Prevalence and risk factors for intrafamilial transmission of hepatitis C virus in Karachi, Pakistan

Risk factors for hepatocellular carcinoma associated with hepatitis C genotype 3 infection: A systematic review

BACKGROUND

Hepatitis C virus (HCV) is a blood-borne virus which globally affects around 79 million people and is associated with high morbidity and mortality. Chronic infection leads to cirrhosis in a large proportion of patients and often causes hepatocellular carcinoma (HCC) in people with cirrhosis. Of the 6 HCV genotypes (G1-G6), genotype-3 accounts for 17.9% of infections. HCV genotype-3 responds least well to directly-acting antivirals and patients with genotype-3 infection are at increased risk of HCC even if they do not have cirrhosis.

AIM

To systematically review and critically appraise all risk factors for HCC secondary to HCV-G3 in all settings. Consequently, we studied possible risk factors for HCC due to HCV-G3 in the literature from 1946 to 2023.

METHODS

This systematic review aimed to synthesise existing and published studies of risk factors for HCC secondary to HCV genotype-3 and evaluate their strengths and limitations. We searched Web of Science, Medline, EMBASE, and CENTRAL for publications reporting risk factors for HCC due to HCV genotype-3 in all settings, 1946-2023.

RESULTS

Four thousand one hundred and forty-four records were identified from the four databases with 260 records removed as duplicates. Three thousand eight hundred and eighty-four records were screened with 3514 excluded. Three hundred and seventy-one full-texts were assessed for eligibility with seven studies included for analysis. Of the seven studies, three studies were retrospective case-control trials, two retrospective cohort studies, one a prospective cohort study and one a cross-sectional study design. All were based in hospital settings with four in Pakistan, two in South Korea and one in the United States. The total number of participants were 9621 of which 167 developed HCC (1.7%). All seven studies found cirrhosis to be a risk factor for HCC secondary to HCV genotype-3 followed by higher age (five-studies), with two studies each showing male sex, high alpha feto-protein, directly-acting antivirals treatment and achievement of sustained virologic response as risk factors for developing HCC.

CONCLUSION

Although, studies have shown that HCV genotype-3 infection is an independent risk factor for end-stage liver disease, HCC, and liver-related death, there is a lack of evidence for specific risk factors for HCC secondary to HCV genotype-3. Only cirrhosis and age have demonstrated an association; however, the number of studies is very small, and more research is required to investigate risk factors for HCC secondary to HCV genotype-3.

A Systematic Review and Meta-Analysis on the Epidemiology of Hepatitis B and Hepatitis C Virus among Beta-Thalassemia Major Patients in Pakistan

Beta-thalassemia major patients are the leading consumers of blood transfusions in Pakistan and, therefore, have a greater risk of acquiring transfusion-transmitted infections, most notably hepatitis B and C virus (HBV and HCV). The present study includes a comprehensive review on the status of HBV and HCV in beta-thalassemia major patients in Pakistan. For this purpose, we examined original articles assessing the epidemiology of HBV and HCV in transfusion-dependent thalassemia patients.

We searched 10 major subscription databases from January through February 2020, that is, Medline, PakMediNet, CINAHL, Scopus, PubMed, Web of Science, Embase, Science Direct, Google Scholar, and Directory of Open Access Journals. The World Health Organization resources were also explored for relevant reports. The search criteria included published articles up to December 31, 2019, with no language restrictions. Articles identified were introduced into the Endnote version X9 software and then screened for relevance and duplication. The results were stated as the pooled prevalence for the overall study and also for region-wise subgroups.

A total of 33 studies conducted from 1995 to 2019 were included in the review. All 33 articles yielded information on HCV prevalence, while 19 of them provided information on HBV prevalence. The overall sample size was 8,554 that tested the prevalence of HCV in thalassemia patients. The sample size from the 19 studies that tested the prevalence of HBV was 6,184. The overall pooled prevalence of HBV was computed to be 4.13%, while the pooled prevalence of HCV was 29.79%. The majority of the studies were obtained from the Punjab Province (33.33%), followed by Khyber Pakhtunkhwa Province (24.24%).

The total sample size of 33 studies was less than 10% of the total number of estimated thalassemic patients, that is, 100,000. Further studies or a national baseline survey are imperative to confirm the actual frequency of HBV and HCV in thalassemia patients across the country.

Occupational Health Update: Evaluation and Management of Exposures and Postexposure Prophylaxis

Health care personnel (HCP) are at risk of exposure to infectious agents depending on their job duties and other factors. Risks include percutaneous exposure to blood-borne pathogens via sharp injuries (eg, human immunodeficiency virus, hepatitis B virus, hepatitis C virus); exposure by direct contact, droplet, or airborne transmission of pathogens through direct patient care (eg, pertussis, invasive meningococcus infections, tuberculosis); and through indirect contact transmission related to the contaminated health care environment (eg, Clostridioides difficile). Occupational health programs must effectively identify and respond to potential exposures and provide guidance to HCP on postexposure prophylaxis.

The prevalence of hepatitis C virus infection in β-thalassemia patients in Pakistan: a systematic review and meta-analysis

Background

Hepatitis C virus infection is the most commonly reported bloodborne infection in Pakistan. Frequent blood transfusions in β-thalassemia patients expose them to a high risk of HCV infection. The purpose of this paper is to summarise the current data on the prevalence of HCV infection in β-thalassemia patients in Pakistan by using a systematic review and meta–analysis.

Methods

PubMed, EMBASE, Web of Sciences, the Cochrane Library, Directory of Open Access Journal and local databases were systematically searched for studies published between January 1st, 1995 and May 31st, 2019. Meta-analysis was performed using the DerSimonian and Laird random-effects models with inverse variance weighting. The presence of publication bias was tested by Egger test, and the methodological quality of each included article was evaluated by the STROBE.

Results

We identified a total of 229 potential studies, of which 27 studies were finally considered in the meta-analysis. The pooled prevalence of HCV in β-thalassemia patients in Pakistan was 36.21% (95% CI: 28.98–43.75%) based on 5789 β-thalassemia patients, but there was considerable heterogeneity. Meta-analysis estimated the HCV prevalence among the β-thalassemia patients at 45.98% (95% CI: 38.15–53.90%) in Punjab, 31.81% (95% CI: 20.27–44.59%) in Sindh, and 28.04% (95% CI: 13.58–45.26%) in Khyber Pakhtunkhwa. Meta–regression analysis showed that geographical location was a key source of heterogeneity.

Conclusions

The pooled prevalence of HCV in β-thalassemia patients in Pakistan was more than one in three, and higher than in neighbouring countries. It varies regionally within the country. With the use of standard prevention procedures during blood transfusion, the risk of HCV transmission in β-thalassemia patients could be controlled and the prevalence of HCV in β-thalassemia patients reduced.

Highlights for Dental Care as a Hepatitis C Risk Factor: A Review of Literature

Hepatitis C (HCV) is a viral infection that affects an estimated 71 million people worldwide, with over 1 million new infections yearly. While medical treatments exist, HCV continues to be a significant public health concern. Primary prevention and transmission risk factor identification remain key in helping decrease disease prevalence. While intravenous drug use, healthcare exposure (i.e. blood transfusions and surgical care), and body modification (i.e. tattooing and piercings) are well accepted risk factors for HCV transmission, others remain controversial. Because dental practice is often associated with procedures and bleeding, the possibility of HCV transmission seemed reasonable to investigate. Here, we review the evidence for dental care as a potential risk factor for HCV transmission. We identified a total of 1,180 manuscripts related to HCV and dental care, of which 26 manuscripts were included in the study after exclusionary criteria were applied. As per our review of the available literature, in the developing world, the improper use of sterile technique and lack of provider education likely increases the risk of HCV transmission during dental care. In developed nations, on the other hand, general dental care does not appear to be a significant risk factor for HCV transmission in non-intravenous drug user patients; although, the improper use and reuse of anesthetics during procedures poses a rare potential risk for viral transmission.

Intrafamilial Transmission of Hepatitis C Virus Among Families of Infected Pediatric Oncology Patients

BACKGROUND

Hepatitis C virus (HCV) is the most commonly encountered blood transmittable hepatitis among cancer patients. Several studies have reported clustering of HCV infections in families or household contacts of infected cases. Data about the epidemiologic aspects of intrafamilial transmission from pediatric cancer patients are scarce and still debated. We aimed to identify the magnitude of horizontal intrafamilial transmission of HCV from infected pediatric oncology patients; its prevalence, risk factors and possible routes of transmission.

METHODS

One hundred fifty-seven (86 HCV positive, 71 HCV negative) pediatric oncology patients who received treatment and follow-up at Zagazig university Hospital-Egypt and their household family contacts (751) were enrolled in this cross-sectional case-control study. Blood samples were collected from 450 relatives of HCV infected cases (group 1) and 301 household contacts of HCV-negative cases (group 2) for analysis of HCV antibodies and HCV RNA to confirm positivity. Family contacts of HCV-infected cases were interviewed, and close-ended questionnaire was completed for each participant to determine risk factors and possible routes of HCV intrafamilial transmission.

RESULTS

Significantly higher HCV prevalence and chronicity rates were documented among relatives of HCV-infected cases as compared with contacts of HCV-negative cases (12.6% and 10.6% for group 1 vs. 7% and 5.3% for group 2, respectively). Risk factors of infection were calculated by univariate and logistic regression analysis among contacts of HCV-infected cases. Female caregivers, particularly mother (OR 5.1, 95% CI: 2-13.5), contact with index cases blood, either directly without using personal protective equipment (OR 7.8, 95% CI: 2.9-23.8) or indirectly through common use of sharps (razors, scissors) (OR 8.9, 95% CI: 3.5-20.5) and nail clippers (OR 2.1, 95% CI: 1.1-5.4) and giving care to infected cases (OR 2.9, 95% CI: 1.3-16.6) represented the real predictors of intrafamilial HCV infection.

CONCLUSIONS

Intrafamilial transmission of HCV from infected children to their relatives does occur. Parenteral route is the only documented way of transmission either directly or indirectly.

Detection of Hepatitis C Virus RNA in Blood and Saliva of Transfusion-Dependent Thalassemia Patients Diagnosed with Hepatitis C

Background:

The aim of the current study was to detect hepatitis C virus (HCV) RNA in blood and saliva of a population of patients with thalassemia who have HCV antibody in their serum.

Materials and Methods:

In this cross-sectional study, blood and saliva samples were collected and were analyzed with quantitative reverse transcription polymerase chain reaction (RT-PCR) for the detection of HCV RNA. In addition, liver-related blood tests were performed, and patients’ medical history was recorded. Data were analyzed by independent samples t-test and Chi-square with a significant level of 0.05.

Results:

Overall, 62 adult patients (29 males and 33 females) were included. Most (87%) of the patients had major thalassemia and genotype 1a was the most common (42%) type. HCV RNA was detected in 71 and 16% of blood and saliva samples, respectively. HCV RNA was detected more in female patients (31%) (P = 0.003) and in intermediate thalassemia (50%) (P < 0.005). The mean age of the patients with positive saliva was almost 10 years older (P < 0.001), and the mean number of blood transfusion was fewer in positive saliva group (P = 0.037). The sensitivity, specificity, and positive and negative predictive values of saliva PCR was calculated to be 18%, 88%, 80%, and 69%, respectively.

Conclusion:

Saliva contained HCV RNA in 16% of the assessed population. The probability of detection of HCV RNA in saliva increased in older patients, less number of blood transfusions, females and intermediate thalassemia. Saliva RT-PCR demonstrated low sensitivity and high specificity with high positive predictive value in the assessed population.

Occupational Health Update: Focus on Preventing the Acquisition of Infections with Pre-exposure Prophylaxis and Postexposure Prophylaxis

Health care personnel are commonly exposed to infectious agents via sharp injuries (eg, human immunodeficiency virus, hepatitis B virus, and hepatitis C virus), direct patient care (eg, pertussis and meningococcus), and the contaminated environment (eg, Clostridium difficile). An effective occupational program is a key aspect of preventing acquisition of an infection by offering the following: (1) education of health care personnel regarding proper handling of sharps, early identification and isolation of potentially infectious patients, and hand hygiene; (2) assuring immunity to vaccine-preventable diseases; and, (3) immediate availability of a medical evaluation after a nonprotected exposure to an infectious disease.

Spouse-to-Spouse Transmission and Evolution of Hypervariable Region 1 and 5' Untranslated Region of Hepatitis C Virus Analyzed by Next-Generation Sequencing

Hepatitis C virus (HCV) transmission between spouses remains poorly characterized, largely due to the limited availability of samples from the early stage of infection, as well as methodological constraints. A fifty-eight year-old male developed acute hepatitis C infection and his 53-year old spouse has been HCV-positive for over 10 years. Serum samples were collected from both at the time of acute hepatitis C diagnosis in male (baseline) and then at 9 and 13 months. Hypervariable region 1 (HVR1) and 5’ untranslated region (5’UTR) sequences were amplified and subjected to next generation sequencing (NGS) using a pyrosequencing platform. Genetic variants were inferred by Shorah reconstruction method and compared by phylogenetic and sequence diversity analysis. As the sequencing error of the procedure was previously determined to be ≤ 1.5%, the analysis was conducted with and without the 1.5% cut-off with regard to the frequency of variants. No identical HVR1 variants were identified in spouses at baseline and follow-up samples regardless whether the cut-off was applied or not. However, there was high similarity (98.3%) between a minor baseline donor variant (1.7% frequency) and the most abundant baseline recipient variant (62.5% frequency). Furthermore, donor and recipient strains clustered together when compared to 10 control subjects from the same area and infected with the same HCV subtype. There was an increase in HVR1 complexity (number of genetic variants) over time in both spouses. In contrast, the 5'UTR region was stable and of low complexity throughout the study. In conclusion, intrafamilial HCV transmission may be established by a very minor variant and investigation of this phenomenon requires high-sensitivity assays, such as NGS.

Identification of risk factors for hepatitis B and C in Peshawar, Pakistan

Background

Hepatitis B and C need immediate worldwide attention as the infection rates are too high. More than 240 million people have chronic (long-term) liver infections. Every year, about 600,000 people die globally due to the acute or chronic consequences of hepatitis B and more than 350,000 people die from hepatitis C-related liver diseases.

Methods

Our study was designed as a case-control, descriptive study. It was conducted through formal interviews by using structured questionnaires. A total of 100 cases were included, with four controls for each case.

Results

This study confirms household contact, history of dental work, history of surgery, sexual contact, and history of transfusion (blood and its components) as the main risk factors which are responsible for the increased prevalence of hepatitis.

Conclusion

The important risk factors, responsible for the high prevalence of hepatitis B and C in our society are household contact, history of dental work, history of surgery, sexual contact, and history of transfusion (blood and its components). The odds ratio of probability for these risk factors are: 4.2 for household contact history, 4.1 for history of dental work, 3.9 for sexual contact, 2.7 for history of surgery, and 2.1 for history of transfusion. Associations of other predictor variables (diabetes status, education level, profession, contact sports, intravenous drug abuse, residence, immunosuppression, and skin tattoos) were not statistically significant.

Potential for human immunodeficiency virus parenteral transmission in the Middle East and North Africa: An analysis using hepatitis C virus as a proxy biomarker

The Middle East and North Africa (MENA) region has endured several major events of infection parenteral transmission. Recent work has established the utility of using hepatitis C virus (HCV) as a proxy biomarker for assessing the epidemic potential for human immunodeficiency virus (HIV) parenteral transmission. In this review, we use data on the prevalence of HCV infection antibody (seroprevalence) among general population and high risk population groups to assess the potential for HIV parenteral transmission in MENA. Relatively low prevalence of HCV infection in the general population groups was reported in most MENA countries indicating that parenteral HIV transmission at endemic levels does not appear to be a cause for concern. Nonetheless, there could be opportunities for localized HIV outbreaks and transmission of other blood-borne infections in some settings such as healthcare facilities. Though there have been steady improvements in safety measures related to parenteral modes of transmission in the region, these improvements have not been uniform across all countries. More precautions, including infection control training programs, surveillance systems for nosocomial infections and wider coverage and evaluation of hepatitis B virus immunization programs need to be implemented to avoid the unnecessary spread of HIV, HCV, and other blood-borne pathogens along the parenteral modes of transmission.

Serological assay and genotyping of hepatitis C virus in infected patients in zanjan province

BACKGROUND

Hepatitis C Virus (HCV), a public health problem, is an enveloped, single-stranded RNA virus and a member of the Hepacivirus genus of the Flaviviridae family. Liver cancer, cirrhosis, and end-stage liver are the outcomes of chronic infection with HCV. HCV isolates show significant heterogeneity in genetics around the world. Therefore, determining HCV genotypes is a vital step in determining prognosis and planning therapeutic strategies.

OBJECTIVES

As distribution of HCV genotypes is different in various geographical regions and HCV genotyping of patients has not been investigated in Zanjan City, this study was designed for the first time, to determine HCV genotypes in the region and to promote the impact of the treatment.

MATERIALS AND METHODS

Serum samples of 136 patients were collected and analyzed for anti-HCV antibodies using ELISA (The enzyme-linked immunosorbent assay) method. Then, positive samples were exposed to RT-PCR, which was performed under standard condition. Afterwards, they investigated for genotyping using allele-specific PCR (AS-PCR), and HCV genotype 2.0 line probe assay (LiPA).

RESULTS

Samples indicated 216 bp bands on 2% agarose gel. Analyses of the results demonstrated that the most dominant subtype was 3a with frequency of 38.26% in Zanjan Province followed by subtypes of 1b, 1a, 2, and 4 with frequencies of 25.73%, 22.05%, 5.14%, and 4.41%, respectively. The frequency of unknown HCV genotypes was 4.41%.

CONCLUSIONS

According to the results, it was found that HCV high prevalent genotype in Zanjan is subtype 3a. Analysis of the results provides identification of certain HCV genotypes, and these valuable findings could affect the type and duration of the treatment.

Genotyping of HCV RNA reveals that 3a is the most prevalent genotype in mardan, pakistan

The clinical outcomes of patients infected with hepatitis C virus (HCV) range from acute resolving hepatitis to chronic liver diseases such as liver cirrhosis or hepatocellular carcinoma. Identification of the infecting virus genotype is indispensable for the exploration of many aspects of HCV infection, including epidemiology, pathogenesis, and response to antiviral therapy. 1419 individuals were screened for anti-HCV in this study, of which 166 (11.7%) were found reactive by ICT (Immunochromatographic test). These 166 anti-HCV positive and 26 normal individuals were further analyzed. RNA was extracted from serum and reverse-transcribed to cDNA and the core region of HCV genome was targeted and amplified by multiplex PCR. HCV RNA was detected in 121 individuals, of which 87 were male and 34 were female. Genotype 3a was the most prevalent among all the genotypes observed followed by 3b. Genotypes 1a, 2a, and 2b were found in 10.89%, 13.22%, and 6.61% patients, respectively. 25.41% of the HCV RNA positive samples were not typed. 6.05% of patients were found having mixed genotypes. These findings will not only help the physicians to prescribe more appropriate treatment for the HCV infection but will also draw the attention of health-related policy makers to devise strategies to curb the disease more effectively.

Intrafamilial spread of hepatitis B virus in Guilan Province-North of Iran

The aim of the present study was to determine the intrafamilial spread of HBV in the family members of patients with Hepatitis B in Guilan Province, North of Iran. In a descriptive-comparative study, 156 patients with Hepatitis B, 415 family members of the index cases and 599 age and gender matched people as a control group were enrolled. Blood samples were taken from the participants and were checked for HBs Ag, HBC Ab, HBs Ab, and HBV DNA. Totally 44 (10.6%) of family members and only 1 (0.2%) of control group were HBs Ag positive (P=0.0001, OR=70.92). The overall prevalence in members of the original family was 5.3% (1.2% of the mothers, 2.2% of the brothers, 1.9% of the sisters), in sexual partners it was 1.4%, in offsprings it was 2.4% and in other households it was 1.4%. The mean age of HBs Ag positive family members was 35.3 ± 12.9 years old. Among them 27 (61.4%) were female. Only 8 (18.2%) of all HBsAg-positive reported previous HBV vaccination but just one person had the vaccine titer checked. The present survey indicates that there is a significant difference in the prevalence of Hepatitis B in the general population and family members of Hepatitis B patients and this is an evidence for horizontal transmission of HBV in household contacts.

Intrafamilial transmission of hepatitis C infection in Egyptian multitransfused thalassemia patients

OBJECTIVE

Detecting the current prevalence of hepatitis C virus (HCV) among Egyptian multitransfused thalassemic patients and evaluating the risk of its transmission within their family members.

METHODS

Multitransfused Egyptian thalassemia patients (n = 137) were tested for HCV infection. Household contacts of positive members were compared with household contacts of HCV-negative patients. Antibodies to HCV were detected by enzyme immunoassay. Antibody-positive cases were retested for viral load using reverse transcriptase polymerase chain reaction. HCV genotyping was performed on positive samples of the patients and the positive household contacts.

RESULTS

In all, 34.4% of patients (n = 47) were positive for HCV antibodies and RNA. The study of 24 families of HCV-positive patients showed 14 affected family members (19.2%). In 27 families of HCV-negative patients, four family members were affected (4.9%). HCV genotyping of seven families was similar in both patients and their family members.

CONCLUSION

Our results support the role of intrafamilial transmission in the spread of HCV.

Stochastic modelling of intra-household transmission of hepatitis C virus: evidence for substantial non-sexual infection

OBJECTIVE

To simulate the probability of HCV transmission from an HCV seropositive index patient to susceptible household contacts through non-sexual exposures.

METHODS

A modified Reed-Frost stochastic simulation model was used to assess the probability of HCV transmission from an HCV seropositive index patient to susceptible household contacts through non-sexual exposures. This mathematical model does not require the specification of infection onset times for individual, nor is it necessary to identify the chains of household infections. Therefore, this model can be used with serologic data on detected asymptomatic infections. The HCV serological data on 341 non-sexual household contacts of 86 HCV seropositive index patients were used in this simulation study. The frequency distribution of HCV infection of susceptibles for each household size of 4-8 initial susceptibles was calculated. A maximum likelihood procedure was used to estimate the non-sexual household transmission parameter for HCV infection for the range of household sizes studied and was used in 1000 stochastic iterations. The goodness-of-fit test was carried out to compare the observed proportions of households where HCV transmission occurred to one or more initial susceptible with mean expected simulated proportions of such households with varying sizes ranging from 4 to 8 initial susceptibles.

RESULTS

The maximum likelihood estimates (90% probability interval (PI)) of binomial probability of HCV transmission within households with varying number of initial susceptible non-sexual household contacts ranged from 0.248 (90%PI: 0.031, 0.560) to 0.164 (90%PI: 0.011, 0.440) for household size of 4 and 8 respectively. The χ(2) goodness-of-fit test of observed and mean expected simulated proportions of households wherein at least one of the susceptibles was infected revealed good fit for households of all sizes examined (P ≥ 0.96). In a household, the probability of HCV transmission from the index HCV seropositive patient to susceptible via non-sexual contacts tended to decrease linearly as the household size increased from four to seven.

CONCLUSION

Intra-household HCV transmission through non-sexual contacts may have substantial impact on HCV transmission and needs to be considered in an HCV control program.

Management of chronic viral hepatitis in patients with thalassemia: recommendations from an international panel

Chelation therapy with new drugs prevents cardiac damage and improves the survival of thalassemia patients. Liver diseases have emerged as a critical clinical issue. Chronic liver diseases play an important role in the prognosis of thalassemia patients because of the high frequency of viral infections and important role of the liver in regulating iron metabolism. Accurate assessment of liver iron overload is required to tailor iron chelation therapy. The diagnosis of hepatitis B virus– or hepatitis C virus–related chronic hepatitis is required to detect patients who have a high risk of developing liver complications and who may benefit by antiviral therapy. Moreover, clinical management of chronic liver disease in thalassemia patients is a team management issue requiring a multidisciplinary approach. The purposes of this paper are to summarize the knowledge on the epidemiology and the risks of transmission of viral infections, to analyze invasive and noninvasive methods for the diagnosis of chronic liver disease, to report the knowledge on clinical course of chronic viral hepatitis, and to suggest the management of antiviral therapy in thalassemia patients with chronic hepatitis B or C virus or cirrhosis.

An overview about hepatitis C: a devastating virus

Hepatitis C (HCV) is the disease that has affected around 200 million people globally. HCV is a life threatening human pathogen, not only because of its high prevalence and worldwide burden but also because of the potentially serious complications of persistent HCV infection. Chronicity of the disease leads to cirrhosis, hepatocellular carcinoma and end-stage liver disease. HCV positive hepatocytes vary between less than 5% and up to 100%, indicating the high rate of replication of viral RNA. HCV has a very high mutational rate that enables it to escape the immune system. Viral diversity has two levels; the genotypes and Quasiaspecies. Major HCV genotypes constitute genotype 1, 2, 3, 4, 5 and 6 while more than 50 subtypes are known. All HCV genotypes have their particular patterns of geographical distribution and a slight drift in viral population has been observed in some parts of the globe.

Hepatitis C virus infection in the family setting of patients with occult hepatitis C

Family members of patients with chronic hepatitis C virus (HCV) infection are at increased risk of HCV infection but the prevalence of HCV among family members of patients with occult HCV infection is not known. Anti-HCV, serum HCV RNA and levels of liver enzymes were determined in 102 family members of 50 index patients with occult HCV infection and in 118 family members of 59 chronic hepatitis C index patients. HCV RNA and/or anti-HCV were detected in 10/102 (9.8%) relatives of patients with occult HCV infection and in 4/118 (3.4%) of patients with chronic hepatitis C. Fourteen additional family members (seven were relatives of index patients with occult HCV infection) had abnormal values of liver enzymes without serological markers of HCV infection. Two of these patients (who were relatives of two index patients with occult HCV infection) underwent a liver biopsy and were diagnosed with an occult HCV infection because HCV RNA was detected in the liver cells in the absence of serological HCV markers. In conclusion, the prevalence of HCV infection among family members of patients with occult HCV infection was similar to that found among family members of patients with chronic hepatitis C. This stresses the need to adopt strategies to prevent the transmission of HCV in the family setting of patients with occult HCV infection.

An autoregressive integrated moving average model for short-term prediction of hepatitis C virus seropositivity among male volunteer blood donors in Karachi, Pakistan

AIM: To identify the stochastic autoregressive integrated moving average (ARIMA) model for short term forecasting of hepatitis C virus (HCV) seropositivity among volunteer blood donors in Karachi, Pakistan.

METHODS: Ninety-six months (1998-2005) data on HCV seropositive cases (1000^-1× month^-1) among male volunteer blood donors tested at four major blood banks in Karachi, Pakistan were subjected to ARIMA modeling. Subsequently, a fitted ARIMA model was used to forecast HCV seropositive donors for 91-96 mo to contrast with observed series of the same months. To assess the forecast accuracy, the mean absolute error rate (%) between the observed and predicted HCV seroprevalence was calculated. Finally, a fitted ARIMA model was used for short-term forecasts beyond the observed series.

RESULTS: The goodness-of-fit test of the optimum ARIMA (2,1,7) model showed non-significant autocorrelations in the residuals of the model. The forecasts by ARIMA for 91-96 mo closely followed the pattern of observed series for the same months, with mean monthly absolute forecast errors (%) over 6 mo of 6.5%. The short-term forecasts beyond the observed series adequately captured the pattern in the data and showed increasing tendency of HCV seropositivity with a mean ± SD HCV seroprevalence (1000^-1× month^-1) of 24.3 ± 1.4 over the forecast interval.

CONCLUSION: To curtail HCV spread, public health authorities need to educate communities and health care providers about HCV transmission routes based on known HCV epidemiology in Pakistan and its neighboring countries. Future research may focus on factors associated with hyperendemic levels of HCV infection.

[Successful elimination of hepatitis C virus after hepatic lobectomy in a patient with hepatocellular carcinoma]

Hepatocellular carcinoma develops frequently after chronic hepatitis C and B virus infections. Hepatitis B virus has a direct, while hepatitis C virus an indirect role in hepatocarcinogenesis.

THE AIM OF OUR WORK

To demonstrate a very unique and interesting case where after the elimination of early detected duplex hepatocellular carcinoma with a combined therapy of PEG-interferon and ribavirin, hepatitis C virus could be eliminated.

CASE PRESENTATION

A 53-year-old male patient had chronic hepatitis C infection in his anamnesis. In 1995 histological examination confirmed cirrhosis in his liver. One year later he was non-responder for conventional interferon therapy. In 2002 CT examination confirmed a process with multiple plexus in the liver. With cytologic proof of hepatocellular carcinoma, a resection of the tumor by left-lobectomy of the liver was carried out. Four years after the operation a one-year PEG-interferon-alfa-2a and ribavirin combined therapy was instituted. The patient became virologically negative.

CONCLUSION

In chronic liver diseases carcinoma can develop from multiple center at the same time. PEG-interferon and ribavirin combined therapy can be effective in chronic liver disease, as well as after resection of established hepatocellular carcinoma.

Hepatitis B and hepatitis C in Pakistan: prevalence and risk factors

BACKGROUND

Pakistan carries one of the world's highest burdens of chronic hepatitis and mortality due to liver failure and hepatocellular carcinomas. However, national level estimates of the prevalence of and risk factors for hepatitis B and hepatitis C are currently not available.

METHODS

We reviewed the medical and public health literature over a 13-year period (January 1994-September 2007) to estimate the prevalence of active hepatitis B and chronic hepatitis C in Pakistan, analyzing data separately for the general and high-risk populations and for each of the four provinces. We included 84 publications with 139 studies (42 studies had two or more sub-studies).

RESULTS

Methodological differences in studies made it inappropriate to conduct a formal meta-analysis to determine accurate national prevalence estimates, but we estimated the likely range of prevalence in different population sub-groups. A weighted average of hepatitis B antigen prevalence in pediatric populations was 2.4% (range 1.7-5.5%) and for hepatitis C antibody was 2.1% (range 0.4-5.4%). A weighted average of hepatitis B antigen prevalence among healthy adults (blood donors and non-donors) was 2.4% (range 1.4-11.0%) and for hepatitis C antibody was 3.0% (range 0.3-31.9%). Rates in the high-risk subgroups were far higher.

CONCLUSIONS

Data suggest a moderate to high prevalence of hepatitis B and hepatitis C in different areas of Pakistan. The published literature on the modes of transmission of hepatitis B and hepatitis C in Pakistan implicate contaminated needle use in medical care and drug abuse and unsafe blood and blood product transfusion as the major causal factors.

The unique HCV genotype distribution and the discovery of a novel subtype 6u among IDUs co-infected with HIV-1 in Yunnan, China

The Yunnan province is the epicenter of HIV-1 epidemics in China and a center for drug trafficking to the other parts of the world. In six prefectures of this province, a total of 132 IDUs were recruited to determine the sero-prevalence of HCV and HIV-1 and the positive rates were 93.94% and 68.18%, respectively (P<0.001). Co-infection with HCV and HIV-1 was found among 89 IDUs, of whom several HCV fragments were amplified and sequenced. Sequences of the HCV 5'NCR-C and NS5B region were determined from 82 IDUs. Phylogenetic analyses showed consistent genotyping among 80 IDUs. Among them HCV genotypes 1a, 1b, 3a, 3b, 6a, 6n, and a tentatively assigned novel 6u subtype were found in 1 (1.25%), 16 (20%), 19 (23.75%), 24 (30%), 4 (5%), 9 (11.25%) and 7 (8.75%) individuals, respectively. In two IDUs, genotyping results were discordant, suggesting mixed HCV infections or recombination. The proportion of patients with HCV 1b tended to decrease from the north to south and from the east to west in this province. Genotype 3 and 6 strains were more frequent in the southern prefectures. The novel subtype 6u strains were only detected in Dehong which borders Myanmar. Our findings showed a unique pattern of HCV genotype distribution, which is similar to that in the southeastern Asian countries but distinct from that among the general population in China. Routes of drug trafficking and the resulting high prevalence of HIV-1 infection may have contributed to this pattern of HCV genotype distribution.

Factors influencing Hepatitis C virus sero-prevalence among blood donors in north west Pakistan

Hepatitis C virus infection is a major health problem worldwide. The current study estimated seroprevalence of Hepatitis C virus (HCV) and evaluated associated factors among volunteer blood donors of the Northwest Frontier Province (NWFP), Pakistan. Of 1,131 volunteer blood donors enrolled, 46 (4.1%) were positive for anti-HCV antibodies. Multivariate logistic regression analysis revealed that positive donors were more likely to be 27-32 years old or >32 years old, have had 1-2 injections or >2 injections in the past year, or 1-5 intravenous (IV) drips or >5 I/V drips in the past 5 years. Positive donors had a family history of jaundice and were more likely to have been shaved (facial and armpit) by barbers. There was high prevalence of anti-HCV antibodies among blood donors of the NWFP. Public awareness programs should target the identified risk factors to prevent HCV transmission. We highlight the weakness of the health care system for blood donation, as it does not offer any record management for donors.

Seroprevalence of hepatitis B and C genotypes among young apparently healthy females of karachi-pakistan

INTRODUCTION

Although the prevalence of hepatitis virus infections in Pakistan is still unknown, limited data indicate that the exposure rate to HBV is 35-38% with 4% being carriers and 32% having anti-HBV surface antibodies through natural conversion [1, 2, 3]. Studies in Pakistan have shown that the prevalence rate of HCV is 4.8-14% for, and that it is continuously increasing. Hence there is an urgent need to create awareness about the prevalence of both hepatitis B and C, and to develop preventive measures aimed at minimizing the prevalence of these diseases in the country.

STUDY DESIGN

Prospective, descriptive study. The study took place from March 2002 till October 2006 at two university campuses in Karachi.

MATERIALS AND METHODS

A total of 4000 healthy female students were screened for HBs Ag, anti-HBs antibodies and anti-HCV antibodies by rapid immunochromatography, ELISA and PCR.

RESULTS

A total of 3820 volunteers (95.5%) were negative by all three methods, 181 (4.5%) tested positive for HB surface antigen and 20 (0.5%) were positive for anti HB surface antibodies; 208 volunteers (5.2%) were positive for HCV. Double infection with HBV and HCV was found in only one patient (0.025%). Out of 180 HBs antigen positive samples 151 (83.89%) were genotype D, 28 (15.56%) showed mixed infection with genotypes B and D, and one patient (0.56%) showed mixed infection with genotypes C and D. Out of 208 samples positive for HCV antibodies, 107 (51.44%) were genotype 3a, 50 (24.04%) were mix of genotype 3a and 3b, 33 (15.87%) were genotype 3b, 10 (4.81%) were genotype 1b while, 8 (3.84%) samples could not be typed.

CONCLUSION

Although the presence of these pathogenic viruses was not very high in our young healthy female population, it is still a matter of concern to control the unregulated spread of these deadly infections by promoting increased awareness and regular immunization programs in the community. Local manufacturing of vaccines and related products may reduce these infections.

Case-control study of risk factors associated with hepatitis C virus infection among pregnant women in hospitals of Karachi-Pakistan

OBJECTIVE

To identify risk factors for hepatitis C virus (HCV) infection among pregnant women seeking antenatal care in tertiary care hospitals of Karachi, Pakistan.

METHODS

We enrolled 119 cases and 238 controls. Cases were enzyme-linked immunosorbent assay (ELISA III) positive pregnant women for antibodies to HCV; controls were anti-HCV ELISA negative pregnant women.

RESULTS

The mean age of study subjects was 26 years (SD 5) ranging from 15 to 50 years. The mean number of pregnancies for cases was 4 (SD 3) and for controls was 3 (SD 2). Among cases an average number of injections in any month was 40%, history of hospitalization was 61% and household contact with jaundice or hepatitis was 35%. In the final multivariable logistic regression model, five or more gestations (aOR = 1.99; 95% CI = 1.08-3.33), > or =1 injection (aOR = 2.33; 95% CI = 1.38-3.91) per month, hospitalization (aOR = 1.78; 95% CI = 1.01-2.99) and household contact with jaundice/hepatitis (aOR = 3.32; 95% CI = 1.89-5.83) were independently associated with HCV.

CONCLUSION

Iatrogenic exposure (health care injections, hospitalizations and gestations) is the major risk factor for transmission of HCV among pregnant women.

Intrafamilial hepatitis C virus infection

A vér és a szövetnedvek hepatitis C-vírus-fertőzést terjesztő szerepe bizonyított. Elsősorban ellenőrizetlen vérkészítmények transzfúziójával, kontaminált eszközökkel történő perkután inokulációval, fertőzött anyáról csecsemőre, valamint szexuális úton terjed. A családon belüli mindennapos kontaktus révén akvirált fertőződés igen ritka, de a szakirodalomban találhatunk ilyen adatokat. Célkitűzés: A Semmelweis Egyetem II. Belgyógyászati Klinika hepatológiai ambulanciáján megjelent betegek között is találtunk olyan esetet, melyben felmerül a hepatitis C-vírus családon belüli átvitele. Munkánkban ezt mutatjuk be. Esetbemutatás: 47 éves krónikus C-hepatitisben szenvedő nő lányának szérumában hepatitis C-vírus-ellenes antitest jelenléte volt kimutatható. Megbeszélés: A hepatitis C-vírus hosszú lappangási ideje, az akut C-hepatitis enyhe, kevéssé jellegzetes tünettana és a nagy százalékban kialakuló tünetmentes betegség miatt a hordozó személy és családja hosszú ideig nincs tudatában a fertőződés lehetőségének, amelynek esélyét a nem megfelelő személyi higiéné növelheti. Konklúzió: A hepatitis C-vírus-fertőzés ritkán halmozódhat családon belül. Minden esetben ajánlott felhívni a C-vírust hordozó személy és családtagjainak figyelmét a személyi higiéné fontosságára.

A comparison of risk factors for HCV-mono-infection, HIV-mono-infection, and HCV/HIV-co-infection in a community setting

The prevalence of HIV infection in HCV patients is much lower than the prevalence of HCV infection in HIV patients. Whereas the higher prevalence of HCV infection in HIV is clearly related to drug abuse, the reasons for the lower prevalence of HIV infection in HCV patients has not been reported. The prevalence of non-sexual and sexual risk factors associated with acquisition of hepatitis C and HIV were studied in HIV-mono-infected, HCV-mono-infected, and HCV/HIV-co-infected individuals. None of the 114 HCV-mono-infected patients tested positive for HIV and this finding was associated with a significantly lower number of men who have sex with men (MSM) among the HCV-mono-infected subjects than among either the HIV-mono-infected or HCV/HIV-co-infected individuals. Unprotected anal intercourse and sex for money or drugs were reported less often by HCV-mono-infected individuals than by HIV-mono-infected and HCV/HIV-co-infected subjects. Having sex with an intravenous-drug user (IVDU) was reported more frequently by both HCV-mono-infected and HCV/HIV-co-infected individuals than by HIV-mono-infected individuals. Sub-analysis of the group of MSM revealed that IVDU differentiated between HIV-mono-infected and HCV/HIV-co-infected subjects. These results reveal that the lower prevalence of HIV in HCV patients is related to a lower number of MSM in this group and that sex with an IVDU is a surrogate marker for drug abuse related to acquiring HCV but not HIV. The guidelines should include strategies for testing for HCV and HIV in patients with these infections.

Hepatitis C virus transmission and its risk factors within families of patients infected with hepatitis C virus in southern Iran: Khuzestan

AIM: To determine whether hepatitis C virus (HCV) infection of index cases increases intrafamilial transmission (sexual and nonsexual contacts) of HCV.

METHODS: In a case-control descriptive study we enrolled 300-household contacts of 60 index cases (40 males and 20 females) of HCV infection and 360 pair-matched controls in Ahwaz JundiShapour University Hospitals from August 1, 1998 to September 1, 2003. The control group consisted of first time blood donors referred to the Regional Blood Transfusion Organization. Serum samples and demographic data and a medical history including the existence of risk factors for HCV (after a questionnaire on the risk factors for parenteral exposure) were obtained from each subject. Antibodies to HCV were detected employing a commercially available second-generation enzyme immunoassay (EIA, Abbott II). Positive serum specimens were retested using a second-generation recombinant immunoblot assay (RIBA-2) and a polymerase chain reaction for HCV RNA. Data analysis was carried out for intra-household clustering.

RESULTS: Only 4 of 300 (1.33%) cases of household contacts without percutaneous risk factors were positive for HCV Ab while the remaining 296 family contacts were negative for anti-HCV. The mean age of the index cases was 28.4 (Std 15.22) years. The anti-HCV prevalences in parents, spouses, children of the index cases were 0.87% (1/115), 3.39% (2/59)) and 0.79% (1/126), respectively. Among couple partners negative for anti-HCV antibodies, the mean duration of the sexual relationship was 6 years. The two-couple partners positive for anti-HCV antibodies married the index cases for longer than 15 years. The prevalence of positive HCV Ab among household contacts (1.33%) was not significantly higher than that in the controls (1%) (P > 0.06).

CONCLUSION: Intrafamilial transmission of HCV is not the significant transmission route and sexual transmission does not seem to play a role in the intrafamilial spread of HCV infection. Intrafamilial transmission of HCV is possible but occurs at a low rate.

Hepatitis C - contamination of toothbrushes: myth or reality?

Chronic hepatitis C patients are advised not to share toothbrushes, razors, nail-scissors or other personal articles that potentially may have been in contact with blood, with others. This study examines the contamination of toothbrushes in patients with chronic hepatitis C as a model for a possible unconventional way of transmission. In 30 patients with chronic hepatitis C, 2 mL of saliva (before and after toothbrushing) and the toothbrush rinsing water after toothbrushing were tested for HCV-RNA. Saliva before and after toothbrushing was positive for HCV-RNA in nine (30%) and 11 patients (36.7%), respectively. Twelve of the toothbrush rinsing water specimens (40%) tested HCV-RNA-positive. In six of these 12 patients, the 'native' saliva had been negative for HCV-RNA. Patients with HCV-RNA-positive toothbrush rinsing water showed no significant differences from those with negative rinsing water with respect to certain clinical, biochemical and virological parameters. In conclusion, our study demonstrates a contamination with HCV-RNA of a considerable portion of toothbrushes used by hepatitis C patients, suggesting at least a theoretical risk of infection by sharing these objects and strengthening the recommendations to take care of a clear separation of these personal care objects between patients and their household members.

Contrasting patterns of hepatitis C virus infection in two regions from Tunisia

This report is a population-based study describing the pattern of hepatitis C virus (HCV) infection in two distinct regions in Tunisia. The study included a total of 11,507 individuals sampled in 1996 from both genders, all age groups, urban and rural settings belonging to 2,973 families. HCV infection was assessed by commercial enzyme immunoassay (EIA) and immunoblot assays and detection of HCV RNA by PCR. HCV genotypes and subtypes were determined by sequencing in the 5'-untranslated region (UTR) viral genomic region and the INNO-LiPA HCVII genotyping kit. Genetic relatedness between HCV strains was assessed by sequencing of a portion of the NS5B region. HCV prevalence was significantly higher in the North-Western region than in the Southern one: 1.7% versus 0.2% (P < 10(-3), chi(2) = 8,506). There was no difference in positivity according to gender or living in rural or urban settings; the only significant risk factor was advanced age. HCV prevalence among household contacts of HCV positives was not significantly higher than the prevalence in the whole study population. These results indicate a heterogeneity in the geographical distribution of HCV in Tunisia. An increased HCV transmission occurs in the North-Western region with large predominance of genotype 1b (88%) and low contribution of intrafamilial transmission.

Intra-household clustering of hepatitis C virus infection in Karachi, Pakistan

Transmission rates of hepatitis C virus (HCV) infection through non-sexual household contacts have been considered to be very low. This study evaluated intra-household clustering of cases of HCV infection in a low socio-economic community in Karachi, Pakistan. Serum samples from 341 household contacts of 86 thalassaemic HCV-seropositive children were evaluated for antibodies to HCV using an ELISA. Spatial analysis of data was carried out to test for intra-household clustering. Seventy of 341 (20.5%) household contacts were HCV-seropositive. Of the households studied, 44.2% (38/86) had one or more contacts who tested HCV-seropositive. Ecological analysis of variables at household level showed that in households where HCV-seropositive index thalassaemic children were male HCV tended to be transmitted to one or more familial contacts. Spatial analysis with an asymptotic score test of the null hypothesis of no extra within-family infectivity revealed that there was a significant tendency of HCV infection to cluster within a household (score statistic = 19.44, P=0.032). The results showed that non-sexual household exposure may play a role in efficient HCV spread to household contacts of HCV-infected persons and needs further evaluation.

Hepatitis C virus infection in asymptomatic male volunteer blood donors in Karachi, Pakistan

The objectives of this study were to assess the proportion of hepatitis C virus (HCV) reactors and to identify risk factors associated with HCV infection in volunteer blood donors in Karachi, Pakistan. Between 1 January 1998 and 31 December 2002, consecutive blood donations tested at two blood banks were used to assess the proportion of HCV sero-reactors donors. To evaluate the potential risk factors, a case-control study design was implemented to select cases and controls between 15 October 2001 and 15 March 2002. The overall seroprevalence of HCV in these blood donors was 1.8% (6349/35 1309). Trend analysis revealed a significant (P < 0.001) linear increase in proportions of HCV-seropositive donors from 1998 to 2002. Final multivariate logistic regression model showed that the cases were more likely than controls to have reported past hospitalization or to have received multiple injections. When a glass syringe was used to give therapeutic injections, it increased the adjusted odds of being HCV seropositive significantly more among cases than in controls and this relationship was stronger when injection was given by general medical practitioner than if the injection was given in hospital setting. Cases were more likely than controls to have reported sexual contact with multiple sexual partners. Primary prevention programmes focused on identified risk factors might help to curtail the spread of HCV infection in this community and in other similar settings in developing countries.