyses, and meta-regression analyses

The objective was to delineate hepatitis C virus (HCV) epidemiology in countries of Central Asia (CA), specifically Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan, and Uzbekistan. A systematic review was conducted guided by the Cochrane Collaboration Handbook, and reported using PRISMA guidelines. Meta-analyses were performed using DerSimonian-Laird random-effects models with inverse variance weighting. Random-effects meta-regression analyses were performed on general population studies. The systematic review identified a total of 208 HCV prevalence measures. No incidence or Turkmenistan studies were identified. Meta-analyses estimated HCV prevalence among the general population at 0.7% (95%CI: 0.7-0.8%) in Kazakhstan, 2.0% (95%CI: 1.7-2.4%) in Kyrgyzstan, 2.6% (95%CI: 1.7-3.6%) in Tajikistan, and 9.6 (95%CI: 5.8-14.2%) in Uzbekistan. Across CA, the pooled mean prevalence was 13.5% (95%CI: 10.9-16.4%) among non-specific clinical populations, 31.6% (95%CI: 25.8-37.7%) among populations with liver-related conditions, and 51.3% (95%CI: 46.9-55.6%) among people who inject drugs. Genotypes 1 (52.6%) and 3 (38.0%) were most frequent. Evidence was found for statistically-significant differences in prevalence by country, but not for a temporal decline in prevalence. CA is one of the most affected regions by HCV infection with Uzbekistan enduring one of the highest prevalence levels worldwide. Ongoing HCV transmission seems to be driven by injecting drug use and healthcare exposures.

The burden of hepatitis C virus in Cameroon: Spatial epidemiology and historical perspective

Cameroon is thought to have one of the highest prevalences of hepatitis C virus (HCV) infection in the world (4.9% among adults). A marked cohort effect exists in several communities where ≈50% of the elderly are infected. Better assessment of HCV distribution is needed for planning treatment programmes. We tested for HCV antibodies 14 150 capillary blood samples collected during the 2011 Demographic and Health Survey, whose participants were representative of the Cameroonian population aged 15-49 (both genders) and 50-59 years (men only). Historical data on exposure to medical care were collected and factors associated with HCV assessed through logistic regression and geospatial analyses. To estimate prevalence in all persons aged ≥15 years, we used data from the survey for the 15-59 years fraction and modelled a cohort effect for older individuals. The nationwide HCV prevalence was 0.81% for the 15-49 years group, and 2.51% for all individuals aged ≥15 years. Only 0.2% of individuals aged 15-19 were seropositive. Among participants aged 15-44 years, HCV was associated with age, rural residence and, for males, with ritual circumcision. For those aged 45-59 years, HCV was associated with age and access to medical care in the late 1950s. Prevalence of HCV seropositivity in Cameroon is half of previous estimates. Nationwide surveys are essential to rationalize resources allocation. The high prevalence among older cohorts, a colonial legacy, has had little spillover into younger cohorts. HCV-free generations might be attainable in countries not plagued with intravenous drug abuse.

Characterizing the temporal evolution of the hepatitis C virus epidemic in Pakistan

Pakistan has the second largest number of HCV infections in the world. We assessed past, present and future levels and trends of the HCV epidemic in Pakistan. An age-structured mathematical model was developed and analysed to describe transmission dynamics over 1980-2050. The model was fitted to a nationally representative survey and a comprehensive database of systematically gathered HCV Ab prevalence data. HCV Ab and chronic infection prevalences peaked at 5.3% and 3.9% in 2000 but were projected to decline to 4.3% and 3.2% by 2017, 3.4% and 2.6% by 2030 and 2.6% and 1.9% by 2050, respectively. The number of chronically infected individuals was estimated at 6 663 906 in 2017 and was projected to peak at 6 665 900 in 2018 and decline to 6 372 100 in 2030 and 5 131 500 in 2050. Annual number of new infections peaked at 346 740 in 1992 but was projected to decline to 198 320 in 2017, 151 090 in 2030 and 98 120 in 2050. Incidence rate per 100 000 person-year peaked at 343 in 1988 but was projected to decline to 99 in 2017, 62 in 2030 and 36 in 2050. Prevalence and incidence varied by age, and the majority of new infections occurred in the 20-39 age group. Prevalence and incidence of HCV in Pakistan have been slowly declining for two decades-Pakistan is enduring a large epidemic that will persist for decades if not controlled. Nearly, 10% of global infections are in Pakistan, with about 200 000 additional infections every year. Rapid and mass scale-up of prevention and treatment programmes are critically needed.

The epidemiology of hepatitis C virus in Pakistan: systematic review and meta-analyses

To characterize hepatitis C virus (HCV) epidemiology in Pakistan and estimate the pooled mean HCV antibody prevalence in different risk populations, we systematically reviewed all available records of HCV incidence and/or prevalence from 1989 to 2016, as informed by the Cochrane Collaboration Handbook. This systematic review was reported following the PRISMA guidelines. Populations were classified into six categories based on the risk of exposure to HCV infection. Meta-analyses were performed using DerSimonian and Laird random-effects models with inverse variance weighting. The search identified one HCV incidence study and 341 prevalence measures/strata. Meta-analyses estimated the pooled mean HCV prevalence at 6.2% among the general population, 34.5% among high-risk clinical populations, 12.8% among populations at intermediate risk, 16.9% among special clinical populations, 55.9% among populations with liver-related conditions and 53.6% among people who inject drugs. Most reported risk factors in analytical epidemiologic studies related to healthcare procedures. Pakistan is enduring an HCV epidemic of historical proportions-one in every 20 Pakistanis is infected. HCV plays a major role in liver disease burden in this country, and HCV prevalence is high in all-risk populations. Most transmission appears to be driven by healthcare procedures. HCV treatment and prevention must become a national priority.

Individual-level key associations and modes of exposure for hepatitis C virus infection in the Middle East and North Africa: a systematic synthesis

PURPOSE

To identify, map, and synthesize the individual-level key associations and modes of exposure for hepatitis C virus (HCV) infection in the Middle East and North Africa (MENA), the most affected region by HCV.

METHODS

Source of data was the MENA HCV Epidemiology Synthesis Project database, populated through systematic literature searches. Risk factors determined to be statistically significant after adjustment for confounders were extracted and categorized into key associations or modes of exposure.

RESULTS

In total, 329 risk factors were identified from 109 articles in 14 of 24 MENA countries. Among key associations, age was most frequently reported (n = 39; 34.2%), followed by other infections/diseases (n = 20; 17.5%), and incarceration (n = 17; 14.9%). Among modes of exposure, health care-related exposures were most frequently reported (n = 127; 59.5%), followed by injecting drug use exposures (n = 45; 20.9%), community-related exposures (n = 34; 15.8%), and sexual-related exposures (n = 8; 3.7%). Blood transfusion, hemodialysis, surgical and other medical procedures, dental work, and medical injections were identified as key health care-related exposures.

CONCLUSIONS

Health care appears to be the primary driver of prevalent (and possibly incident) infections in MENA, followed by injecting drug use. HCV screening should target the identified modes of exposure. Commitment to prevention should be an integral component of HCV response to achieve HCV elimination by 2030, with focus on strengthening infection control in health care facilities, improving injection safety and blood screening, and expanding harm reduction services for people who inject drugs.

Characterizing hepatitis C virus epidemiology in Egypt: systematic reviews, meta-analyses, and meta-regressions

Egypt is the most affected nation by hepatitis C virus (HCV) and needs a comprehensive characterization of HCV epidemiology to inform the scale-up of treatment and prevention programs. Systematic reviews, meta-analyses, and meta-regressions were conducted. A total of 25 incidence, 259 prevalence, and 47 genotype studies were identified. Incidence and prevalence levels were high across all populations. Genotype 4 accounted for 94.1% of infections with a relative Shannon Diversity Index of only 14.4%. Pooled mean HCV prevalence was estimated at 11.9% (95% CI = 11.1–12.6%) among the general population, 55.6% (95% CI = 49.4–61.7%) among populations at high risk, 14.3% (95% CI = 10.3–18.8%) among populations at intermediate risk, 56.0% (95% CI = 50.4–61.6%) among populations with liver-related conditions, and 35.0% (95% CI = 27.3–43.1%) among special clinical populations. Mean HCV viremic rate was estimated at 66.7% (95% CI = 61.7–71.5%). Meta-regression indicated 6% lower odds for HCV prevalence for each one-year increment in publication year (AOR = 0.94; 95% CI = 0.92–0.96). HCV prevalence is high with evidence for ongoing transmission mainly through healthcare. Genotype diversity is low with genotype 4 dominance. Two-thirds of antibody-positive Egyptians are chronically infected and need treatment. Clinical populations should be prioritized for screening. Despite the large-scale epidemic, prevalence appears to be declining rapidly consistent with a contracting epidemic.

The epidemiology of hepatitis C virus in Iran: Systematic review and meta-analyses

The aim of this study was to characterize hepatitis C virus (HCV) epidemiology in Iran and estimate the pooled mean HCV antibody prevalence in different risk populations. We systematically reviewed and synthesized reports of HCV incidence and/or prevalence, as informed by the Cochrane Collaboration Handbook, and reported our findings following the PRISMA guidelines. DerSimonian-Laird random effects meta-analyses were implemented to estimate HCV prevalence in various risk populations. We identified five HCV incidence and 472 HCV prevalence measures. Our meta-analyses estimated HCV prevalence at 0.3% among the general population, 6.2% among intermediate risk populations, 32.1% among high risk populations, and 4.6% among special clinical populations. Our meta-analyses for subpopulations estimated HCV prevalence at 52.2% among people who inject drugs (PWID), 20.0% among populations at high risk of healthcare-related exposures, and 7.5% among populations with liver-related conditions. Genotype 1 was the most frequent circulating strain at 58.2%, followed by genotype 3 at 39.0%. HCV prevalence in the general population was lower than that found in other Middle East and North Africa countries and globally. However, HCV prevalence was high in PWID and populations at high risk of healthcare-related exposures. Ongoing transmission appears to be driven by drug injection and specific healthcare procedures.

Impact of old Schistosomiasis infection on the use of transient elastography (Fibroscan) for staging of fibrosis in chronic HCV patients

BACKGROUND AND AIM

In tropical regions, Hepatitis C virus (HCV) - Schistosomiasis coinfection remains one of the health problems. With the new era of HCV treatment and the variety of methods of assessment of liver fibrosis so we aimed to evaluate the effectiveness of FibroScan for staging hepatic fibrosis in HCV-Schistosomiasis coinfected patients.

METHODOLOGY

Three groups of patients were enrolled. Group 1: chronic HCV with out antischistosomal antibody (122 patients), Group 2: chronic HCV with positive antischistosomal antibodies and without periportal tract thickening (122 patients), Group 3: chronic HCV with positive antischistosomal antibodies and ultrasonographic picture of periportal tract thickening (108 patients). Routine laboratory workup, serum Antischistosomal antibody, and Schistosomal antigen in serum were performed. Ultrasound guided liver biopsy with histopathological examination; abdominal ultrasound and fibroscan examination were done for all patients.

RESULTS

The agreement between results of liver biopsy and results of fibroscan in the staging of fibrosis was the best in group 1 (55.7%), Although the agreement was higher among those with no periportal tract thickening (70.7%) and the disagreement was higher among those with positive schistosomal serology (66.5%), yet this relation was not statistically significant. Multivariate logistic regression analysis showed that disagreement is significantly associated with older age, higher BMI (≥30), and increase in anti Schistosomal antibody titer.

CONCLUSION

Fibroscan is a reliable, non-invasive tool for staging hepatic fibrosis among HCV-schistosomiasis co-infected patients with no effect of the induced periportal tract thickening on the readings. Only higher antischistosomal antibody titres may cause disagreement between liver biopsy and fibroscan.

Quillaja saponaria bark saponin protects Wistar rats against ferrous sulphate-induced oxidative and inflammatory liver damage

CONTEXT

Saponins from different sources are historically reported in Chinese medicine to possess many beneficial effects. However, insufficient experimental data are available regarding the hepatoprotective potential of Quillaja bark saponin.

OBJECTIVE

The protective effect of Quillaja saponaria Molina (Quillajaceae) bark triterpenoid saponin against iron-induced hepatotoxicity is compared to the standard N-acetylcysteine in adult male Wistar rats.

MATERIALS AND METHODS

Animals were divided into (six) groups, namely a normal control, an N-acetylcysteine control (300 mg/kg/day, p.o., 10 days), a saponin control (100 mg/kg/day, p.o., for 10 days), a hepatotoxicity control (two doses of ferrous sulphate, 30 mg/kg/day each, i.p., on 9th and 10th day), an N-acetylcysteine plus ferrous sulphate (standard treatment) and a saponin plus ferrous sulphate (test treatment) group. Hepatocyte integrity loss markers (serum ALT, AST, ALP, GGT and LDH), oxidative stress markers (hepatic MDA, GSH and NOx), dyslipidaemic markers (serum TC and TG) and hepatocyte functioning markers (serum bilirubin and albumin) were assessed.

RESULTS

Quillaja bark saponin decreased iron-induced elevation of ALT (reaching 57% of hepatotoxicity control), AST (66%), ALP (76%), GGT (60%), LDH (54%), MDA (65%), NOx (77%), TC (70%), TG (54%), and total (54%), direct (54%) and indirect (54%) bilirubin, coupled with increased GSH (219%) and albumin (159%) levels. Histopathological study strongly supported biochemical estimations, while immunohistochemical study showed marked effect on eNOS and iNOS expression.

CONCLUSIONS

Quillaja bark saponin has a good hepatoprotective effect. Amelioration of oxidative stress and suppression of NOS expression, with resultant maintenance of hepatocyte integrity and functioning, may explain this beneficial effect.

Hepatitis C Virus Exposure Rate among Health-care Workers in Rural Lower Egypt Governorates

BACKGROUND AND OBJECTIVES

Studies on hepatitis C virus (HCV) in Egypt supported a strong role for various exposures in the health-care setting. In this study, we attempted to estimate the frequency of HCV exposure among Egyptian health-care workers (HCWs).

METHODS

Five hundred and sixty-four (564) HCWs were included in this study. Two hundred and fifty-eight (45.74%) were health-care providers and 306 (54.25%) were non-health-care providers. All HCWs completed both the study questionnaire and provided a blood sample for anti-HCV testing by third-generation enzyme-linked immunosorbent assay. Subsequently, anti-HCV-positive samples were tested for HCV RNA using nested polymerase chain reaction (PCR).

RESULTS

The mean age of included HCWs was 33.0 ± 9.8 years; of them, 319 (56.56%) were males and 245 (43.44%) were females. The mean duration of health-care work was 9.3 ± 6.7 years. The frequency of antibody against hepatitis C virus (anti-HCV) among included HCWs was 8.7% (n = 49). Old age and prolonged duration of health-care work were significantly associated with anti-HCV seropositivity. Forty (81.63%) of 49 with anti-HCV-positive HCWs had positive hepatitis C viremia. The frequency of HCV RNA positivity increased with age. The frequency of eradicated past infection among nurses (36.85%) was markedly higher than that (6.7%) detected in non-health-care providers.

CONCLUSION

High rate of HCV infection is detected in Egyptian HCWs in rural Lower Egypt governorates. Health-care providers seem to eradicate HCV infection more frequently than non-health-care providers. National screening and treatment of infected HCWs are recommended.

Critical flicker frequency is diagnostic of minimal hepatic encephalopathy

Minimal hepatic encephalopathy may affect up to 80% of cirrhotic patients, in the absence of overt hepatic encephalopathy. The objective of the study is to evaluate the accuracy of diagnosis of minimal hepatic encephalopathy with critical flicker frequency (CFF). The study was conducted on 180 patients with post hepatitis C liver cirrhosis and on 60 healthy subjects as control. Patients and controls were divided into four groups: group 1 (60), healthy individuals as a control group; group 2 (60), patients with liver cirrhosis (Child class A); group 3 (60), patients with liver cirrhosis (Child class B); and group 4 (60), patients with liver cirrhosis (Child class C). All participants were subjected to estimation of CFF, line drawing test, complete blood picture, liver functions, viral markers, and abdominal ultrasound. CFF detected abnormality in 90% of patients. Accuracy of CFF in differentiation of Child A from normal is 100%, Child B from normal is 100%, Child C from normal is 100%, Child A from Child B is 80%, Child A from Child C is 100% and Child B from Child C is 100%, and it has higher accuracy than line drawing test. CFF is a simple, reliable and accurate method for the diagnosis of minimal hepatic encephalopathy. It is not influenced by the patient level of education.

Impact of treatment on hepatitis C virus transmission and incidence in Egypt: A case for treatment as prevention

Egypt has launched a hepatitis C virus (HCV) treatment programme using direct-acting antivirals (DAAs). Our aim was to assess the impact of five plausible programme scale-up and sustainability scenarios for HCV treatment as prevention in Egypt. We developed and analysed a mathematical model to assess programme impact using epidemiologic, programming and health economics measures. The model was parametrized with current and representative natural history, HCV prevalence and programme data. HCV incidence in Egypt is declining, but will persist at a considerable level for decades unless controlled by interventions. Across the five programme scenarios, 1.75-5.60 million treatments were administered by 2030. Reduction in incidence (annual number of new infections) by 2030 ranged between 29% and 99%, programme-attributed reduction in incidence rate (new infections per susceptible person per year) ranged between 18% and 99%, number of infections averted ranged between 42 393 and 469 599, and chronic infection prevalence reached as low as 2.8%-0.1%. Reduction in incidence rate year by year hovered around 7%-15% in the first decade of the programme in most scenarios. Treatment coverage in 2030 ranged between 24.9% and 98.8%, and number of treatments required to avert one new infection ranged between 9.5 and 12.1. Stipulated targets for HCV by 2030 could not be achieved without scaling-up treatment to 365 000 per year and sustaining it for a decade. In conclusion, DAA scale-up will have an immense and immediate impact on HCV incidence in Egypt. Elimination by 2030 is feasible if sufficient resources are committed to programme scale-up and sustainability. HCV treatment as prevention is a potent and effective prevention approach.

Aspects on the history of transmission and favor of distribution of viruses by iatrogenic action: perhaps an example of a paradigm of the worldwide spread of HIV

Transmission of infectious agents might be associated with iatrogenic actions of charitable help in health care. An example is the vaccination against yellow fever in USA that transmitted hepatitis B virus. Another example is injections of praziquantel for treatment and cure of schistosomiasis in Central and Northern Africa, with a focus in Egypt that has spread hepatitis C virus. There is no indication that human T-lymphotropic virus type 1 was spread by injection treatment for African trypanosomiasis, syphilis and treponematosis, but these treatments might have contributed to the early spread of human immunodeficiency virus type 1 (HIV-1) in Central Africa. Slave trade contributed as well to the spread of viruses from Africa to the Americas; it was stopped in 1850. Until that date HIV-1 was not transported to the Americas. By analysis of nucleic acid sequence data it can be concluded that the continental spread of HCV and HIV-1 might have started around 1920 with an exponential phase from 1940 to 1970. Further iatrogenic actions that promoted the spread of HCV and HIV-1 might be vaccinations to prevent deadly diseases. The successful vaccination was followed by diminution of the infectious agent in the population such as small pox, yellow fever and measles. Measurements to reduce the spread of plague and cholera were further benefits increasing survival of diseased subjects in a population. Thus, the reduction of exposure to deadly infectious agents might have given a chance to HIV-1 infected subjects to survive and for HIV-1 to be distributed around the world starting from Central Africa in the 1950s.

Transfusion transmitted infections in frequently transfused thalassemic children living in Fayoum Governorate, Egypt: Current prevalence and risk factors

Regular blood transfusion therapy remains the primary treatment in thalassemia major (TM). Transfusion-transmitted infections (TTIs) and iron overload are considered to be the major drawbacks of this therapy. This cross-sectional study aimed to update the prevalence of the hepatitis C virus (HCV) antibody, PCR-confirmed HCV, hepatitis B surface antigen (HBsAg), and human immunodeficiency virus (HIV) antibody among TM children. Clinical and epidemiological factors that can affect HCV infection prevalence rate were studied. This study evaluated 121 children with βTM, including 61 males and 60 females with a mean age of 7.99±3.57years. Patients were evaluated for the HCV, HBsAg, and HIV-1 & 2 antibodies. All tests were performed using ELISA. HCV positive cases were confirmed by RT-PCR. Twenty-five patients were positive for the HCV antibody (20.7%); 22 were confirmed positive by PCR. Six patients (5%) were HBsAg-positive. No patients were HIV-positive. Older age were associated with an increased frequency of HCV positive infection (P<0.003). More frequent transfusion, ≥10 times/year, and older age, ≥10years, were reported as predictors of HCV infection (P=0.018 and 0.011, respectively). A significant association of HCV between HBV infections was reported (P value=0.01). There was no significant effect of the pre-transfusion or post-transfusion hemoglobin level on the frequency of HCV positive cases. HCV still represents a major health challenge for frequently transfused Egyptian patients. The prevalence rate of HBV infection remains relatively high. Therefore, it is necessary to implement measures to improve blood transfusion screening.

Transient elastography as a noninvasive assessment tool for hepatopathies of different etiology in pediatric type 1 diabetes mellitus

AIM

To identify the prevalence and effect of hepatopathies of different etiologies among pediatric patients with type 1 diabetes mellitus (T1DM) using transient elastography (TE) and its relation to glycemic control.

METHODS

One hundred T1DM patients were studied focusing on liver functions, fasting lipid profile, hemoglobin A1c (HbA1c), hepatitis C virus (HCV), serum immunoglobulins, autoimmune antibodies; anti-nuclear antibody (ANA), anti-smooth muscle antibody (ASMA), and anti-liver kidney microsomal antibody (anti-LKM). Abdominal ultrasound was performed and TE was done for patients with HCV, positive autoimmune antibody and/or abnormal ultrasound findings.

RESULTS

Thirty-one patients were found to have one or more hepatic abnormalities; clinical hepatomegaly in 8%, elevated alanine aminotransferase (ALT) in 10%, HCV in 6%, autoimmune hepatitis (AIH) in 11% (10 were positive for ASMA and 2 were positive for ANA while anti-LKM antibodies were negative) and abnormal hepatic ultrasound in 20% (12 non-alcoholic fatty liver disease, 5 AIH, 2 HCV, 1 Mauriac syndrome). Mean liver stiffness in those 31 patients was 7.0±2.1kPa (range, 3.1-11.8kPa); 24 were Metavir F0-F1, 7 were F2-F3 while none was F4. Type 1 diabetic patients with abnormal hepatic ultrasound had higher fasting blood glucose, HbA1c and total cholesterol than those with normal findings. Liver stiffness was significantly higher in patients with abnormal liver ultrasound compared with normal sonography. Liver stiffness was positively correlated to HbA1c and ALT.

CONCLUSIONS

Hepatic abnormalities are prevalent in T1DM and related to poor metabolic control. TE provides a non-invasive method for detection of hepatopathy-induced fibrosis.

Serum Beta-2 Microglobulin: a Possible Marker for Disease Progression in Egyptian Patients with Chronic HCV Related Liver Diseases

BACKGROUND

Egypt has the highest prevalence of HCV infection in the world (~14.7%). Around 10-15% of HCV-infected persons will advance to cirrhosis within the first 20 years. The incidence of HCC is expected to grow in the next two decades, largely due to HCV related cirrhosis, and detection of HCC at an early stage is critical for a favorable clinical outcome. No simple reliable non-invasive marker has been available till now. B2M, a non-glycosylated polypeptide composed of 99 amino acids, is one of the components of HLA class I molecules on the surfaces of all nucleated cells. It has been reported that the level of serum B2M is elevated in patients with chronic hepatitis C and HCV-related HCC when compared to HCV-negative patients or healthy donors. Determining the clinical utility of serum β2M as a marker for disease progression in Egyptian patients with HCV related chronic hepatitis, cirrhosis and hepatocellular carcinoma was the aim of the present study.

MATERIALS AND METHODS

In this analytical cross sectional study 92 participants were included in 4 equal groups: Group (1) non cirrhotic chronic HCV; Group (2) HCV related liver cirrhosis; Group (3) HCC on top of HCV,; and Group (4) healthy controls. History taking, clinical examination, routine labs and abdominal ultrasound were conducted for all patients, PCR and Metavir scores for group (1) patients, and triphasic CT abdomen and AFP for Group (3) patients. β2M levels were measured in serum with a fully-automated IMX system.

RESULTS

The mean serum B2M level of Group (1) was 4.25 ± 1.48 μg/ml., Group (2) was 7.48 ± 3.04, Group (3) was 6.62 ± 2.49 and Group (4) was 1.62 ± 0.63. Serum B2M levels were significantly higher in diseased than control group (p<0.01) being significantly higher in cirrhosis (7.48 ± 3.04) and HCC groups (6.62 ± 2.49) than the HCV group (4.25 ± 1.48) (p<0.01). There was a significant correlation between B2M Level and ALK, total and direct bilirubin and INR (p<0.05), and a significant inverse correlation between B2M level and albumin, total proteins, HB and WBCS values (p<0.05). There was no significant correlation between B2M level and viral load or Metavir score, largest tumour size or AFP (p>0.05). The best B2M cut-off for HCV diagnosis was 2.6 with a sensitivity of 100%, a specificity of 92%, a positive predictive value (PPV) of 97% and a negative predictive value (NPV) of 100%. The best B2M cut-off for HCC diagnosis was 4.55 which yielded sensitivity, specificity, positive predictive value, negative predictive values of 74%, 62%, 39.5, 87.8% respectively (p-value <0.01) while best cut-off for cirrhosis was 4.9, with sensitivity 74 % and specificity 74%. The sensitivity for HCC diagnosis increased upon B2M and AFP combined estimation to 91%, specificity to 79%, NPV to 95% and accuracy to 83%.

CONCLUSIONS

Serum B2M level is elevated in HCV related chronic liver diseases and may be used as a marker for HCV disease progression towards cirrhosis and carcinoma.

Diagnostic non-invasive model of large risky esophageal varices in cirrhotic hepatitis C virus patients

AIM

To build a diagnostic non-invasive model for screening of large varices in cirrhotic hepatitis C virus (HCV) patients.

METHODS

This study was conducted on 124 post-HCV cirrhotic patients presenting to the clinics of the Endemic Medicine Department at Mansoura University Hospital for evaluation before HCV antiviral therapy: 78 were Child A and 46 were Child B (score ≤ 8). Inclusion criteria for patients enrolled in this study was presence of cirrhotic HCV (diagnosed by either biopsy or fulfillment of clinical basis). Exclusion criteria consisted of patients with other etiologies of liver cirrhosis, e.g., hepatitis B virus and patients with high MELD score on transplant list. All patients were subjected to full medical record, full basic investigations, endoscopy, and computed tomography (CT), and then divided into groups with no varices, small varices, or large risky varices. In addition, values of Fibrosis-4 score (FIB-4), aminotransferase-to-platelet ratio index (APRI), and platelet count/splenic diameter ratio (PC/SD) were also calculated.

RESULTS

Detection of large varies is a multi-factorial process, affected by many variables. Choosing binary logistic regression, dependent factors were either large or small varices while independent factors included CT variables such coronary vein diameter, portal vein (PV) diameter, lieno-renal shunt and other laboratory non-invasive variables namely FIB-4, APRI, and platelet count/splenic diameter. Receiver operating characteristic (ROC) curve was plotted to determine the accuracy of non-invasive parameters for predicting the presence of large esophageal varices and the area under the ROC curve for each one of these parameters was obtained. A model was established and the best model for prediction of large risky esophageal varices used both PC/SD and PV diameter (75% accuracy), while the logistic model equation was shown to be (PV diameter × -0.256) plus (PC/SD × -0.006) plus (8.155). Values nearing 2 or more denote large varices.

CONCLUSION

This model equation has 86.9% sensitivity and 57.1% specificity, and would be of clinical applicability with 75% accuracy.

Systematic review and meta-analysis of hepatitis C virus infection in the Democratic Republic of Congo

OBJECTIVES

Hepatitis C virus (HCV) infection is endemic in the Democratic Republic of the Congo (DRC), where the prevalence of HCV antibodies (anti-HCV) is reported to range from 0.2% to 13.7%. However, the reported prevalence rates have been inconsistent. Therefore, a meta-analysis of observational studies was conducted to provide updates on the prevalence of HCV infection in the DRC.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

Medline, EMBASE and Google Scholar were searched for publications reporting on HCV infection in the DRC up to autumn 2015. In addition, a manual search was undertaken to detect relevant papers. Studies performed in groups at low risk of HCV (blood donors and pregnant women) were used for the meta-analysis. The random effects model was used to estimate the pooled prevalence of anti-HCV.

RESULTS

Sixteen studies with 13,799 participants (aged 6 months-71 years) met the inclusion criteria. The studies were performed in blood donors, pregnant women, military personnel, individuals with human immunodeficiency virus, children, commercial sex workers, Congolese patients living in Canada, patients with sickle cell disease and hospitalized patients. The reviewed studies revealed the presence of anti-HCV in almost all studied age groups and did not differ between sexes. The pooled prevalence of anti-HCV was 2.9% [95% confidence interval 1.5-4.3%]. Subgroup analyses revealed that the prevalence rates of anti-HCV in blood donors and pregnant women were 2.7% (95% confidence interval: 1.1-4.4%) and 3.3% (1.4-5.1%), respectively.

CONCLUSIONS

HCV infection remains an issue of public concern in the DRC, demonstrating a need for adequate hepatitis control programmes. Efforts must be made to virtually eliminate transfusion-transmitted HCV throughout the country.

Antiviral treatment prioritization in HCV-infected patients with extrahepatic manifestations - An Egyptian perspective

Egypt, the single country with highest incidence of HCV infection in the world, has embarked on a government-sponsored mass treatment program using several combinations of DAAs. Recognizing the importance of extrahepatic manifestations, independently of the hepatic, a subcommittee was assigned to develop national guidelines for respective prioritizing indications and protocols. It evaluated the benefit of treating patients with different extrahepatic manifestations, and reviewed relevant clinical trials and guidelines concerning DAA combinations available in Egypt. The latter included Sofosbuvir plus either peg-interferon, Simeprevir, Ledipasvir or daclatasvir, and the Viekera family comprising paritaprevir/ritonavir + ombitasvir with (GT-1) or without (GT-4) Dasabuvir. Any of these protocols may be used with or without Ribavirin according to indication. A blueprint was subjected to peer debate in dedicated workshops in two national meetings and subsequently to an online professional review, eventually leading to a final report that was adopted by the health authorities. Seven compelling and 10 optional indications were identified for treating patients with predominantly extrahepatic manifestations. The former include kidney disease at different stages, cryoglobulinemic vasculitis and non-Hodgkin lymphoma. Selected treatment protocols, were encoded and their use was prioritized on the basis of evidence of efficacy and safety. We concluded that any of the studied protocols may be used, preferably with ribavirin, for 12-week treatment in all patients with extrahepatic manifestations without cirrhosis and with eGFR above 30 ml/min/1.73 sqm. Ribavirin should be included in protocols for treating patients with compensated cirrhosis. Daclatasvir-based protocols are recommended for decompensated cirrhosis, while the Viekera family is recommended in patients with eGFR < 30 ml/min/1.73 sqm, including those on dialysis. In kidney-transplanted patents, caution is due to avoidance of the pharmacokinetic interaction with the Cytochrome-P450 enzyme system, in-between immunosuppressive agents and most DAAs, particularly the Viekera family.

Hepatitis C Virus Epidemiology in Djibouti, Somalia, Sudan, and Yemen: Systematic Review and Meta-Analysis

OBJECTIVES

To characterize hepatitis C virus (HCV) epidemiology and assess country-specific population-level HCV prevalence in four countries in the Middle East and North Africa (MENA) region: Djibouti, Somalia, Sudan, and Yemen.

METHODS

Reports of HCV prevalence were systematically reviewed as per PRISMA guidelines. Pooled HCV prevalence estimates in different risk populations were conducted when the number of measures per risk category was at least five.

RESULTS

We identified 101 prevalence estimates. Pooled HCV antibody prevalence in the general population in Somalia, Sudan and Yemen was 0.9% (95% confidence interval [95%CI]: 0.3%-1.9%), 1.0% (95%CI: 0.3%-1.9%) and 1.9% (95%CI: 1.4%-2.6%), respectively. The only general population study from Djibouti reported a prevalence of 0.3% (CI: 0.2%-0.4%) in blood donors. In high-risk populations (e.g., haemodialysis and haemophilia patients), pooled HCV prevalence was 17.3% (95%CI: 8.6%-28.2%) in Sudan. In Yemen, three studies of haemodialysis patients reported HCV prevalence between 40.0%-62.7%. In intermediate-risk populations (e.g.. healthcare workers, in patients and men who have sex with men), pooled HCV prevalence was 1.7% (95%CI: 0.0%-4.9%) in Somalia and 0.6% (95%CI: 0.4%-0.8%) in Sudan.

CONCLUSION

National HCV prevalence in Yemen appears to be higher than in Djibouti, Somalia, and Sudan as well as most other MENA countries; but otherwise prevalence levels in this subregion are comparable to global levels. The high HCV prevalence in patients who have undergone clinical care appears to reflect ongoing transmission in clinical settings. HCV prevalence in people who inject drugs remains unknown.

Hepatitis C Virus Epidemiology in Djibouti, Somalia, Sudan, and Yemen: Systematic Review and Meta-Analysis

OBJECTIVES

To characterize hepatitis C virus (HCV) epidemiology and assess country-specific population-level HCV prevalence in four countries in the Middle East and North Africa (MENA) region: Djibouti, Somalia, Sudan, and Yemen.

METHODS

Reports of HCV prevalence were systematically reviewed as per PRISMA guidelines. Pooled HCV prevalence estimates in different risk populations were conducted when the number of measures per risk category was at least five.

RESULTS

We identified 101 prevalence estimates. Pooled HCV antibody prevalence in the general population in Somalia, Sudan and Yemen was 0.9% (95% confidence interval [95%CI]: 0.3%-1.9%), 1.0% (95%CI: 0.3%-1.9%) and 1.9% (95%CI: 1.4%-2.6%), respectively. The only general population study from Djibouti reported a prevalence of 0.3% (CI: 0.2%-0.4%) in blood donors. In high-risk populations (e.g., haemodialysis and haemophilia patients), pooled HCV prevalence was 17.3% (95%CI: 8.6%-28.2%) in Sudan. In Yemen, three studies of haemodialysis patients reported HCV prevalence between 40.0%-62.7%. In intermediate-risk populations (e.g.. healthcare workers, in patients and men who have sex with men), pooled HCV prevalence was 1.7% (95%CI: 0.0%-4.9%) in Somalia and 0.6% (95%CI: 0.4%-0.8%) in Sudan.

CONCLUSION

National HCV prevalence in Yemen appears to be higher than in Djibouti, Somalia, and Sudan as well as most other MENA countries; but otherwise prevalence levels in this subregion are comparable to global levels. The high HCV prevalence in patients who have undergone clinical care appears to reflect ongoing transmission in clinical settings. HCV prevalence in people who inject drugs remains unknown.

Hepatitis C Virus Epidemiology in Djibouti, Somalia, Sudan, and Yemen: Systematic Review and Meta-Analysis

OBJECTIVES

To characterize hepatitis C virus (HCV) epidemiology and assess country-specific population-level HCV prevalence in four countries in the Middle East and North Africa (MENA) region: Djibouti, Somalia, Sudan, and Yemen.

METHODS

Reports of HCV prevalence were systematically reviewed as per PRISMA guidelines. Pooled HCV prevalence estimates in different risk populations were conducted when the number of measures per risk category was at least five.

RESULTS

We identified 101 prevalence estimates. Pooled HCV antibody prevalence in the general population in Somalia, Sudan and Yemen was 0.9% (95% confidence interval [95%CI]: 0.3%-1.9%), 1.0% (95%CI: 0.3%-1.9%) and 1.9% (95%CI: 1.4%-2.6%), respectively. The only general population study from Djibouti reported a prevalence of 0.3% (CI: 0.2%-0.4%) in blood donors. In high-risk populations (e.g., haemodialysis and haemophilia patients), pooled HCV prevalence was 17.3% (95%CI: 8.6%-28.2%) in Sudan. In Yemen, three studies of haemodialysis patients reported HCV prevalence between 40.0%-62.7%. In intermediate-risk populations (e.g.. healthcare workers, in patients and men who have sex with men), pooled HCV prevalence was 1.7% (95%CI: 0.0%-4.9%) in Somalia and 0.6% (95%CI: 0.4%-0.8%) in Sudan.

CONCLUSION

National HCV prevalence in Yemen appears to be higher than in Djibouti, Somalia, and Sudan as well as most other MENA countries; but otherwise prevalence levels in this subregion are comparable to global levels. The high HCV prevalence in patients who have undergone clinical care appears to reflect ongoing transmission in clinical settings. HCV prevalence in people who inject drugs remains unknown.

Seroprevalence of HCV among Cairo University students in Egypt

Hepatitis C virus (HCV) is highly prevalent in Egypt. This work aimed at determining the seroprevalence of HCV among Cairo University students. The present study included 3,000 students from Cairo University, Egypt. Blood sample was obtained from each participant to be tested for HCV seromarker. HCV RNA detection by polymerase chain reaction (PCR) was carried out for those with positive anti-HCV. Overall prevalence rate of HCV antibody (anti-HCV) was 4.6%. It showed that the prevalence was relatively higher among females (86/1660; 5.2%) while males (51/1340; 3.8%) with no significant difference. PCR for HCV RNA was detected in 31.4% of the HCV antibody positive subjects (43/137). Which showed statistical significant difference between males (29/51) and females (14/86) at P = 0.001. Despite the prevalence rate reported in the present study was similar to anti-HCV prevalence among persons in the same age group, confirmed that HCV infection is detected among Cairo University students. J. Med. Virol. 88:1384-1387, 2016. © 2016 Wiley Periodicals, Inc.

Epidemiology of hepatitis C virus exposure in Egypt: Opportunities for prevention and evaluation

AIM: To critically evaluate the current epidemiology data on exposures, rather than infection, to hepatitis C virus (HCV) transmission and recommend epidemiologic strategies to fill gaps.

METHODS: Standard methods for identifying and evaluating relevant epidemiologic literature and available data were used.

RESULTS: There is a large body of literature on the epidemiology of HCV transmission in Egypt that collectively identifies ongoing iatrogenic exposures as the major driver for HCV transmission due to short comings in infection control and standard procedures. Additional epidemiologic studies on HCV transmission that requires the participation of human subject is unwarranted. Alternatively, very little literature was found on the epidemiology of exposure to HCV, infection control, and safe injection practices. The information that is available on patterns of HCV exposure shows high frequencies of inadequate infection control, problems in sterilization in health care facilities, low rates of hand washing, untrained personnel, lack of stated policies in facilities, HCV contamination of instruments and very large injection frequencies with low but very significant syringe and needle reuse. There is an important need to increase the number, size, and diversity of epidemiologic studies on HCV exposures, patterns of risk factors for infection, infection control, and safe injection practices. In addition to health care facilities evaluation, relevant knowledge attitude and practice studies are recommended.

CONCLUSION: Epidemiologic methods on HCV exposure can be used to characterize the magnitude of exposures to HCV infection, target interventions to reduce exposures, and provide the best method for evaluating interventions by demonstrating the reduction of exposure to HCV infection.

Low-density lipoprotein receptor genetic polymorphism in chronic hepatitis C virus Egyptian patients affects treatment response

AIM: To correlate a genetic polymorphism of the low-density lipoprotein (LDL) receptor with antiviral responses in Egyptian chronic hepatitis C virus (HCV) patients.

METHODS: Our study included 657 HCV-infected patients with genotype 4 who received interferon-based combination therapy. Patients were divided into two groups based on their response to therapy: 356 were responders, and 301 were non-responders. Patients were compared to 160 healthy controls. All patients and controls underwent a thorough physical examination, measurement of body mass index (BMI) and the following laboratory tests: serum alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, albumin, total bilirubin, direct bilirubin, prothrombin time, prothrombin concentration, INR, complete blood count, serum creatinine, fasting blood sugar, HCV antibody, and hepatitis B surface antigen. All HCV patients were further subjected to the following laboratory tests: HCV-RNA using quantitative polymerase chain reaction (PCR), antinuclear antibodies, thyroid-stimulating hormone, an LDL receptor (LDLR) genotype study of LDLR exon8c.1171G>A and exon10c.1413G>A using real-time PCR-based assays, abdominal ultrasonography, ultrasonographic-guided liver biopsy, and histopathological examination of liver biopsies. Correlations of LDL receptor polymorphisms with HAI, METAVIR score, presence of steatosis, and BMI were performed in all cases.

RESULTS: There were no statistically significant differences in response rates between the different types of interferon used or LDLR exon10c.1413G>A. However, there was a significant difference in the frequency of the LDL receptor exon8c.1171G>A genotype between cases (AA: 25.9%, GA: 22.2%, GG: 51.9%) and controls (AA: 3.8%, GA: 53.1% and GG: 43.1%) (P < 0.001). There was a statistically significant difference in the frequency of the LDLR exon 8C:1171 G>A polymorphism between responders (AA: 3.6%, GA: 15.2%, GG: 81.2%) and non-responders (AA: 52.2%, GA: 30.6%, GG: 17.2%) (P < 0.001). The G allele of LDL receptor exon8c.1171G>A predominated in cases and controls over the A allele, and a statistically significant association with response to interferon was observed. The frequency of the LDLR exon8c.1171G>A allele in non-responders was: A: 67.4% and G: 32.6 vs A: 11.2% and G: 88.8% in responders (P < 0.001). Therefore, carriers of the A allele exhibited a 16.4 times greater risk for non-response. There was a significant association between LDL receptors exon8 c.1171G>A and HAI (P < 0.011). There was a significant association between LDL receptors exon8c.1171G>A and BMI. The mean BMI level was highest in patients carrying the AA genotype (28.7 ± 4.7 kg/m²) followed by the GA genotype (28.1 ± 4.8 kg/m²). The lowest BMI was the GG genotype (26.6 ± 4.3 kg/m²) (P < 0.001). The only significant associations were found between LDL receptors exon8 c.1171G>A and METAVIR score or steatosis (P < 0.001).

CONCLUSION: LDL receptor gene polymorphisms play a role in the treatment response of HCV and the modulation of disease progression in Egyptians infected with chronic HCV.

The epidemiology of hepatitis C virus in Afghanistan: systematic review and meta-analysis

OBJECTIVES

To characterize hepatitis C virus (HCV) epidemiology and inform public health research, policy, and programming priorities in Afghanistan.

METHODS

Records of HCV incidence and prevalence were reviewed systematically and synthesized following PRISMA guidelines. Meta-analyses were implemented using a DerSimonian-Laird random effects model with inverse variance weighting to estimate HCV prevalence among various at risk populations. A risk of bias assessment was incorporated.

RESULTS

The search identified one HCV incidence and 76 HCV prevalence measures. HCV incidence was only assessed among people who inject drugs (PWID), and was reported at 66.7 per 100 person-years. Meta-analyses estimated HCV prevalence at 0.7% among the general population (range 0-9.1%, 95% confidence interval (CI) 0.5-0.9%), 32.6% among PWID (range 9.5-70.0%, 95% CI 24.5-41.3%), and 2.3% among populations at intermediate risk (range 0.0-8.3%, 95% CI 1.3-3.7%). No data were available for other high risk populations such as hemodialysis, thalassemia, and hemophilia patients.

CONCLUSIONS

HCV prevalence among the general population in Afghanistan is comparable to global levels. Data are needed for the level of infection among key clinical populations at high risk of infection. There is also an immediate need for expansion of harm reduction programs among PWID and prisoners.

The Epidemiology of Hepatitis C Virus in the Fertile Crescent: Systematic Review and Meta-Analysis

OBJECTIVE

To characterize hepatitis C virus (HCV) epidemiology in countries of the Fertile Crescent region of the Middle East and North Africa (MENA), namely Iraq, Jordan, Lebanon, Palestine, and Syria.

METHODS

We systematically reviewed and synthesized available records of HCV incidence and prevalence following PRISMA guidelines. Meta-analyses were implemented using a DerSimonian-Laird random effects model with inverse weighting to estimate the country-specific HCV prevalence among the various at risk population groups.

RESULTS

We identified eight HCV incidence and 240 HCV prevalence measures in the Fertile Crescent. HCV sero-conversion risk among hemodialysis patients was 9.2% in Jordan and 40.3% in Iraq, and ranged between 0% and 3.5% among other populations in Iraq over different follow-up times. Our meta-analyses estimated HCV prevalence among the general population at 0.2% in Iraq (range: 0-7.2%; 95% CI: 0.1-0.3%), 0.3% in Jordan (range: 0-2.0%; 95% CI: 0.1-0.5%), 0.2% in Lebanon (range: 0-3.4%; 95% CI: 0.1-0.3%), 0.2% in Palestine (range: 0-9.0%; 95% CI: 0.2-0.3%), and 0.4% in Syria (range: 0.3-0.9%; 95% CI: 0.4-0.5%). Among populations at high risk, HCV prevalence was estimated at 19.5% in Iraq (range: 0-67.3%; 95% CI: 14.9-24.5%), 37.0% in Jordan (range: 21-59.5%; 95% CI: 29.3-45.0%), 14.5% in Lebanon (range: 0-52.8%; 95% CI: 5.6-26.5%), and 47.4% in Syria (range: 21.0-75.0%; 95% CI: 32.5-62.5%). Genotypes 4 and 1 appear to be the dominant circulating strains.

CONCLUSIONS

HCV prevalence in the population at large appears to be below 1%, lower than that in other MENA sub-regions, and tending towards the lower end of the global range. However, there is evidence for ongoing HCV transmission within medical facilities and among people who inject drugs (PWID). Migration dynamics appear to have played a role in determining the circulating genotypes. HCV prevention efforts should be targeted, and focus on infection control in clinical settings and harm reduction among PWID.

Milestones along the road of infection prevention in Egypt

Sequela of infectious diseases include not only morbidity and mortality, but are also associated with chronic illnesses that has long constituted public health problems and huge economic burdens. This review gives a brief idea about important infectious diseases (ID) in Egypt, the main lines taken to combat them, the challenges still existing, and the possible barriers keeping IDs still forming threats to the community. Egypt has the highest prevalence rates of HCV infection worldwide. Significant evidence points towards that the HCV epidemic was initiated and propagated by the anti-schistosomal mass campaigns during the last century. Though the rates of HCV infection are declining, still the decline has not yet met the full expectations. Therefore, infection control programs are gaining more ground all over the country, especially with the growing problem of antimicrobial resistance complicating healthcare-associated infections (HAI) worldwide. Also, mass immnunization of childhood, mycobacterial tuberculosis infections, and avian influenza will be discussed.

Features of hepatitis C virus infection, current therapies and ongoing clinical trials in ten Asian Pacific countries

Estimated hepatitis C virus (HCV) infection rates in the general populations were 1.3, 0.9, 0.4-1.0, 14.7, 0.1-0.3, 0.9-1.9, 1.0-2.0, 5, 4.4-8.6 and 0.5-1.3 % in Australia, Bangladesh, Mainland China, Egypt, Hong Kong, India, Japan, Pakistan, Taiwan and Turkey, respectively. The main HCV genotypes (Gs) are G1, G3, G1b, G4, G1b, G3, G1b, G3, G1b and G2, and G1 in Australia, Bangladesh, Mainland China, Egypt, Hong Kong, India, Japan, Pakistan, Taiwan and Turkey, respectively. Of IL28B genotypes, favorable alleles are ~50 % in Australia and Turkey, but 60-70 % in most of the other Asian countries. Peginterferon plus ribavirin is available in all ten Asian Pasific countries. In addition, HCV NS3/4A protease inhibitors with peginterferon plus ribavirin are currently available in several countries. Clinical trials of interferon-free regimens for HCV are ongoing in most of the ten Asian Pacific countries.

The epidemiology of hepatitis C virus in the Maghreb region: systematic review and meta-analyses

Objective

To systematically review and synthesize available epidemiological data on hepatitis C virus (HCV) prevalence and incidence in the Maghreb region and to estimate the country-specific population-level HCV prevalence.

Methods

We conducted a systematic review of HCV antibody prevalence and incidence in the Maghreb countries as outlined by the PRISMA guidelines. Meta-analyses were conducted using DerSimonian-Laird random-effect models with inverse variance weighting to pool HCV prevalence estimates among general population groups.

Results

We identified 133 HCV prevalence measures and two HCV incidence measures. Among high risk groups, HCV prevalence ranged between 22% and 94% among people who inject drugs, 20% and 76% among dialysis patients, and 2% and 51% among hemophiliacs. Among intermediate-risk groups, considerable but widely variable HCV prevalence was found. Most common risk factors cited across studies were the duration of dialysis, number of transfusions, and having a history of surgery or dental work. The national HCV prevalence in Algeria was estimated at 0.3% (95%CI: 0.1–0.5), Libya 1.2% (95%CI: 1.1–1.3), Mauritania 1.1% (95%CI: 0–2.3), Morocco 0.8% (95%CI: 0.5–1.2), and Tunisia 0.6% (95%CI: 0.5–0.8).

Conclusions

HCV prevalence in the Maghreb region of the Middle East and North Africa is comparable to that in developed countries of about 1%. HCV exposures appear often to be linked to medical care and are suggestive of ongoing transmission in such settings. Injecting drug use appears also to be a major, though not dominant, contributor to HCV transmission. Further research is needed to draw a more thorough understanding of HCV epidemiology, especially in the countries with limited number of studies. HCV prevention policy and programming in these countries should focus on the settings of exposure.