Analysis of a hepatitis C screening programme for US veterans

Substitution of the CD81 Binding Site and β-Sandwich Area in E2 of HCV in Cambodia

The high genetic variability of hepatitis C virus (HCV) is the main obstacle to developing a vaccine. E2 has attracted attention for vaccine development because targeting this protein could potentially overcome issues related to the genetic diversity of HCV. In this study, we analyzed HCV genes in the general population of Cambodia and investigated the E2 locus as a candidate for vaccine development. HCV sero-epidemiological surveys were conducted between the period 2010 and 2014, with an HCV RNA–positive rate of 1.3% (11/868). Follow-up blood samples were collected from four anti-HCV– and HCV RNA– positive patients (genotype 1b: 2 cases, 6e: 1 case, 6r: 1 case) after 4.12 years. Analysis of HCV full-length nucleotide sequences in paired specimens revealed that the mutation rates of HCV genotypes 1b and 6e/6r were 1.61–2.03 × 10⁻³ and 2.52–2.74 × 10⁻³ substitutions/site/year, respectively. Non-synonymous substitutions were detected in HVR1, the front layer of the CD81 binding site, and the β-sandwich, but not in the N-terminal region or adjacent to the CD81 binding site. Therefore, we conclude that the CD81 binding site is a promising locus for HCV vaccine development.

Community viral load and hepatitis C virus infection: Community viral load measures to aid public health treatment efforts and program evaluation

BACKGROUND

Hepatitis C virus (HCV) infection is the most prevalent blood-borne infection and causes more deaths than any other infectious disease in the US. Incident HCV infection in the US increased nearly 300 % between 2010 and 2015, Community viral load (CVL) measures have been developed for HIV to measure both transmission risk and treatment engagement in programs or areas.

OBJECTIVE

This paper presents a systematic review exploring the published literature on CVL constructs applied to HCV epidemiology and proposes novel CVL measures for HCV.

STUDY DESIGN AND SETTING

A systematic review was conducted of electronic databases; the search sought to identify published literature on HCV which discussed or applied CVL measures to HCV epidemiology. Novel CVL measures were constructed to apply to HCV.

RESULTS

No reports examining quantitative measures of HCV CVL were identified. Using the HIV CVL literature and the specific characteristics of HCV epidemiology, five HCV CVL measures are proposed. Narrower measures focusing on those engaged-in-care may be useful for program evaluation and broader measures including undiagnosed people may be useful for surveillance of HCV transmission potential.

CONCLUSION

Despite their potential value, CVL constructs have not yet formally been developed and applied to HCV epidemiology. The CVL measures proposed here could serve as valuable HCV program and surveillance measures. There is a need for informative surveillance measures to enhance policy and public health responses to achieve HCV control. Further study of these proposed HCV CVL measures to HCV epidemiology is warranted.

The Association of Abnormal Liver Tests with Hepatitis C Testing in Primary Care

BACKGROUND

As hepatitis C virus birth cohort (1945-1965) screening in primary care improves, testing patterns in response to persistently abnormal liver tests are less well known.

METHODS

This retrospective cohort study of a patient-centered medical home between 2007 and 2016 evaluates the association of abnormal liver chemistries and other clinical and demographic factors with hepatitis C antibody (HCV Ab) testing in patients with persistently abnormal liver tests. Patients with at least 2 consecutive abnormal liver tests were categorized by the clinical pattern of liver chemistry abnormality, including cholestatic, hepatocellular, and mixed patterns. The primary outcomes were: 1) completed HCV Ab tests; and 2) positive HCV Ab results for those patients tested.

RESULTS

Of 4512 patients with consecutive abnormal liver tests, only 730 (16%) underwent HCV Ab testing within 1 year of the second abnormality; 81/730 (11%) had HCV Ab detected. A logistic regression model revealed that mixed (odds ratio [OR] 2.20; 95% confidence interval [CI], 1.72-2.82) and hepatocellular (OR 1.43; 95% CI, 1.15-1.79) patterns of liver test abnormality, female sex, and alcohol and tobacco abuse were associated with higher odds of HCV Ab testing. Hepatocellular (OR 7.51; 95% CI, 2.18-25.94) and mixed patterns (OR 5.88; 95% CI, 1.64-21.15) of liver test abnormalities, male sex, Medicaid enrollment, and drug and tobacco abuse had higher odds of positive HCV Ab results.

CONCLUSIONS

There is opportunity to improve hepatitis C diagnostic testing in patients with consecutively elevated liver tests, and hepatocellular and mixed patterns of abnormality should prompt primary care providers to action.

Current challenges and possible solutions to improve access to care and treatment for hepatitis C infection in Vietnam: a systematic review

Background

Hepatitis C infection is a major public health concern in low- and middle-income countries where an estimated 71.1 million individuals are living with chronic infection. The World Health Organization (WHO) has recently released new guidance for hepatitis C virus (HCV) treatment programs, which include improving the access to new direct-acting antiviral agents. In Vietnam, a highly populated middle-income country, the seroprevalence of HCV infection is approximately 4% and multiple genotypes co-circulate in the general population. Here we review what is currently known regarding the epidemiology of HCV in Vietnam and outline options for reducing the significant burden of morbidity and mortality in our setting.

Methods

We performed a systematic review of the currently available literature to evaluate what has been achieved to date with efforts to control HCV infection in Vietnam.

Results

This search retrieved few publications specific to Vietnam indicating a significant gap in baseline epidemiological and public health data. Key knowledge gaps identified included an understanding of the prevalence in specific high-risk groups, characterization of circulating HCV genotypes in the population and likely response to treatment, and the extent to which HCV treatment is available, accessed and utilized.

Conclusions

We conclude that there is an urgent need to perform up to date assessments of HCV disease burden in Vietnam, especially in high-risk groups, in whom incidence is high and cross infection with multiple genotypes is likely to be frequent. Coordinating renewed surveillance measures with forthcoming HCV treatment studies should initiate the traction required to achieve the WHO goal of eliminating HCV as a public health threat by 2030, at least in this region.

HCV Screening Behaviors and Infection Status among Vietnamese Americans

OBJECTIVES

The aim of this study was to identify socio-economic and acculturation factors associated with hepatitis C (HCV) screening and infection among US Vietnamese Americans.

METHODS

Participants were recruited from 7 Vietnamese community-based organizations in Pennsylvania and New Jersey. The analysis ultimately included 309 participants who participated in a HCV education intervention program.

RESULTS

Overall, 82.5% (255 of 309) intervention participants completed HCV screening over the 6 months prior to the post-intervention assessment. In multivariate-adjusted analysis, participants who lived in Vietnam for 40 years versus 20 years were more likely to receive HCV screening; unemployed individuals were less likely to receive HCV screening than employed people. Among screened participants, 7.5% had HCV infection.

CONCLUSIONS

These findings will guide future culturally and linguistically appropriate interventions to reduce HCV infection and HCV-related liver cancer.

Outcomes of hepatitis C screening programs targeted at risk groups hidden in the general population: a systematic review

BACKGROUND

Effective screening programs are urgently needed to provide undiagnosed hepatitis C virus (HCV)-infected individuals with therapy. This systematic review of characteristics and outcomes of screening programs for HCV focuses on strategies to identify HCV risk groups hidden in the general population.

METHODS

We conducted a comprehensive search of MEDLINE and EMBASE databases for articles published between 1991-2010, including studies that screened the general population using either a newly developed (nonintegrated) screening program or one integrated in existing health care facilities. Look-back studies, prevalence studies, and programs targeting high-risk groups in care (e.g., current drug users) were excluded.

RESULTS

After reviewing 7052 studies, we identified 67 screening programs: 24 nonintegrated; 41 programs integrated in a variety of health care facilities (e.g., general practitioner); and 2 programs with both integrated and nonintegrated strategies. Together, these programs identified approximately 25,700 HCV-infected individuals. In general, higher HCV prevalence was found in programs in countries with intermediate to high HCV prevalence, in psychiatric clinics, and in programs that used a prescreening selection based on HCV risk factors. Only 6 programs used a comparison group for evaluation purposes, and 1 program used theory about effective promotion for screening. Comparison of the programs and their effectiveness was hampered by lack of reported data on program characteristics, clinical follow-up, and type of diagnostic test.

CONCLUSIONS

A prescreening selection based on risk factors can increase the efficiency of screening in low-prevalence populations, and we need programs with comparison groups to evaluate effectiveness. Also, program characteristics such as type of diagnostic test, screening uptake, and clinical outcomes should be reported systematically.

Association of tattooing and hepatitis C virus infection: a multicenter case-control study

Although injection drug use (IDU) and blood transfusions prior to 1992 are well-accepted risk factors for hepatitis C virus (HCV) infection, many studies that evaluated tattooing as a risk factor for HCV infection did not control for a history of IDU or transfusion prior to 1992. In this large, multicenter, case-control study, we analyzed demographic and HCV risk factor exposure history data from 3,871 patients, including 1,930 with chronic HCV infection (HCV RNA-positive) and 1,941 HCV-negative (HCV antibody-negative) controls. Crude and fully adjusted odds ratios (ORs) of tattoo exposure by multivariate logistic regression in HCV-infected versus controls were determined. As expected, IDU (65.9% versus 17.8%; P < 0.001), blood transfusion prior to 1992 (22.3% versus 11.1%; P < 0.001), and history of having one or more tattoos (OR, 3.81; 95% CI, 3.23-4.49; P < 0.001) were more common in HCV-infected patients than in control subjects. After excluding all patients with a history of ever injecting drugs and those who had a blood transfusion prior to 1992, a total of 1,886 subjects remained for analysis (465 HCV-positive patients and 1,421 controls). Among these individuals without traditional risk factors, HCV-positive patients remained significantly more likely to have a history of one or more tattoos after adjustment for age, sex, and race/ethnicity (OR, 5.17; 95% CI, 3.75-7.11; P < 0.001).

CONCLUSION

Tattooing is associated with HCV infection, even among those without traditional HCV risk factors such as IDU and blood transfusion prior to 1992.

Effectiveness of a risk screener in identifying hepatitis C virus in a primary care setting

OBJECTIVES

We evaluated an intervention designed to identify patients at risk for hepatitis C virus (HCV) through a risk screener used by primary care providers.

METHODS

A clinical reminder sticker prompted physicians at 3 urban clinics to screen patients for 12 risk factors and order HCV testing if any risks were present. Risk factor data were collected from the sticker; demographic and testing data were extracted from electronic medical records. We used the t test, χ(2) test, and rank-sum test to compare patients who had and had not been screened and developed an analytic model to identify the incremental value of each element of the screener.

RESULTS

Among screened patients, 27.8% (n = 902) were identified as having at least 1 risk factor. Of screened patients with risk factors, 55.4% (n = 500) were tested for HCV. Our analysis showed that 7 elements (injection drug use, intranasal drug use, elevated alanine aminotransferase, transfusions before 1992, ≥ 20 lifetime sex partners, maternal HCV, existing liver disease) accounted for all HCV infections identified.

CONCLUSIONS

A brief risk screener with a paper-based clinical reminder was effective in increasing HCV testing in a primary care setting.

Primary care-based interventions are associated with increases in hepatitis C virus testing for patients at risk

BACKGROUND

An estimated 3.2 million persons are chronically infected with the hepatitis C virus (HCV) in the U.S. Effective treatment is available, but approximately 50% of patients are not aware that they are infected. Optimal testing strategies have not been described.

METHODS

The Hepatitis C Assessment and Testing Project (HepCAT) was a serial cross-sectional evaluation of two community-based interventions designed to increase HCV testing in urban primary care clinics in comparison with a baseline period. The first intervention (risk-based screener) prompted physicians to order HCV tests based on the presence of HCV-related risks. The second intervention (birth cohort) prompted physicians to order HCV tests on all patients born within a high-prevalence birth cohort (1945-1964). The study was conducted at three primary care clinics in the Bronx, New York.

RESULTS

Both interventions were associated with an increased proportion of patients tested for HCV from 6.0% at baseline to 13.1% during the risk-based screener period (P<0.001) and 9.9% during the birth cohort period (P<0.001).

CONCLUSIONS

Two simple clinical reminder interventions were associated with significantly increased HCV testing rates. Our findings suggest that HCV screening programs, using either a risk-based or birth cohort strategy, should be adopted in primary care settings so that HCV-infected patients may benefit from antiviral treatment.

Transmission of hepatitis C virus infection through tattooing and piercing: a critical review

Tattoos and piercings are increasing, especially among youths, but the risk of hepatitis C virus (HCV) infection from these practices has not been adequately assessed and there are conflicting findings in the literature. We evaluated the risk of HCV infection from tattooing and piercing using the Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines. Studies that specified the venue of tattooing and/or piercing showed no definitive evidence for an increased risk of HCV infection when tattoos and piercings were received in professional parlors. However, the risk of HCV infection is significant, especially among high-risk groups (adjusted odds ratio, 2.0-3.6), when tattoos are applied in prison settings or by friends. Prevention interventions are needed to avoid the transmission of hepatitis C from tattooing and piercing in prisons, homes, and other potentially nonsterile settings. Youths also should be educated on the need to have tattoos and piercings performed under sterile conditions to avoid HCV infection.

Reduced naive CD4 T cell numbers and impaired induction of CD27 in response to T cell receptor stimulation reflect a state of immune activation in chronic hepatitis C virus infection

BACKGROUND

Chronic hepatitis C virus (HCV) infection is characterized by reduced numbers of functional HCV-specific T cells. In addition, chronically HCV-infected individuals have reduced response to vaccine. Alterations in naive CD4 T cell phenotype or function may contribute to these immune impairments.

METHODS

Using flow cytometric analysis and enzyme-linked immunospot assay, we examined peripheral naive CD4 T cell phenotype and function in chronically HCV-infected patients and control subjects.

RESULTS

We observed significantly lower absolute cell numbers of naive CD4 T cells in HCV-infected patients, localized to the CD127(+)CD25(low/-) and CD31(+) (RTE) subsets. Moreover, we found greater percentages of naive cells expressing CD25 and KI67 in HCV-infected patients, consistent with immune activation, further supported by higher plasma sCD27 levels. Functional analysis revealed an intact interferon-γ response to allogeneic B cell stimulus. However, after direct TCR stimulation, naive CD4 T cells from HCV-infected patients had altered up-regulation of KI67 and CD25 and less CD27 expression. The latter was associated with elevated baseline activation state. In addition, naive CD4 T cells from HCV-infected patients were more susceptible to cell death.

CONCLUSIONS

These numerical and functional defects may contribute to inadequate formation of virus and neoantigen-specific T cell responses during chronic HCV infection.

Prevalence and challenges of liver diseases in patients with chronic hepatitis C virus infection

Hepatitis C virus (HCV) infections pose a growing challenge to health care systems. Although chronic HCV infection begins as an asymptomatic condition with few short-term effects, it can progress to cirrhosis, hepatic decompensation, hepatocellular carcinoma (HCC), and death. The rate of new HCV infections is decreasing, yet the number of infected people with complications of the disease is increasing. In the United States, people born between 1945 and 1964 (baby boomers) are developing more complications of infection. Men and African Americans have a higher prevalence of HCV infection. Progression of fibrosis can be accelerated by factors such as older age, duration of HCV infection, sex, and alcohol intake. Furthermore, insulin resistance can cause hepatic steatosis and is associated with fibrosis progression and inflammation. If more effective therapies are not adopted for HCV, more than 1 million patients could develop HCV-related cirrhosis, hepatic decompensation, or HCC by 2020, which will impact the US health care system. It is important to recognize the impact of HCV on liver disease progression and apply new therapeutic strategies.

Body of evidence: tattoos, body piercing, and eating disorder symptoms among adolescents

OBJECTIVE

Tattoos and body piercing have been linked to risk-taking behaviors, including disordered eating, but the findings have come from selected samples that were at greater risk for bias due to comorbidity. This study set out to explore concurrently the prevalence of tattoos and body piercing, and eating disorder symptoms in a representative adolescent sample of a community in Sardinia, a major island in Italy.

METHODS

A community sample of 828 students (female, 535; male, 282; mean age=17.5+/-1.4 years) among those attending high school in the district of Cagliari, Italy, were invited to take the Eating Attitudes Test, the Bulimic Investigatory Test of Edinburgh, and the Body Attitudes Test, alongside a short questionnaire aimed at evaluating their resorting to body modification practices, including tattooing and body piercing.

RESULTS

Females scored higher than males at all eating disorder inventories. More males than females admitted the use of tattoos (14.5% vs. 5.4%), whereas the reverse was found for body piercing (18.4% vs. 21.3%). Tattoos among females and body piercing in both genders were statistically associated with eating disorder measures related to bulimia symptoms. On the whole, the degree of association was modest.

CONCLUSIONS

Tattoos and body piecing should be seen as desires to show a subject's identity rather than as a marker of psychopathology. Greater health education, however, is needed in the wake of the growing popularity of these body modification practices.