Profile of hepatitis C virus and the possible modes of transmission of the virus in the Gizan area of Saudi Arabia: a community-based study

Epidemiology, disease burden, and treatment strategies of chronic hepatitis C virus infections in Saudi Arabia in the new treatment paradigm shift

BACKGROUND/AIMS

Around 101,000 individuals are estimated to be viremic for chronic hepatitis C virus (HCV) in the Kingdom of Saudi Arabia (KSA) in 2014; however, only about 20% have been diagnosed. We aim to assess baseline epidemiology, disease burden, and evaluate strategies to eliminate HCV in KSA.

MATERIALS AND METHODS

The infected population and disease progression were modeled using age- and gender-defined cohorts to track HCV incidence, prevalence, hepatic complications, and mortality. Baseline assumptions and transition probabilities were extracted from the literature. The impacts of two scenarios on HCV-related disease burden were considered through increases in treatment efficacy alone or treatment and diagnosis.

RESULTS

In 2030, it is estimated by the base scenario that viremic prevalence will increase to 103,000 cases, hepatocellular carcinoma (HCC) to 470, decompensated and compensated cirrhosis cases to 1,300 and 15,400, respectively, and liver-related mortality to 670 deaths. Using high efficacy treatment alone resulted in 2030 projection of 80,700 viremic cases, 350 HCC cases, 480 liver-related deaths, and 850 and 11,500 decompensated and compensated cirrhosis cases, respectively. With an aggressive treatment strategy, in 2030 there will be about 1,700 viremic cases, 1 HCC case, about 20 liver-related deaths, and 5 and 130 cases of decompensated and compensated cirrhosis, respectively. Delaying this strategy by one year would result in 360 additional deaths by 2030.

CONCLUSIONS

HCV in KSA remains constant, and cases of advanced liver disease and mortality continue to rise. Considered increases in treatment efficacy and number treated would have a significantly greater impact than increased treatment efficacy alone. The projected impact will facilitate disease forecasting, resource planning, and strategies for HCV management. Increased screening and diagnosis would likely be required as part of a national strategy.

The present and future disease burden of hepatitis C virus infections with today's treatment paradigm - volume 3

The total number, morbidity and mortality attributed to viraemic hepatitis C virus (HCV) infections change over time making it difficult to compare reported estimates from different years. Models were developed for 15 countries to quantify and characterize the viraemic population and forecast the changes in the infected population and the corresponding disease burden from 2014 to 2030. With the exception of Iceland, Iran, Latvia and Pakistan, the total number of viraemic HCV infections is expected to decline from 2014 to 2030, but the associated morbidity and mortality are expected to increase in all countries except for Japan and South Korea. In the latter two countries, mortality due to an ageing population will drive down prevalence, morbidity and mortality. On the other hand, both countries have already experienced a rapid increase in HCV-related mortality and morbidity. HCV-related morbidity and mortality are projected to increase between 2014 and 2030 in all other countries as result of an ageing HCV-infected population. Thus, although the total number of HCV countries is expected to decline in most countries studied, the associated disease burden is expected to increase. The current treatment paradigm is inadequate if large reductions in HCV-related morbidity and mortality are to be achieved.

Historical epidemiology of hepatitis C virus (HCV) in select countries - volume 3

Detailed, country-specific epidemiological data are needed to characterize the burden of chronic hepatitis C virus (HCV) infection around the world. With new treatment options available, policy makers and public health officials must reconsider national strategies for infection control. In this study of 15 countries, published and unpublished data on HCV prevalence, viraemia, genotype, age and gender distribution, liver transplants and diagnosis and treatment rates were gathered from the literature and validated by expert consensus in each country. Viraemic prevalence in this study ranged from 0.2% in Iran and Lebanon to 4.2% in Pakistan. The largest viraemic populations were in Pakistan (7 001 000 cases) and Indonesia (3 187 000 cases). Injection drug use (IDU) and a historically unsafe blood supply were major risk factors in most countries. Diagnosis, treatment and liver transplant rates varied widely between countries. However, comparison across countries was difficult as the number of cases changes over time. Access to reliable data on measures such as these is critical for the development of future strategies to manage the disease burden.

Association between Schistosomiasis mansoni and hepatitis C: systematic review

OBJECTIVE

To perform a systematic review of the prevalence of the HCV/ S. mansoni co-infection and associated factors in Schistosoma mansoni -infected populations.

METHODS

The bibliographic search was carried out using the Medline, Lilacs, SciELO, Cochrane Library and Ibecs databases. The criteria for the studies' selection and the extraction data were based on systematic review methods. Forty five studies were found, with nine being excluded in a first screening. Thirteen articles were used for data extraction.

RESULTS

The HCV infection rates in schistosomiasis populations range from 1% in Ethiopia to 50% in Egypt. Several studies had poorly defined methodologies, even in areas characterized by an association between hepatitis C and schistosomiasis, such as Brazil and Egypt, which meant conclusions were inconsistent. HCV infection rates in schistosomotic populations were heterogeneous and risk factors for acquiring the virus varied widely.

CONCLUSIONS

Despite the limitations, this review may help to identify regions with higher rates of hepatitis C and schistosomiasis association. However, more studies are necessary for the development of public health policies on prevention and control of both diseases.

HCV infection prevalence in a population recruited at health centers in Jordan

BACKGROUND

Jordan lacks statistical data regarding prevalence of HCV.

AIM

To determine the prevalence of HCV in selected areas of Jordan (north, middle and south of Jordan).

METHODS

A random sample of 700 patients attending health centers was used to determine HCV prevalence. ELISA testing was used to determine HCV-Ab positive cases, which were confirmed by PCR testing.

RESULTS AND CONCLUSION

The study concluded that the prevalence of HCV infection in the population recruited from different health centers in Jordan is relatively low and estimates a prevalence of 0.42% among all age groups and 0.56% among those aged >15 years old.

Predictors of sustained virological response to a 48-week course of pegylated interferon alfa-2a and ribavirin in patients infected with hepatitis C virus genotype 4

BACKGROUND AND OBJECTIVES

Knowledge of the predictors of sustained viral response (SVR) to pegylated interferon (PEG-INF) alfa-2a and ribavirin (RBV) therapy in patients with hepatitis C genotype-4 (HCV-4) is crucial for selecting patients who would benefit most from therapy. We assessed the predictors of SVR to this combination therapy in Saudi patients with chronic HCV-4 infection.

PATIENTS AND METHODS

This retrospective study included 148 patients with HCV-4 infection who underwent clinical, biochemical and virological assessments before treatment and at 12, 24, 48 and 72 weeks post-treatment.

RESULTS

Of the 148 patients, 90 (60.8%) were males. Mean (SD) for age was 48.5 (12.7) years and BMI was 27.9 (7.5) kg/m(2). Seventy-nine of 148 (60.1%) patients were treatment naïve and 110 (74.3%) underwent pre-treatment liver biopsy. Eighteen (12.2%) patients did not complete therapy because of side effects or they were lost to follow up. Early virological response was achieved in 84 of 91 (92.3%) patients. In the 130 (87.8%) patients who completed therapy, 34 (26.2%) were non-responders and 96 (63.8%) achieved end-of-treatment virological response (ETVR). SVR and virological relapse (24 weeks after ETVR) occurred in 66/130 (50.7%) and 30/130 (31.2%) patients, respectively. Compared to relapsers, sustained responders were significantly younger (P=.005), non-diabetic (P=.005), had higher serum albumin (P=.028), lower alpha-fetoprotein level (P=.026), lower aspartate aminotransferase (AST) (P=.04) levels, and were treatment-naïve (P=.008). In a multivariate regression analysis, the independent predictors of SVR were younger age (P=.016), lower serum AST (P=.012), and being treatment naïve (P=.021).

CONCLUSION

Approximately half of HCV-4 patients who complete the course of combination therapy achieve an SVR, especially if they are young, treatment naA ve and have lower AST levels.

Epidemiology of hepatitis C virus (HCV) infection

Hepatitis C virus remains a large health care burden to the world. Incidence rates across the world fluctuate and are difficult to calculate given the asymptomatic, often latent nature of the disease prior to clinical presentation. Prevalence rates across the world have changed as well with more countries aware of transfusion-related hepatitis C and more and more evidence supporting intravenous drug use as the leading risk factor of spread of the virus. This article reviews current hepatitis C virus prevalence and genotype data and examines the different risk factors associated with the virus.

Effect of chronic viral hepatitis on graft survival in Saudi renal transplant patients

BACKGROUND

In Saudi Arabia the prevalence of hepatitis C among hemodialysis patients is very high ranging from 60 to 80%. A large number of these dialysis patients go for renal transplant, resulting into a higher prevalence of hepatitis C virus (HCV) infection in renal transplant patients. Yet no current systematic report is available on the influence of hepatitis C status on patient and graft survival. The present study was therefore undertaken to address this objective.

METHODS

Retrospective analysis of data of 448 renal transplantation subjects was undertaken. The mean follow-up period was 5.85 +/- 2.7 (median 5.3) years. The factors associated with renal graft survival were reviewed and these include: age, sex, and type of donor, immunosuppressive medication, episodes of infection, blood pressure, serum creatinine, and status of hepatitis. The primary end-points were renal graft function and patient survival. Logistic regression, COX regression analysis, and Kaplan-Meier survival estimates were used to evaluate the influence of hepatitis C on the above parameters.

RESULTS

Among 448 recipients of first kidney transplant patients, 286 (63.8%) were positive for HCV infection. In the HCV-positive group, 204 (71.32%) were males. Kaplan-Meier survival analysis showed a significantly better graft survival for HCV-negative patients than HCV-positive patients (p < 0.001; log-rank test). Logistic regression analysis and COX regression analysis have shown different grades of graft dysfunction were present in HCV-positive patients after adjustment for covariates: age, sex, blood pressure, type of donor, and immunosuppressive medication; the presence of HCV was a major predictor of bad outcome and significantly influenced graft survival (odds ratio = 4.37; 95% Cl = 1.81-4.77). Significant deterioration of liver function was noted in HCV-positive patients at the last follow-up, taking ALT as a marker (ALT level 80.6 +/- 5.8 U/l at the last follow-up versus 49.5 +/- 32 U/l at baseline p < or = 0.0001). Sixteen patients had a chronic active course and 1 patient developed biopsy-proven liver cirrhosis and portal hypertension. A serious and significantly greater incidence of fatal chest infections was seen in HCV-positive patients. Although mortality was greater in HCV-positive versus HCV-negative patients (20 vs. 7), the difference did not attain statistical significance (p = 0.23) and none of the patients died as a result of hepatic failure.

CONCLUSION

The presence of HCV infection greatly influenced graft survival in renal transplant patients and a higher proportion of infected patients had renal and hepatic dysfunction. A significant increase in fatal chest infections was noted in HCV-positive patients. Overall mortality was higher in HCV-positive patients, but it was not statistically significant. All measures should be taken to prevent HCV transmission in the dialysis population. Renal transplant recipients with HCV infection need close monitoring for both graft and liver function.

Very low prevalence of hepatitis C virus infection in rural communities of northeastern Brazil with a high prevalence of schistosomiasis mansoni

The association of hepatitis C virus infection and the hepatosplenic form of schistosomiasis mansoni has been claimed to result in the concomitant evolution of the two pathologies, with a poor prognosis due to aggravated liver disease. Recently, however, some authors have begun to reject the hypothesis of a higher susceptibility of hepatosplenic schistosomal patients to HCV. The aim of the present transverse study carried out between July and August 1990 was to determine the possible association between SM and HCV markers in residents of Catolândia, Bahia State. Anti-HCV markers were assayed by ELISA-II and RIBA-II in serum samples obtained from 1,228 residents (85.8%). The anti-HCV antibody (ELISA-II) was positive in six (0.5%) individuals, eight (0.6%) cases were inconclusive and 1,214 (98.9%) were negative. However, only in one ELISA-positive serum sample (0.08%) were antibodies confirmed by RIBA-II, while two other samples assayed by RIBA-II were indeterminate. These three patients presented the hepatointestinal form of SM during the follow-up period (1976 to 1996). In conclusion, no association was observed between HCV and SM in the endemic area studied, especially among patients with the hepatosplenic form of the disease.

Peginterferon alpha-2b plus ribavirin compared with interferon alpha-2b plus ribavirin for initial treatment of chronic hepatitis C in Saudi patients commonly infected with genotype 4

AIM

Comparing the efficacy of peginterferon alpha-2b plus ribavirin with interferon alpha -2b plus ribavirin in Saudi patients with chronic hepatitis C virus (HCV) commonly infected with genotype 4.

METHODS

A total of 96 patients with chronic HCV infection were randomly assigned to two treatment groups. Forty-eight patients received once weekly 100 microg of peginterferon alpha-2b plus ribavirin given orally 800 mg/day (peginterferon group). Another 48 patients received thrice weekly 3 million units of interferon alpha-2b plus ribavirin 800 mg/day (interferon group). At the end of treatment (48 weeks) and sustained (72 weeks) biochemical and virologic responses were determined.

RESULTS

In the peginterferon group, 70.8% (34/48) patients attained both biochemical and virologic responses at the end of the treatment as against 52.1% (25/48) patients in the interferon group. (P=0.09 for both). Similarly, sustained biochemical and virologic responses in the peginterferon group were attained in 52.1% (25/48) and 43.8% (21/48) patients as against 43.8% (21/48) and 29.2% (14/48) patients in the interferon group, respectively (P=0.54 and 0.20, respectively). The sustained virologic response rates in patients with genotype 4 were 42.9% (12/28) in the peginterferon group and 32.3% (10/31) in the interferon group (P=0.43). Patients in peginterferon group had higher, although statistically not significant adverse reactions.

CONCLUSIONS

Saudi patients with chronic HCV attained a higher, although statistically not significant sustained virologic response with pegylated interferon plus ribavirin compared with interferon plus ribavirin.

Management of hepatitis C virus genotype 4

Hepatitis C virus (HCV) genotype 4 is predominantly found in the Middle East and North Africa. Because most of the large randomized controlled trials of antiviral therapy for chronic hepatitis C were conducted in North America and Europe, little is known about management of patients with this particular genotype. Based on the available data, sustained virological response rates to interferon-based therapies appear to be intermediate between the relatively resistant HCV genotype 1 and the readily responsive genotypes 2 and 3. Several large prospective studies of pegylated interferon plus ribavirin combination therapy, the current gold-standard treatment, have recently been completed and will be reviewed.

Hepatocellular carcinoma in Saudi Arabia: role of hepatitis B and C infection

BACKGROUND AND AIM

To estimate the risk of hepatocellular carcinoma (HCC) in non-alcoholic patients with chronic hepatitis B virus (HBV) and hepatitis C virus (HCV) infections, 118 patients who were admitted to a regional hospital in Saudi Arabia were compared with 118 age- and sex-matched healthy individuals.

RESULTS

The prevalence of HBsAg in HCC patients (67%; 95% confidence interval (CI): 57.7-75.3) was significantly higher than the rate (6.7%; 95%CI: 3.0-12.9) in the controls (OR: 28.4; 95%CI: 12.6-63.9; P < 0.001). There was a high risk of HCC in the presence of HBsAg alone (OR: 34.3; 95%CI: 14.8-79.1, P < 0.001) and anti-HCV alone (OR: 12.2; 95%CI: 3.2-47.2; P < 0.001). Although HBV and HCV were independent risk factors in the development of HCC, there was no interactive relationship between the two viruses. Dual infections occurred in only 3.4% and were associated with only a moderate increase in the risk of HCC (OR: 14.6; 95%CI: 1.57-135.9). In 24.6% of the cases no virus was identified as the etiologic factor.

CONCLUSION

Hepatitis B virus constitutes a major risk factor and HCV contributes a less significant role in the development of HCC. The ongoing program of HBV vaccination may significantly decrease the prevalence of HBV-associated HCC in this population.

Changing pattern of hepatitis viral infection in Saudi Arabia in the last two decades

BACKGROUND

Information on the epidemiology of viral hepatitis B, C and A in the Kingdom of Saudi Arabia (KSA) has accumulated over the last two decades. We review the changing epidemiology of these infections and suggest possible strategies for eradication.

METHODS

We screened Saudi medical journals and Medline for reports dealing with hepatitis B, C and A, and analyzed official of blood donor screening data from the Ministry of Health (MOH) Central Blood Bank and the King Khalid University Hospital (KKUH) Blood Bank.

RESULTS

Several studies from the 1980s found a high endemicity for HBV, with 5% to 10% of the population infected and prevalence varying from one region to another. In children (age 1 to 12 years), the prevalence was almost 7% in 1989, just before the addition of the HBV vaccine to the Extended Program of Immunization (EPI). By 1997, the prevalence of HBV infection in children had declined to 0.3%. Blood donor results have also shown a steady decrease in HBV infection. At KKUH, prevalence declined from 3.7% in 1987 to 1.7% in 2000. Hepatitis C infection has also shown a marked decline among Saudi blood donors at KKUH, HAV infection among children has declined from 50% in 1989 to 25% in 1997, but the infection rate is still high, reaching 50% in a few regions.

CONCLUSIONS

Hepatitis B, C, and A infection has declined in KSA in the last two decades by more than 50%. The reasons for this marked decline are multifactorial. An important reason is the adoption in the last two decades of the MOH strategy for prevention of viral hepatitis infection, which needs to continue. Improvements in the economic status of the population and the decline in illiteracy have also contributed to the decline in viral hepatitis infection.

Hepatitis C: an epidemiological review

The aim of the study was to analyse the current literature regarding the mode of transmission of HCV and its global prevalence in different groups of people. A systematic review of the literature on the epidemiology of hepatitis C from 1991 to 2000 using computerized bibliographic databases which include Medline, Current Content and Embase. The prevalence of hepatitis C virus (HCV) varies tremendously in different parts of the world, with the highest incidence in the Eastern parts of the globe compared with the Western parts. Furthermore, certain groups of individuals such as intravenous drug users are at increased risk of acquiring this disease irrespective of the geographical location. Although the main route of transmission is via contaminated blood, curiously enough in up to 50% of the cases no recognizable transmission factor/route could be identified. Therefore, a number of other routes of transmission such as sexual or household exposure to infected contacts have been investigated with conflicting results. Hepatitis C infection is an important public health issue globally. Better understanding of routes of transmission will help to combat the spread of disease. In order to prevent a world wide epidemic of this disease, urgent measures are required to (i) develop a strategy to inform and educate the public regarding this disease and (ii) expedite the efforts to develop a vaccine.

Treatment of chronic hepatitis C genotype IV with interferon-ribavirin combination in Saudi Arabia: a multicentre study

Between 1996 and 1997, we conducted a multicentre study to assess the effect of combination therapy of interferon (IFN) + ribavirin on chronic hepatitis C genotype 4. Ninety-seven patients were enrolled. Sixty-eight patients (47 male and 21 female) were non-responders to previous therapy with IFN (Group I). Twenty-nine patients (19 male and 10 female) were new (Group II). Following treatment with IFN, 23% in Group I and 9% in Group II had a sustained biochemical response. Only 12% in Group I and 5% in Group II achieved a sustained virological response. Virus load was found to be the major factor determining response, followed by histology grading and staging. Like HCV genotype 1, HCV genotype 4 seems to have a poor response to therapy.

Hepatitis C virus infections in dialysis centers in The Netherlands: a national survey by serological and molecular methods

A national survey of hepatitis C virus (HCV) infections among dialysis patients in The Netherlands was performed. The study involved 2,653 patients (2,108 hemodialysis patients and 545 chronic ambulatory peritoneal dialysis [CAPD] patients) from 39 of the 49 dialysis centers in the country. Patient sera were analyzed by both serological and molecular methods. Screening by a third-generation enzyme immunoassay (EIA) yielded 79 reactive sera. The presence of anti-HCV antibodies was confirmed in 70 patients by a line immunoassay. All seropositive samples were tested by reverse transcriptase PCR, and 57 samples were found to contain HCV RNA. Of the nine EIA-positive and line immunoassay-negative or indeterminate samples, four were HCV RNA positive. All seronegative samples were screened for the presence of HCV RNA in pools of five sera. Of 2,576 antibody-negative samples, 6 contained HCV RNA. All antibody-positive and RNA-positive samples were also tested by a second serological assay. The prevalence of HCV infections among Dutch dialysis patients as determined by serology or the presence of HCV RNA was 3% (80 of 2,653), i.e., 3.5% (73 of 2,108) in patients treated on hemodialysis and 1.3% (7 of 545) in patients on CAPD. Of these 80 HCV-infected dialysis patients, 67 (84%) were HCV RNA positive. Serological screening alone would have diagnosed only 70 infected patients. Therefore, antibody screening combined with detection of HCV RNA should be considered as the "gold standard" for diagnosing HCV infection in dialysis patients. The prevalence of HCV-infected patients in Dutch dialysis centers ranged from 0 to 8%, suggesting the existence of local risk factors for acquiring HCV infection. Genotyping analysis by reverse hybridization line probe assay revealed the presence of genotypes la (23%), 1b (46%), 2 (3%), 2a (13%), 2b (1%), 3a (7%), and 4a (4%). In four (6%) samples multiple genotypes were detected. The genotype distribution of HCV isolates among Dutch dialysis patients was similar to the distribution among nondialysis patients from the Benelux, except for subtype 1a, which was significantly more prevalent among dialysis patients. In only one center, a high prevalence of an uncommon genotype was suggestive of infection from a common source.

Tropical aspects of viral hepatitis. Hepatitis C

This paper reviews our current understanding of hepatitis C infection in tropical countries. Since its discovery in 1989, hepatitis C has been recognized as an important disease in many tropical countries. In Egypt the prevalence in some sections of the population may-exceed 20%. In most tropical areas, however, the epidemiology of hepatitis C infection is poorly defined. There are clear variations in the distribution of genotypes in different areas and this may be one of the factors which influence the natural history of infection in different regions of the world. Routes of infection in tropical countries are poorly defined, most carriers having no clear risk factors for infection. There is some speculation that inadequate sterilization of medical equipment may be a route of infection in some areas. A combination of factors may result in an increased risk of hepatocellular carcinoma developing in patients from the tropics infected with hepatitis C and the prognosis may be worse due to co-infection with hepatitis B and human immunodeficiency virus, both of which may lead to accelerated liver disease. Prospects for disease control are poor due to the difficulty of developing a vaccine to the virus.

Enterically transmitted hepatitis in Saudi Arabia: an epidemiological study

Rates of exposure to two, enterically transmitted viruses, hepatitis E virus (HEV) and hepatitis A virus (HAV), were investigated among the populations of two areas of Saudi Arabia: Gizan (a rural area) and Riyadh (an urban area, with relatively good sanitation). In Riyadh, 24.7% and 1.2% of children were seropositive for HAV and HEV, respectively, by the age of 12 years. There was a sharp increase in exposure to HAV between 13 and 20 years of age (to 63.5%) and most (80.0%) of the subjects aged 50 years had apparently been exposed to HAV. Although seropositivity to HEV also increased with subject age, it only reached 18.8% (in subjects aged > 50 years). The age-specific patterns of exposure to HAV and HEV in Gizan were similar to those in Riyadh but the rates of exposure were generally higher; mean rates of exposure to HAV and HEV were 76.3% and 14.9% in Gizan and 61.3% and 8.37% in Riyadh, respectively. That rates of exposure to HEV in Gizan were almost twice those in Riyadh emphasizes the importance of sanitation as an effective measure in controlling the spread of HEV in developing countries.