Surveillance for newly acquired hepatitis C in Australia

Needle syringe programmes and opioid substitution therapy for preventing hepatitis C transmission in people who inject drugs

BACKGROUND

Needle syringe programmes and opioid substitution therapy for preventing hepatitis C transmission in people who inject drugsNeedle syringe programmes (NSP) and opioid substitution therapy (OST) are the primary interventions to reduce hepatitis C (HCV) transmission in people who inject drugs. There is good evidence for the effectiveness of NSP and OST in reducing injecting risk behaviour and increasing evidence for the effectiveness of OST and NSP in reducing HIV acquisition risk, but the evidence on the effectiveness of NSP and OST for preventing HCV acquisition is weak.

OBJECTIVES

To assess the effects of needle syringe programmes and opioid substitution therapy, alone or in combination, for preventing acquisition of HCV in people who inject drugs.

SEARCH METHODS

We searched the Cochrane Drug and Alcohol Register, CENTRAL, the Cochrane Database of Systematic Reviews (CDSR), the Database of Abstracts of Reviews of Effects (DARE), the Health Technology Assessment Database (HTA), the NHS Economic Evaluation Database (NHSEED), MEDLINE, Embase, PsycINFO, Global Health, CINAHL, and the Web of Science up to 16 November 2015. We updated this search in March 2017, but we have not incorporated these results into the review yet. Where observational studies did not report any outcome measure, we asked authors to provide unpublished data. We searched publications of key international agencies and conference abstracts. We reviewed reference lists of all included articles and topic-related systematic reviews for eligible papers.

SELECTION CRITERIA

We included prospective and retrospective cohort studies, cross-sectional surveys, case-control studies and randomised controlled trials that measured exposure to NSP and/or OST against no intervention or a reduced exposure and reported HCV incidence as an outcome in people who inject drugs. We defined interventions as current OST (within previous 6 months), lifetime use of OST and high NSP coverage (regular attendance at an NSP or all injections covered by a new needle/syringe) or low NSP coverage (irregular attendance at an NSP or less than 100% of injections covered by a new needle/syringe) compared with no intervention or reduced exposure.

DATA COLLECTION AND ANALYSIS

We followed the standard Cochrane methodological procedures incorporating new methods for classifying risk of bias for observational studies. We described study methods against the following 'Risk of bias' domains: confounding, selection bias, measurement of interventions, departures from intervention, missing data, measurement of outcomes, selection of reported results; and we assigned a judgment (low, moderate, serious, critical, unclear) for each criterion.

MAIN RESULTS

We identified 28 studies (21 published, 7 unpublished): 13 from North America, 5 from the UK, 4 from continental Europe, 5 from Australia and 1 from China, comprising 1817 incident HCV infections and 8806.95 person-years of follow-up. HCV incidence ranged from 0.09 cases to 42 cases per 100 person-years across the studies. We judged only two studies to be at moderate overall risk of bias, while 17 were at serious risk and 7 were at critical risk; for two unpublished datasets there was insufficient information to assess bias. As none of the intervention effects were generated from RCT evidence, we typically categorised quality as low. We found evidence that current OST reduces the risk of HCV acquisition by 50% (risk ratio (RR) 0.50, 95% confidence interval (CI) 0.40 to 0.63, I2 = 0%, 12 studies across all regions, N = 6361), but the quality of the evidence was low. The intervention effect remained significant in sensitivity analyses that excluded unpublished datasets and papers judged to be at critical risk of bias. We found evidence of differential impact by proportion of female participants in the sample, but not geographical region of study, the main drug used, or history of homelessness or imprisonment among study samples.Overall, we found very low-quality evidence that high NSP coverage did not reduce risk of HCV acquisition (RR 0.79, 95% CI 0.39 to 1.61) with high heterogeneity (I2 = 77%) based on five studies from North America and Europe involving 3530 participants. After stratification by region, high NSP coverage in Europe was associated with a 76% reduction in HCV acquisition risk (RR 0.24, 95% CI 0.09 to 0.62) with less heterogeneity (I2 =0%). We found low-quality evidence of the impact of combined high coverage of NSP and OST, from three studies involving 3241 participants, resulting in a 74% reduction in the risk of HCV acquisition (RR 0.26 95% CI 0.07 to 0.89).

AUTHORS' CONCLUSIONS

OST is associated with a reduction in the risk of HCV acquisition, which is strengthened in studies that assess the combination of OST and NSP. There was greater heterogeneity between studies and weaker evidence for the impact of NSP on HCV acquisition. High NSP coverage was associated with a reduction in the risk of HCV acquisition in studies in Europe.

Enhancing the detection and management of acute hepatitis C virus infection

Acute HCV infection refers to the 6-month period following infection acquisition, although this definition is somewhat arbitrary. While spontaneous clearance occurs in approximately 25%, the majority will develop chronic HCV infection with the potential for development of cirrhosis, end stage liver disease and hepatocellular carcinoma. Detection of acute HCV infection has been hampered by its asymptomatic or non-specific presentation, lack of specific diagnostic tests and the inherent difficulties in identifying and following individuals at highest risk of transmitting and acquiring HCV infection, such as people who inject drugs (PWID). However, recognition of those with acute infection may have individual and population level benefits and could represent an ideal opportunity for intervention. Despite demonstration that HCV treatment is feasible and successful in PWID, treatment uptake remains low with multiple barriers to care at an individual and systems level. Given the burden of HCV-related disease among PWID, strategies to enhance HCV assessment, treatment and prevention in this group are urgently needed. As the therapeutic landscape of chronic HCV management is revolutionised by the advent of simple, highly effective directly-acting antiviral (DAA) therapy, similar opportunities may exist in acute infection. This review will discuss issues surrounding improving the detection and management of acute HCV infection, particularly in PWID.

Discrimination by health care workers versus discrimination by others: countervailing forces on HCV treatment intentions

Hepatitis C virus (HCV) infection is a major public health burden. Despite recent advances in HCV treatment, uptake remains low, particularly amongst people who inject drugs. HCV-related stigma and discrimination are common, especially within the health care sector. This research examines a more nuanced approach for how HCV-related stigma and discrimination impacts treatment access and uptake. Based on a social identity framework, we explore whether perceived HCV-related discrimination is associated with attempts to remove the stigma of being HCV-positive via HCV treatment intentions. Based on the results of prior research it was also hypothesised that the source of discrimination (health care workers versus others), and whether the discrimination is perceived to be directed to oneself or to the HCV-positive group, will differentially impact treatment intentions. The sample consisted of 416 people living with HCV in New South Wales, Australia, who acquired HCV from injecting drugs. Participants were asked about their experiences of perceived discrimination directed towards themselves versus their HCV-positive group and perceived discrimination within the health care sector. Findings indicate that discrimination towards the self is a more powerful indicator of treatment intentions than discrimination aimed at the HCV-positive group. This finding is consistent with social identity theory suggesting that people from low status groups are motivated to change their stigmatised status when it is possible to do so. The source of the perceived discrimination also matters, however, as participants who report experiencing discrimination from health workers have lowered intentions to engage with HCV treatment in the future. In combination, the results indicate that while perceived discrimination is commonly understood to act as a barrier to treatment uptake, the relationship is actually more complex than previously conceptualised.

Treatment of hepatitis C virus infection among people who are actively injecting drugs: a systematic review and meta-analysis

BACKGROUND

Although guidelines recommend that people who inject drugs (PWID) should not be excluded from hepatitis C (HCV) treatment, some services remain reluctant to treat PWID. The aim of this review was to investigate sustained virologic response (SVR), adherence, discontinuation, and HCV reinfection among PWID.

METHODS

A search of Medline, Embase, and Cochrane databases (between 2002 and January 2012) was conducted for primary articles/conference abstracts examining HCV treatment outcomes in PWID. Meta-analysis was used to obtain pooled estimates of SVR, adherence, discontinuation, and HCV reinfection.

RESULTS

Ten primary articles and 1 conference abstract met the inclusion criteria. Across 6 studies (comprising 314 drug users, of whom 141 [45%] were PWID), pooled SVR was 56% (95% confidence interval [CI], 50%-61%) for all genotypes, 37% (95% CI, 26%-48%) for genotypes 1/4, and 67% (95% CI, 56%-78%) for genotypes 2/3. Pooled 80/80/80 adherence was 82% (95% CI, 74%-89%) across 2 studies, and pooled treatment discontinuation was 22% (95% CI, 16%-27%) across 4 studies. Across 5 studies (comprising 131 drug users) examining reinfection, pooled risk was 2.4 (95% CI, .9-6.1) per 100 person-years.

CONCLUSIONS

HCV treatment outcomes are acceptable in PWID, supporting treatment guidelines. The pooled estimate of HCV reinfection risk was low, but there was considerable uncertainty around this estimate. Further studies on the risk of reinfection are needed to assess the long-term effectiveness of HCV treatment in PWID.

Intensity of human prion disease surveillance predicts observed disease incidence

BACKGROUND

Prospective national screening and surveillance programmes serve a range of public health functions. Objectively determining their adequacy and impact on disease may be problematic for rare disorders. We undertook to assess whether objective measures of disease surveillance intensity could be developed for the rare disorder sporadic Creutzfeldt-Jakob disease (CJD) and whether such measures correlate with disease incidence.

METHOD

From 10 countries with national human prion disease surveillance centres, the annual number of suspected prion disease cases notified to each national unit (n=17,610), referrals for cerebrospinal fluid (CSF) 14-3-3 protein diagnostic testing (n=28,780) and the number of suspect cases undergoing diagnostic neuropathological examination (n=4885) from 1993 to 2006 were collected. Age and survey year adjusted incidence rate ratios with 95% CIs were estimated using Poisson regression models to assess risk factors for sporadic, non-sporadic and all prion disease cases.

RESULTS

Age and survey year adjusted analysis showed all three surveillance intensity measures (suspected human prion disease notifications, 14-3-3 protein diagnostic test referrals and neuropathological examinations of suspect cases) significantly predicted the incidence of sporadic CJD, non-sporadic CJD and all prion disease.

CONCLUSIONS

Routine national surveillance methods adjusted as population rates allow objective determination of surveillance intensity, which correlates positively with reported incidence for human prion disease, especially sporadic CJD, largely independent of national context. The predictive relationship between surveillance intensity and disease incidence should facilitate more rapid delineation of aberrations in disease occurrence and assessment of the adequacy of disease monitoring by national registries.

Diagnosis and treatment of acute hepatitis C virus infection

The first 6 months after exposure to hepatitis C virus (HCV) are regarded as acute hepatitis C (AHC). Two patient populations worldwide share the highest prevalence of AHC virus infection: injection drug users and HIV-positive men who have sex with men. Diagnosis of AHC is often difficult in both patient populations as the acute inflammatory phase can be clinically asymptomatic and patients at highest risk for acquiring AHC (injection drug users) tend to evade regular medical care. This article addresses similarities and differences in the epidemiology, diagnosis, and management of AHC monoinfection and coinfection.

Current and emerging antiviral treatments for hepatitis C infection

Newly licensed direct acting antivirals for hepatitis C virus HCV are able to cure up to 75% of patients chronically infected with genotype-1 infection, which is the predominant HCV strain in Europe and North America. Emerging antiviral therapies promise further increases in virological response, as well as improved tolerability, reduced duration of therapy, and will potentially eliminate the need for interferon use. This review highlights the main therapeutic agents used in current standard of care, including telaprevir and boceprevir. It goes on to evaluate the mechanisms of emerging drugs, their stage of development and response rates seen in research to date. Finally, it projects into the not too distant future to consider treatment strategies involving combinations of agents and interferon-free therapies, and in which patients they might prove most successful.

Risk factors for and incidence of acute hepatitis C after the achievement of blood supply safety in Italy: results from the national surveillance system

Surveillance systems for acute hepatitis C allow monitoring of disease incidence trends and transmission patterns. This study aimed to describe the epidemiological profile of reported cases of symptomatic acute hepatitis C in Italy after the achievement of blood supply safety. The incidence of symptomatic acute hepatitis C since 1991 was estimated. Risk factors for acute hepatitis C were analyzed for the period 2003-2010 through a case-control study within a population-based surveillance for acute viral hepatitis. From 1991 to 2010, the incidence decreased from 2 to 0.2 per 100,000, with a more evident decrease among persons aged 15-24 years. During 2003-2010, 1,053 cases were reported. Intravenous drug use (adjusted odds ratio [(adj) OR], 30.5; 95% confidence interval [CI], 18.9-49.1), cohabitation or sexual partnership with an hepatitis C virus (HCV) carrier ((adj) OR, 11.2; 95% CI, 6.6-19.2), nosocomial exposure ((adj) OR, 6.6; 95% CI, 4.6-9.4); unsafe sexual practices ((adj) OR, 3.1; 95% CI, 1.9-5.2), and cosmetic treatments with percutaneous exposure ((adj) OR, 1.7; 95% CI, 1.2-2.4) were independently associated with acute hepatitis C. Population attributable risk estimates indicated nosocomial exposure (39.6%) and intravenous drug use (30.5%) as responsible for most cases. In conclusion, the incidence of symptomatic acute hepatitis C is declining in Italy. Currently, the most important risk factors are: having an HCV-positive household or sexual partner, unsafe sexual practices, cosmetic percutaneous treatments, intravenous drug use, and nosocomial exposure; the latter two factors are responsible for most cases. Effective prevention programs for intravenous drug users and strict adherence to universal precautions in healthcare settings are needed.

Case definitions for acute hepatitis C virus infection: a systematic review

BACKGROUND & AIMS

Case definitions for recent hepatitis C virus (HCV) infection vary considerably between studies. The aim of this systematic review was to characterize case definitions for recent HCV and explore the heterogeneity in studies performed to date.

METHODS

A systematic literature search of MEDLINE, SCOPUS, and ISI Web of Knowledge was performed covering all studies of recent HCV infection cited between January 2000 and June 2011. The criteria used by each study to define cases of recent HCV infection were extracted, structured, and analyzed.

RESULTS

Overall, 195 articles were included, with 87% (n=169) providing a clear case definition for recent HCV infection. The most frequently used individual criteria for defining a case included HCV antibody seroconversion (77%), alanine aminotransferase (ALT) elevation (68%), and HCV RNA detection (63%). In studies using HCV antibody seroconversion, the window period between the last negative and the first positive antibody test varied widely across studies (4 weeks to 4 years). Considerable diversity was also observed with respect to the ALT threshold used to characterize ALT elevations, ranging from 2 to 20 times the upper limit of normal. HCV antibody seroconversion was used as a single criterion in 41% of the studies, while all other studies used at least two criteria (range: 2-9). Epidemiology/surveillance studies mostly used a more sensitive case definition, whereas treatment studies, natural history studies, and diagnosis studies used more specific case definitions.

CONCLUSIONS

Marked heterogeneity in case definitions for recent HCV infection was observed. Although a single case definition for recent HCV is not warranted, a degree of standardization within specific study categories would enable improved cross-study comparison and more uniform evaluation of HCV prevention and management strategies.

Incidence analyses and space-time cluster detection of hepatitis C in Fujian Province of China from 2006 to 2010

BACKGROUND

There is limited epidemiologic information about the incidence of hepatitis C in China, and few studies have applied space-time scan statistic to detect clusters of hepatitis C and made adjustment for temporal trend and relative risk of regions.

METHODOLOGY AND PRINCIPAL FINDINGS

We analyzed the temporal changes and characteristics of incidence of hepatitis C in Fujian Province from 2006 through 2010. The discrete Poisson model of space-time scan statistic was chosen for cluster detection. Data on new cases of hepatitis C were obtained from the Center for Disease Control and Prevention of Fujian Province. Between 2006 and 2010, there was an annualized increase in the incidence of hepatitis C of 23.0 percent, from 928 cases (2.63 per 100,000 persons) to 2,180 cases (6.01 per 100,000 persons). The incidence among women increased more rapidly. The cumulative incidence showed that people who were over 60 years had the highest risk to suffer hepatitis C (52.51 per 100,000 persons), and women had lower risk compared to men (OR=0.69). Putian had the highest cumulative incidence among all the regions (86.95 per 100,000 persons). The most likely cluster was identified in Putian during March to August in 2009 without adjustment, but it shifted to three contiguous cities with a two-month duration after adjustment for temporal trend and relative risk of regions.

CONCLUSIONS/SIGNIFICANCE

The incidence of hepatitis C is increasing in Fujian Province, and women are at a more rapid pace. The space-time scan statistic is useful as a screening tool for clusters of hepatitis C, with adjustment for temporal trend and relative risk of regions recommended.

Identifying newly acquired cases of hepatitis C using surveillance: a literature review

Surveillance of newly acquired hepatitis C virus (HCV) infection is crucial for understanding the epidemiology of HCV and informing public health practice. However, monitoring such infections via surveillance systems is challenging because they are commonly asymptomatic. A literature review was conducted to identify methodologies used by HCV surveillance systems to identify newly acquired infections; relevant surveillance systems in 15 countries were identified. Surveillance systems used three main strategies to identify newly acquired infections: (1) asking physicians to classify cases; (2) identifying symptomatic cases or cases with elevated alanine aminotransferases; and (3) identifying cases with documented evidence of anti-HCV antibody seroconversion within a specific time-frame. Case-ascertainment methods varied with greater completeness of data in enhanced compared to passive surveillance systems. Automated systems that extract and link testing data from multiple laboratory and clinic databases may provide an opportunity for collecting testing histories for individuals that is less resource intensive than enhanced surveillance.

A systematic review of hepatitis C virus epidemiology in Asia, Australia and Egypt

BACKGROUND

The hepatitis C pandemic has been systematically studied and characterized in North America and Europe, but this important public health problem has not received equivalent attention in other regions.

AIM

The objective of this systematic review was to characterize hepatitis C virus (HCV) epidemiology in selected countries of Asia, Australia and Egypt, i.e. in a geographical area inhabited by over 40% of the global population.

METHODOLOGY

Data references were identified through indexed journals and non-indexed sources. In this work, 7770 articles were reviewed and 690 were selected based on their relevance.

RESULTS

We estimated that 49.3-64.0 million adults in Asia, Australia and Egypt are anti-HCV positive. China alone has more HCV infections than all of Europe or the Americas. While most countries had prevalence rates from 1 to 2% we documented several with relatively high prevalence rates, including Egypt (15%), Pakistan (4.7%) and Taiwan (4.4%). Nosocomial infection, blood transfusion (before screening) and injection drug use were identified as common risk factors in the region. Genotype 1 was common in Australia, China, Taiwan and other countries in North Asia, while genotype 6 was found in Vietnam and other Southeast Asian countries. In India and Pakistan genotype 3 was predominant, while genotype 4 was found in Middle Eastern countries such as Egypt, Saudi Arabia and Syria.

CONCLUSION

We recommend implementation of surveillance systems to guide effective public health policy that may lead to the eventual curtailment of the spread of this pandemic infection.

Treatment of acute HCV infection

In developed nations, the majority of new HCV infections are acquired by injection drug users. Acute HCV infection is generally asymptomatic and is followed by spontaneous viral clearance in approximately 25% of individuals. However, given the asymptomatic nature of infection and difficulties in identifying and following those at risk of acquiring infection, our knowledge of treatment for acute HCV infection has been hampered. Much of what is known about the timing, optimal regimen and duration of therapy comes from small, prospective, observational studies and randomized, controlled trials in selected populations. Furthermore, data on the treatment of acute HCV infection among injection drug users and patients co-infected with HCV and HIV are limited. Genetic testing for variations in IL28B may provide an additional diagnostic tool for the optimal management and treatment of acute HCV infection. This Review highlights current knowledge of the epidemiology, diagnosis, natural history and treatment of acute HCV infection, including proposed recommendations for the assessment and treatment of this infection.

Patterns and characteristics of hepatitis C transmission clusters among HIV-positive and HIV-negative individuals in the Australian trial in acute hepatitis C

BACKGROUND

Injecting drug users remain the population at greatest risk of acquiring hepatitis C virus (HCV) infection, although a recent increase in cases of sexually transmitted HCV infection has been observed among human immunodeficiency virus (HIV)-infected individuals. The extent to which these separate epidemics overlap is unknown.

METHODS

The Australian Trial in Acute Hepatitis C (ATAHC) enrolled 163 individuals (29% of whom were HIV infected) with recent HCV infection. E1/HVR1 sequences were used to construct phylogenetic trees demonstrating monophyletic clusters or pairs, and viral epidemic history and phylogeography were assessed using molecular clock analysis. Individual clusters were characterized by clinical and demographic characteristics.

RESULTS

Transmission through injection drug use occurred for 73% of subjects, with sexual transmission occurring for 18% (92% of whom were HIV infected). Among 112 individuals with available E1/HVR1 sequences, 23 (20%) were infected with a strain of HCV identical to that of another subject, comprising 4 homologous clusters and 3 monophyletic pairs, the majority of which (78%) were HIV infected. Clusters contained individuals with both injection drug use-related and sex-related acquisition, and in all clusters (except for 1 female HIV-uninfected pair), individuals identified as men who have sex with men, irrespective of HIV status.

CONCLUSIONS

This large unique study of HIV-infected and HIV-uninfected individuals with recently acquired HCV infection demonstrates that clustering is common in the HIV-infected population and that it occurred almost invariably among men who have sex with men, irrespective of the actual mode of acquisition. These findings suggest the coexistence of both injection drug use and sexual risk behaviors for individuals in the same social networks and have implications for the development of public health messages. Clinical trial registration. NCT00192569.

High prevalence of late relapse and reinfection in prisoners treated for chronic hepatitis C

BACKGROUND AND AIM

Prisoners have a high prevalence of injection drug use (IDU) and chronic hepatitis C (CHC) infection. Treatment of CHC in these patients is effective; however, their long-term outcomes following treatment are unknown. We determined the durability of a sustained virological response (SVR) in prisoners treated for CHC.

METHODS

Patients were treated as part of routine clinical practice with interferon (IFN) and ribavirin. A retrospective review of medical records and a computerized pathology system was performed for clinical and laboratory information.

RESULTS

Seventy-four prisoners (70 males, mean age 34 years, IDU in 55%) were evaluable for a SVR over a 12-year period to December 2008; the mean follow-up period was 1243 days. Genotype 1, 2, 3, and 6 infection was present in 18, three, 38 and three patients, respectively; the genotype was unknown in 12. Three out of 52 biopsied had cirrhosis. Standard IFN was administered to 25 (34%; 11 with ribavirin), and 49 received pegylated IFN and ribavirin; one did not complete treatment, and two had breakthrough relapses. The end-of-treatment response was achieved in 57 and SVR in 53; 14 were non-responders. Five male patients, four with unknown genotypes and treated with standard IFN alone, relapsed late (following SVR, 9%). Five patients, all treated with pegylated IFN and ribavirin, were reinfected (one prior to and four following SVR).

CONCLUSIONS

Prisoners are often successfully treated for CHC. However, this retrospective study indicates that there is a high (17%) prevalence of late recurrence of viremia that is likely a reflection of reinfection due to ongoing risk-taking behavior.

The epidemiology of hepatitis C in Australia: notifications, treatment uptake and liver transplantations, 1997-2006

BACKGROUND AND AIM

Regular monitoring of hepatitis C (HCV)-related surveillance data is essential to inform and evaluate strategies to reduce the expanding HCV burden. The aim of this study was to examine trends in the epidemiology and treatment of HCV in Australia.

METHODS

We reviewed data about HCV notifications, treatment of HCV infection through the Highly Specialised Drugs (s100) Program, and liver transplants (Australia and New Zealand Liver Transplant Registry) for the period 1997-2006.

RESULTS

HCV case notification rates declined by almost 50% between 1999 and 2006, with the greatest reductions between 2001 and 2002 and amongst young adults. For newly acquired HCV cases, 89% were Australian-born and 90% reported injecting drug use as a risk factor for infection. Overall, 30% of liver transplant recipients had HCV-related cirrhosis, but the number and proportion of HCV diagnoses increased between 1997 and 2006. HCV treatment also increased over the review period. However, only 1.4% of the 202,400 people estimated to be living with chronic HCV at the end of 2006 received treatment that year.

CONCLUSION

The decline in HCV notifications is consistent with a decline in HCV incidence in Australia. However, the burden of advanced HCV disease continues to expand. To reduce this burden, treatment uptake needs to increase. Consistent and sensitive surveillance mechanisms are required to detect newly acquired cases together with an expansion of surveillance for chronic HCV infections.

Characteristics and treatment outcomes among HIV-infected individuals in the Australian Trial in Acute Hepatitis C

BACKGROUND

The Australian Trial in Acute Hepatitis C (ATAHC) is a National Institutes of Health-funded prospective cohort study of the natural history and efficacy of treatment in individuals with recently acquired hepatitis C. Enrollment is open to both human immunodeficiency virus (HIV)-infected and -uninfected individuals. The aim of this article was to evaluate characteristics and virological outcomes among HIV-infected individuals enrolled in ATAHC.

METHODS

Eligibility criteria included the first positive result of testing for anti-hepatitis C virus (HCV) antibody within 6 months and either clinical hepatitis diagnosed within the past 12 months or documented anti-HCV seroconversion within the past 24 months.

RESULTS

Of the initial 103 patients enrolled, 27 (26%) were HIV infected. HIV-infected patients were more likely to be older, to have HCV genotype 1 infection and high levels of HCV RNA at baseline than were HCV-monoinfected patients. Sexual acquisition accounted for the majority (56%) of HCV infections among HIV-infected patients, compared with only 8% of HCV-monoinfected patients. The median duration from estimated HCV infection to treatment was 30 weeks. Treatment with 24 weeks of pegylated interferon and ribavirin resulted in rates of undetectability of HCV RNA of 95%, 90%, and 80% at weeks 12, 24, and 48, respectively. Undetectability at week 4 was achieved in 44% of patients and yielded positive and negative predictive values for sustained virological response of 100% and 33%, respectively.

CONCLUSIONS

Significant differences were demonstrated between HIV-infected and HIV-uninfected individuals enrolled in ATAHC. Treatment responses among HIV-infected individuals with both acute and early chronic infection are encouraging and support regular HCV screening of high-risk individuals and early treatment for recently acquired HCV infection.

Using a surveillance system to identify and treat newly acquired hepatitis C infection

BACKGROUND AND AIM

Hepatitis C treatment uptake in Australia is low. We describe the rate of acute hepatitis C treatment in the Australian state of Victoria by linking the centralized passive notifications system for hepatitis C with the Australian Trial in Acute Hepatitis C (ATAHC), a nationwide clinical trial aimed at providing people with newly acquired hepatitis C with 24 weeks' pegylated interferon monotherapy.

METHODS

Mandatory notifications of clinical or laboratory evidence of hepatitis C were further investigated for evidence of newly acquired infection. Followed-up individuals were then screened for eligibility for the ATAHC study (which included documented hepatitis C antibody positivity within the previous 6 months) and offered acute hepatitis C treatment if this was the case. We examined the first 18 months of the recruitment.

RESULTS

A total of 4591 hepatitis C cases were notified with 414 (9%) of these flagged as being potentially newly acquired. Through follow-up of doctors and patients, 160 of these were confirmed as newly acquired; 87 of these 160 (54%) were potentially eligible for ATAHC and were referred to ATAHC researchers. Fourteen (16%) were successfully enrolled in ATAHC. Eight individuals commenced acute hepatitis C treatment during this period.

CONCLUSION

The use of hepatitis C surveillance system has been successful in identifying cases of newly acquired hepatitis C which are often difficult to identify in a clinical setting. In addition, marginalized patients who may otherwise never have been referred to a clinic are able to access hepatitis C treatment and specialist services. Despite this, only eight out of 87 eligible individuals (9%) began acute hepatitis C treatment.

Epidemiological characteristics and medical follow-up of 61 patients with acute hepatitis C identified through the hepatitis C surveillance system in France

This study aimed to describe current epidemiological and clinical characteristics, medical follow-up and outcome in the real practice of acute hepatitis C (AHC) patients. AHC cases were retrospectively identified through the French Hepatology Reference Centres Surveillance system and additional data were collected. Sixty-one patients with AHC were identified (sex ratio: M/F 1.7/1; mean age 39 years). Forty-four (72%) had documented seroconversion within a 6-month period. Main reported risk exposures were intravenous or nasal drug use (35%), invasive medical procedures (25%) and sexual contact with a HCV-positive partner (20%). Spontaneous clearance of HCV RNA was observed in seven out of 16 patients followed without therapy. This study confirms the major role of drug use in HCV transmission and highlights the role of invasive medical procedures and occupational exposure.

The acceptability and feasibility of peer worker support role in community based HCV treatment for injecting drug users

Hepatitis C is the most common blood borne virus in Australia affecting over 200 000 people. Effective treatment for hepatitis C has only become accessible in Australia since the late 1990's, although active injecting drug use (IDU) remained an exclusion criteria for government-funded treatment until 2001. Treatment uptake has been slow, particularly among injecting drug users, the largest affected group. We developed a peer-based integrated model of hepatitis C care at a community drug and alcohol clinic. Clients interested and eligible for hepatitis C treatment had their substance use, mental health and other psychosocial comorbidities co-managed onsite at the clinic prior to and during treatment. In a qualitative preliminary evaluation of the project, nine current patients of the clinic were interviewed, as was the clinic peer worker. A high level of patient acceptability of the peer-based model and an endorsement the integrated model of care was found. This paper describes the acceptability of a peer-based integrated model of hepatitis C care by the clients using the service.

Epidemiology of hepatitis C virus infection

Globally, hepatitis C virus (HCV) has infected an estimated 130 million people, most of whom are chronically infected. HCV-infected people serve as a reservoir for transmission to others and are at risk for developing chronic liver disease, cirrhosis, and primary hepatocellular carcinoma (HCC). It has been estimated that HCV accounts for 27% of cirrhosis and 25% of HCC worldwide. HCV infection has likely been endemic in many populations for centuries. However, the wave of increased HCV-related morbidity and mortality that we are now facing is the result of an unprecedented increase in the spread of HCV during the 20th century. Two 20th century events appear to be responsible for this increase; the widespread availability of injectable therapies and the illicit use of injectable drugs.

Epidemiology of hepatitis C virus infection

Globally, hepatitis C virus (HCV) has infected an estimated 130 million people, most of whom are chronically infected. HCV-infected people serve as a reservoir for transmission to others and are at risk for developing chronic liver disease, cirrhosis, and primary hepatocellular carcinoma (HCC). It has been estimated that HCV accounts for 27% of cirrhosis and 25% of HCC worldwide. HCV infection has likely been endemic in many populations for centuries. However, the wave of increased HCV-related morbidity and mortality that we are now facing is the result of an unprecedented increase in the spread of HCV during the 20^th century. Two 20^th century events appear to be responsible for this increase; the widespread availability of injectable therapies and the illicit use of injectable drugs.

Acute hepatitis C in Israel: a predominantly iatrogenic disease?

BACKGROUND AND AIMS

Acute hepatitis C virus infection in the era of universal screening of blood products has not disappeared, and is thought to be transmitted primarily via injecting drug use. A growing body of evidence supports iatrogenic transmission as an important mode of transmission. The aim of this study was to examine transmission routes and clinical characteristics in a group of patients with acute hepatitis C in Israel.

METHODS

A retrospective chart review was conducted in three different liver clinics in Israel, of all new hepatitis C patients. Patients identified as possible acute hepatitis C were re-interviewed and all other sources such as blood bank records and pre-employment check-ups reviewed in order to establish the diagnosis of acute hepatitis C infection and to identify the transmission route.

RESULTS

Twenty-nine patients were found to have acute hepatitis C, representing 0.75% of all new referrals for hepatitis C. The most frequent (65%) mode of transmission was iatrogenic involving several, often minimal, procedures and clinical settings. The group in which iatrogenic transmission was suspected was older and the patients more often in monogamous relationship compared with other transmission routes groups. Injecting drug use was the second most common route of infection. Spontaneous seroconversion has occurred in approximately one third of the patients.

CONCLUSIONS

Acute hepatitis C in the post universal blood products screening era was found to be predominantly an iatrogenic disease in the investigated localities. This finding should direct attention and resources towards the development and implementation of preventive measures.

Educational and health service needs of Australian general practitioners in managing hepatitis C

BACKGROUND

There has been interest in recent years in the role of primary care practitioners in managing hepatitis C, but there has been minimal research to identify educational and health service needs. A national survey of Australian general practitioners (GPs) was therefore conducted to assess their needs and identify areas for service development.

METHODS

A self-administered questionnaire was developed that included questions to assess caseload, confidence in patient management, educational needs and approaches to management and prevention. Questionnaires were sent to a random sample of Australian GPs. Returned questionnaires were coded, frequencies tabulated and significant associations identified.

RESULTS

A 70% response rate was achieved from 658 eligible GPs. A total of 76% of respondents had managed one patient in the previous year with hepatitis C. While 69% reported feeling more confident about their management of hepatitis C than 5 years previously, 55% identified a high level of need for hospital-based clinics. Financial benefits for case conferences and chronic case management were not considered useful by most GPs. Topics identified for further skills development included therapeutics and diagnostic testing. Only 39% were highly likely to discuss psychosocial issues as part of initial patient management and 37% reported finding it difficult to play a central role in the medical and psychosocial care of patients with hepatitis C.

CONCLUSION

These results have significant implications for policy and service development, as well as identifying areas where GPs need support. The findings invite further discussion between health authorities about the source and magnitude of funding for hospital-based services and further consideration of how to provide services to address patients' psychosocial needs.

Prevalence and risk factors of hepatitis C in HIV-negative homosexual men in Sydney, Australia

OBJECTIVE

To determine the prevalence and risk factors for hepatitis C (HCV) in HIV-negative homosexual men in Sydney.

METHODS

A cohort study was conducted in a sample of community-based, HIV-negative, homosexual men in Sydney. Participants underwent a face-to-face interview regarding sexual behaviour, sexually transmissible infections, and injecting drug use (IDU).

RESULTS

Eight hundred and twenty-four men consented to HCV testing, and the prevalence was 0.85% (95% CI 0.34-1.74). HCV seropositivity was strongly associated with a history of IDU (OR = 60.43, 95% CI 6.70-544.79). All HCV seropositive individuals reported a history of either IDU or other means by which they may have had parenteral exposure to HCV. There was no evidence of an independent association between sexual behaviour and HCV infection.

CONCLUSION

The prevalence of HCV in this cohort was about the same as in the general population in Australia, and there was no evidence for sexual transmission in this population.

Prevention of viral hepatitis in the Nordic countries and Germany

The Viral Hepatitis Prevention Board (VHPB) convened a meeting of international experts from the public and private sectors in the Nordic countries and Germany, in order to review the epidemiological situation, the surveillance systems for infectious diseases, the immunization programmes and policy, and the monitoring of adverse events after hepatitis vaccination in those countries, to evaluate prevention and control measures, and to identify the issues that arose and the lessons learnt. Considerable progress has been made in the past decades in the prevention and control of viral hepatitis in the respective countries. Vaccination programmes have been set up, blood products' safety has significantly been improved, and outbreak investigations remain the basis for the implementation of control measures. However, additional work remains to be done. Awareness of viral hepatitis among the public and professionals should further be raised, and more political support is needed regarding the value of prevention efforts and vaccination programmes.

The impact of changes to heroin supply on blood-borne virus notifications and injecting related harms in New South Wales, Australia

Background

In early 2001 Australia experienced a sudden and unexpected disruption to heroin availability, know as the 'heroin shortage'. This 'shortage has been linked to a decrease in needle and syringe output and therefore possibly a reduction in injecting drug use. We aimed to examine changes, if any, in blood-borne viral infections and presentations for injecting related problems related to injecting drug use following the reduction heroin availability in Australia, in the context of widespread harm reduction measures.

Methods

Time series analysis of State level databases on HIV, hepatitis B, hepatitis C notifications and hospital and emergency department data. Examination of changes in HIV, hepatitis B, hepatitis C notifications and hospital and emergency department admissions for injection-related problems following the onset of the heroin shortage; non-parametric curve-fitting of number of hepatitis C notifications among those aged 15–19 years.

Results

There were no changes observed in hospital visits for injection-related problems. There was no change related to the onset heroin shortage in the number of hepatitis C notifications among persons aged 15–19 years, but HCV notifications have subsequently decreased in this group. No change occurred in HIV and hepatitis B notifications.

Conclusion

A marked reduction in heroin supply resulted in no increase in injection-related harm at the community level. However, a delayed decrease in HCV notifications among young people may be related. These changes occurred in a setting with widespread, publicly funded harm reduction initiatives.

Treatment for Hepatitis C Virus Infection among Current Injection Drug Users in Australia

An estimated 210,000 people were living with hepatitis C virus (HCV) infection in Australia at the end of 2001, and the number of people developing cirrhosis was projected to increase 4-fold by 2020. Eighty percent of prevalent and 90% of incident HCV infections are related to injection drug use. Current injection drug use was an exclusion criterion for access to government-funded treatment for HCV infection until May 2001. Despite the removal of this barrier to treatment access for current injection drug users (IDUs), the number of IDUs receiving treatment remains extremely low. Treatment outcomes among IDUs with chronic HCV infection treated at 2 public hospital-based hepatitis clinics are presented. These data demonstrate that IDUs who continue to inject infrequently during treatment for HCV infection can achieve a sustained virological response. Further studies are under way to examine outcomes of treatment for HCV among clients undergoing treatment for drug dependency who have chronic HCV infection and among current IDUs with acute and newly acquired HCV infection.

Prevalence of hepatitis C infection in a population of asymptomatic people in a checkup unit in Mexico city

Hepatitis C virus (HCV) infection has an estimated prevalence of 3% around the world. Unfortunately, many persons with HCV infection are asymptomatic. The aim of this study was to determine the prevalence of hepatitis C Virus infection in asymptomatic persons. This study was carried out in a population-based cross-sectional study in the Checkup Unit of University Hospital in Mexico City. Patients with two or more HCV risk factors were studied. Serum specimens from all patients were screened for HCV RNA by qualitative polymerase chain reaction (PCR). HCV RNA-positive serum was also screened by quantitative PCR and for HCV genotype. Three hundred asymptomatic people were included, 194 men and 106 women, with a mean age of 46.8+/-11.9. Six (2%) of the 300 people were positive and viremic. The most common risk factors in positive patients were manicures or pedicures with a nonpersonal instrument and more than three sexual partners. We concluded that hepatitis C is frequent in asymptomatic people, and those people are often viremic. In addition, this study suggests that the spectrum of liver disease in asymptomatic and newly diagnosed HCV-positive persons is broad.