High seroprevalence of HCV in the Abruzzo Region, Italy: results on a large sample from opt-out pre-surgical screening

Mortality related to HCV and other chronic liver diseases in Veneto (Italy), 2008-2021: Changes in trends and age-period-cohort effects

BACKGROUND AND AIMS

The objective of this study was to assess the impact of the COVID-19 pandemic and direct-acting antiviral (DAA) agents on mortality related to chronic liver diseases (CLD).

METHODS

Age-standardized mortality rates were computed based on CLD as the underlying cause of death (UCOD) and as any mention in death certificates (multiple causes of death-MCOD). Time trends in age-standardized mortality rates were investigated using generalized estimation equation models. Additionally, we conducted age, period, and birth cohort (APC) analyses on CLD-related mortality associated with alcohol and hepatitis C virus (HCV).

RESULTS

Between 2008 and 2021, among residents in the Veneto region (Northeastern Italy) aged ≥35 years, there were 20 409 deaths based on the UCOD and 30 069 deaths based on MCOD from all CLD. We observed a 4% annual decline in age-standardized MCOD-based mortality throughout 2008-2021, with minor peaks corresponding to COVID-19 epidemic waves. Starting in 2016, the decline in HCV-related mortality accelerated further (p < .001). A peak in HCV-related mortality in the 1963-1967 birth cohort was observed, which levelled off by the end of the study period. Mortality related to alcoholic liver disease declined at a slower pace, becoming the most common aetiology mentioned in death certificates.

CONCLUSIONS

The study demonstrates a significant decrease in HCV-related mortality at the population level in Italy with the introduction of DAAs. Continuous monitoring of MCOD data is warranted to determine if this favourable trend will continue. Further studies utilizing additional health records are needed to clarify the role of other CLD etiologies.

Epidemiology of HCV and HBV in a High Endemic Area of Southern Italy: Opportunities from the COVID-19 Pandemic-Standardized National Screening or One Tailored to Local Epidemiology?

Simple Summary

Epidemiological data on viral hepatitis are essential to optimize screening programs. For HCV, the Italian Health Ministry planned a cohort screening for those born in 1969–1989. In order to update the epidemiological data of viral hepatitis in a highly endemic area of Southern Italy and assess whether the screening programs currently planned by the Italian government for those born between 1969–1989 will be effective, a retrospective multicenter study was carried out enrolling all COVID-19 hospitalized patients screened for markers of HCV and HBV infection. Indeed, the COVID-19 pandemic has resulted in access to the national health system of an unselected population similar to the general one. Among the 2126 patients evaluated, HBsAg and HCV-Ab prevalence was 1.6% and 5.1%, respectively. For HCV infection, a bimodal distribution was observed, with peaks in the birth cohorts 1930–1939 and 1960–1969 (11.6% and 5.6%, respectively). An analysis of the screening period imposed (born: 1969–1989) demonstrates that only 17% of HCV infection could be captured. Thus, an alignment of the screening period (i.e., birth cohort 1960–1984) would capture 40% of cases. Data show a high endemicity of hepatitis virus in our geographic area and the need for a tailored regional screening program.

Abstract

The COVID-19 pandemic led to the hospitalization of an unselected population with the possibility to evaluate the epidemiology of viral hepatitis. Thus, a retrospective multicenter study was conducted in an area of Southern Italy with the aim of assessing the prevalence of HCV and HBV markers and the ability of current screening program to capture cases. We evaluated 2126 hospitalized patients in seven COVID Centers of Naples and Caserta area in which 70% of the Campania population lives. HBsAg and HCV-Ab prevalence was 1.6% and 5.1%, respectively, with no differences between gender. Decade distribution for birth year shows a bimodal trend of HCV prevalence, with a peak (11.6%) in the decade 1930–1939 and a second peak (5.6%) for those born in 1960–1969. An analysis of the screening period imposed by the Italian government for those born between 1969 and 1989 shows that only 17% of cases of HCV infection could be captured. A small alignment of the screening period, i.e., those born from 1960 to 1984, would capture 40% of cases. The data confirm the high endemicity of our geographical area for hepatitis virus infections and underline the need for a tailored screening program according to the regional epidemiology.

Prevalence of chronic liver disease among young/middle-aged adults in Northern Italy: role of hepatitis B and hepatitis C virus infection by age, sex, ethnicity

Background

Sparse population-based data are available on the prevalence and etiology of chronic liver disease (CLD) in Italy. The study aims to assess the role of hepatitis B virus (HBV) and hepatitis C virus (HCV) infection in CLD according to age, gender and ethnicity.

Methods

Clinically diagnosed CLD in the general population aged 20–59 years in the Veneto Region (North-Eastern Italy) were identified through the Adjusted Clinical Groups System, by record linkage of the archive of subjects enrolled in the Regional Health System with Hospital Discharge Records, Emergency Room visits, Chronic disease registry for copayment exemptions, and the Home care database. Age-standardized prevalence rates (PR) were computed in Italians and immigrants, based on country of citizenship.

Results

Overall 22,934 subjects affected by CLD in 2016 were retrieved, 21% related to HBV and 43% to HCV infection. The prevalence of HCV-related CLD was higher in males, peaking at 50–54 years (males = 11/1000; females = 4/1000). The PR of HBV-related CLD was almost negligible in the Italian population (1/1000), and higher among immigrants, especially from East Asia (males = 17/1000; females = 11/1000) and Sub-Saharan Africa (males = 13/1000; females = 10/1000).

Conclusion

Specific population sub-groups identified by age, gender, and ethnicity, were demonstrated to be at increased risk, and these trends are in line with global epidemiological patterns of viral hepatitis.

The inpatient hospital burden of comorbidities in HCV-infected patients: A population-based study in two Italian regions with high HCV endemicity (The BaCH study)

BACKGROUND & AIMS

Hepatitis C (HCV) is associated with several extrahepatic manifestations, and estimates of the hospitalization burden related to these comorbidities are still limited. The aim of this study is to quantify the hospitalization risk associated with comorbidities in an Italian cohort of HCV-infected patients and to assess which of these comorbidities are associated with high hospitalization resource utilization.

METHODS

Individuals aged 18 years and older with HCV-infection were identified in the Abruzzo's and Campania's hospital discharge abstracts during 2011-2014 with 1-year follow-up. Cardio-and cerebrovascular disease, diabetes and renal disease were grouped as HCV-related comorbidities. Negative binomial models were used to compare the hospitalization risk in patients with and without each comorbidity. Logistic regression model was used to identify the characteristics of being in the top 20% of patients with the highest hospitalization costs (high-cost patients).

RESULTS

15,985 patients were included; 19.9% had a liver complication and 48.6% had one or more HCV-related comorbidities. During follow-up, 36.0% of patients underwent at least one hospitalization. Liver complications and the presence of two or more HCV-related comorbidities were the major predictors of hospitalization and highest inpatient costs. Among those, patients with cardiovascular disease had the highest risk of hospitalization (Incidence Rate Ratios = 1.42;95%CI:1.33-1.51) and the highest likelihood of becoming high-cost patients (Odd Ratio = 1.37;95%CI:1.20-1.57).

CONCLUSION

Beyond advanced liver disease, HCV-related comorbidities (especially cardiovascular disease) are the strongest predictors of high hospitalization rates and costs. Our findings highlight the potential benefit that early identification and treatment of HCV might have on the reduction of hospitalization costs driven by extrahepatic conditions.

Mortality associated with hepatitis C and hepatitis B virus infection: A nationwide study on multiple causes of death data

AIM

To analyze mortality associated with hepatitis C virus (HCV) and hepatitis B virus (HBV) infection in Italy.

METHODS

Death certificates mentioning either HBV or HCV infection were retrieved from the Italian National Cause of Death Register for the years 2011-2013. Mortality rates and proportional mortality (percentage of deaths with mention of HCV/HBV among all registered deaths) were computed by gender and age class. The geographical variability in HCV-related mortality rates was investigated by directly age-standardized rates (European standard population). Proportional mortality for HCV and HBV among subjects aged 20-59 years was assessed in the native population and in different immigrant groups.

RESULTS

HCV infection was mentioned in 1.6% (n = 27730) and HBV infection in 0.2% (n = 3838) of all deaths among subjects aged ≥ 20 years. Mortality rates associated with HCV infection increased exponentially with age in both genders, with a male to female ratio close to unity among the elderly; a further peak was observed in the 50-54 year age group especially among male subjects. HCV-related mortality rates were higher in Southern Italy among elderly people (45/100000 in subjects aged 60-79 and 125/100000 in subjects aged ≥ 80 years), and in North-Western Italy among middle-aged subjects (9/100000 in the 40-59 year age group). Proportional mortality was higher among Italian citizens and North African immigrants for HCV, and among Sub-Saharan African and Asian immigrants for HBV.

CONCLUSION

Population ageing, immigration, and new therapeutic approaches are shaping the epidemiology of virus-related chronic liver disease. In spite of limits due to the incomplete reporting and misclassification of the etiology of liver disease, mortality data represent an additional source of information for surveillance.

Infection with hepatitis viruses, FIB-4 index and risk of hepatocellular carcinoma in southern Italy: a population-based cohort study

BACKGROUND

The incidence of hepatocellular carcinoma (HCC) and its association with hepatitis C (HCV) and hepatitis B virus (HBV) infections, FIB-4 index and liver enzymes was assessed in an area of the province of Naples covered by a population-based cancer registry.

METHODS

We conducted a cohort investigation on 4492 individuals previously enrolled in a population-based seroprevalent survey on HCV and HBV infections. The diagnosis of HCC was assessed through a record linkage with the cancer registry. Hepatic metabolic activity was measured through serum alanine transaminase, aspartate aminotransferase, gamma-glutamyl-transferase, and platelet. The FIB-4 index was used as a marker of fibrosis. We computed HCC incidence rates (IR) for 100,000 (105) person-years of observation, and multivariable hazard ratios (HR) with 95 % confidence intervals (CI) to assess risk factors for HCC.

RESULTS

Twenty two cases of HCC were diagnosed during follow-up (IR = 63.3 cases/105). Significantly increased HCC risks were documented in individuals with higher than normal liver enzymes and low platelet count; in the 239 HCV RNA-positives (HR = 61.8, 95 % CI:13.3-286); and in the 95 HBsAg-positives (HR = 75.0) -as compared to uninfected individuals. The highest FIB-4 score was associated with a 17.6-fold increased HCC risk.

CONCLUSIONS

An elevated FIB-4 index turned out to be an important predictor of HCC occurrence. Although the standard method to assess hepatic fibrosis in chronic hepatitis remains the histologic staging of liver biopsy specimen, the assessment of FIB-4 in HCV RNA-positive individuals may help in identifying the highest HCC-risk individuals who need anti-HCV treatment most urgently.

Web-Based HIV Testing in Abruzzo, Italy: Analysis of 15-Month Activity Results

Undiagnosed cases of HIV infection in developed countries are estimated at 20-30% of individuals living with HIV. Web-based strategies may represent a new approach to easier, wider, and unrestricted access to early testing. The Abruzzo Region, Italy, developed a Web-based tool to recruit persons at high risk of HIV and other sexually transmitted infections (STIs). At the Website www.failtestanchetu.it , browsers found information on STIs (HIV, hepatitis B and C, and syphilis), a structured questionnaire called "risk calculator" to assess one's own risk behaviors and direct booking of their test at one of six sites throughout the region. The Website was advertised on local media and in pharmacies, high schools, sports facilities, and factories. Between February 1, 2014, and May 31, 2015, about 6000 users visited the Website; 3046 people attended a visit for counseling on risk behaviors, signs, or symptoms of STIs and accepted blood drawing for HIV, hepatitis B Virus (HBV), hepatitis C Virus (HCV), and syphilis tests. Fifty-eight (1.90%) subjects were positive for HCV, 56 (1.84%) for HBsAg, 90 (2.95%) for Treponema pallidum antibodies, and 28 (0.92%) for HIV. Ninety-two percent of HIV-positive patients were successfully linked to care. Late presenters were less frequent in this sample than in the population diagnosed with HIV in Italy in 2014. An overall 7% proportion of HIV, HBV, HCV, and syphilis-unaware cases were all transferred to care, with the exception of three people. HIV seropositivity among testers was higher than 2/1000, the cost-effectiveness threshold suggested for effective testing. Therefore, our Web-based unrestricted and free access methodology appears worth further and wider evaluation.