Epidemiological burden estimates for pathologies with a nonconstant risk: an application to HCV in Italy according to age, Metavir score, and genotype: A systematic review and meta-analysis

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

Simple Summary

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

Abstract

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

Intention to Screen for Hepatitis C Among University Students: Influence of Different Communicative Scenarios

This study aimed to evaluate the influence of different narrative scenarios regarding students' intentions to undergo diagnostic screening for hepatitis C, and whether gender identification with the characters of the scenario could influence the students' intentions to undergo a medical test. A sample of 600 participants was administered three narrative scenarios with different frames (positive, negative, and ambivalent), including two gender options (male and female) for the main character of the story. A statistically significant three-way interaction between scenario, gender identification, and time resulted. There were significant simple main effects on the intention to have a diagnostic test for hepatitis C for the scenarios with the protagonist of the same gender as the participant and after the administration of the negative scenario. The use of a negative scenario with the same gender character was always more effective than the use of a positive framed scenario, even though there was a high level of knowledge regarding the disease. Personal diagnostic testing was not directly associated with knowledge regarding the infection. The findings of this study can ultimately help policymakers develop communication campaigns adapted to target populations such as college students, in order to raise awareness of the risk, promote prevention and behavioral change, and encourage medical screening.

Frequent inappropriate use of unweighted summary statistics in systematic reviews of pathogen genotypes or genogroups

OBJECTIVES

Our study aimed to systematically assess and report the methodological quality used in epidemiological systematic reviews (SRs) and meta-analysis (MA) of pathogen genotypes/genogroups.

STUDY DESIGN AND SETTING

Nine electronic databases and manual search of reference lists were used to identify relevant studies. The method types were divided into three groups: 1) with weighted pooling analysis (which we call MA), (2) unweighted analysis of the study-level measures (which we call summary statistics), and (3) without any data pooling (which we call SR only). Characteristics were evaluated using Assessment of Multiple Systematic Reviews (AMSTAR), Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA), and Risk Of Bias In Systematic reviews (ROBIS) tools. The protocol was registered in PROSPERO with CRD42017078146.

RESULTS

Among 36 included articles, 5 (14%) studies conducted SR only, 16 (44%) performed MA, and 15 (42%) used summary statistics. The univariable and multivariable linear regression of AMSTAR and PRISMA scores showed that MA had higher quality compared with those with summary statistics. The SR only and summary statistics groups had approximately equal scores among three scales of AMSTAR, PRISMA, and ROBIS. The methodological quality of epidemiological studies has improved from 1999 to 2017.

CONCLUSION

Despite the frequent use of unweighted summary statistics, MA remains the most suitable method for reaching rational conclusions in epidemiological studies of pathogen genotypes/genogroups.

NS5A Gene Analysis by Next Generation Sequencing in HCV Nosocomial Transmission Clusters of HCV Genotype 1b Infected Patients

Background: The aim of the study was to investigate the intra-host variability through next-generation-sequencing (NGS) of the NS5A-gene in nosocomial transmission-clusters observed in two Italian hospitals among hepatitis C virus (HCV)-genotype-1b infected patients. Methods: HCV-sequencing was performed by Sanger-sequencing (NS3 + NS5A + NS5B) and by NGS (NS5A, MiSeq-Illumina) in 15 HCV-1b infected patients [five acute with onco-hematologic-disease and 10 (4/6 acute/chronic) with β-thalassemia]. Resistance-associated-substitutions (RAS) were analysed by Geno2pheno-algorithm. Nucleotide-sequence-variability (NSV, at 1%, 2%, 5%, 10% and 15% NGS-cutoffs) and Shannon entropy were estimated. Phylogenetic analysis was performed by Mega6-software and Bayesian-analysis. Results: Phylogenetic analysis showed five transmission-clusters: one involving four HCV-acute onco-hematologic-patients; one involving three HCV-chronic β-thalassemia-patients and three involving both HCV-acute and chronic β-thalassemia-patients. The NS5A-RAS Y93H was found in seven patients, distributed differently among chronic/acute patients involved in the same transmission-clusters, independently from the host-genetic IL-28-polymorphism. The intra-host NSV was higher in chronic-patients versus acute-patients, at all cutoffs analyzed (p < 0.05). Even though Shannon-entropy was higher in chronic-patients, significantly higher values were observed only in chronic β-thalassemia-patients versus acute β-thalassemia-patients (p = 0.01). Conclusions: In nosocomial HCV transmission-clusters, the intra-host HCV quasispecies divergence in patients with acute-infection was very low in comparison to that in chronic-infection. The NS5A-RAS Y93H was often transmitted and distributed differently within the same transmission-clusters, independently from the IL-28-polymorphism.

Optimizing patient referral and center capacity in the management of chronic hepatitis C: Lessons from the Italian experience

AIMS

In 2017 the Italian Drug Agency (Agenzia Italiana del Farmaco, AIFA) revised the criteria for access to therapy for patients with chronic hepatitis C as part of a three-year plan to eradicate HCV. We conducted a Delphi study to determine strategies to identify and treat patients with HCV and to develop through a shared pathway, a model to manage patient referral and optimize prescription center capacity with the overall aim of increasing access to therapy.

METHODS

The process took place in two phases - Phase I (January 2017), before the criteria for treatment of HCV were revised and Phase II (May 2017) when AIFA developed a framework for the eradication of HCV infection in Italy. Two questionnaires were devised with Q1 administered in Phase I and Q2 in Phase II.

RESULTS

Q1 was sent to 823 hepatitis specialists working in 235 Italian HCV centers authorized to prescribe direct-acting antiviral drugs (DAAs). Overall, 167 centers (71%) participated with a good geographical representativeness (North 69%, Centre 74%; South and islands 70%). 548 prescribers (68.8%) provided responses to Q1 and 443 (80%) specialists who responded to Q1 completed Q2. Over 70% considered that to meet the new therapy targets local/regional networks need to be consolidated and reinforced with GPs providing the 'missing link' in current regional networks. Adherence to therapy was considered important by 75% of clinicians with reduction in follow-up intervals/length considered important by 65% - to free up staff/resources to manage increasing numbers of new patients. About 80% of respondents stated that medical personnel were principally involved in follow-up with follow-up having a significant impact on center capacity.

CONCLUSION

Enhancing patient referral, the need for an increased role of GPs, increasing center capacity in particular medical personnel in outpatient centers and greater liaison between Hub centers and healthcare professionals currently managing high-risk groups as yet untreated, were factors that need to be streamlined in order to meet treatment targets for eradication of HCV.

High dietary inflammatory index scores are associated with an elevated risk of hepatocellular carcinoma in a case-control study

Chronic inflammation and diet play crucial roles in the development of hepatocellular carcinoma (HCC); yet the association between dietary inflammatory potential and risk of HCC has rarely been investigated. This study aimed to examine whether a higher dietary inflammatory index (DII®) score (indicating a pro-inflammatory diet) is associated with an increased risk of HCC in a matched case-control study conducted between September 2013 and October 2017 in South China. A total of 659 cases with newly diagnosed, previously untreated HCC and 659 controls individually matched on age (±3 years) and sex were included in this study. DII scores were computed based on dietary intake information collected via a validated 79-item food frequency questionnaire (FFQ) during the one year prior to diagnosis (for the cases) or interview (for the controls). Logistic regression was used to estimate the odds ratio (OR) and 95% confidence interval (CI) between the DII score and the risk of HCC, adjusted for age, energy intake, body mass index, physical activity, marital status, education, household income, smoking status, and hepatitis B virus (HBV) infection status. Compared with subjects in the lowest DII tertile, subjects in the highest tertile had an elevated risk of HCC (fully adjusted OR: 3.22, 95% CI: 1.30-7.98, P-trend = 0.009). In stratified analyses, a significantly positive association was observed only in men, individuals with lower education level, smokers and non-alcohol drinkers. In conclusion, a higher DII score, representing a more inflammatory diet, was associated with an increased risk of HCC, in men, individuals with lower education level, smokers and non-alcohol drinkers.

The elderly and direct antiviral agents: Constraint or challenge?

BACKGROUND

Direct antiviral agents (DAAs) for chronic hepatitis C showed great effectiveness and good safety profile. So far, few data are available about their use in elderly subjects.

AIM

To assess management, safety and outcome of DAAs treatments in the elderly.

METHODS

This retrospective, single-centre study enrolled all patients aged ≥65 years, compared by age (group A: 65-74 years, group B: ≥75 years), who completed DAAs between February 2015-November 2016. Variables potentially associated to adverse events (AEs) were analyzed. Sustained virological response (SVR) was evaluated at 12-weeks follow-up.

RESULTS

DAAs were administered to 221 patients aged ≥65 years (males: 112; group A: 130, group B: 91). Prescribed regimens were: sofosbuvir-based: 44 patients (19.9%), simeprevir-based: 25 (15%), ledipasvir-based: 49 (22.2%), daclatasvir-based: 12 (5.4%), paritaprevir/ritonavir+ombitasvir±dasabuvir: 91 (41.2%). Ribavirin was used in 121 patients. In 58 subjects co-medications were adjusted due to drug interactions. At least one AE occurred in 130 patients, including 13 SAEs, mainly in older subjects (p=0.04). Female sex (p=0.04), liver stiffness (p=0.023), use of simeprevir (p=0.03) and ribavirin (p=0.009) were associated with AEs. SVR-12 was achieved in 96,9% of subjects.

CONCLUSIONS

A careful baseline evaluation and a strict monitoring allow to optimise management and outcome of DAAs in elderly.