Multiple viral infections in a group of intravenous drug users: hepatitis B virus exposure is the risk factor

Hepatitis C virus infection epidemiology among people who inject drugs in Europe: a systematic review of data for scaling up treatment and prevention

BACKGROUND

People who inject drugs (PWID) are a key population affected by hepatitis C virus (HCV). Treatment options are improving and may enhance prevention; however access for PWID may be poor. The availability in the literature of information on seven main topic areas (incidence, chronicity, genotypes, HIV co-infection, diagnosis and treatment uptake, and burden of disease) to guide HCV treatment and prevention scale-up for PWID in the 27 countries of the European Union is systematically reviewed.

METHODS AND FINDINGS

We searched MEDLINE, EMBASE and Cochrane Library for publications between 1 January 2000 and 31 December 2012, with a search strategy of general keywords regarding viral hepatitis, substance abuse and geographic scope, as well as topic-specific keywords. Additional articles were found through structured email consultations with a large European expert network. Data availability was highly variable and important limitations existed in comparability and representativeness. Nine of 27 countries had data on HCV incidence among PWID, which was often high (2.7-66/100 person-years, median 13, Interquartile range (IQR) 8.7-28). Most common HCV genotypes were G1 and G3; however, G4 may be increasing, while the proportion of traditionally 'difficult to treat' genotypes (G1+G4) showed large variation (median 53, IQR 43-62). Twelve countries reported on HCV chronicity (median 72, IQR 64-81) and 22 on HIV prevalence in HCV-infected PWID (median 3.9%, IQR 0.2-28). Undiagnosed infection, assessed in five countries, was high (median 49%, IQR 38-64), while of those diagnosed, the proportion entering treatment was low (median 9.5%, IQR 3.5-15). Burden of disease, where assessed, was high and will rise in the next decade.

CONCLUSION

Key data on HCV epidemiology, care and disease burden among PWID in Europe are sparse but suggest many undiagnosed infections and poor treatment uptake. Stronger efforts are needed to improve data availability to guide an increase in HCV treatment among PWID.

The outcome of a rapid hepatitis B vaccination programme in a methadone treatment clinic

AIM

Injecting drug users are a high-risk population for hepatitis B (HBV), but are difficult to engage in vaccination programmes. This study examines the completion rates of a HBV vaccination schedule and seroconversion in a group of patients in methadone maintenance treatment.

METHODS

Patients at a public methadone maintenance programme in Sydney, Australia, were screened for viral hepatitis (hepatitis A, B and C) and offered a rapid HBV vaccination schedule (0, 1 and 2 months). Hepatitis B surface antibody (antiHBs) was retested on completion of the vaccination schedule.

RESULTS

A total of 143 patients [71.3% male, mean age 33.1 (standard deviation +/- 8.3)] enrolled in the project. Forty-nine per cent of patients were HAV antibody (Ab) positive, 81.1% hepatitis C virus (HCV) antibody (Ab) positive and 38.9% antiHBs positive. Exposure to multiple hepatitis viruses was common, with 24.5% testing positive for all three viruses. Seventy-three (83%) of the 88 antiHBs negative patients completed the vaccination schedule. Post-vaccination serology indicated a seroconversion rate of 75.4% (55 of 73) of completors, or 62.5% of eligible participants (55 of 88).

CONCLUSION

While there was a high rate of completion of the rapid vaccination schedule in this population, a moderate seroconversion rate was achieved. Further work is required to identify an optimal vaccination schedule in opioid substitution patients.

Molecular detection of hepatitis B, hepatitis C, and torque teno viruses in drug users in Saudi Arabia

Injecting drug users are at increased risk of infection with hepatitis viruses and blood-borne pathogens. The aim of this study was to examine HBV, HCV, HDV, and TTV infections in Saudi drug users (N = 344). Extraction of nucleic acid from serum, reverse-transcription, amplification of viral nucleic acids, and HBV and HCV genotyping were done using established techniques. Of the analyzed samples, 41 (12%) contained detectable HBV DNA, 131 (38%) contained detectable HCV RNA, and 174 (51%) had detectable TTV DNA. The predominant HBV genotype was found to be genotype D and the predominant HCV genotype was found to be genotype 1b. All the samples were negative for HDV. Twelve samples (3.5%) were found to contain mixed HBV and HCV genomes, 24 samples (7%) were found to contain mixed HBV and TTV genomes, 82 samples (24%) were found to contain mixed HCV and TTV genomes, and 9 samples (2.6%) were found to contain mixed HBV, HCV, and TTV genomes. Identification of various infections in drug users will help the control of these infections in this group as well as in the community.

Simultaneous detection of hepatitis C virus core antigen and antibodies in Saudi drug users using a novel assay

Drug users and particularly, injecting drug users, are at increased risk for infection with hepatitis C virus (HCV). The aims of the study were to simultaneously detect HCV core antigen and specific antibodies in sera from Saudi drug users using the new HCV combination assay and to compare this data with HCV core antigen, anti-HCV antibodies and HCV RNA data from the same patients. A total of 297 patients who are followed up or admitted to a drug rehabilitation hospital over a period of 3 years were included in this study. Samples were analyzed using the new HCV Ag/Ab combination assay (Meurex), HCV core Ag assay, HCV antibodies and with the HCV RNA assay. Out of the 297 samples from Saudi drug users, 111 samples (37.4%) have detectable HCV core Ag, 112 samples (37.7%) have detectable HCV antibodies, 118 have detectable HCV RNA, and 116 samples were positive by the HCV Ag/Ab combination assay (39.1%). Out of the 116 samples, HCV core Ag was detected in 110 samples (94.8%), HCV antibodies were detected in 111 (95.7%) samples and HCV RNA was detected in 114 samples (98.3%). In the control group (n = 305), only 2 (0.66%) blood donor were positive by HCV antibodies assay, HCV RNA assay as well as HCV Ag/Ab combination assay. The new HCV Ag/Ab combination assay may well improve the overall quality of diagnosis of HCV infection especially in high risk population such as drug users that necessitates rigorous testing.

Changing serological status and low vaccination-induced protection rates against hepatitis B characterize chronic hepatitis C virus-infected injecting drug users in Greece: need for immunization policy

OBJECTIVE

To evaluate the serological status of hepatitis B virus infection among Greek injecting drug users with chronic hepatitis C virus infection; to correlate hepatitis B virus infection status with the possible time of infection and the principal genotype of hepatitis C virus infection.

METHODS

Two hundred and thirty consecutive injecting drug users with chronic hepatitis C virus infection were evaluated for serological markers of hepatitis B virus infection. One hundred and three of them (44.8%) reported intravenous drug use beginning before 1992 (group A) and 127/230 (55.2%) after 1992 (group B). Statistical analysis of data was based on Student's t-test and chi analyses.

RESULTS

Eighty-five of 103 patients from group A (82.5%) and 28/127 (22%) from group B had serological markers of previous hepatitis B virus infection (P<0.001). Eleven patients from group A (10.6%) and 78 (61.4%) from group B were seronegative for all hepatitis B virus markers (P<0.001). Only 3.8% (4/103) of group A patients and 16.5% (21/127) of group B had vaccination-induced protective antibody levels (anti-HBs) against hepatitis B (P=0.02). The majority of patients were infected with hepatitis C virus genotype-3 (64.7% from group A vs 56.7% from group B, P=0.42). The percentages of patients infected with genotype-1 were also comparable in both groups (15.5% from group A vs 30.8% from group B, P=0.09). A significantly higher percentage of group A patients were infected with genotype-4 (19.7%) than those in group B (4.9%, P=0.02).

CONCLUSION

The serological profile of hepatitis B virus infection among Greek hepatitis C virus-infected injecting drug users is changing. The proportion of successfully vaccinated hepatitis B virus injecting drug users, although significantly higher than the previous decades, is still relatively low. Vaccination policy in this high-risk group for viral hepatitis is urgently needed.

Serological profile of HBV infection and liver histopathology among injecting drug users with chronic HCV infection in Greece

BACKGROUND

The aim of this study was to evaluate the serological status of HBV infection and liver histology in chronic HCV-infected injecting drug users (IDUs) and to correlate them with the possible time of infection and the principal HCV genotype.

METHODS

Some 130 prior IDUs with chronic HCV infection were consecutively evaluated for the serological status of HBV infection. Fifty-eight (44.62%) reported intravenous drug use beginning before 1992 (group A) and 72 (55.38%) after 1992 (group B). HCV genotyping was available in 86 patients (PCR). Liver biopsy was performed in 48 patients (Ishak scoring system). There was no available data about alcohol consumption in the study population. Statistical analysis was based on the t-test and the chi(2) test (p<0.05).

RESULTS

Some 82.8% of group A patients had previous HBV infection, whereas only 22.2% of group B patients did (p<0.001). Among group A patients, 10.3% were HBV-seronegative whereas 61.1% of group B patients were (p<0.001). Only 3.4% of group A patients were HBV-vaccinated compared to 16.7% in group B (p=0.016). HCV genotype was not associated with HBV serological status. No significant differences were detected in age, sex, possible time of infection, HBV serological status, or HCV genotype among those with higher vs. lower total grading scores. Seventy-five percent of patients had mild or no detectable fibrosis unrelated to the possible period of infection, the HBV serological status, and the HCV genotype.

CONCLUSIONS

The serological profile of HBV infection is changing among Greek chronic HCV-infected IDUs, while the percentages of successfully HBV-vaccinated IDUs are relatively low. Severe liver disease is an uncommon finding in these patients, irrespective of the possible time of infection, the HBV serological status, and the HCV genotype.

Outbreak of hepatitis A in the injecting drug user and homeless populations in Bristol: control by a targeted vaccination programme and possible parenteral transmission

OBJECTIVE

To study the use of hepatitis A virus (HAV) vaccination in controlling an outbreak of HAV in inner-city Bristol among injecting drug users (IDUs). To study whether hepatitis C virus (HCV) and hepatitis B virus (HBV) co-infection increases morbidity.

DESIGN

Community-based cohort study.

SETTING

Avon Health Authority area, UK.

PARTICIPANTS

All laboratory-confirmed cases of HAV infection notified in 2000.

INTERVENTION

Administration of a targeted vaccination, education and liaison programme.

MAIN OUTCOME MEASURES

Number of cases of HAV before and after introduction of HAV vaccination programme. Mortality and number of patients requiring hospital admission. Association of HCV and HBV co-infection with hospital admission.

RESULTS

Ninety cases of HAV were reported in the first 6 months of 2000, of whom a substantial number were IDUs and/or inner-city hostel residents. In the second 6 months of 2000, following the introduction of a vaccination programme among homeless people, hostel residents, and IDUs, the number of HAV cases fell to 33. Sixteen patients had evidence of HCV co-infection. No patient had chronic HBV infection. Two patients died as a result of HAV, and two subsequently died from drug misuse. Fifty-six per cent of HCV-co-infected patients required admission to hospital compared with 28% non-HCV-co-infected patients.

CONCLUSIONS

This is the first reported successful use of vaccination to control an outbreak of HAV in a population of IDUs and to prevent transmission to the wider population. HCV co-infection appears to increase the severity of HAV illness, as demonstrated by increased incidence of hospital admission.

Hepatitis C virus and human immunodeficiency virus coinfection in Spain

OBJECTIVE AND METHODS

In a cross-sectional study, based on a cohort composed of HIV-infected patients of fifteen tertiary level institutions of Spain, the main data of the entire cohort are described, characteristics of patients with or without hepatitis C coinfection are compared, and the possible association of hepatitis C virus coinfection with socioeconomic, HIV-related, and hepatitis B-related variables is assessed.

RESULTS

A total of 4,709 patients are studied. Median of age is 37 years, 78.3% are male. HIV risk behaviours are: parenteral drug use in 63.8% of patients, heterosexual in 22.3%, and homosexual in 10.8%. Serology of hepatitis C is positive in 69.2% of participants. The following variables are associated with increased prevalence of hepatitis C coinfection, both in univariate and in multivariate analysis: HIV risk behaviour, positive anti-HBs, longer time elapsed since HIV infection diagnosis, younger age, lower social status, lower CD4 cell count increase between nadir and last available result, and lower educational level (all P<0.001). Patients with heterosexual behaviour are more frequently coinfected than patients with homosexual behaviour (P<0.001).

CONCLUSION

This study highlights that, in Spain, more than two thirds of patients with HIV infection are coinfected with hepatitis C virus.