Trends and projections of hepatitis C virus epidemiology in Latin America

Prevalence and associated risk factors of hepatitis C antibody and RNA among people who inject drugs in Puerto Rico

INTRODUCTION

As a public health crisis, hepatitis C viral infection (HCV) is highly prevalent among people who inject drugs (PWID). We aimed to assess factors associated with HCV antibody (Ab) and HCV ribonucleic acid (RNA) positivity among PWID in Puerto Rico.

METHODS

The study recruited a total of 150 persons in rural and peri-urban community settings through the respondent-driven sampling method and administered a structured questionnaire. We conducted HIV and HCV testing using dried blood spots (DBS). We examined correlates of HCV infection with sociodemographics, drug use patterns, and injection practices using regression in bivariate and multivariable analysis.

RESULTS

Of the 150 participants, 89 % were male; 11 % were female; 72 % identified as mixed race; and the median duration of drug injection was 17.8 years. The mean age was 43.1 years, with 64 % of the population being from 23 to 45 years old. Among study participants (n = 150), the prevalence of HCV Ab was 73 %, and HCV RNA was 53 %. Factors significantly associated with HCV Ab and RNA included older age, increasing years of injection, incarceration, injecting other people, and identifying as Black. The belief that syringe air blowing reduces HCV transmission was also independently associated with HCV Ab positivity.

CONCLUSIONS

Our findings regarding risk factors associated with HCV infection show the need to enhance prevention and control strategies for reducing transmission among PWID. Direct-acting antiviral treatment, sustained access to harm reduction, and culturally tailored services will be required to substantially reduce rates of HCV. Community-based treatment models and treatment in correctional settings are needed.

Prevalence of Chronic Infection by Hepatitis C Virus in Asymptomatic Population With Risk Factors in Cartagena, Colombia

Introduction

Infection by the hepatitis C virus (HCV) is an important cause of chronic liver disease, considered a public health problem worldwide with high morbidity and mortality due to limited access to diagnostic tests in developing countries. Only a small percentage know their infection status and receive timely treatment. It is critical to make diagnostic tests for HCV infection accessible and to provide timely treatment, which not only reduces the spread of infection but also stops the progression of HCV disease without symptoms.

Objective

To determine the prevalence of chronic infection by HCV in patients with risk factors by using rapid tests in Cartagena, Colombia, and describe their epidemiological characteristics.

Methodology

A cross-sectional descriptive observational study was carried out on asymptomatic adults with risk factors for HCV infection in the city of Cartagena between December 2017 and November 2019. A rapid immunochromatographic test was performed to detect antibodies, characterizing the population.

Results

In total, 1,023 patients were identified who met the inclusion criteria, 58.5% women and 41.4% men, obtaining nine positive results, confirming chronic infection with viral load for HCV, finding seven cases of genotype 1b and two genotype 1a.

Conclusion

In our study, a prevalence of hepatitis C infection of 0.9% was found in asymptomatic individuals with risk factors, which allows us to deduce that the active search for cases in risk groups constitutes a pillar for the identification of the disease, the initiation of antiviral therapy, and decreased morbidity and mortality.

Liver Diseases in Latin America: Current Status, Unmet Needs, and Opportunities for Improvement

Purpose of review

To assess the current challenges regarding liver diseases, including the burden of disease, access to care, screening, and treatment needs in Latin America.

Recent findings

Latin America is a region with a rich multicultural heritage and important socioeconomic differences. The burden of liver diseases is high and mainly determined by a high level of alcohol intake and the surge of risk factors associated with NAFLD (i.e., sedentary lifestyles, broader access to highly processed foods, obesity, and type 2 diabetes mellitus). Hepatotropic viruses also play a role in the development of chronic liver diseases, although their comparative frequency has been decreasing over the last decades. There are important disparities in access to screening and treatment for liver diseases in Latin America, which are reflected in low access to critical treatments such as direct-acting antiviral agents and drugs to treat hepatocellular carcinoma. Also, important barriers to liver transplantation are present in multiple countries, including a low deceased donors’ rate and a lack of availability in several countries (especially in Central America). Our region also has disadvantages in research and education in liver diseases, which limits regional academic development and improvement in quality of care of liver diseases.

Summary

In order to tackle an increasing health burden due to liver diseases, Latin America urgently needs tailored interventions aiming to control the main risk factors for these disorders through the establishment of effective public health policies. Also, development of liver transplantation programs and improvement of medical education and research capabilities as well as extensive collaboration between all stakeholders are keys to address the liver disease agenda in the region.

Genetic diversity of hepatitis C virus and resistance associated substitutions to direct-acting antiviral treatment in Colombia

Hepatitis C virus (HCV) infection is one of the leading risk factors for end-stage liver disease development worldwide. This RNA virus displays high genetic diversity with 8 genotypes and 96 subgenotypes with heterogeneous geographical distribution around the world. In this study, we carried out an active case finding of individuals with a history of transfusion events before 1996 in three cities in Colombia. Then, the characterization of the HCV genotypes, subgenotypes, and resistance associate substitutions (RAS) was performed in samples positives for antibodies anti-HCV + from this study population. In addition, samples from PWID and patients with end-stage liver disease submitted to liver transplantation were included in the phylogenetic and RAS analysis. The 5'UTR, NS5A, and NS5B regions of the HCV genome were amplified in serum or liver explants samples. After the edition, assembly, and alignment of the sequences, genotyping through phylogenetic analysis was performed using IQTREE V2.0.5 based on the maximum likelihood approach. The identification of RAS was carried out by alignments based on the reference sequence (GenBank NC_004102). Two hundred sixty individuals with blood transfusion events before 1996 were recruited. The seroprevalence of antibodies anti-HCV was 2.69% in this population. The HCV genotypes 1, 2, and 4 and subgenotypes 1a, 1b, 2a, 4a and 4d were characterized in samples of the study populations. Three RAS (Q30R, C316N, and Y93H) were identified in samples obtained from 2 individuals who received blood transfusion before 1996 and without previous antiviral treatment and 6 samples obtained from patients with end-stage liver disease. Among the 20 samples analyzed, the HCV genotype 1, subgenotype 1b, was the most frequent (60%). We report the first characterization of HCV subgenotypes 4a and 4d and the first RAS identification in patients in Colombia.

HEPLA: A multicenter study on demographic and disease characteristics of patients with hepatitis C in Latin America

INTRODUCTION AND OBJECTIVES

Currently, there are limited data on the epidemiology and disease characteristics of patients with chronic hepatitis C (CHC) in Latin America. The primary objective of this study was to evaluate demographic and disease characteristics of patients with CHC in Latin America.

PATIENTS AND METHODS

HEPLA was a non-interventional, multicenter study of the epidemiology and disease characteristics of patients with CHC in Argentina, Brazil, Chile, Colombia, and Mexico.

RESULTS

Of the 817 included patients, the median age was 58 years, 53.9% were female, and 39.3% had cirrhosis. Overall, 41.2% were treatment naive, 49.8% were treatment experienced, and 8.9% were currently undergoing treatment. In patients with available data, genotype 1b accounted for 41.6% of infections, followed by genotype 1a (29.9%) and genotype 3 (11.3%). Probable mode of infection was transfusion in 46.8% of patients. Liver-related comorbidities were present in 26.4% of patients and non-liver-related comorbidities were present in 72.3%. Most patients (71.8%) received concomitant medications, with proton-pump inhibitors (20.8%) being the most commonly reported.

CONCLUSIONS

At the time the HEPLA study was carried out, the data from this cross-section of patients in Latin America showed that the CHC population has variation in disease and viral characteristics, with a minority of patients receiving treatment and many patients having advanced disease. Increased awareness and access to treatment are necessary in Latin America in order to meet the goal of hepatitis C virus elimination by 2030.

Effectiveness of direct-acting agents for chronic hepatitis C treatment in South America: A systematic review and meta-analysis

The effectiveness of direct-acting agents (DAAs) for hepatitis C treatment in limited-resource settings remains unclear. We estimated the pooled sustained virological response rates of DAA therapy in South America. We searched online databases for studies that reported 12-week sustained virological response (SVR12) to hepatitis C virus (HCV) treatment in individuals living in South America. Pooled SVR12 in intention-to-treat (ITT) and per-protocol were estimated. Additionally, using all studies with available data, the pooled relative risk (RR) of SVR12 using a random-effects model (DerSimonian-Laird) was estimated to compare effectiveness of DAAs in patients with or without cirrhosis, HIV co-infection or previous HCV therapy. Heterogeneity was assessed using the I² statistics. We identified 20 studies [14 manuscripts and 6 conference abstracts] comprising 7393 individuals from five countries [Brazil (n = 11), Argentina (n = 4), Chile (n = 1), Colombia (n = 1) and Peru (n = 1)] and two South-American collaborations. The pooled overall SVR12 rates [95% confidence interval (CI)] were 92.6% [90.2-94.7] and 95.5% [94.3-96.6] by ITT (11 studies; n = 4,153; I²  = 84.2%) and per-protocol analysis (15 studies; n = 4,833; I²  = 64.5%), respectively. The RR of SVR12 was similar in patients with or without HIV co-infection [4 studies; RR = 1.03 (0.99-1.07)] and those naive compared with treatment experimented-individuals [9 studies; RR = 1.01 (1.00-1.03)], but significantly higher in patients without cirrhosis compared with those with cirrhosis [11 studies; RR = 1.04 (1.02-1.05), P < .001]. DAAs are highly effective for HCV treatment in South America. The use of DAAs should be considered in limited-resource settings to decrease the burden of liver disease in HCV-infected patients. PROSPERO[CRD 42019134603].

Seroprevalence of hepatitis B, hepatitis C and HIV infection among patients undergoing haemodialysis in Buenos Aires, Argentina

Introduction. Blood-borne infections are a major cause of harm in individuals on haemodialysis (HD). In particular, knowledge about hepatitis B (HBV), hepatitis C (HCV) and human immunodeficiency virus (HIV) status in HD patients is a major concern, since these infections may cause comorbidities in this setting. There is a paucity of data regarding this issue in Argentina.Hypothesis/Gap Statement. The epidemiological surveillance of HBV, HCV, and HIV is a fundamental tool for planning and implementing health strategies in order to prevent and control viral transmission of these viral agents.Aim. To determine the seroprevalence of HBV, HCV and HIV infections in HD patients in Buenos Aires, Argentina.Methodology. Seven hundred and forty-eight HD patients were included in a retrospective cross-sectional study. Serological assays were performed to determine HBV, HCV and HIV status. HBV HBsAg and anti-HBc IgG were analysed using AxSYM (samples before 2010) or the Architect Abbott system (samples since 2010), anti-HCV IgG testing was performed using the anti-HCV enzyme immunoassay AxSYM HCV V3.0 and ARCHITECT anti-HCV, while HIV was tested for using AxSYM HIV 1/2 gO and ARCHITECT HIV Ag/Ab Combination. HCV genotyping was carried out by phylogenetic analysis of the NS5B partial gene.Results. Infection with one of the viruses was detected in 31.1 % of patients [HBV in 82 (11.0 %), HCV in 179 (23.9 %) and HIV in 6 (0.8 %)]. Thirty-two (4.3 %) patients had 2 virus markers [27 (3.6 %) with HCV/HBV, 4 (0.5 %) with HCV/HIV and 1 (0.13 %) with HBV/HIV]. Finally, a single patient (0.13 %) presented all three markers. Time on dialysis was correlated with HCV but not with HBV infection. The HCV subtype distribution in HD patients was inverted with respect to that observed in the general population (HCV-1a 73.2 % and HCV-1b 26.8 % in HD vs HCV-1a 26.5 % and HCV-1b 73.5 % in the general population, P <0.001).Conclusion. Despite the implementation of universal precautionary biosafety standards for dialysis, infection with HBV and HCV continues to occur at very high rates in HD patients. The results emphasize the need to carry out proactive tasks for early diagnosis and treatment of infected individuals and to vaccinate those with non-protective antiHBs antibodies in order to reduce morbidity and mortality in HD patients.

Efficacy and safety of glecaprevir/pibrentasvir in patients with HCV genotype 5/6: An integrated analysis of phase 2/3 studies

BACKGROUND & AIMS

Hepatitis C virus (HCV) has high genetic diversity with six major genotypes (GT) GT1-6 and global distribution. HCV GT5 and 6 are rare with < 10 million people infected worldwide. Data on direct-acting antiviral use in these rare HCV genotypes are limited. The study aimed to evaluate the efficacy and safety of glecaprevir/pibrentasvir (G/P) in a pooled analysis of phase 2/3 trials in HCV GT5 or 6-infected patients without cirrhosis or with compensated cirrhosis.

METHODS

Patients with chronic HCV GT5 or 6 infection received oral G/P (300 mg/120 mg) once daily for 8 or 12 weeks. The primary efficacy endpoint was sustained virological response at post-treatment week 12 (SVR12) in the intention-to-treat population.

RESULTS

One hundred eighty-one patients were evaluated; 56 with HCV GT5 and 125 with HCV GT6. The majority were treatment-naïve (88%) and non-cirrhotic (85%). Overall SVR12 rate with 8- or 12-week G/P treatment was 98% (178/181). Eight-week treatment with G/P yielded SVR12 rates of 95% (21/22) in HCV GT5- and 99% (69/70) in HCV GT6-infected non-cirrhotic patients. Eight- and 12-week treatment of patients with compensated cirrhosis achieved SVR12 rates of 100% (10/10) and 94% (17/18) respectively. The G/P regimen was well-tolerated; 3% (6/181) Grade 3 or higher adverse events, and no serious adverse events were attributed to G/P or led to study drug discontinuation.

CONCLUSIONS

This integrated dataset demonstrates a high SVR12 rate following 8-week G/P treatment in patients with HCV GT5 (96%) or GT6 (99%) infection without cirrhosis or with compensated cirrhosis.

Direct antiviral therapy for treatment of hepatitis C: A real-world study from Brazil

INTRODUCTION AND OBJECTIVES

Direct antiviral agents (DAAs) including sofosbuvir (SOF), daclatasvir (DCV), simeprevir (SIM) and ombitasvir, paritaprevir and dasabuvir were introduced 2015 in Brazil for treatment of hepatitis C virus (HCV) infection. The aims of this study were to assess effectiveness and safety of HCV treatment with DAA in real-life world in a highly admixed population from Brazil.

MATERIALS AND METHODS

All Brazilian reference centers for HCV treatment were invited to take part in a web-based registry, prospectively conducted by the Brazilian Society of Hepatology, to assess outcomes of HCV treatment in Brazil with DAAs. Data to be collected included demographics, disease severity and comorbidities, genotype (GT), viral load, DAA regimens, treatment side effects and sustained virological response (SVR).

RESULTS

3939 patients (60% males, mean age 58±10 years) throughout the country were evaluated. Most had advanced fibrosis or cirrhosis, GT1 and were treated with SOF/DCV or SOF/SIM. Overall SVR rates were higher than 95%. Subjects with decompensated cirrhosis, GT2 and GT3 have lower SVR rates of 85%, 90% and 91%, respectively. Cirrhosis and decompensated cirrhosis in GT1 and male sex and decompensated cirrhosis in GT3 were significantly associated with no SVR. Adverse events (AD) and serious AD occurred in 18% and 5% of those subjects, respectively, but less than 1% of patients required treatment discontinuation.

CONCLUSION

SOF-based DAA regimens are effective and safe in the heterogeneous highly admixed Brazilian population and could remain an option for HCV treatment at least in low-income countries.

Hepatitis C screening, diagnosis, and cascade of care among people aged > 40 years in Brasilia, Brazil

Background

Identifying patients with hepatitis C virus (HCV) infection and enhancing the cascade of care are essential for eliminating HCV infection. This study aimed to estimate the prevalence of positive anti-HCV serology in Brasilia, Brazil, and evaluate the efficiency of the cascade of care for HCV-positive individuals.

Methods

This cross-sectional study analyzed 57,697 rapid screening tests for hepatitis C in individuals aged > 40 years between June 2018 and June 2019. HCV-positive patients were contacted and scheduled to undergo the HCV RNA viral test, genotyping, and transient elastography.

Results

The prevalence of positive serology was 0.27%. Among 161 patients with positive anti-HCV serology, 124 (77%) were contacted, 109 (67.7%) were tested for HCV RNA viral load, and 69 (42.8%) had positive results. Genotype 1 (75%) was the most prevalent genotype. Among 65 patients (94.2%) who underwent transient elastography, 30 (46.2%) presented with advanced fibrosis. Additionally, of the 161 patients, 55 (34.1%) were referred for treatment, but only 39 (24.2%) complied, with 36 (22.4%) showing sustained virological response. By the end of the study, 16 patients were still awaiting to receive medication.

Conclusions

The prevalence of HCV-positive patients was low in Brasilia, and the gaps in the cascade of care for these patients were significantly below the targets of HCV infection elimination. This study opens new avenues for eliminating HCV infection and suggests that partnerships with clinical laboratories to conduct anti-HCV tests are a useful strategy to improve HCV diagnosis.

Trial registration

Research Ethics Committee of the Faculty of Health Sciences of the University of Brasília - UNB (CAAE number 77818317.2.0000.0030) and by the Ethics Committee of the Health Science Teaching and Research Foundation - FEPECS/SES/DF (CAAE number 77818317.2.3001.5553).

Hepatitis C in the three main health institutions in Mexico: a 13-year mortality and hospitalization analysis

There are no studies in Mexico comparing Hepatitis C virus (HCV) epidemiology among Health Institutions. In this report, we described the deaths and hospitalizations due to HCV in the three main Health Institutions in Mexico: the Mexican Institute of Social Security, the Institute of Social Security for State Workers and the Ministry of Health, during the period 2004-2017. A secondary analysis was carried out across the country using hospital administrative death databases. Adult deaths and hospitalizations rates were calculated in reference to the total affiliated population and all-cause in-hospital mortality risk were also evaluated. There were 7,914 deaths and 9,002 hospitalizations due to HCV. Mortality and hospitalization rates of these three institutions together showed a continuous decrease over the analyzed time: the mortality rate dropped from 1.25 to 0.41 per 100,000 affiliates during 2004 and 2017, respectively (66.9% of change), and the hospitalization rate dropped from 2.19 to 0.39 per 100,000 affiliates (81.9% of change). All-cause in-hospital survival accounted for 89.6%. Older age groups and Ministry of Health hospitalizations were associated with higher all-cause in-hospital death rates. In conclusion, the mortality and hospitalizations rates found in this study reflect a decrease in the burden of HCV in Mexico.

Variation in Hepatitis C Virus Subtype Distribution during 20 Years in Venezuela

OBJECTIVE

Hepatitis C virus (HCV) infection is a public health problem and a major cause of chronic hepatitis. This virus exhibits a great genetic variability, with 8 genotypes and numerous subtypes. The aim of this study was to evaluate the fluctuations of HCV subtypes during 2 decades in Venezuela.

METHODS

HCV genotypes were determined by direct sequencing of the 5'-noncoding region in 392 isolates circulating in patients attended during the years 2014-2015. HCV subtype assignment was confirmed in a subset of samples (n = 24) by partial sequencing of the NS5B region. The genotype distribution was compared with the one observed in a previous study of patients followed up during the years 1994-1996 and 2005-2006.

RESULTS

Some variation was observed in the HCV genotype distribution over these 20 years. HCV genotype 1b prevalence was reduced significantly from 1994-1995 to 2004-2005, as previously described, and then remained constant. During the last 10 years, a significant decrease of HCV subtype 2b (36/237 in 2005-2006 vs. 24/392 in 2014-2015, p < 0.001) was observed. Patients infected with HCV G2acj were significantly older than the ones infected with G1 (53 vs. 47 years, p = 0.004), and male sex was significantly more prevalent among G3a-infected patients compared to the other ones (71 vs. 47%, p = 0.047).

CONCLUSIONS

Fluctuations in HCV subtype distribution have been observed over 2 decades in Venezuela. Different major mode of transmission and susceptibility to the available HCV treatment during each period might be playing a role in the observed fluctuations in HCV subtype distribution.

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

OBJECTIVES

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

STUDY DESIGN AND SETTING

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

RESULTS

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

CONCLUSION

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

The ECHO model proved to be a useful tool to increase clinicians' self-effectiveness for care of patients with Hepatitis C in Argentina

The ECHO model was developed to expand access to medical care for populations with HCV infection in underserved areas. We aimed to compare HCV treatment outcomes in community-based clinics with the Austral University Hospital (AUH) and to assess improvement in physician knowledge and skills. In October 2015, we established an HCV ECHO clinic at the AUH in Buenos Aires. To evaluate the impact of this programme, we conducted a prospective cohort study comparing treatment for HCV infection at the AUH with healthcare providers from different Argentinean provinces. A survey evaluating skills and competence in HCV care was administered, and results were compared. The primary endpoint was sustained virologic response (SVR) and under direct-acting antivirals. Since the implementation of ECHO clinics, a total of 25 physicians participated in at least one session (median 10.0; IQR 3.0-18.0). SVR rates (n = 437 patients) were 94.2% (95% CI 90.4-96.8) in patients treated at AUH clinic (n = 227/242) and 96.4% (95% CI 92.7-98.5) in those treated at ECHO sites (n = 188/195), with a nonsignificant difference between sites, 2.2% SVR difference (95% CI -0.24-0.06; P = 0.4). We also found a significant improvement in all the evaluated skills and abilities. Replicating the ECHO model helped to improve participants' skills in the management of HCV achieving similar SVR rates. ECHO model was demonstrated to be an effective intervention able to multiply and expand HCV treatment, a critical barrier to access to care that needs to be solved if we are committed with WHO goals to eliminate HCV by 2030.

The First Complete Genome Sequences of Hepatitis C Virus Subtype 2b from Latin America: Molecular Characterization and Phylogeographic Analysis

The hepatitis C virus (HCV) has remarkable genetic diversity and exists as eight genotypes (1 to 8) with distinct geographic distributions. No complete genome sequence of HCV subtype 2b (HCV-2b) is available from Latin American countries, and the factors underlying its emergence and spread within the continent remain unknown. The present study was conducted to determine the first full-length genomic sequences of HCV-2b isolates from Latin America and reconstruct the spatial and temporal diversification of this subtype in Brazil. Nearly complete HCV-2b genomes isolated from two Brazilian patients were obtained by direct sequencing of long PCR fragments and analyzed together with reference sequences using the Bayesian coalescent and phylogeographic framework approaches. The two HCV-2b genomes were 9318 nucleotides (nt) in length (nt 37-9354). Interestingly, the long RT-PCR technique was able to detect co-circulation of viral variants that contained an in-frame deletion of 2022 nt encompassing E1, E2, and p7 proteins. Spatiotemporal reconstruction analyses suggest that HCV-2b had a single introduction in Brazil during the early 1980s, displaying an epidemic history characterized by a low and virtually constant population size until the present time. These results coincide with epidemiological data in Brazil and may explain the low national prevalence of this subtype.

Liver cancer: A leading cause of cancer death in the United States and the role of the 1945-1965 birth cohort by ethnicity

Liver cancer is highly fatal and the most rapidly increasing cancer in the US, where chronic hepatitis C (HCV) infection is the leading etiology. HCV is particularly prevalent among the 1945-1965 birth cohort, the so-called “baby boomers”. Focusing on this cohort-etiology link, we aim to characterize liver cancer patterns for 15 unique US populations: White, African American, Mexican Immigrant, Mexican American, Cuban and Chinese, among others.

Methods

Individual-level mortality data from 2012–2016 from the health departments of 3 large states – California, Florida, New York – were pooled to compute liver cancer mortality rates for each racial/ethnic group and for 2 birth cohorts of interest: “1945–1965 cohort” and “older cohort”.

Results

Liver cancer is a major cause of cancer death among all US male groups and the leading cause in Mexican American men. Over 50% of the age-adjusted liver cancer mortality of White, African American, Mexican American, and Puerto Rican males came from the 1945-1965 birth cohort. In contrast, foreign-born male and all female populations had higher liver cancer mortality originating from the older cohort. Internationally, US White male baby boomers had a 49% higher liver cancer mortality rate than their counterparts in Europe (mortality rate ratio 1.49; 95% CI 1.43–1.56).

Conclusions

Populations burdened disproportionately by liver cancer in the 1945–1965 cohort include US-born males who were all present in the US during the 1960s–1990s when significant HCV transmission took place; these individuals will benefit most from HCV screening and treatment. For the others, including all women, Asian subgroups, and especially burgeoning Hispanic immigrant populations, comprehensive liver cancer prevention efforts will require detailed study of the distribution of etiologies.

Lay summary

Liver cancer, a major cause of cancer death among US males, is increasing. The causes of liver cancer are varied, including hepatitis C, hepatitis B, alcohol-related liver disease, and non-alcoholic fatty liver disease. Racial/ethnic groups are impacted differently, but the highest rates are seen among US-born men born between 1945–1965, the so-called “baby boomers”, whether White, Black, or Hispanic, likely linked to the known high prevalence of hepatitis C infection among this cohort.

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Liver cancer is now the leading cause of cancer death among Mexican American males.

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Rates vary intra-racially: e.g. Vietnamese have high rates; South Asians have low.

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US-born male “baby boomers” of any race/ethnicity have the highest liver cancer mortality.

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Foreign-born men and all women have higher mortality at older ages, 70 or more.

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In the “baby boomer” cohort, US Whites have higher liver cancer mortality than Europeans.

Safer Crack Kits and Smoking Practices: Effectiveness of a Harm Reduction Intervention among Active Crack Users in Mexico City

BACKGROUND

Crack cocaine use has increased rapidly throughout Mexico, coinciding with rising HIV and HCV infections among vulnerable groups. Due to the increased risk of infection among crack users, harm reduction approaches have been identified to reduce the spread of disease. However, Mexico has yet to adopt these techniques for crack users.

OBJECTIVES

To evaluate the impact of a pilot crack kit distribution program on risky smoking behaviors of active crack users in an impoverished colonia of Mexico City, Mexico.

METHODS

Fifty crack kits, containing safer smoking paraphernalia and related health items (i.e., condoms, alcohol wipes, etc.), were distributed to active crack users. A sample of 58 crack users were surveyed prior to the intervention and 35 were successfully relocated and surveyed three months after the intervention. Surveys assessed drug use, crack kit utilization, and smoking practices.

RESULTS

Findings indicate that crack kit utilization was high throughout the sample. Use of risky or unsafe paraphernalia decreased, specifically the use of cans as pipes (Z = -2.653, p = .008). Similarly, Pyrex pipe use increased significantly (Z = -3.132, p = .002). Sharing of paraphernalia also decreased throughout the sample.

CONCLUSION

These findings identify the potential benefits in reducing risky smoking behaviors of crack kit distribution programs in Mexico City. This evidence supports expansion of crack kit programs in Mexico and similar impoverished regions.

Burden of Chronic Viral Hepatitis and Liver Cirrhosis in Brazil - the Brazilian Global Burden of Disease Study

INTRODUCTION AND AIM

Data on epidemiology of liver diseases in Brazil is scarce. This study aimed to estimate the burden of chronic viral hepatitis and liver cirrhosis in the country.

MATERIALS AND METHODS

The indicator used was disability-adjusted life year (DALY), a sum of years of life lost due to premature mortality (YLL) and years lived with disability (YLD). Liver cirrhosis was analyzed in etiologic categories and cirrhosis of viral origin was considered part of the burden of chronic hepatitis.

RESULTS

There were 57,380 DALYs (30.3 per 100,000 inhabitants) attributable to chronic hepatitis B and cirrhosis due to hepatitis B, with 41,262 DALYs in men. Most burden was caused by YLL (47,015 or 24.8/100,000) rather than YLD (10,365 or 5.5/100,000). Chronic hepatitis C and cirrhosis due to hepatitis C were responsible for 207,747 DALYs (109.6/100,000), of which 137,922 were YLL (72.7/100,000) and 69,825 (36.8/100,000) were YLD, with a higher proportion of DALYs in men (73.9%). Cirrhosis due to alcohol or other causes had a total of 536,169 DALYs (1,4% of total DALYs in Brazil), with 418,272 YLL (341,140 in men) and 117,897 YLD (97,965 in men). Highest DALYs' rates occurred at ages 60-69 in chronic hepatitis and at ages 45-59 in cirrhosis due to alcohol or other causes.

CONCLUSION

Chronic viral hepatitis and liver cirrhosis are responsible for a significant burden in Brazil, affecting mainly men and individuals still in their productive years. Most burden is related to non-viral causes of cirrhosis, with a major contribution of alcohol.

Prevalence of hepatitis C virus infection according to the year of birth: identification of risk groups

Hepatitis C virus (HCV) screening according to the year of birth is recommended is some countries based on epidemiological data. The aim of this study was to analyze anti-HCV prevalence among people born between 1905 and 2015 in Argentina. Patients attending a tertiary care hospital in Buenos Aires, Argentina, from 2001 to 2015, who had a determination of anti-HCV, were included. Of 22,079 patients analyzed, 1,152 (5.2%; 95% confidence interval [CI]: 4.9%-5.5%) patients showed positive anti-HCV and 729 (3.3%; 95% CI: 3.1%-3.5%) patients showed detectable viremia. Three risk groups were identified (HCV prevalence): low-risk group-outpatient clinics/emergencies (2.8%); intermediate-risk group-in-patients (8%); and high-risk group-dialysis/transplants (27.2%). In the low-risk group, being born in 1973 or before was identified as a cut-off value for the risk of anti-HCV acquisition (area under the receiver-operator characteristic curve: 75.1 [95% asymptotic CI: 0.732-0.770; p < 0.001]). Ninety-one patients born after 1973 (0.8%) showed positive anti-HCV versus 457 individuals born in 1973 or before (5.8%), p < 0.001. In this group, positive anti-HCV was observed in 252 females (2.1%) and 296 males (4.1%), p < 0.001. In a multivariate analysis adjusted for gender, alanine-aminotransferase levels and HIV coinfection, being born in 1973 or before was independently identified as a risk for positive anti-HCV (adjusted odds ratio: 14.234 [95% CI: 9.993-20.277]; p < 0.001). People born in 1973 or before without other risk factors should be included in screening programs to link the highest possible number of HCV-infected patients to appropriate care and treatment.

Ombitasvir/paritaprevir/ritonavir/dasabuvir ± ribavirin is safe and effective in HCV-infected patients in a real-life cohort from Latin America

Information about the use of ombitasvir/paritaprevir/ritonavir/dasabuvir ± ribavirin (OBV/PTV/r/DSV ± RBV) in real-clinical practice in Latin America is scarce. We aimed to confirm safety and effectiveness of OBV/PTV/r/DSV ± RBV therapy in real-world setting. We analyzed a cohort of patients with genotype 1 infection treated with OBV/PTV/r/DSV ± RBV. Data on demographics, clinical features, safety, and virological response were retrospectively collected from 21 centers in Latin America. A total of 96 patients received OBV/PTV/r/DSV, associated with RBV in 68% of the cases. Most were genotype 1b (80%), 56 (58%) had cirrhosis, and 45 (47%) failed prior HCV treatment. Adverse events occurred in 62% of patients. The most common adverse events were pruritus (21%), hyperbilirubinemia (17%), and asthenia (17%). Five patients discontinued therapy prematurely due to hepatic decompensation, three of them were Child-Pugh B at baseline and one patient died due to multi-organ failure. Follow up HCV-RNA 12 weeks after completion of therapy was evaluated in all the patients and sustained virologic response rate was 97%. No virologic breakthrough was detected. Our study confirms that OBV/PTV/r/DSV treatment is highly effective in patients with chronic HCV without cirrhosis or with Child-Pugh A cirrhosis in non-European populations. Adverse events were often mild and rarely led to treatment discontinuation except for patients with Child-Pugh B cirrhosis or with previous history of hepatic decompensation. These results can support the development of public strategies to expand the access of OBV/PTV/r + DSV and other DAAs combinations in order to reduce the burden of HCV infection in our region.

Pharmacokinetics, Safety, and Tolerability Following Single and Multiple Doses of Pibrentasvir in a First-in-Human Study

This first-in-human dose-ascending study investigated pharmacokinetics, safety, and tolerability of pibrentasvir following single and multiple doses in healthy volunteers. Additionally, the effects of food and ritonavir on pibrentasvir were assessed in a crossover study design. The starting dose of pibrentasvir was selected based on the no-observed-adverse-effect-level exposure from preclinical studies. Dose escalations of subsequent cohorts were dependent on reviews of the safety, tolerability, and pharmacokinetic data from previous dose cohorts. Pibrentasvir exposures increased in a greater than dose-proportional manner across the 1.5- to 120-mg dose range and became linear across the 120- to 600-mg dose range. Following multiple dosing, pibrentasvir steady state was attained by day 5 with an accumulation ratio of 25% to 35%. Pibrentasvir harmonic mean terminal half-life ranged from 20 to 22 hours. Food had minimal effect (<14%) on pibrentasvir bioavailability, but ritonavir increased pibrentasvir peak concentration and area under the concentration-time curve by 60% and 89%, respectively. All adverse events were assessed by the investigator as mild, and no clinically significant vital signs, electrocardiogram, or clinical laboratory values were observed. The pharmacokinetic results from this study support once-daily dosing and administration of pibrentasvir without regard to food. A maximum tolerated dose was not attained in the single- and multiple-ascending-dose assessments for pibrentasvir.

Early Detection of Liver Damage in Mexican Patients with Chronic Liver Disease

BACKGROUND AND OBJECTIVE

Liver cirrhosis is usually detected at the later stages of disease. This study is aimed to detect liver damage in patients with chronic liver disease using transitional elastography (TE) and to assess the biochemical parameters associated with liver damage.

METHODS

In 578 patients, chronic liver disease based on etiology was diagnosed by clinical and laboratory tests. Liver damage was evaluated with TE (FibroScan®), while its association with biochemical parameters was performed using the logistic regression tests.

RESULTS

Overall, the main etiologies of liver damage were hepatitis C virus (HCV) (37%), alcoholic liver disease (ALD) (33%) and non-alcoholic steatohepatitis (NASH) (26%). Patients were 40 to 50 years of age. ALD and hepatitis B prevailed in men, whereas HCV and NASH in women. The stages of fibrosis were F0 (n = 121, 21%), F1 (n = 122, 21%), F2 (n = 58, 10%), F3 (n = 46, 8%) and F4 (n = 87, 15%). In patients with liver cirrhosis, ALD (n = 96/217, 45%), HCV (n = 94/217, 43%) and NASH (n = 21/217, 10%) were the leading etiologies. Platelets count (OR=3.31, 95%CI 1.61-6.78), glucose (OR=3.07, 95%CI 1.50-6.26), gamma-glutamyl-transferase (OR=3.60, 95%CI 1.79-7.25), albumin (OR=3.89, 95%CI 1.61-9.36), and total bilirubin (OR=3.93, 95%CI 1.41-10.91) were associated to advanced stages of fibrosis (F3-F4) regardless of etiology. The concordance and positive predictive values of these parameters were higher as compared to other scores.

CONCLUSION

Asymptomatic liver disease due to HCV, ALD and NASH prevailed in young adults. Advanced liver damage assessed by TE was associated with five biochemical parameters. In conjunction, both methodologies may be useful for the early detection of fibrosis and cirrhosis in Latin America.

Hepatitis C virus pharmacogenomics in Latin American populations: implications in the era of direct-acting antivirals

In recent years, great progress has been made in the field of new therapeutic options for hepatitis C virus (HCV) infection. The new direct-acting antiviral agents (DAAs) represent a great hope for millions of chronically infected individuals because their use may lead to excellent cure rates with fewer side effects. In Latin America, the high prevalence of HCV genotype 1 infection and the significant association of Native American ancestry with risk predictive single-nucleotide polymorphisms (SNPs) in IFNL4 and ITPA genes highlight the need to implement new treatment regimens in these populations. However, the universal accessibility to DAAs is still not a reality in the region as their high cost is one of the major, although not the only, limiting factors for their broad implementation. Therefore, under these circumstances, could the assessment of host genetic markers be a useful tool to prioritize DAA treatment until global access to these new drugs can be achieved? This review will summarize the scientific evidences and the potential implications of HCV pharmacogenomics in this rapidly evolving era of anti-HCV drug development.

[Hepatitis C virus genotypes circulating in Colombia]

INTRODUCTION

Chronic hepatitis C virus infection is a worldwide public health problem; it has been estimated that over 180 million people are infected with this virus worldwide. Its precise incidence and prevalence (i.e., epidemiology) and the most frequent circulating genotypes in Colombia are unknown.

OBJECTIVE

To describe the hepatitis C virus (HCV) genotypes and subtypes in infected Colombian patients.

MATERIALS AND METHODS

We recovered the data on 1,538 HCV isolates from 1,527 patients in two Colombian reference laboratories typed by PAGE or qPCR.

RESULTS

Patients' mean age was 53 years; 70% of them were 40 to 70 years old, and 52%, females; 57% of all tests were ordered in Bogotá and 80% of cases were from Cundinamarca, Valle and Atlántico departments. Genotype 1 was detected in 88.6% of cases, distributed as follows: 70% subtype 1b, 13.5% subtype 1a and 5.1%, undetermined subtypes. Genotype 2 was found in 5.4% of the patients, genotype 3 in 2% and genotype 4 in 4%. Mixed genotypes were found in 0.8% of the samples.

CONCLUSION

Genotype 1 is the most common HCV genotype circulating in Colombia, and subtype 1b the most frequent.

Risk factors for hepatitis C virus infection in the Colombian Caribbean coast: A case-control study

INTRODUCTION

An estimated 6.8-8.9 million people are infected with hepatitis C virus in Latin America, of which less than 1% receives antiviral treatment. Studies so far in Colombia have attempted to determine the prevalence of the disease in some risk groups, thus preventing the identification of other factors potentially involved in the spread of the infection.

OBJECTIVES

To identify traditional and non-traditional risk factors for chronic hepatitis C in the Colombian Caribbean coast.

MATERIALS AND METHODS

This was a case-control study (1:3) matched by health care provider and age (± 10 years) conducted at the primary care level of gastroenterology and hepatology outpatient services. All patients with a positive ELISA underwent a confirmatory viral load test. A multivariate logistic regression analysis identified the independent predictors of infection.

RESULTS

Blood transfusion (OR=159.2; 95% CI: 35.4-715; p<0.001) and history of hospitalization before 1994 (OR=4.7; 95% CI: 1.3-17.1; p=0.018) were identified as the only two independent predictors of infection.

CONCLUSION

It is necessary to check the reproducibility of these results and to conduct cost-effectiveness studies before recommending their use in the design of new screening strategies.

Geographic integration of hepatitis C virus: A global threat

AIM

To assess hepatitis C virus (HCV) geographic integration, evaluate the spatial and temporal evolution of HCV worldwide and propose how to diminish its burden.

METHODS

A literature search of published articles was performed using PubMed, MEDLINE and other related databases up to December 2015. A critical data assessment and analysis regarding the epidemiological integration of HCV was carried out using the meta-analysis method.

RESULTS

The data indicated that HCV has been integrated immensely over time and through various geographical regions worldwide. The history of HCV goes back to 1535 but between 1935 and 1965 it exhibited a rapid, exponential spread. This integration is clearly seen in the geo-epidemiology and phylogeography of HCV. HCV integration can be mirrored either as intra-continental or trans-continental. Migration, drug trafficking and HCV co-infection, together with other potential risk factors, have acted as a vehicle for this integration. Evidence shows that the geographic integration of HCV has been important in the global and regional distribution of HCV.

CONCLUSION

HCV geographic integration is clearly evident and this should be reflected in the prevention and treatment of this ongoing pandemic.

Hepatitis C virus (HCV) genotypes distribution: an epidemiological up-date in Europe

Hepatitis C virus (HCV) infection is a major public health burden in Europe, causing an increasing level of liver-related morbidity and mortality, characterized by several regional variations in the genotypes distribution.

A comprehensive review of the literature from 2000 to 2015 was used to gather country-specific data on prevalence and genotype distribution of HCV infection in 33 European countries (about 80 % of the European population), grouped in three geographical areas (Western, Eastern and Central Europe), as defined by the Global Burden of Diseases project (GBD).

The estimated prevalence of HCV in Europe is 1.7 % showing a decrease than previously reported (− 0.6 %) and accounting over 13 million of estimated cases. The lowest prevalence (0.9 %) is reported from Western Europe (except for some rural areas of Southern Italy and Greece) and the highest (3.1 %) from Central Europe, especially Romania and Russia. The average HCV viraemic rate is 72.4 %, with a population of almost 10 million of HCV RNA positive patients.

Genotype distribution does not show high variability among the three macro-areas studied, ranging between 70.0 % (Central Europe), 68.1 % (Eastern Europe) and 55.1 % (Western Europe) for genotype 1, 29.0 % (Western Europe), 26.6 % (Eastern Europe) and 21.0 % (Central Europe) for genotype 3. Genotype 2 seems, instead, to have a major prevalence in the Western Europe (8.9 %), if compared to Eastern (4.3 %) or Central (3.2 %), whereas genotype 4 is present especially in Central and Western area (4.9 % and 5.8 %, respectively).

Despite the eradication of transmission by blood products, HCV infection continues to be one of the leading blood-borne infections in Europe. The aim of this review is, therefore, to provide an update on the epidemiology of HCV infection across Europe, and to foster the discussion about eventual potential strategies to eradicate it.

Global epidemiology of hepatitis C virus infection: An up-date of the distribution and circulation of hepatitis C virus genotypes

AIM

To review Hepatitis C virus (HCV) prevalence and genotypes distribution worldwide.

METHODS

We conducted a systematic study which represents one of the most comprehensive effort to quantify global HCV epidemiology, using the best available published data between 2000 and 2015 from 138 countries (about 90% of the global population), grouped in 20 geographical areas (with the exclusion of Oceania), as defined by the Global Burden of Diseases project (GBD). Countries for which we were unable to obtain HCV genotype prevalence data were excluded from calculations of regional proportions, although their populations were included in the total population size of each region when generating regional genotype prevalence estimates.

RESULTS

Total global HCV prevalence is estimated at 2.5% (177.5 million of HCV infected adults), ranging from 2.9% in Africa and 1.3% in Americas, with a global viraemic rate of 67% (118.9 million of HCV RNA positive cases), varying from 64.4% in Asia to 74.8% in Australasia. HCV genotype 1 is the most prevalent worldwide (49.1%), followed by genotype 3 (17.9%), 4 (16.8%) and 2 (11.0%). Genotypes 5 and 6 are responsible for the remaining < 5%. While genotypes 1 and 3 are common worldwide, the largest proportion of genotypes 4 and 5 is in lower-income countries. Although HCV genotypes 1 and 3 infections are the most prevalent globally (67.0% if considered together), other genotypes are found more commonly in lower-income countries where still account for a significant proportion of HCV cases.

CONCLUSION

A more precise knowledge of HCV genotype distribution will be helpful to best inform national healthcare models to improve access to new treatments.

The burden of non-Hodgkin lymphoma in Central and South America

RATIONALE AND OBJECTIVE

The burden of non-Hodgkin lymphoma (NHL) has increased in some Central and South American countries. We describe the current patterns and trends in NHL incidence and mortality in Central and South America.

METHODS

We obtained regional- and national-level incidence data from 48 population-based cancer registries in 13 countries, and national-level cancer mortality data from the WHO mortality database for 18 countries. We estimated world population age-standardized incidence rates (ASRs) and mortality rates (ASMRs) per 100,000 person-years for 2003-2007, and presented distributions by histological subtype.

RESULTS

NHL incidence and mortality rates varied between countries by 2-8- and 6-fold, respectively. ASRs per 100,000 ranged from 1.4 to 10.9 among males and 1.3-9.2 among females. Corresponding ASMRs were between 0.5 and 4.8 among males and between 0.5 and 3.0 among females. The highest incidence was observed in Uruguay (males), Ecuador, Peru and Colombia (males). The highest mortality was seen in Uruguay and Costa Rica. Trends in NHL incidence and mortality in Argentina, Brazil, Chile and Costa Rica did not show marked changes. B-cell neoplasms and NHL not otherwise specified (NOS) accounted for 44% and 34% of all NHL cases. Diffuse large B-cell lymphoma, NOS, was the most frequent histological subtype.

CONCLUSION

The geographic variations in NHL rates may partially reflect differences in registration practices, disease classification, diagnostic practice, and death certification quality. There is a need for high-quality data and improvements in the accuracy of NHL histological diagnosis. Given the expected increase in NHL, careful monitoring of rates remains a priority to guide cancer control programs.

Cancer patterns and trends in Central and South America

RATIONALE AND OBJECTIVE

Cancer burden is increasing in Central and South America (CSA). We describe the current burden of cancer in CSA.

METHODS

We obtained regional and national-level cancer incidence data from 48 population-based registries (13 countries) and nation-wide cancer mortality data from the WHO (18 countries). We estimated world population age-standardized incidence and mortality rates per 100,000 person-years.

RESULTS

The leading cancers diagnosed were prostate, lung, breast, cervix, colorectal, and stomach, which were also the primary causes of cancer mortality. Countries of high/very high human development index (HDI) in the region experienced a high burden of prostate and breast cancer while medium HDI countries had a high burden of stomach and cervical cancers. Between countries, incidence and mortality from all cancers combined varied by 2-3-fold. French Guyana, Brazil, Uruguay, and Argentina had the highest incidence of all cancers while Uruguay, Cuba, Argentina, and Chile had the highest mortality. Incidence of colorectum, prostate and thyroid cancers increased in Argentina, Brazil, Chile and Costa Rica from 1997 to 2008, while lung, stomach and cervical cancers decreased.

CONCLUSION

CSA carries a double-burden of cancer, with elevated rates of infection- and lifestyle-related cancers. Encountered variation in cancer rates between countries may reflect differences in registration practices, healthcare access, and public awareness. Resource-dependent interventions to prevent, early diagnose, and treat cancer remain an urgent priority. There is an overwhelming need to improve the quality and coverage of cancer registration to guide and evaluate future cancer control policies and programs.

Prevalence of hepatitis C virus infection among patients undergoing haemodialysis in Latin America

Hepatitis C infection is a worldwide problem. The global prevalence of the hepatitis C virus (HCV) averages 3%. Moreover, its prevalence among patients undergoing haemodialysis (HD) varies worldwide, ranging from as low as 1% to up to 70%. There are few data on its prevalence in developing countries, and even less information is available on HD patients. A literature review revealed that the prevalence of HCV infection among patients undergoing HD in Latin America ranges from 4.2 to 83.9%, with most data stemming from Argentina, Brazil, Mexico, Peru, Chile, Venezuela and Cuba. The most common genotype was genotype 1, and subtype 1b was the most frequent. The risk factors associated with this condition were the duration of the HD treatment and blood transfusion before hepatitis C screening. In addition, HCV RNA detection by polymerase chain reaction is crucial for the diagnosis of HCV infection in HD patients. Trials using combinations of new oral antiviral drugs, such as sofosbuvir and combo (ombitasvir, paritaprevir, ritonavir and dasabuvir), should be the next step in the improvement of care among HD patients with HCV, because these therapeutic agents apparently do not require dose adjustment according to renal function. Finally, information on this subgroup of patients remains unavailable in some countries; therefore, additional studies are needed to determine the prevalence trend of HCV infection in these populations.

Hepatitis C seroprevalence in an at-risk population in the southwest Madrid region of Spain

INTRODUCTION

The estimated seroprevalence of hepatitis C virus (HCV) in Spain is 1.7%, but is much higher in the at-risk population. The most efficient national screening strategy is unclear.

AIMS

To estimate the prevalence of HCV among the at-risk population seen in primary care (PC), and to determine their epidemiological profile.

MATERIALS AND METHODS

Cross-sectional descriptive prevalence study that included adult patients with risk factors for HCV infection seen in PC in the southwest Madrid region between 2010 and 2012.

RESULTS

A total of 158 patients (men=51.3%), mean age 46 years (SD=16.6), were included. The most common risk factors were hypertransaminasaemia (44.3%) and major surgery (13.3%). Immigration, unsafe sexual practices, and tattoos or body piercing were more prevalent in patients younger than 45 years of age. Fifteen patients (9.5%) were positive for anti-HCV; 9 of these (5.7%) were HCV-ARN positive. Of the positive patients, 4 (44.4%) had significant fibrosis at diagnosis (F3-F4). Male patients had a higher rate of positive anti-HCV results (13.8 vs. 5.3%; P=.072), as did patients older than 45 years of age (12.8 vs. 6.3%; P=.167). Intravenous and intranasal drug use were associated with a higher rate of positive anti-HCV results (50 vs. 8.5%; P=.005 and 66.7 vs. 8.4%; P=.001, respectively).

CONCLUSIONS

Patients with risk factors for HCV infection have high seroprevalence. Screening programmes must therefore be implemented to detect HCV infection in this population in PC.

Potential market size and impact of hepatitis C treatment in low- and middle-income countries

The introduction of direct-acting antiviral agents (DAAs) has made hepatitis C infection curable in the vast majority of cases and the elimination of the infection possible. Although initially too costly for large-scale use, recent reductions in DAA prices in some low- and middle-income countries (LaMICs) has improved the prospect of many people having access to these drugs/medications in the future. This article assesses the pricing and financing conditions under which the uptake of DAAs can increase to the point where the elimination of the disease in LaMICs is feasible. A Markov simulation model is used to study the dynamics of the infection with the introduction of treatment over a 10-year period. The impact on HCV-related mortality and HCV incidence is assessed under different financing scenarios assuming that the cost of the drugs is completely paid for out-of-pocket or reduced through either subsidy or drug price decreases. It is also assessed under different diagnostic and service delivery capacity scenarios separately for low-income (LIC), lower-middle-income (LMIC) and upper-middle-income countries (UMIC). Monte Carlo simulations are used for sensitivity analyses. At a price of US$ 1680 per 12-week treatment duration (based on negotiated Egyptian prices for an all oral two-DAA regimen), most of the people infected in LICs and LMICs would have limited access to treatment without subsidy or significant drug price decreases. However, people in UMICs would be able to access it even in the absence of a subsidy. For HCV treatment to have a significant impact on mortality and incidence, a significant scaling-up of diagnostic and service delivery capacity for HCV infection is needed.

Need of righteous attitudes towards eradication of hepatitis C virus infection in Latin America

Over the last few years, we have expanded our knowledge on numerous facets of the hepatitis C virus (HCV). Beginning with its discovery and viral life cycle, its impact on health, the development of liver disease and currently, effective antiviral treatments. The latter point has become of great interest throughout the developed world, where the possible eradication of HCV through specific strategies to reach all HCV-infected people has been announced. However, this scenario is very different in the countries of Latin America (LA), in which < 2% of infected patients requiring treatment have access to HCV medications. It has been estimated that at least ten million Latin Americans may be infected with HCV. Despite the numbers, viral hepatitis does not seem to be considered a health problem in this region of the world. This reality poses a challenge for politicians and governments of these countries, as well as to the pharmaceutical industry, the medical practitioners, and academics in LA. In this editorial, we state the need for alterations in the attitudes of the integral players involved in this situation. A recognition shift could help to create preventive strategies of viral hepatitis and to advocate for accessibility to new HCV treatments.

Hepatitis C virus infection in Argentina: Burden of chronic disease

AIM: To estimate the progression of the hepatitis C virus (HCV) epidemic and measure the burden of HCV-related morbidity and mortality.

METHODS: Age- and gender-defined cohorts were used to follow the viremic population in Argentina and estimate HCV incidence, prevalence, hepatic complications, and mortality. The relative impact of two scenarios on HCV-related outcomes was assessed: (1) increased sustained virologic response (SVR); and (2) increased SVR and treatment.

RESULTS: Under scenario 1, SVR raised to 85%-95% in 2016. Compared to the base case scenario, there was a 0.3% reduction in prevalent cases and liver-related deaths by 2030. Given low treatment rates, cases of hepatocellular carcinoma and decompensated cirrhosis decreased < 1%, in contrast to the base case in 2030. Under scenario 2, the same increases in SVR were modeled, with gradual increases in the annual diagnosed and treated populations. This scenario decreased prevalent infections 45%, liver-related deaths 55%, liver cancer cases 60%, and decompensated cirrhosis 55%, as compared to the base case by 2030.

CONCLUSION: In Argentina, cases of end stage liver disease and liver-related deaths due to HCV are still growing, while its prevalence is decreasing. Increasing in SVR rates is not enough, and increasing in the number of patients diagnosed and candidates for treatment is needed to reduce the HCV disease burden. Based on this scenario, strategies to increase diagnosis and treatment uptake must be developed to reduce HCV burden in Argentina.

Hepatitis C virus in Mexican Americans: a population-based study reveals relatively high prevalence and negative association with diabetes

This study aimed to estimate the prevalence and risk factors for hepatitis C virus (HCV) infection in Mexican Americans living in South Texas. We tested plasma for the presence of HCV antibody from the Cameron County Hispanic Cohort (CCHC), a randomized, population-based cohort in an economically disadvantaged Mexican American community on the United States/Mexico border with high rates of chronic disease. A weighted prevalence of HCV antibody of 2·3% [n = 1131, 95% confidence interval (CI) 1·2-3·4] was found. Participants with diabetes had low rates of HCV antibody (0·4%, 95% CI 0·0-0·9) and logistic regression revealed a statistically significant negative association between HCV and diabetes (OR 0·20, 95% CI 0·05-0·77) after adjusting for sociodemographic and clinical factors. This conflicts with reported positive associations of diabetes and HCV infection. No classic risk factors were identified, but important differences between genders emerged in analysis. This population-based study of HCV in Mexican Americans suggests that national studies do not adequately describe the epidemiology of HCV in this border community and that unique risk factors may be involved.

Oxidative stress modulation in hepatitis C virus infected cells

Hepatitis C virus (HCV) replication is associated with the endoplasmic reticulum, where the virus can induce cellular stress. Oxidative cell damage plays an important role in HCV physiopathology. Oxidative stress is triggered when the concentration of oxygen species in the extracellular or intracellular environment exceeds antioxidant defenses. Cells are protected and modulate oxidative stress through the interplay of intracellular antioxidant agents, mainly glutathione system (GSH) and thioredoxin; and antioxidant enzyme systems such as superoxide dismutase, catalase, GSH peroxidase, and heme oxygenase-1. Also, the use of natural and synthetic antioxidants (vitamin C and E, N-acetylcysteine, glycyrrhizin, polyenylphosphatidyl choline, mitoquinone, quercetin, S-adenosylmethionine and silymarin) has already shown promising results as co-adjuvants in HCV therapy. Despite all the available information, it is not known how different agents with antiviral activity can interfere with the modulation of the cell redox state induced by HCV and decrease viral replication. This review describes an evidence-based consensus on molecular mechanisms involved in HCV replication and their relationship with cell damage induced by oxidative stress generated by the virus itself and cell antiviral machinery. It also describes some molecules that modify the levels of oxidative stress in HCV-infected cells.

Historical epidemiology of hepatitis C virus (HCV) in select countries - volume 3

Detailed, country-specific epidemiological data are needed to characterize the burden of chronic hepatitis C virus (HCV) infection around the world. With new treatment options available, policy makers and public health officials must reconsider national strategies for infection control. In this study of 15 countries, published and unpublished data on HCV prevalence, viraemia, genotype, age and gender distribution, liver transplants and diagnosis and treatment rates were gathered from the literature and validated by expert consensus in each country. Viraemic prevalence in this study ranged from 0.2% in Iran and Lebanon to 4.2% in Pakistan. The largest viraemic populations were in Pakistan (7 001 000 cases) and Indonesia (3 187 000 cases). Injection drug use (IDU) and a historically unsafe blood supply were major risk factors in most countries. Diagnosis, treatment and liver transplant rates varied widely between countries. However, comparison across countries was difficult as the number of cases changes over time. Access to reliable data on measures such as these is critical for the development of future strategies to manage the disease burden.

The Seroprevalence of Hepatitis C Antibodies in Immigrants and Refugees from Intermediate and High Endemic Countries: A Systematic Review and Meta-Analysis

BACKGROUND & AIMS

Hepatitis C virus (HCV) infection is a significant global health issue that leads to 350,000 preventable deaths annually due to associated cirrhosis and hepatocellular carcinoma (HCC). Immigrants and refugees (migrants) originating from intermediate/high HCV endemic countries are likely at increased risk for HCV infection due to HCV exposure in their countries of origin. The aim of this study was to estimate the HCV seroprevalence of the migrant population living in low HCV prevalence countries.

METHODS

Four electronic databases were searched from database inception until June 17, 2014 for studies reporting the prevalence of HCV antibodies among migrants. Seroprevalence estimates were pooled with a random-effect model and were stratified by age group, region of origin and migration status and a meta-regression was modeled to explore heterogeneity.

RESULTS

Data from 50 studies representing 38,635 migrants from all world regions were included. The overall anti-HCV prevalence (representing previous and current infections) was 1.9% (95% CI, 1.4-2.7%, I2 96.1). Older age and region of origin, particularly Sub-Saharan Africa, Asia, and Eastern Europe were the strongest predictors of HCV seroprevalence. The estimated HCV seroprevalence of migrants from these regions was >2% and is higher than that reported for most host populations.

CONCLUSION

Adult migrants originating from Asia, Sub-Saharan Africa and Eastern Europe are at increased risk for HCV and may benefit from targeted HCV screening.

Hepatitis C in key populations in Latin America and the Caribbean: systematic review and meta-analysis

Objectives

Summarize hepatitis C virus (HCV) prevalence in injecting (IDU) and non-injecting drug users (NIDU), men who have sex with men (MSM), sex workers, and prison inmates in Latin America and the Caribbean (LAC).

Methods

Systematic review on HCV prevalence in sub-populations in LAC. Databases searched from 1-1-2000 to 10-30-2013. Inclusion criteria: prevalence studies in sub-populations in LAC. HCV-antibody was marker for prevalence of current/past HCV infection and HCV-RNA for prevalence of HCV current infection.

Results

IDU HCV current/past infection presented highest prevalence, from 1.7 % in Colombia to over 95 % in Ciudad Juarez and Tijuana, Mexico and pooled regional anti-HCV prevalence was 49 % (CI 95 % 22.6–76.3 %). NIDU, MSM and sex workers anti-HCV prevalence was below 10 %, and pooled regional prevalence of 4 % (CI 95 % 2.6–4.5 %), 3 % (CI 95 % 1.7–4.5 %) and 2 % (CI 95 % 1.0–3.4 %), respectively. Prison inmates presented higher values, but prevalence decreased over the 15-year time span (p < 0.001). Current HCV infection from three countries showed prevalence under 10 % in prison inmates and 1–46 % among drug users.

Conclusions

Disease burden is high and surveillance, prevention and treatment should target these groups in LAC.

Electronic supplementary material

The online version of this article (doi:10.1007/s00038-015-0708-5) contains supplementary material, which is available to authorized users.

A genetic variant in the interleukin 28B gene as a major predictor for sustained virologic response in chronic hepatitis C virus infection

BACKGROUND AND AIMS

The IL28B single nucleotide polymorphism (SNP) rs12979860 is a major predictor of treatment outcomes in hepatitis C virus (HCV) infection, but its distribution widely varies among populations and ethnicities. We undertook this study to investigate the distribution of IL28B SNP rs12979860 in Mexican patients with HCV infection and to assess its usefulness in predicting response to pegylated interferon-alpha and ribavirin (PegIFN-α/RVB) therapy.

METHODS

Three hundred and fifty patients with chronic HCV infection were studied. The frequency of sustained virologic response (SVR), non-responders and relapses following a course of standard therapy was longitudinally assessed in 295 of these patients. IL28B SNP rs12979860 was genotyped from genomic DNA using real-time RT-PCR. The number needed to treat (NNT) to achieve a SVR was calculated.

RESULTS

Seventy six (22%) patients were CC homozygous, 210 (60%) were heterozygous and 64 (18%) showed TT homozygosity for the IL28B SNP rs12979860. After a standard course of PegIFN-α/RVB, 69% of patients with the CC genotype, 46% of the heterozygous group and 38% of those with the TT genotype (p = 0.001) achieved a SVR. Conversely, the percentage of non-responders was 15, 43, and 48% (p <0.0001), respectively. The NNT to achieve a SVR was strongly influenced by the IL28B rs12979860 genotype and ranged from 2-10.

CONCLUSIONS

The IL-28B rs12979860 CC genotype was found in 22% of Mexican patients chronically infected by HCV. Genotyping IL28B SNP rs12979860 is useful to predict the response to a standard regimen with PegIFN-α/RVB, especially in those infected with HCV genotype 1.