Multiple viral hepatitis in injection drug users and associated risk factors

Acute Viral Hepatitis Due to Co-infection With Hepatitis A and Hepatitis B in an Intravenous Drug User

Injection drug users are at high risk of contracting human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) due to parenteral exposure. Hepatitis A virus (HAV) is classically thought to be transmitted through the fecal-oral route, but injection drug use is increasingly recognized as a risk factor. It is well documented that there is a high prevalence of total antibodies to HAV in injection drug users, although there is limited data about the prevalence of acute HAV in injection drug users. Acute viral hepatitis is most often due to HAV, HBV, or hepatitis E virus (HEV), and it is rare to have acute co-infection with these viruses. We report a case of acute viral hepatitis due to co-infection with both HAV and HBV in an injection drug user.

Recreational Drugs and the Risk of Hepatocellular Carcinoma

Recreational or aesthetic drug use is a distinctive behavior of humans, principally attested in the last century. It is known that recreational and illegal drugs are major contributors to the universal morbidity rate worldwide. Many of these substances have a well-established hepatotoxic potential, causing acute or chronic liver injury, liver fibrosis and cirrhosis, but their implications for hepatocellular carcinoma or other varieties of liver tumors are little known. In this article, we perform an extensive literature review, aiming to provide updated information about recreational drug use and the risk of developing liver tumors. Khat use and pyrrolizidine alkaloid consumption (present in some natural plants) have been linked to liver cirrhosis. Kava intake is associated with different liver tumors in animal models but not in humans. Cannabis' potential to accelerate liver fibrosis in chronic hepatitis is controversial according to the existing data. Cigarette smoking is an important contributor to hepatocellular carcinoma, and anabolic androgen steroids are well-defined causes of a variety of liver cancers and other hepatic tumors. Long-term follow-up studies of subjects who have developed injuries in association with the use of recreational drugs are warranted so as to better define the risk of developing hepatocellular carcinoma in association with these substances and, thus, to implement health care policies to combat this preventable cause of cancer.

Utilization and effectiveness of elbasvir/grazoprevir and adoption of resistance-associated substitutions testing in real-world treatment of hepatitis C virus genotype 1A infection: results from the German Hepatitis C-Registry

BACKGROUND

For treatment of genotype 1a (GT1a) infection with elbasvir/grazoprevir, the German guidelines recommend a differentiated approach depending on baseline viral load (BVL). For low BVL ≤800 000 IU/mL, treatment with 12 weeks elbasvir/grazoprevir should be considered, whereas for high BVL >800 000 IU/mL, this regimen is only recommended in nonstructural protein 5A (NS5A) resistance-associated substitutions (RAS) absence. With present NS5A RAS or when RAS-testing is not available, 16 weeks elbasvir/grazoprevir + ribavirin is preferred. Here, we investigated the adherence to these recommendations and the effectiveness of elbasvir/grazoprevir in a large German Hepatitis C-Registry GT1a cohort.

METHODS

From September 2016 until July 2018, 195 GT1a-infected patients were treated with elbasvir/grazoprevir ± ribavirin for 12-16 weeks. The primary outcome was per protocol SVR12 or SVR24.

RESULTS

Mean age was 50 years, 89% were male, 19% had cirrhosis, 72% were treatment-naïve. Forty-five percent had low BVL ≤800 000 IU/mL, 55% high BVL >800 000 IU/mL, of whom 49 vs. 42% were baseline RAS-tested. Four patients with high (7.7%) and two with low BVL (5%) had NS5A RAS of whom 50% received elbasvir/grazoprevir+ribavirin, respectively. Ninety-four percent of patients with low and 65% with high BVL received elbasvir/grazoprevir without ribavirin. Thirty-five percent of patients with high BVL received ribavirin, mostly without prior RAS-testing. Per protocol sustained virologic response (SVR) by low vs. high BVL was 98.8 and 95.1%. All patients with NS5A RAS achieved SVR.

CONCLUSIONS

In German, real-world most patients received elbasvir/grazoprevir without ribavirin. Ribavirin was mainly added in GT1a patients >800 000 IU/mL, who were not NS5A RAS tested. SVR rates were consistently high and comparable to clinical trial results.

Rare clinically significant hepatic events and hepatitis B reactivation occur more frequently following rather than during direct-acting antiviral therapy for chronic hepatitis C: Data from a national US cohort

Recently, cases of hepatitis B virus reactivation (HBVr) with direct-acting antiviral therapy (DAAs) for HCV have been reported. However, few data exist from large, Western cohorts. The study objectives were to evaluate the incidence of alanine aminotransferase (ALT) flares, clinically significant hepatic events, and HBVr among a national cohort of US veterans with prior exposure to HBV (anti-HBc+) treated with DAAs. We used a national administrative database to identify patients treated with DAAs from January 2014 through November 2016 and obtained clinical and demographic as well as HBV and HCV treatment data. HBVr was defined as an at least 1-log increase in HBV DNA titre. Among 17 779 anti-HBc+ patients, 17 400 were HIV- and 379 were HIV+. Among the HIV- patients, 17 266 (99%) were HBsAg- prior to DAA therapy and 134 were HBsAg+. Among HIV-, HBsAg- patients, ALT elevations greater than 10 times the upper limit of normal (ULN; ≥300 IU/mL) were rare and occurred more frequently after treatment completion: 31 cases (<0.1%) during vs 85 (0.6%) following treatment. Clinically significant hepatic events defined as ALT increases >100 IU/L with total bilirubin >2.5 mg/dL occurred in 39 cases (0.3%), most often following DAA completion (n = 35 cases, 3/35 in setting of HCV relapse). Among 31 patients with post-DAA hepatic events without HCV relapse, 10 (32%) were confirmed unrelated to HBVr by HBsAg and/or HBV DNA testing, 1 (3%) confirmed due to HBVr, and 20 (65%) did not have documented HBV-related testing. One additional case of HBsAg- to + seroreversion was identified. Among HBsAg+ DAA recipients, 2/97 (2%), both with cirrhosis, experienced ALT elevations ≥300 IU/mL in the setting of HBVr. In conclusion, clinically significant hepatic events and HBVr were rare and much more likely among HBsAg-positive individuals. Anti-HBc + patients should be monitored for ALT flares and HBVr during and possibly for up to 6 months post-DAA therapy.

Epidemiology of hepatitis C in Greece

Hepatitis C is a global health issue and constitutes a major cause of chronic liver disease worldwide. In this article, a comprehensive literature search was conducted for the prevalence of hepatitis C virus (HCV) infection in Greece, since data on the HCV prevalence, viremia and genotypes are important for developing strategies to manage or eliminate HCV infection. In addition, the pattern of HCV infection was analyzed according to the geographic region and the risk factors. These differences reflect not only distinct epidemiological characteristics among populations, but also differences on the strategy of data acquisition and quantification. Although there are not enough data, the estimation of the current prevalence of Hepatitis C in Greece ranges from 0.5% to 2%. The most important risk factors for HCV infection include blood product transfusion, intravenous drug use, chronic hemodialysis, organ transplantation, occupational exposure, sexual transmission, and vertical transmission. Because of lack of vaccine or effective post-exposure prophylaxis for HCV, the main focus of prevention is to recognize and control these risk factors. HCV infection in Greece is closely associated with the development of chronic liver disease, cirrhosis, and primary hepatocellular carcinoma. As far as the genotype distribution is concerned genotype 1 estimated to be 45%-47% and it constitutes the prevalent genotype in Greece, followed by genotype 3.

Hepatitis C Virus: A European Perspective

Chronic hepatitis C virus (HCV) infection is a major public health burden in Europe, being one of the leading causes of chronic liver disease, liver cirrhosis, and hepatocellular carcinoma. Properties of the HCV disease burden are heterogeneous across the European continent, with differences in incidence, prevalence, diagnosis and treatment rates, transmission routes, and genotype distribution. Recent estimates expect an increase in HCV-related morbidity and mortality in most European countries until 2030 even when current treatment options are taken into account. The European perspective on hepatitis C virus infection is summarized herein.

Hepatitis A and B among young persons who inject drugs--vaccination, past, and present infection

BACKGROUND

Our study aims were to assess hepatitis A virus (HAV) and hepatitis B virus (HBV) susceptibility and infection among young persons who inject drugs (PWID) who may have been vaccinated as children and to evaluate self-report of HAV and HBV vaccination.

METHODS

We recruited PWID aged 18-40 years-old in San Diego during 2009 and 2010 and collected demographic, socioeconomic, health, and behavioral factors. Participants were asked if they had been vaccinated against HAV and HBV, and serum samples were collected for HAV and HBV serologic testing.

RESULTS

Of 519 participants, 365 (72%) were male, 252 (49%) were white non-Hispanic, 38 (7%) were Black non-Hispanic, 138 (27%) were White Hispanic, and 22 (4%) were born outside the U. S. Of the total participants, 245 (47%) had surface hepatitis B antibody (anti-HBs) titers <10mIU/ml (i.e., HBV susceptible) and 325 (63%) had no detectable HAV antibodies (HAV susceptible). Hepatitis B surface antigen was detected in 7 (1%) of total participants; and 135 (26%) were anti-HCV-antibody positive. Compared to serologic findings, self-report of HBV and HAV vaccination was 71% and 41% sensitive, and 58% and 73% specific, respectively.

CONCLUSION

HAV and HBV antibodies in half or more of this young PWID population did not have levels indicative of protection, and about a quarter had HCV infection, putting them at risk for complications resulting from co-infection with HAV or HBV. Programs serving this population should vaccinate PWIDs against HAV and HBV and not rely on self-report of vaccination.

Epidemiology of hepatitis C in Europe

The advent of potent and safe direct-acting antivirals against the hepatitis C virus has the potential of fulfilling the dream of eliminating this infection and its impact on global public health. However, even if effective drugs are at hand, most patients remain unaware of their infection, which may be recognized only in late stages when dire complications have occurred. Europe is not spared by this scourge, with its estimated 19,000,000 persons infected, and knowledge of the epidemiology of HCV and its drivers is a critical tool in fighting this virus. A thorough review is provided on the extent of the HCV epidemic across Europe, with a discussion of the most important subgroups affected, and of the risk factors of infection, both traditional and new.

A multicentre sero-behavioural survey for hepatitis B and C, HIV and HTLV among people who inject drugs in Germany using respondent driven sampling

Background

People who inject drugs are at high risk for hepatitis B, hepatitis C and HIV. HTLV was reported by neighboring countries to be prevalent in this population, but the situation for Germany is unclear. To generate seroprevalence and related behavioural data and to enhance prevention efforts against these infections for drug users in Germany, a multicentre sero- and behavioural survey was initiated. People who inject drugs are not well reached by services for testing and counselling for blood-borne infections in Germany. An interventional part of the study is intended to prove feasibility and acceptance of testing and counselling in low-threshold drop-in settings.

Methods/Design

Between May 2011 and March 2015, eligible participants (persons having injected drugs within the last 12 months, aged 16 years+, and living in the study city) are recruited by respondent driven sampling, using low-threshold drop-in facilities as study-sites in eight German cities with large drug scenes. Calculated sample size is 2,033 participants. Capillary blood samples collected as dried blood spots are anonymously tested for serological and molecular markers of hepatitis B and C, HIV, and HTLV I and II. A detailed face-to-face-interview about hepatitis- and HIV-related knowledge, former testing, imprisonment, sexual and injecting risk behaviour is conducted with participants. Staff is trained to offer pre- and post-test-counselling of blood-borne infections and HIV rapid testing to participants.

Discussion

We chose respondent driven sampling for recruitment of participants to improve representativeness of results. Persons, who are not reached by the facility where the study is conducted, are aimed to be included by recruitment through their personal social network of injecting drug users. To reduce differential biases in the questions on knowledge of transmission and prevention of infections, we present true statements on hepatitis B, C and HIV, their possible routes of transmission and measures of prevention to participants. Participants are told that the statements are true and are asked to answer if they knew this fact already or if it is new to them. In case of knowledge gaps they are offered free targeted counselling as well as free HIV rapid testing and post-test counselling of HIV and hepatitis test results.

Occult hepatitis B virus infection among injecting drug users in the Central-West Region of Brazil

The prevalence of occult hepatitis B virus (HBV) infection was investigated in 149 hepatitis B surface antigen (HBsAg) negative injecting drug users (IDUs) in the Central-West Region of Brazil. Of these individuals, 19 were positive for HBV DNA, resulting in an occult HBV infection prevalence of 12.7% (19/149); six of these 19 individuals had anti-HBV core and/or anti-HBV surface antibodies and 13 were negative for HBV markers. All IDUs with occult hepatitis B reported sexual and/or parenteral risk behaviours. All HBV DNA-positive samples were successfully genotyped. Genotype D was the most common (17/19), followed by genotype A (2/19). These findings reveal a high prevalence of occult HBV infection and the predominance of genotype D among IDUs in Brazil's Central-West Region.

Durability of response to vaccination against viral hepatitis A in HIV-infected patients: a 5-year observation

The aim of this study was to estimate the prevalence of total antibodies to hepatitis A virus (anti-HAV-T) in the group of HIV-positive adults in Lodz region of Poland, and to evaluate the response and long-term immunity after vaccination against hepatitis A virus. In the group of 234 HIV-infected patients, 72 persons (30.8%) were anti-HAV-T positive (>20 IU/L). In multivariate analysis, two independent factors associated with the presence of anti-HAV-T were identified: the age of patients (OR = 1.07) and the presence of antibodies to hepatitis C virus (OR = 2.87). Vaccination was completed in 83 patients. Good response (anti-HAV-T >20 IU/L one month after the booster dose) was obtained in 79.5% of patients. In patients with CD4 >200 cells/µL in multivariate analysis only presence of antibodies to hepatitis C virus was a prognostic factor for the response to vaccination (OR = 0.13). Among responders available for the follow-up, 82% (50 out of 61) had detectable anti-HAV-T at 1 year and 75.5% (37 out of 49) at 5 years. Our results demonstrate that most of the studied HIV-positive patients were susceptible to hepatitis A virus infection. Most HIV-infected adults with high CD4 counts had a durable response even up to 5 years after vaccination. Patients with a HIV/hepatitis C virus coinfection displayed a worse response to vaccination.

Physical illness in psychiatric inpatients: comparison of patients with and without substance use disorders

BACKGROUND

Physical comorbidities and substance use are commonly reported in patients with mental disorders.

AIM

To examine somatic comorbidity in patients with substance use disorders (SUD) compared to patients with mental disorders but no SUD.

METHODS

Lifetime prevalence data on mental and physical health status were collected from inpatients in 12 mental health care facilities in five different countries. Differences in somatic comorbidity were examined by means of logistic regression analysis controlling for age and gender.

RESULTS

Of 2,338 patients, 447 (19%) had a primary or secondary SUD diagnosis. In comparison to patients with other mental disorders, patients with SUD had a higher prevalence of infectious and digestive diseases but a lower prevalence of endocrine, nutritional and metabolic disorders. Patterns of physical comorbidities differed according to type of substance used (alcohol use - cardiovascular; tobacco use - respiratory, neoplasms; cannabinoid use - injuries; opioid use - infectious, digestive; benzodiazepine use - endocrine, nutritional, metabolic; stimulants - urogenital).

CONCLUSIONS

SUD are related to specific somatic health risks while some of our findings point to potentially protective effects. The widespread prescription of benzodiazepines requires research on physical health effects. Early detection of SUD and their integration into programmes targeting physical comorbidity should be a priority in organizing mental health care.

Education and counseling in the methadone treatment setting improves knowledge of viral hepatitis

The aim of this study was to evaluate the effectiveness of an educational method of providing viral hepatitis education for methadone maintenance patients. Four hundred forty participants were randomly assigned to either a control or a motivationally-enhanced viral hepatitis education and counseling intervention. Viral hepatitis A (HAV), B (HBV), and C (HCV) knowledge tests were administered at baseline, following each of two education sessions (post-education), and at a 3-month follow-up assessment. Results indicated a significant increase in knowledge of HAV, HBV, and HCV over time. No differences were found in knowledge between the intervention groups in knowledge acquisition regarding any of the hepatitis viruses suggesting that a motivational interviewing style may not augment hepatitis knowledge beyond standard counseling. A two-session viral hepatitis education intervention effectively promotes hepatitis knowledge and can be integrated in methadone treatment settings.

The burden of liver disease in Europe: a review of available epidemiological data

To survey the burden of liver disease in Europe and its causes 260 epidemiological studies published in the last five years were reviewed. The incidence and prevalence of cirrhosis and primary liver cancer are key to understand the burden of liver disease. They represent the end-stage of liver pathology and thus are indicative of the associated mortality. About 0.1% of Hungarian males will die of cirrhosis every year compared with 0.001% of Greek females. WHO estimate that liver cancer is responsible for around 47,000 deaths per year in the EU. Harmful alcohol consumption, viral hepatitis B and C and metabolic syndromes related to overweight and obesity are the leading causes of cirrhosis and primary liver cancer in Europe. Chronic hepatitis B affects 0.5-0.7% of the European population. In the last decade the prevalence of chronic hepatitis C was 0.13-3.26%. It is of great concern that about 90% of people in Europe infected by viral hepatitis are unaware of their status. Available data suggest the prevalence rate of NAFLD is 2-44% in the general European population (including obese children) and 42.6-69.5% in people with type 2 diabetes. Each of these four major causes of liver disease is amenable to prevention and treatment, reducing the burden of liver disease in Europe and saving lives. Further surveys are urgently needed to implement cost-effective prevention programmes and novel treatments to tackle this problem.

Intravenous Drug Users Can Achieve a High Sustained Virological Response Rate: experience From Croatian Reference Center for Viral Hepatitis

BACKGROUND

Hepatitis C virus (HCV) is one of the major infectious disease agents among injecting drug users (IVDUs). However, most of the IVDUs are not still treated.

OBJECTIVES

To examine the treatment course, adherence, tolerability and safety profiles and SVR rates in IVDUs compared to non-IVDUs.

PATIENTS AND METHODS

Demographic and clinical data were collected from medical records of 345 adult patients diagnosed with chronic hepatitis C (CHC) who were treated with a PEG-IFN-α and ribavirin in Croatian Reference Center for Viral Hepatitis in Zagreb between January 2003 and January 2010. Efficacy, safety and tolerability treatment profiles were analyzed in IVDUs vs. non-IVDUs. Positive predictors for treatment outcome were evaluated by univariate and multivariate logistic regression.

RESULTS

A total of 106 (30.46%) IVDUs were identified. The IVDUs were mainly male (81.13% vs. 52.30%, P = 0.0001), young (mean ± SD age: 32.46 ± 5.33 y vs. 46.12 ± 11.48 y, P = 0.0001), had lower fibrosis and HAI score (measured by ISHAK) and shorter duration of infection (mean ± SD: 8.98 ± 5.87 vs. 16.79 ± 8.99 y, P = 0.0001) compared to non-IVDU group. In IVDUs, genotype 1a (24.52%) and 3a (38.68%) were predominant. There were no differences in completion rate between the two studied groups. IVDUs achieved a significantly higher rate of overall SVR (70.75% vs. 51.04%, P < 0.0009) and in genotypes 1 and 4 (65.08% vs. 48.73%, P = 0.0294) vs. non-IVDUs. Treatment discontinuation rates due to side-effects were not significantly different in IVDUs and non-IVDUs (2.83% vs. 7.11%, P = 0.1390). IVDU group had a higher rate of lost to follow-up (13.21% vs. 4.60%, P = 0.0071). There were no statistically significant differences in SVR rate between IVDUs with, or without substitution therapy (55.55% vs. 74.62%, P = 0.0866). Independent predictors of SVR were age < 40 years and genotypes 2 and 3. Type of PEG-IFN-α used was not associated with SVR.

CONCLUSIONS

Treatment of CHC in IVDUs should strongly be encouraged as they have positive predictors for achieving SVR such as younger age, shorter duration of infection, and consequently favorable histological stage of the disease, and good adherence to treatment. There is no difference in safety and tolerability profiles of treatment in IVDUs compared to patients with no history of drug abuse.

Intravenous Drug Users Can Achieve a High Sustained Virological Response Rate: experience From Croatian Reference Center for Viral Hepatitis

BACKGROUND

Hepatitis C virus (HCV) is one of the major infectious disease agents among injecting drug users (IVDUs). However, most of the IVDUs are not still treated.

OBJECTIVES

To examine the treatment course, adherence, tolerability and safety profiles and SVR rates in IVDUs compared to non-IVDUs.

PATIENTS AND METHODS

Demographic and clinical data were collected from medical records of 345 adult patients diagnosed with chronic hepatitis C (CHC) who were treated with a PEG-IFN-α and ribavirin in Croatian Reference Center for Viral Hepatitis in Zagreb between January 2003 and January 2010. Efficacy, safety and tolerability treatment profiles were analyzed in IVDUs vs. non-IVDUs. Positive predictors for treatment outcome were evaluated by univariate and multivariate logistic regression.

RESULTS

A total of 106 (30.46%) IVDUs were identified. The IVDUs were mainly male (81.13% vs. 52.30%, P = 0.0001), young (mean ± SD age: 32.46 ± 5.33 y vs. 46.12 ± 11.48 y, P = 0.0001), had lower fibrosis and HAI score (measured by ISHAK) and shorter duration of infection (mean ± SD: 8.98 ± 5.87 vs. 16.79 ± 8.99 y, P = 0.0001) compared to non-IVDU group. In IVDUs, genotype 1a (24.52%) and 3a (38.68%) were predominant. There were no differences in completion rate between the two studied groups. IVDUs achieved a significantly higher rate of overall SVR (70.75% vs. 51.04%, P < 0.0009) and in genotypes 1 and 4 (65.08% vs. 48.73%, P = 0.0294) vs. non-IVDUs. Treatment discontinuation rates due to side-effects were not significantly different in IVDUs and non-IVDUs (2.83% vs. 7.11%, P = 0.1390). IVDU group had a higher rate of lost to follow-up (13.21% vs. 4.60%, P = 0.0071). There were no statistically significant differences in SVR rate between IVDUs with, or without substitution therapy (55.55% vs. 74.62%, P = 0.0866). Independent predictors of SVR were age < 40 years and genotypes 2 and 3. Type of PEG-IFN-α used was not associated with SVR.

CONCLUSIONS

Treatment of CHC in IVDUs should strongly be encouraged as they have positive predictors for achieving SVR such as younger age, shorter duration of infection, and consequently favorable histological stage of the disease, and good adherence to treatment. There is no difference in safety and tolerability profiles of treatment in IVDUs compared to patients with no history of drug abuse.

Changes in somatic disease incidents during opioid maintenance treatment: results from a Norwegian cohort study

Objectives To examine the effect of opioid maintenance treatment (OMT) on somatic morbidity in a cohort of OMT patients. Design Retrospective cohort study. Setting OMT programme in two Norwegian counties. Participants 200 OMT patients, participation rate 71.2%. Main outcome measures Incidence rates (IR) before, during and after OMT for acute/subacute hospital-treated somatic disease incidents (drug-related, non-drug-related, injuries) and rates for inpatient days and outpatient treatment contacts. Results IR for drug-related hospital treatment episodes were 76% lower during compared to before OMT (before versus during incidence rate ratio (IRR) 4.2 (95% CI 2.9 to 6.2), p<0.001) and 11 times higher after compared to during OMT (after versus during IRR 11.1 (6.6 to 18.5), p<0.001). For non-drug-related treatment episodes, IR were 35% higher during than before OMT (before versus during IRR 0.7 (0.6 to 1.0), p=0.02) and 32% higher after compared to during OMT (IRR 1.4 (0.9 to 2.2), p=0.15), while injuries showed little change according to OMT status. Although patients with on-going drug-taking during OMT showed less reduction in drug-related hospital-treated incidents during treatment than patients not using illicit drugs, the quartile with most drug-taking showed a significant reduction (before versus during IRR 3.6 (2.4 to 5.3)). Patients who had experienced cessation of OMT showed a significant reduction in drug-related treatment episodes during OMT (before versus during IRR 1.7 (1.0 to 2.9)), although less than patients without OMT interruptions (before versus during IRR 6.1 (3.6 to 10.6)), and a significant increase after OMT cessation compared with during OMT (IRR 5.4 (3.0 to 9.7)). Conclusion Acute/subacute drug-related somatic morbidity is reduced during compared to before OMT. This was also found for patients with on-going drug-taking during OMT. However, acute drug-related health problems show an increase after OMT cessation, and this is a matter of concern. Further studies on somatic morbidity after OMT cessation should be carried out.

Recommendations for the prevention, diagnosis, and treatment of chronic hepatitis B and C in special population groups (migrants, intravenous drug users and prison inmates)

The global spread of hepatitis B virus (HBV) and hepatitis C virus (HCV), their high chronicity rates and their progression to cirrhosis and hepatocellular carcinoma, are major public health problems. Research and intervention programmes for special population groups are needed in order to assess their infection risk and set up suitable prevention and control strategies. Aim of this paper is to give health care professionals information on HBV and HCV infections amongst migrants, drug users and prison inmates. The manuscript is an official Position Paper on behalf of the following Scientific Societies: Italian Association for the Study of the Liver (A.I.S.F.), Italian Society of Infectious and Tropical Diseases (S.I.M.I.T.), Italian Federation Department's Operators and Addiction Services (FederSerD), Italian Prison Medicine and Healthcare Society (S.I.M.S.Pe.). The considered population groups, having a high prevalence HBV and HCV infections, require specific interventions. In this context, the expression "special population" refers to specific vulnerable groups at risk of social exclusion, such as migrants, prison inmates, and intravenous drug users. When dealing with special population groups, social, environmental and clinical factors should be considered when selecting candidates for therapy as indicated by national and international guidelines.

A systematic review of hepatitis C virus epidemiology in Europe, Canada and Israel

BACKGROUND AND AIM

Decisions on public health issues are dependent on reliable epidemiological data. A comprehensive review of the literature was used to gather country-specific data on risk factors, prevalence, number of diagnosed individuals and genotype distribution of the hepatitis C virus (HCV) infection in selected European countries, Canada and Israel.

METHODOLOGY

Data references were identified through indexed journals and non-indexed sources. In this work, 13,000 articles were reviewed and 860 were selected based on their relevance.

RESULTS

Differences in prevalence were explained by local and regional variances in transmission routes or different public health measures. The lowest HCV prevalence (≤ 0.5%) estimates were from northern European countries and the highest (≥ 3%) were from Romania and rural areas in Greece, Italy and Russia. The main risk for HCV transmission in countries with well-established HCV screening programmes and lower HCV prevalence was injection drug use, which was associated with younger age at the time of infection and a higher infection rate among males. In other regions, contaminated glass syringes and nosocomial infections continue to play an important role in new infections. Immigration from endemic countries was another factor impacting the total number of infections and the genotype distribution. Approximately 70% of cases in Israel, 37% in Germany and 33% in Switzerland were not born in the country. In summary, HCV epidemiology shows a high variability across Europe, Canada and Israel.

CONCLUSION

Despite the eradication of transmission by blood products, HCV infection continues to be one of the leading blood-borne infections in the region.

Multicentric evaluation of new commercial enzyme immunoassays for the detection of immunoglobulin M and total antibodies against hepatitis A virus

A multicentric clinical study was conducted on representative sera from 1,738 European and U.S. subjects for the evaluation of new anti-hepatitis A virus enzyme immunoassays from Bio-Rad Laboratories. Comparison with reference DiaSorin S.p.A. tests confirmed the good performance of Bio-Rad assays (99.85% and 99.47% overall agreement in detecting total antibodies and IgM, respectively).

Antiviral treatment of hepatitis B virus and hepatitis C virus co-infection

Hepatitis B virus (HBV) and hepatitis C virus (HCV) infections are among the most common causes of advanced chronic liver disease worldwide. HBV/HCV co-infection is not uncommon with an estimated 7-20 million individuals affected worldwide. Patients with HBV/HCV co-infection have an increased risk of cirrhosis, hepatocellular carcinoma (HCC), and even death. The pathophysiology of HBV/HCV co-infection is complex, as different patterns of virological dominance may occur, which can even fluctuate over time. Recently, combination of pegylated interferon (PEG-IFN) plus ribavirin has been explored in HBV/HCV-coinfected patients who are positive for HCV-RNA. In this paper, we summarize the epidemiology, viral interaction and clinical features of HBV/HCV co-infection and the available treatment options. Detailed serological and virological evaluations are required for HBV/HCV-co-infected patients before initiation of antiviral therapy. At present, PEG-IFN-a plus ribavirin should be the treatment of choice in patients with dominant HCV replication. However, HBV rebound may occur after elimination of HCV, and thus close monitoring for both viruses is recommended even for patients with initially suppressed HBV DNA.

Heroin dependence and bloodborne virus transmission behaviors for HIV infection among newly incarcerated injection drug users in Taiwan

The purpose of the study was to determine heroin dependence and risky behaviors associated with human immunodeficiency virus (HIV) infection among newly incarcerated injection drug users (IDUs). Three self-administrated questionnaires were collected among 450 newly incarcerated male heroin users during 2005-2007. Inmates were categorized as heroin-dependent if they met three or more of the six ICD-10 criteria. Heroin-dependent inmates had higher scores of bloodborne virus transmission risk than non-dependent IDUs (12.8 ± 16.0 vs. 7.2 ± 11.5, p < 0.001). Multiple logistic regression analysis indicated that heroin dependence was a significant moderator of the association between risky injection behaviors and HIV infection. It is crucial to integrate substance treatment with behavioral interventions into harm reduction programs to prevent bloodborne virus transmission among IDUs.

Hepatitis A Virus among Drug Users and the Role of Vaccination: A Review

In countries with advanced economies better health and hygiene conditions, along with the introduction, in some cases, of global vaccination, have relegated most viral hepatitis to marginal social groups and, in particular, drug users (DUs). The availability of safe and effective vaccines for hepatitis A virus (HAV) and B (HBV) may play a major role in combating this phenomenon. Despite the availability of a safe and effective vaccine for over a decade and the recommendations of international health organizations, vaccinations against HAV among DUs are not as widely known and available as are HBV vaccinations. The purpose of this review article is to present the most significant data in the literature on the prevalence of HAV among DUs and the role of targeted vaccination. To our knowledge, the present article is the first to solely deal with vaccination against HAV in DUs. Immunization after the administration of anti-HAV vaccine has been demonstrated in DUs even if they have responded significantly less than either the general population or carriers of chronic liver disease. All the vaccines were well tolerated and adherence to the vaccine schedule was good. Further studies are needed to optimize the timing and doses of vaccine to be administered to DUs, especially to assess adherence and antibody persistence. Vaccination campaigns are feasible among DUs and have proven to be highly cost-effective.

[Quality of life among patients in drug-assisted rehabilitation programmes]

BACKGROUND

Drug-assisted rehabilitation programmes reduce mortality and improve somatic and mental health among opioid abusers. We have explored changes in patients' perception of their QoL (quality of life) after enrollment in such a programme, and their explanations for these changes.

MATERIAL AND METHODS

26 patients, enrolled a drug-assisted rehabilitation programme, were interviewed according to a semi-structured guide. Changes in QoL were recorded on a five-point scale; from much worse to much better. Answers to the question "What are your two main explanations for improved/reduced QoL?" were recorded literally and analysed by systematic text condensation.

RESULTS

The informants made 42 statements on reasons for improved QoL and six for reduced QoL. Important explanations for improved QoL were that life is no longer ruled by addiction, fewer social problems, and improved relationships to family and friends. Improved physical and psychological health was rarely mentioned. Loneliness and isolation, as well as the control imposed on them by the programme were explanations for reduced QoL.

INTERPRETATION

A large majority of patients experienced improved QoL, and having regained control of their life was the most important explanation. Some felt the treatment dominated their life too much, and therefore expressed a poorer QoL.

Treatment of HBV/HCV coinfection

IMPORTANCE OF THE FIELD

Hepatitis B (HBV) and hepatitis C (HCV) virus infections are among the most common causes of advanced chronic liver disease worldwide. HBV/HCV coinfection is not uncommon with an estimated 7 - 20 million individuals affected worldwide. Patients with HBV/HCV coinfection have an increased risk for cirrhosis, hepatocellular carcinoma (HCC) and even death.

AREAS COVERED IN THIS REVIEW

The pathophysiology of HBV/HCV coinfection is complex, as different patterns of virological dominance may occur, which can even fluctuate over time. Recently, combination of pegylated interferon (PEG-IFN) plus ribavirin has been explored in HBV/HCV coinfected patients who are positive for HCV-RNA. HBV polymerase inhibitors may be indicated if HBV-DNA concentrations are above 2000 IU/ml. In this review, we summarize the epidemiology, viral interaction, its clinical features and the available treatment options.

WHAT THE READER WILL GAIN

Insights into viral interaction of HBV/HCV coinfection and treatment individualization strategies are provided in the review.

TAKE HOME MESSAGE

Detailed serological and virological evaluations are required for HBV/HCV coinfected patients before initiation of antiviral therapy. At present, PEG-IFN-alpha plus ribavirin should be the treatment of choice in patients with dominant HCV replication. However, HBV rebound may occur after elimination of HCV, and thus close monitoring for both viruses is recommended even for patients with initially suppressed HBV-DNA.

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.

Evaluation of morphological changes of the liver caused by heroin abuse in forensic practice

Background/Aim. A study of morphological lesions in the liver of heroin addicts enables a precise overview of the type and degree of the liver damages caused by intravenous (iv) heroin abuse, additive effects of viral infections and alcohol consumption, as well as whether the expressiveness of these lesions depends on the duration of the time period of heroin application. The aim of the study was to investigate histopathological, ultrastructural and morphometric features of the liver of heroin addicts in forensic samples of the liver. Methods. The study involved the autopsy conducted on 40 bodies of iv heroin addicts and 10 control autopsies. The investigated group consisted of liver samples of 36 male subjects and 4 female subjects aged 35-40 years and the control group of 8 male and 2 female cadaveric bodies aged 15-35 years. The liver tissue samples were prepared for light microscopy. Sections of the tissue paraffin blocks 5 ? thick were stained using classical Hematoxylin and Eosin method (H&E), as well as PAS Van Gieson, Gomori, and Congo Red techniques. For investigation purposes of ultrastructural changes, liver tissue was fixed in glutaraldehyde and molded with epon. The analysis was performed using the method of transmission electron microscopy. Morphometric investigation of the liver sinusoidal macrophages was performed by using the M42 test system. Results. In the investigated group of iv heroin addicts, the liver autopsy samples showed degenerative vesicular and fat changes, chronic hepatitis, cirrhosis, sedimentation of pathologic protein amyloidosis, dysplastic changes, reduction in the amount of glycogen in hepatocytes, as well as the change in the number of Kupfer and endothelial cells. The established changes correlated with the duration of iv heroin abuse, whereas sinusoidal macrophages were activated in cases with active hepatitis, and no significant change in their number was found in hepatocytes with alcohol-related fatty changes. Conclusion. The study showed that the most present change in the hepatocytes of drug addicts was vesicular degeneration, and it is the only direct consequence of the effect of heroin. Other morphological changes were present due to viral infections and they correlated with the duration of narcotic abuse. The finding of dysplastic changes in this susceptible population of young people is particularly significant. The forensic significance of the established changes in the liver tissue is in the possibility of their practical application for determination of the immediate cause of death of iv heroin addicts, as well as the differential diagnosis of not only heroin, but also alcohol, sedative and other substances abuse, and all that on the basis of morphological damages of the liver.

The role of injection versus socioeconomic factors in hepatitis A virus infection among young heroin users: Implications for vaccination policies

The aim of this study was to determine whether heroin users have a higher prevalence of HAV infection than the general population in Spain, and whether injection is an independent risk factor. A cross-sectional cohort study was conducted between April 2001 and December 2003 in Spain that included 953 current heroin users aged 18-30 years. Dried blood spot samples were tested for HAV by ELISA. The prevalence of HAV infection (35.5%) was higher than in the general population of the same age. The logistic regression analysis did not show association between HAV infection and injection. HAV infection was associated with low educational level (OR=4.8; 95% CI=2.1-10.9) and other low-income variables. Injection is not an independent risk factor for HAV infection; rather, the principal determinants are socioeconomic factors. Consequently, HAV vaccination should be recommended not only in IDUs but also in non-IDUs depending on their socioeconomic characteristics.

Seroprevalence of hepatitis A virus infection in persons with HIV infection in Taiwan: implications for hepatitis A vaccination

OBJECTIVES

To retrospectively determine the prevalence of anti-hepatitis A virus (HAV) antibody in HIV-positive persons with different routes of HIV exposure and to describe its characteristics in order to guide vaccination policy.

METHODS

The prevalence of anti-HAV antibody was compared between 1580 HIV-positive persons seeking medical attention and 2581 HIV-negative controls seeking health check-ups, who had undergone anti-HAV tests between 2004 and 2007. Comparisons were also made among groups of the HIV-positive patients who had acquired HIV via different routes of transmission. A multivariate logistic regression model was built to identify independent variables associated with anti-HAV seropositivity.

RESULTS

The overall prevalence of anti-HAV antibody was 60.9% in the HIV-positive and 48.0% in the controls (p<0.001). The overall adjusted odds ratio (AOR) for positive anti-HAV antibody was 2.604 (95% confidence interval (CI) 2.106-3.219) in HIV-positive persons compared with HIV-negative persons. In addition, HIV-positive men who have sex with men (MSM), heterosexuals, and injecting drug users (IDU) all had significantly higher AOR for positive anti-HAV antibody than HIV-negative persons. In HIV-positive persons, older age (AOR 1.284, 95% CI 1.246-1.322) and IDU (AOR 5.137, 95% CI 3.499-7.542) were independently associated with an increased prevalence of anti-HAV antibody. Nearly 90% of the IDU had become seropositive for HAV after age 36-40 years, compared with heterosexuals and MSM after age 46-50 years, and controls after age 51-55 years.

CONCLUSION

Our findings suggest that age groups to be targeted for HAV vaccination vary with the different routes of HIV exposure.

[Prevention of hepatitis C virus infection in drug users]

The high prevalence and incidence rates of the hepatitis C virus (HCV) infections in drug users demonstrate the urgent necessity for a coordinated national prevention strategy. In the shadow of HIV/AIDS the necessary attention to the rapid spreading of the hepatitis C in drug users was started late, without being able to reach the public attention level of HIV/AIDS. The present efforts in the primary and secondary prevention of the hepatitis C in drug users are obviously not sufficient to reduce the prevalence with long-lasting results. Substitution treatment is of central relevance in the prevention of hepatitis C in opiate-dependent subjects, but requires, as current data of the HCV incidence of substituted opiate dependents illustrate, a stronger HCV-specific accentuation. Further settings, which are relevant for the group of intravenous drug users, have to be accessed and sensitized. Furthermore structural and political efforts are necessary, in order to develop a systematic and evidence-based answer to the challenge of the HCV spreading in drug users, in particular due to the fact that a German HCV strategy is still lacking.

The North American Opiate Medication Initiative (NAOMI): profile of participants in North America's first trial of heroin-assisted treatment

The North American Opiate Medication Initiative (NAOMI) is a randomized controlled trial evaluating the feasibility and effectiveness of heroin-assisted treatment (HAT) in the Canadian context. Our objective is to analyze the profile of the NAOMI participant cohort in the context of illicit opioid use in Canada and to evaluate its comparability with patient profiles of European HAT studies. Recruitment began in February 2005 and ended in March 2007. Inclusion criteria included opioid dependence, 5 or more years of opioid use, regular opioid injection, and at least two previous opiate addiction treatment attempts. Standardized assessment instruments such as the European Addiction Severity Index and the Maudsley Addiction Profile were employed. A total of 251 individuals were randomized from Vancouver, BC (192, 76.5%), and Montreal, Quebec (59, 23.5%); 38.5% were female, the mean age was 39.7 years (SD:8.6), and participants had injected drugs for 16.5 years (SD:9.9), on average. In the prior month, heroin was used a mean of 26.5 days (SD:7.4) and cocaine 16 days (SD;12.6). Vancouver had significantly more patients residing in unstable housing (88.5 vs. 22%; p < 0.001) and higher use of smoked crack cocaine (16.9 days vs. 2.3 days in the prior month; p < 0.001), while a significantly higher proportion of Montreal participants reported needle sharing in the prior 6 months (25% vs. 3.7%; p < 0.001). In many respects, the patient cohort was similar to the European trials; however, NAOMI had a higher proportion of female participants and participants residing in unstable housing. This study suggests that the NAOMI study successfully recruited participants with a profile indicated for HAT. It also raises concern about the high levels of crack cocaine use and social marginalization.

Hepatitis infection in the treatment of opioid dependence and abuse

Many new and existing cases of viral hepatitis infections are related to injection drug use. Transmission of these infections can result directly from the use of injection equipment that is contaminated with blood containing the hepatitis B or C virus or through sexual contact with an infected individual. In the latter case, drug use can indirectly contribute to hepatitis transmission through the dis-inhibited at-risk behavior, that is, unprotected sex with an infected partner. Individuals who inject drugs are at-risk for infection from different hepatitis viruses, hepatitis A, B, or C. Those with chronic hepatitis B virus infection also face additional risk should they become co-infected with hepatitis D virus. Protection from the transmission of hepatitis viruses A and B is best achieved by vaccination. For those with a history of or who currently inject drugs, the medical management of viral hepatitis infection comprising screening, testing, counseling and providing care and treatment is evolving. Components of the medical management of hepatitis infection, for persons considering, initiating, or receiving pharmacologic therapy for opioid addiction include: testing for hepatitis B and C infections; education and counseling regarding at-risk behavior and hepatitis transmission, acute and chronic hepatitis infection, liver disease and its care and treatment; vaccination against hepatitis A and B infection; and integrative primary care as part of the comprehensive treatment approach for recovery from opioid abuse and dependence. In addition, participation in a peer support group as part of integrated medical care enhances treatment outcomes. Liver disease is highly prevalent in patient populations seeking recovery from opioid addiction or who are currently receiving pharmacotherapy for opioid addiction. Pharmacotherapy for opioid addiction is not a contraindication to evaluation, care, or treatment of liver disease due to hepatitis virus infection. Successful pharmacotherapy for opioid addiction stabilizes patients and improves patient compliance to care and treatment regimens as well as promotes good patient outcomes. Implementation and integration of effective hepatitis prevention programs, care programs, and treatment regimens in concert with the pharmacological therapy of opioid addiction can reduce the public health burdens of hepatitis and injection drug use.

Markers for hepatitis A, B and C in methadone maintained patients: an unexpectedly high co-infection with silent hepatitis B

AIMS

To determine the prevalence of hepatitis A, B and C viruses in patients attending a methadone maintenance clinic in New York City.

DESIGN

Cross-sectional.

SETTING

The Adult Services Clinic of Weill Cornell Medical College, an urban hospital-affiliated methadone program.

PARTICIPANTS

Former heroin addicted adults (n = 103) on methadone maintenance therapy.

MEASUREMENTS

Markers for hepatitis A virus [HAV immunoglobulin M (IgM) and imunoglobulin G (IgG)], hepatitis B [hepatitis B surface antigen (HBsAg), hepatitis B surface antibody (HBsAb) and hepatitis B core antibody (HBcAb)] and hepatitis C virus (HCVAb). Serum alanine aminotransferase (ALT) and quantitative HCV RNA were also obtained. Qualitative detection of HBV DNA and HCV genotype were obtained in a subset of subjects.

FINDINGS

More than 40% of subjects had markers for all three viruses. HCVAb was the most prevalent (83.5%), followed by HBcAb (65.0%), HAV IgG (46.1%) and HBsAb (41.1%). Hepatitis C RNA was detected in 70.6% of HCVAb positive subjects. While no subject had HBsAg, HBV DNA was detected in 26.4% of subjects who underwent this measure; all (n = 20) had HBcAb as their only HBV marker. The presence of HBV DNA did not influence ALT. Subjects with HCV RNA had higher ALTs than those without HCV RNA.

CONCLUSIONS

Most methadone-maintained subjects had at least one marker for viral hepatitis, with 41.8% having markers for HAV, HBV and HCV. A quarter of subjects had silent HBV infection, defined as the presence of HBV DNA in the absence of HBsAg. These subjects should be considered infectious and pose a public health risk.

Somatic health among heroin addicts before and during opioid maintenance treatment: a retrospective cohort study

Background

The long-term impact of opioid maintenance treatment (OMT) on morbidity and health care utilization among heroin addicts has been insufficiently studied. The objective of this study was to investigate whether health care utilization due to somatic disease decreased during OMT, and if so, whether the reduction included all kinds of diseases and whether a reduction was related to abstinence from drug use.

Methods

Cohort study with retrospective registration of somatic disease incidents (health problems, acute or sub-acute, or acute problems related to chronic disease, resulting in a health care contact). Medical record data were collected from hospitals, Outpatients' Departments, emergency wards and from general practitioners (GPs) and prospective data on substance use during OMT were available from 2001 onwards. The observation period was five years before and up to five years during OMT. The cohort consisted of 35 out of 40 patients who received OMT between April 1999 and January 2005 in a Norwegian district town. Statistical significance concerning changes in number of incidents and inpatient and outpatient days during OMT compared with the pre OMT period was calculated according to Wilcoxon signed rank test. Significance concerning pre/during OMT changes in disease incidents by relation to the type of health service contacts, as well as the impact of ongoing substance use during OMT on the volume of contacts, was calculated according to Pearson chi-square and Fisher's exact tests.

Results

278 disease incidents were registered. There was a reduction in all incidents by 35% (p = 0.004), in substance-related incidents by 62% (p < 0.001) and in injection-related incidents by 70% (p < 0.001). There was an insignificant reduction in non-fatal overdose incidents by 44% (p = 0.127) and an insignificant increase in non-substance-related incidents by 13% (p = 0.741). Inpatient and outpatient days were reduced by 76% (p = 0.003) and 46% (p = 0.060), respectively. The disease incidents were less often drug-related during OMT (p < 0.001). Patients experienced a reduction in substance-related disease incidents regardless of ongoing substance use, however there was a trend towards greater reductions in those without ongoing abuse.

Conclusion

Although as few as 35 patients were included, this study demonstrates a significant reduction in health care utilization due to somatic disease incidents during OMT. The reduction was most pronounced for incidents related to substance use and injection. Inpatient and outpatient days were reduced. Most probably these findings reflect somatic health improvement among heroin addicts during OMT.