Hepatitis B virus and hepatitis C virus infections in Belgium: similarities and differences in epidemics and initial management

Estimating the proportion of people with chronic hepatitis B virus infection eligible for hepatitis B antiviral treatment worldwide: a systematic review and meta-analysis

BACKGROUND

In 2016, of the estimated 257 million people living with chronic hepatitis B virus (HBV) infection worldwide, only a small proportion was diagnosed and treated. The insufficiency of information on the proportion of people infected with HBV who are eligible for treatment limits the interpretation of global treatment coverage. We aimed to estimate the proportion of people with chronic HBV infection who were eligible for antiviral treatment worldwide, based on the WHO 2015 guidelines.

METHODS

In this systematic review and meta-analysis, we searched Medline, EMBASE, and the Cochrane databases from Jan 1, 2007, to Jan 31, 2018, for studies describing HBsAg-positive people in the population or health-care facilities. We extracted information from published studies using a standardised form to estimate the frequency of cirrhosis, abnormal alanine aminotransferase (ALT), HBV DNA exceeding 2000 IU/mL or 20 000 IU/mL, presence of HBeAg, and eligibility for treatment as per WHO and other guidelines as reported in the studies. We pooled proportions through meta-analysis with random effects. The study was registered with PROSPERO, CRD42020132345.

FINDINGS

Of the 13 497 studies, 162 were eligible and included in our analysis. These studies included 145 789 participants. The pooled estimate of the proportion of cirrhosis was 9% (95% CI 8-10), ranging from 6% (4-8) in community settings to 10% (9-11) in clinic settings. Examining the proportion of participants who had characteristics used to determine eligibility in the WHO guidelines, 1750 (10·1%) of 17 394 had HBV DNA exceeding 20 000 IU/mL, and 20 425 (30·8%) of 66 235 had ALT above the upper limit of normal. 32 studies reported eligibility for treatment according to WHO or any other guidelines, with a pooled estimate of eligibility at 19% (95% CI 18-20), ranging from 12% (6-18) for studies in community settings to 25% (19-30) in clinic settings.

INTERPRETATION

Many studies described people with HBV infection, but few reported information in a way that allowed assessment of eligibility for treatment. Although about one in ten of the 257 million people with HBV infection (26 million) might be in urgent need of treatment because of cirrhosis, a larger proportion (12-25%) is eligible for treatment in accordance with different guidelines. Future studies describing people with HBV infection should report on treatment eligibility, according to broadly agreed definitions.

FUNDING

WHO and US Centers for Disease Control and Prevention.

Swim-up as a strategy for isolation of spermatozoa without viral incorporation in men with chronic hepatitis B: A pilot study

Hepatitis B virus (HBV) incorporates into spermatozoa which raises safety concerns about paternofetal transmission performing intracytoplasmatic sperm injection (ICSI) in men with chronic hepatitis B (cHB). HBV reduces sperm cell motility, assuming spermatozoa with highest motility are least HBV-incorporated. This study investigates an ICSI preparation technique (swim-up) to isolate most motile spermatozoa in order to select HBV-free spermatozoa. Semen and blood samples were collected from four patients with cHB. Spermatozoa were incubated in trajectories of gamete medium to create non-motile, motile/non-progressive and motile/progressive fractions. After DNA-extraction, HBV DNA loads were determined in every fraction. Participants (mean age 31) were HBsAg+(4/4), anti-HBc+(4/4) and HBV DNA+(2/4). They were treated (3/4) with entecavir(1/4) or tenofovir (2/4) and had no adverse sperm parameters(3/4). CRP-gene was detected in 95/96 sample fractions, proving successful DNA-extraction. HBV DNA was detected in none of the sample fractions, except for the motile, non-progressive fraction of one patient (HBeAg+, HBV DNA+). Since no HBV DNA was detected in progressive fractions, this study suggests swim-up a successful strategy to select HBV-free spermatozoa. Since all but one fraction was HBV DNA-negative, this study also suggests that patients with well-controlled disease have no HBV-contaminated sample fractions. This study encourages evaluation of guidelines restricting reproductive possibilities in men with cHB.

Antiviral drug utilization and annual expenditures for patients with chronic HBV infection in Guangzhou, China, in 2008-2015

BACKGROUND

The aims of this study were to describe antiviral drug (AD) utilization and costs in patients with chronic HBV infection.

METHODS

We conducted a retrospective study of patients in the hospital and calculated annual proportions of AD utilization and costs among patients. A two-part model was used to estimate adjusted odds ratio (OR) for antiviral therapy and cost ratios for antiviral costs associated with demographics.

RESULTS

Of a total of 14,920 records, 143,658 records were involved in the analysis. The annual proportions of AD utilization were 56.99% (45.65%) for inpatients (outpatients) during 2008-2015 and increased annually. Entecavir (ETV), in particular, increased from 11.08% to 70.26% (11.05% to 49.35%) for inpatients (outpatients). The patients with medical insurance were more likely to use AD than patients without insurance, and the adjusted OR was 1.11 (95% CI: 1.03, 1.19) for inpatients and 1.66 (1.59, 1.73) for outpatients. With the disease progressing, the proportion of antiviral costs in total direct medical costs decreased from 13.91% to 4.07% (71.29% to 49.29%) for inpatients (outpatients).

CONCLUSIONS

The use of AD for chronic HBV infection was less than expected based on established guidelines, and only half of patients received antiviral treatment. However, the AD utilization, especially ETV, increased annually. Reimbursement policy was the most important factor affecting antiviral treatment. Antiviral therapy was an important part of the direct medical costs, especially in the early stage of disease.

Prevalence and risk factors of hepatitis B virus infection in Middle-Limburg Belgium, year 2017: Importance of migration

BACKGROUND AND AIM

The hepatitis B virus (HBV) prevalence study performed in 2003 in Belgium is believed to be underestimating HBV prevalence due to underrepresentation of the non-Belgian population. Therefore, we assessed the prevalence and risk factors of HBV infection in a multi-ethnic region situated in Middle-Limburg Belgium, in 2017.

METHODS

Between May and November 2017, blood samples and questionnaires were taken from patients who presented at the emergency department of a large educational hospital. Blood samples were tested for hepatitis B surface antigen (HBsAg) and hepatitis B core antibodies (anti-HBc). A sample size of 1000 persons was required to obtain a representative sample of the general Middle-Limburg population.

RESULTS

Of the 1131 patients screened, the overall HBsAg prevalence was 0.97% with differences between Belgians (0.67%) and first-generation-migrants (2.55%), (P = 0.015). Five (45.5%) of 11 HBsAg-positive individuals were not aware of their HBV status. All five (100%) newly diagnosed HBsAg-positive patients had further clinical evaluation and all had a normal level of alanine aminotransferase (ALT). The prevalence of anti-HBc was 8.4%, and was significantly associated with age-gender-ethnicity interaction, presence of HBV-infected household member, hepatitis C virus infection, men who have sex with men, and hemodialysis.

CONCLUSIONS

In this area with large immigrant populations, we found a higher prevalence of HBV infection compared with the nationwide study of 2003. National HBV screening for first-generation migrants is needed as this high-risk group will go unnoticed due to the possible incorrect interpretation of normal ALT values.

Characteristics of patients with hepatitis B virus and hepatitis C virus dual infection in a Western European country: Comparison with monoinfected patients

The epidemiology of hepatitis B virus (HBV) and hepatitis C virus (HCV) infections is continuously evolving. Updated data on dual HBV and HCV infection are still needed.

AIMS

To assess the main characteristics of patients with HBV and HCV dual infection, to compare these with those of patients infected with either HBV or HCV and, among patients with dual infection, to assess fibrosis according to HCV replication.

METHODS

Data of 23 patients with dual infection were compared to data from 92 age and sex-matched HBV or HCV monoinfected patients.

RESULTS

Patients with dual infection were more often immigrants from Africa or Asia than HCV or HBV patients (52% vs. 20% and 22%, respectively, P=0.01). Intravenous drug use was the route of transmission in 22% of patients with dual infection, which was less frequent than in HCV patients (41%) but more frequent than in HBV patients (0%). Extensive fibrosis or cirrhosis was as frequent among dual-infected patients as among those with HCV or chronic hepatitis B infection (19% vs. 29% vs. 14%, respectively, P=0.4), even when fibrosis stage was reported considering the duration of infection. In dual-infected patients, the prevalence of extensive fibrosis or cirrhosis was similar in patients with and without detectable HCV RNA (18% vs. 20%).

CONCLUSIONS

Patients with HBV and HCV dual infection were more often immigrants from Africa or Asia and had similar fibrosis stages than HCV or HBV monoinfected patients. In patients with dual infection, extensive fibrosis or cirrhosis was not associated with HCV replication.

Infectious diseases in North Africa and North African immigrants to Europe

The epidemiological transition has reduced infectious diseases mortality in most European countries, yet increased migrant influx risks importing diseases. All reported prevalence rates must be considered on a case-by-case basis depending on the disease in question, respective European Union (EU) country and migratory patterns at work. Tuberculosis has seen a re-emergence in Europe and is concentrated among migrants. Migrants arriving from North Africa (NA) and sub-Saharan Africa (SSA) carry higher rates of hepatitis C and B than the local EU population. The human immunodeficiency virus (HIV) impact of NA migrants to Europe is very low but a hallmark of the HIV epidemic is the penetration and circulation of non-B strains, recombinant forms and HIV-drug-resistant profiles through SSA migrants using NA as a transit point into Europe. Leishmaniasis is a re-emerging zoonotic disease prevalent to Southern Europe although not specifically isolated in migrant groups. Although not endemic in NA countries, malaria represent S: a risk in terms of re-emergence in Europe through transitory migrants arriving from SSA with the destination to Europe. Schistosomiasis has been largely eliminated from NA. High migrant flux into European countries has resulted in changing patterns of communicable disease and collectively requires a continuous surveillance. World Health Organization guidelines recommend targeted screening and preventative vaccination, followed by integration of migrants into the local health-care systems allowing for long-term treatment and follow-up. Finally, effective public health campaigns as a form of prevention are essential for the mitigation of disease dissemination in the migrant pool and for second-generation children of migrants.

Clinical characteristics and current management of hepatitis B and C in China

AIM: To describe a population of outpatients in China infected by hepatitis B virus (HBV) and/or hepatitis C virus (HCV), and assess their current management status.

METHODS: A multicenter, cross-sectional study of HBV- and/or HCV-infected patients was conducted from August to November, 2011 in western China. Patients ≥ 18 years of age with HBV and/or HCV infections who visited outpatient departments at 10 hospitals were evaluated, whether treated or not. Data were collected on the day of visit from medical records and patient interviews.

RESULTS: A total 4010 outpatients were analyzed, including 2562 HBV-infected and 1406 HCV-infected and 42 HBV/HCV co-infected patients. The median duration of documented infection was 7.5 years in HBV-infected and 1.8 years in HCV-infected patients. Cirrhosis was the most frequent hepatic complication (12.2%), appearing in one-third of patients within 3 years prior to or at diagnosis. The HCV genotype was determined in only 10% of HCV-infected patients. Biopsy data were only available for 54 patients (1.3%). Antiviral medications had been received by 58.2% of patients with HBV infection and 66.6% with HCV infection. Nucleos(t)ide analogs were the major antiviral medications prescribed for HBV-infected patients (most commonly adefovir dipivoxil and lamivudine). Ribavirin + pegylated interferon was prescribed for two-thirds of HCV-infected patients. In the previous 12 mo, around one-fifth patients had been hospitalized due to HBV or HCV infection.

CONCLUSION: This observational, real-life study has identified some gaps between clinical practice and guideline recommendations in China. To achieve better health outcomes, several improvements, such as disease monitoring and optimizing antiviral regimens, should be made to improve disease management.

Historical epidemiology of hepatitis C virus (HCV) in selected countries

Chronic infection with hepatitis C virus (HCV) is a leading indicator for liver disease. New treatment options are becoming available, and there is a need to characterize the epidemiology and disease burden of HCV. Data for prevalence, viremia, genotype, diagnosis and treatment were obtained through literature searches and expert consensus for 16 countries. For some countries, data from centralized registries were used to estimate diagnosis and treatment rates. Data for the number of liver transplants and the proportion attributable to HCV were obtained from centralized databases. Viremic prevalence estimates varied widely between countries, ranging from 0.3% in Austria, England and Germany to 8.5% in Egypt. The largest viremic populations were in Egypt, with 6,358,000 cases in 2008 and Brazil with 2,106,000 cases in 2007. The age distribution of cases differed between countries. In most countries, prevalence rates were higher among males, reflecting higher rates of injection drug use. Diagnosis, treatment and transplant levels also differed considerably between countries. Reliable estimates characterizing HCV-infected populations are critical for addressing HCV-related morbidity and mortality. There is a need to quantify the burden of chronic HCV infection at the national level.