Methodology of a nationwide cross-sectional survey of prevalence and epidemiological patterns of hepatitis A, B and C infection in Brazil

Sociodemographic and spatiotemporal profiles of hepatitis-A in the state of Pará, Brazil, based on reported notified cases

Hepatitis-A virus is a worldwide healthcare problem, mainly affecting countries with poor sanitary and socioeconomic conditions. This communication evaluates the spatiotemporal variability of the disease's socioepidemiological profile in one of the endemic Brazilian regions (Pará State) prior to (2008-2013) and after (2014-2017) the launch of the national public vaccination programme. Hepatitis-A epidemiological reports concerning Pará State - Brazil - were used for this study including municipalitylevel data of the disease's reported positive notification cases (PNCs). The analyses involved socioepidemiological profiling and space-time scan statistics. A total of 5500 PNCs were reported in the study period. On average, PNCs decreased over time throughout the state, with strongest drops after 2015. The PNCs were specific for gender, race/ethnic origin and age group. The predominant gender and race/ethnic groups was male and brown, respectively. While children were the most susceptible age group prior to 2015, there was a shift towards older ages (young and adults) in later years. Those found to be the most affected by the disease, as shown by space-time scan statistics, were people in densely populated municipalities with unsatisfactory sanitary conditions and also less well covered by the public vaccination programme. Despite drops in the number of hepatitis-A PNCs, thanks to the national vaccination programme, the disease still persists in Pará State and elsewhere in Brazil. The present study reinforces the need of continuous prevention and control strategies for effective control and erradication of hepatitis-A.

Prevalence of hepatitis A in the capitals of the States of North, Southeast and South regions of Brazil: decrease in prevalence and some consequences

Hepatitis A virus (HAV) infection has been considered one of the leading causes of acute hepatitis. The aim of the present study was to estimate the prevalence of HAV among children and adolescents in a population-based study in the capitals of the States of the North, Southeast and South of Brazil and identify predictive factors for the infection. A multi-stage sampling was used to select subjects aged between 5-9 and 10-19 years. Individual and household levels aside from the level of variables in the areas were collected. The outcome was the total IgG antibodies to HAV levels detected using a commercial Enzyme Immuno Assay (EIA). The associations between HAV and the independent variables were assessed using the odds ratio. A multilevel analysis was performed by GLLAMM using the Stata software. The prevalence of HAV infection in the 5-9 and 10-19 age groups was 28.7% and 67.5%, respectively for the North, 20.6% and 37.7%, for the Southeast and 18.9% and 34.5% for the South Region. The prevalence of HAV increased according to age in all sites. Variables related to education at the individual level (North and South), family and area level (South and Southeast) and family income level (Southeast and South) were independently associated with HAV infection. This emphasizes the need for individualized strategies to prevent the infection.

Seroprevalence of hepatitis B virus and hepatitis C virus infection among Malaysian population

Malaysia is a country with an intermediate endemicity for hepatitis B. As the country moves toward hepatitis B and C elimination, population-based estimates are necessary to understand the burden of hepatitis B and C for evidence-based policy-making. Hence, this study aims to estimate the prevalence of hepatitis B and C in Malaysia. A total of 1458 participants were randomly selected from The Malaysian Cohort (TMC) aged 35 to 70 years between 2006 and 2012. All blood samples were tested for hepatitis B and C markers including hepatitis B surface antigen (HBsAg), anti-hepatitis B core antibody (anti-HBc), antibodies against hepatitis C virus (anti-HCV). Those reactive for hepatitis C were further tested for HCV RNA genotyping. The sociodemographic characteristics and comorbidities were used to evaluate their associated risk factors. Descriptive analysis and multivariable analysis were done using Stata 14. From the samples tested, 4% were positive for HBsAg (95% CI 2.7-4.7), 20% were positive for anti-HBc (95% CI 17.6-21.9) and 0.3% were positive for anti-HCV (95% CI 0.1-0.7). Two of the five participants who were reactive for anti-HCV had the HCV genotype 1a and 3a. The seroprevalence of HBV and HCV infection in Malaysia is low and intermediate, respectively. This population-based study could facilitate the planning and evaluation of the hepatitis B and C control program in Malaysia.

Hepatitis B and C prevalence and risk factors among young men presenting to the Brazilian Army: A STROBE-compliant national survey-based cross-sectional observational study

Viral hepatitis is caused by different etiological agents with distinct epidemiological, clinical, and laboratory characteristics accounting for significant worldwide morbidity and mortality. Since 1996, the Brazilian Department of Sexually Transmitted Infections (STIs), Acquired Immune Deficiency Syndrome (AIDS) and Viral Hepatitis (DIAHV) in collaboration with the Ministry of Defense has been conducting periodic serosurveys of conscripts enlisted for the Brazilian army to assess STI prevalence and obtain data on knowledge and risk factors pertaining to STIs. This article aims to present the hepatitis B (hepatitis B surface antigen - HBsAg) and C (anti-HCV) seroprevalence estimates and risk factors as per the 8th edition of the Conscript Survey performed in 2016.This cross-sectional study was conducted among conscripts across Brazil aged 17 to 22 years from August to December 2016. It included a self-reported questionnaire and blood testing for syphilis, human immunodeficiency virus (HIV), and hepatitis B and C.In total 38,247 conscripts were enrolled; after applying exclusion criteria, 37,282 conscripts were included. The estimated HBsAg and anti-HCV prevalence rates were 0.22% and 0.28%, respectively. Higher HBsAg and anti-HCV prevalence rates were observed in the North Region (0.49%) and in the Central-west Region (0.65%), respectively. Regarding hepatitis B vaccination, 23.5% (n = 8412) of the individuals reported being unvaccinated and 47.4% (n = 16,970) did not know if they had been vaccinated. Among the anti-HCV positive conscripts, 53% (n = 51, 0.56%, P = .049) reported that they had never had sexual intercourse. Regarding self-reported STI status, most of the positive anti-HCV (n = 100, 0.29%, P < .01) and positive HBsAg (n = 76, 0.22%, P = .205) conscripts reported not having a STI. From those who tested positive for HBsAg, 89% (n = 42, 0.28%, P = .005) reported not making consistent use of condoms with steady partners.Our data suggest a low prevalence of hepatitis B virus (HBV) and hepatitis C virus (HCV) infections among Brazilian young men, and relatively low rates of self-reported HBV immunization. History of STIs, higher number of partners, inconsistent use of condoms, and lack of awareness of routes of transmission were significantly associated with HBV and HCV infections. To achieve the World Health Organization's goal of viral hepatitis elimination, access to hepatitis information, testing, and surveillance need to be improved.

Accuracy of rapid test for diagnosis of hepatitis A with different infection rate settings and with predictive modeling

AIM

We evaluated the accuracy of a commercial rapid immunochromatographic test (rapid test [RT]) for hepatitis A (HA) diagnosis and epidemiological studies.

MATERIALS & METHODS

The accuracy of a RT was evaluated in laboratory and in field conditions. Predictive modeling estimated the test performance in a hypothetical population.

RESULTS

The RT showed sensitivities of 66-86%, and specificities of 21-100%, depending on the antibody isotype (IgM or IgG) analyzed and prevalence of infection.

CONCLUSION

The RT is a good alternative for diagnostic in HA outbreaks. The predictive model indicates that it should not be used alone for HA diagnosis in low prevalence populations. These data can be used in the future to strengthen decision-making during the implementation of rapid diagnostic methods in health services.

HEPATITIS B AND C IN PREGNANT WOMEN ATTENDED BY A PRENATAL PROGRAM IN AN UNIVERSITARY HOSPITAL IN RIO DE JANEIRO, BRAZIL: RETROSPECTIVE STUDY OF SEROPREVALENCE SCREENING

BACKGROUND

Hepatitis B and C are diseases with high morbimortality and constitute a global public health problem. In Brazil, the prevalence is not homogeneous, oscillating among different regions, but it is estimated that currently about 1% of the population present chronic disease related to the B virus and that there are 1.5 million infected with the C virus. Despite the development of hepatitis B vaccine, improvement in diagnostic methods and therapeutic advances in the field of viral hepatitis, there is still a large number of people who continues to be infected by these viruses, especially in populations at risk and also due to several factors, including vaccination and migration policies. Vertical and perinatal transmissions are of great importance in the epidemiology of viral hepatitis and the blood tests performed during prenatal care constitute a great opportunity for screening and identifying these viruses.

OBJECTIVE

To evaluate the seroprevalence of markers for B and C viruses in women who underwent prenatal care at the Hospital Universitário Antônio Pedro (Antonio Pedro University Hospital) from 2006 to 2013 and to compare the results found with regional data and those described in the specific literature.

METHODS

A descriptive, cross-sectional, quantitative study with retrospective data collected from 635 records of pregnant women attended at the Prenatal Service of the Hospital Universitário Antônio Pedro, Niterói, state of Rio de Janeiro, from March 2006 until December 2013. The database was built in the Microsoft Office Access program and was later exported to Microsoft Office Excel. For the processing and analysis of the data, it was used the SPSS (Statistical Package for Social Science, IBM) version 22.0, for Windows.

RESULTS

Twelve cases with positive HBsAg (1.9%), 189 cases with positive anti-HBs (35.9%) and seven positive anti-HCV patients (1.3%) were observed. There was no significant association between age and positivity for HBsAg, anti-HBs and anti-HCV (P =0.205, 0.872 and 0.676, respectively). There was a direct relationship between the anti-HBs positivity and the last four years of the study (P<0.0001).

CONCLUSION

A high prevalence of HBsAg was observed, higher than the expected for the evaluated region; there was a prevalence of anti-HCV, consistent with the current Brazilian reality; and a likely low rate of hepatitis B immunization, with a relatively high rate of susceptibility to this infection and no case of co-infection between B and C viruses and HIV. It is emphasized not only the need to trace hepatitis B and C, without exceptions, during prenatal care, since even though the current advances in therapy may not cure, at least they may allow a better quality of life for patients with chronic disease and the mandatory completion of immunoprophylaxis in all newborns. Special attention should be given to those patients susceptible to HBV, with prompt diagnosis and referral for specific vaccination.

Prevalence of serological markers for hepatitis and potential associated factors in patients with diabetes mellitus

Objective:

to estimate the prevalence of serological markers for hepatitis B and C in patients with diabetes mellitus and analyze potential associated factors.

Method:

a cross-sectional study with 255 patients with diabetes mellitus. Demographic, clinical, and risk behavior factors for hepatitis B and C were selected. The markers HBsAg, Anti-HBc IgG, Anti-HBc IgM, Anti-HBs, and Anti-HCV were investigated. A questionnaire and venous blood collection and inferential statistical analysis were used.

Results:

16.8% of the patients had a total reactive Anti-HBc marker, 8.2% an isolated Anti-HBs, and 75% were non-reactive for all hepatitis B markers. No case of reactive HBsAg was found and 3.3% of the patients had a reactive anti-HCV marker. The prevalence of prior hepatitis B virus infection was directly associated with the time of diabetes mellitus and the prevalence of hepatitis C virus infection was not associated with the investigated variables. The prevalence of hepatitis B and C infection in patients with diabetes mellitus was higher when compared to the national, with values of 16.8% and 3.3%, respectively.

Conclusion:

the results suggest that patients with diabetes are a population of higher vulnerability to hepatitis B and C, leading to the adoption of preventive measures of their occurrence.

Hepatitis D infection in Brazil: Prevalence and geographical distribution of anti-Delta antibody

In Brazil, the Amazon Basin is endemic for hepatitis D virus (HDV) infection; however, studies in other regions of the country are scarce. This study aims to map the seroepidemiological situation of anti-Delta antibodies in chronic hepatitis B carriers in all five Brazilian geographic regions. Serum samples from 1240 HBsAg positive individuals (55.4% men; mean age 43.1 ± 13.4 years) from 24 of 26 Brazilian states were tested for the presence of anti-Delta antibodies using a commercial immunoassay. Anti-Delta antibodies were detected in 40 samples (3.2%; 52.5% female; mean age of 38.1 ± 13.8 years). Age less than 20 years was significantly associated with anti-HDV positivity (P < 0.001). The distribution of anti-Delta differed markedly in the diverse regions of the country. The highest prevalence of anti-HDV was found in the North (8.5%; P < 0.001), followed by Central West (2.5%), Southeast (1.7%), Northeast (0.8%), and South (0.0%). Anti-Delta antibodies were detected in 12 states, but more than 60% of the positive cases were observed in two states, Amazonas and Acre, located in the western portion of the Amazon region. The overall HDV prevalence of 3.2% emphasizes that HDV is far from being a disease under control in Brazil. Despite the low HDV prevalence in non-endemic regions, this infection persists as a major concern in two states (Acre and Amazonas) in the north of the country, indicating that a continuous epidemiological surveillance program should be implemented in all Brazilian 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.

Modeling the hepatitis A epidemiological transition in Brazil and Mexico

BACKGROUND

Many low- to middle-income countries have completed or are in the process of transitioning from high or intermediate to low endemicity for hepatitis A virus (HAV). Because the risk of severe hepatitis A disease increases with age at infection, decreased incidence that leaves older children and adults susceptible to HAV infection may actually increase the population-level burden of disease from HAV. Mathematical models can be helpful for projecting future epidemiological profiles for HAV.

METHODS

An age-specific deterministic, dynamic compartmental transmission model with stratification by setting (rural versus urban) was calibrated with country-specific data on demography, urbanization, and seroprevalence of anti-HAV antibodies. HAV transmission was modeled as a function of setting-specific access to safe water. The model was then used to project various HAV-related epidemiological outcomes in Brazil and in Mexico from 1950 to 2050.

RESULTS

The projected epidemiological outcomes were qualitatively similar in the 2 countries. The age at the midpoint of population immunity (AMPI) increased considerably and the mean age of symptomatic HAV cases shifted from childhood to early adulthood. The projected overall incidence rate of HAV infections decreased by about two thirds as safe water access improved. However, the incidence rate of symptomatic HAV infections remained roughly the same over the projection period. The incidence rates of HAV infections (all and symptomatic alone) were projected to become similar in rural and urban settings in the next decades.

CONCLUSION

This model featuring population age structure, urbanization and access to safe water as key contributors to the epidemiological transition for HAV was previously validated with data from Thailand and fits equally well with data from Latin American countries. Assuming no introduction of a vaccination program over the projection period, both Brazil and Mexico were projected to experience a continued decrease in HAV incidence rates without any substantial decrease in the incidence rates of symptomatic HAV infections.

Hepatitis A seroprevalence in public school children in Campos dos Goytacazes, Rio de Janeiro State, Brazil, prior to the introduction of the hepatitis A universal childhood vaccination

This cross-sectional study was carried out between August 2011 and July 2012 in the city of Campos dos Goytacazes in Rio de Janeiro State, Brazil. Dried blood spot samples were collected on filter paper from 919 individuals between the ages of 1 and 19 and were tested for antibodies against the hepatitis A virus (anti-HAV). The total prevalence was 20.7%, while 94.7% of children under the age of 5 were found to be susceptible to HAV infection. The prevalence of anti-HAV increased with age, reaching 33.3% among individuals aged between 15 and 19, thereby indicating that this municipality has a low level of endemicity for hepatitis A. Age, non-white skin color, accustomed to swimming in the river and more than five people living at home were the factors that were associated with an increase in the chance of a positive anti-HAV result. Mother's education level (secondary or tertiary) was considered a protective factor for HAV infection. The data obtained showed that a large proportion of the children from Campos dos Goytacazes were at risk of HAV infection, which should be minimized with the introduction of the vaccination program against hepatitis A that was launched in the municipality in 2011.

Prevalence of hepatitis B and C markers in a population of an urban university in Rio de Janeiro, Brazil: a cross-sectional study

BACKGROUND AND RATIONALE

Epidemics of hepatitis B and C are a public health burden, and their prevalence in Brazil varies among regions. We determined the prevalence of hepatitis markers in an urban university population in order to support the development of a comprehensive program for HBV immunization and HBV/HCV diagnosis. Students, employees, and visitors (n = 2,936, 31 years IQR 24.5-50, female = 69.0% and 81.1% with at least 12 years of education) were enrolled from May to November 2013. Antibodies against hepatitis B surface antigen (anti-HBs), against hepatitis B core antigen (anti-HBc), and hepatitis B surface antigen (HBsAg) were detected with enzyme immunoassays and anti-hepatitis C virus (anti-HCV) antibodies with a chemiluminescence immunoassay. The results were confirmed with polymerase chain reaction for HCV and nucleic acid amplification test for hepatitis B virus (HBV).

RESULTS

The overall prevalence of markers among the participants was 0.136% (95% confidence interval [CI]: 0.003-0.270) for HBsAg, 6.44% (95% CI: 5.55-7.33%) for anti-HBc, 50.8% (95% CI: 48.9-52.7%) for anti-HBs > 10 mIU/mL, and 0.44% (95% CI: 0.20-0.68) for anti-HCV. Almost 30.4% had anti-HBs titers > 100 mIU/mL. Participants with a detectable HCV viral load (n = 9) were infected with genotype 1a.

CONCLUSIONS

In an urban university population, in which 80% of participants had > 11 years of education, prevalence increased with age, and self-declared ethnicity for anti-HBc and with age, marital status and professional activity for anti-HCV antibodies. A periodical offer of HCV rapid testing should be implemented, and HBsAg rapid testing should be offered to individuals above 20 years of age.

State of viral hepatitis knowledge and testing uptake in Brazil: Findings from the National Survey of Knowledge, Attitudes and Practices (PCAP-2013)

Background

Data were obtained from the third National Survey of Knowledge, Attitudes and Practices of HIV and other Sexually Transmitted Infections (STI) (PCAP-2013) and used to describe the current state of viral hepatitis (VH) knowledge and screening as well as the prevalence of viral hepatitis B (HBV) vaccination in Brazil and to assess the factors associated with testing uptake.

Methods

A probability sample survey of 12,000 individuals (50 % men) aged between 15 and 64 years was conducted between October and December of 2013. The participants completed the survey in their own homes through computer-assisted face-to-face interviews and self-interviews. We analysed data related to self-reported knowledge of VH routes and screening uptake after weighting the variables to account for unequal selection probabilities and correct for differences in sex, age and region according to 2010 census figures.

Results

The levels of correct knowledge regarding HBV and HCV transmission through unprotected sex were 33.1 and 34.3 %, respectively. The levels of correct knowledge regarding HBV and HCV transmission through tattooing/piercing were 26.4 and 24.5 %, respectively. Overall, 29 % of the respondents reported having underwent VH screening and 73.9 % reported prior HBV vaccination. VH screening was associated with the following factors: age between 25 and 49 years (adjusted male odds ratio (OR): 2.29, [95 % confidence interval (CI): 1.83–2.87]; female OR: 1.36, [95 % CI: 1.10-1.67]); age between 50 and 64 years (male OR: 1.52, [CI: 1.13–2.03]; female OR: 1.29, [CI: 1.02–1.63]); initial sexual intercourse before the age of 15 years in men (OR: 1.32, [CI: 1.10–1.57]); higher socioeconomic statuses of group A (male OR: 2.38, [CI: 1.81–3.13]; female OR: 2.10, [CI: 1.66–2.68]) and B (female OR: 1.56, [CI: 1.27–1.93]); and having ever been tested for HIV (male OR: 7.50, [CI: 5.82–8.53]; female OR: 7.13, [CI: 5.97–8.54]).

Conclusions

This study revealed low levels of knowledge regarding VH transmission and screening practices in the general Brazilian population, especially among younger individuals and those with lower socioeconomic status. Efforts to enhance awareness campaigns and expand testing sites are needed to remove barriers to testing.

Serological markers of hepatitis B and C in patients with HIV/AIDS and active tuberculosis

Infection with hepatitis B virus (HBV) and C virus (HCV) are common in patients with HIV/AIDS and tuberculosis (TB). This is a cross-sectional study with patients infected with HIV/AIDS and active TB in Recife, Brazil, aiming to verify the prevalence of markers for HBV: antibody to hepatitis B core antigen (anti-HBc); and HCV: antibody to hepatitis C virus (anti-HCV) by chemiluminescence, and to identify the frequency of associated factors. Data were collected through questionnaires, and blood was drawn from patients for analysis. We used the chi-square test and the Fisher exact test when necessary. We conducted a bivariate logistic regression analysis and the magnitude of the associations was expressed as odds ratio (OR) with a confidence interval of 95%. Among 166 patients studied with HIV/AIDS and active TB, anti-HBc was positive in 61 patients [36.7%; 95%CI (29.4-44.6%)] and anti-HCV in 11[6.6%; 95%CI (3.4-11.5%)]. In the logistic regression analysis, male sex, and age ≥40 years were independent factors associated with the occurrence of anti-HBc. In conclusion, we verified a high frequency of HBV contact marker and a low frequency of HCV markers in patients with HIV/AIDS and TB in Recife.

Observational descriptive study of cutaneous manifestations in patients from Mato Grosso with viral chronic hepatitis

BACKGROUND

Extrahepatic manifestations are seen in association with chronic infection by hepatitis B or C virus including cutaneous disorders. The frequency of these findings seems to vary among different places and reports. There is a lack of information about this issue in Brazil.

OBJECTIVES

To estimate the prevalence of cutaneous findings affecting HBV or HCV carriers from a reference outpatient unit in Mato Grosso.

METHODS

A cross-sectional observational study.

RESULTS

108 patients were studied. 88.9% presented some cutaneous findings but must of them were nonrelated to chronic viral infection. Four patients had cutaneous or autoimmune syndromes that may be HBV or HCV related.

CONCLUSION

In our study we found no statistical association between viral hepatitis and skin diseases.

Population-Based Multicentric Survey of Hepatitis B Infection and Risk Factors in the North, South, and Southeast Regions of Brazil, 10-20 Years After the Beginning of Vaccination

A population-based hepatitis survey was carried out to estimate the prevalence of hepatitis B virus (HBV) infection and its predictive factors for the state capitals from the north, south, and southeast regions of Brazil. A multistage cluster sampling was used to select, successively, census tracts, blocks, households, and residents in the age group 10-69 years in each state capital. The prevalence of hepatitis B surface antigen (HBsAg) was lower than 1% in the north, southeast, and south regions. Socioeconomic condition was associated with HBV infection in north and south regions. Variables related to the blood route transmission were associated with HBV infection only in the south whereas those related to sexual behavior were associated with HBV infection in the north and south regions. Drug use was associated in all regions, but the type of drug differed. The findings presented herein highlight the diversity of the potential transmission routes for hepatitis B transmission in Brazil. In one hand, it reinforces the importance of national control strategies of large impact already in course (immunization of infants, adolescents, and adults up to 49 years of age and blood supply screening). On the other hand, it shows that there is still room for further control measures targeted to different groups within each region.

Cross-Sectional Study of Hepatitis A Virus Infection in the Pantanal Population before Vaccine Implementation in Brazil: Usage of Non-Invasive Specimen Collection

Population-based prevalence studies are essential tools for screening of hepatitis A and provide important data on susceptible groups. However, surveillance in isolated communities is difficult because of the limited access to these areas and the need for blood sample collection. This study aimed to determine the anti-HAV prevalence using oral fluid samples to provide an alternative tool for epidemiological studies that might be useful for vaccination-related decisions. The study population was composed of 224 volunteers from South Pantanal, aged 3 to 86 years old. This study was performed using oral fluids, previously standardized for anti-HAV antibody detection, which were collected using a ChemBio device. Eluates were tested using modified commercial EIA to detect anti-HAV antibodies. The overall prevalence was 79.1%, corresponding to 178 reactive EIA tests out of 224 samples. The age stratified data revealed a prevalence of 47.8% between 0–10 years, 84% in 11–20 years and 91.9% in subjects older than 21 years. Results indicate that hepatitis A prevalence was higher in adolescents and adults, corroborating the literature reports. Thus, oral fluid samples could replace serum in HAV epidemiological studies in isolated communities as they are efficient at detecting anti-HAV antibodies.

The seroprevalence of both hepatitis B and hepatitis C at the first-step health organizations and the difference between the urban and rural areas

BACKGROUND

Hepatitis B virus (HBV) and hepatitis C virus (HCV) are very important infectious agents for public health. The aim of this retrospective study was to assess the seroprevalence of hepatitis B surface antigen (HBsAg), hepatitis B surface antibody (anti-HBs) and anti-HCV test results of patients who admitted to first-step health organizations in central and peripheral districts of Konya, the central region of Turkey during the period 2005-2010.

METHODS

In this study, HBsAg, anti-HBs and anti-HCV screening test results of patients who admitted to first-step health organizations in Konya during the period 2005-2010 were retrospectively investigated from the laboratory records. This study was approved by the Konya Health Directorate. All screening tests were performed on the automatic third-generation enzyme-linked immunosorbent assay (MEIA). This immunoassay method was carried out according to the instructions of the manufacturer. Borderline and positive results were retested.

RESULTS

Konya is the largest city of Turkey in terms of surface area and one of the economically developed cities. For HBsAg, anti-HBs and anti-HCV screening, whole test results of 5 years are given in Table 1 and Figure 1. The differences between the urban and rural for HBsAg (p = 0.062 > 0.05) and anti-HCV(p = 0.874 > 0.05) were not statistically significant. Among the markers only for anti-HBs, the difference between the urban and rural was statistically significant (P = 0.042 < 0.05). Of them, 4.15 % were positive for HBsAg, 36.46 % were positive for anti-HBs and 1.16 % were positive for anti-HCV.

CONCLUSION

In this study, Konya has been evaluated as two regions: central and peripheral. Our study showed us that distribution of the diseases vary from one region to another. We consider that difference in social diversity is one of the factors. These infections are major health problems. So the results of immunodiagnostic tests for HBsAg, anti-HBs and anti-HCV will be useful for guiding control actions and for new preventive strategies.

12 years of universal access to hepatitis C treatment: Brazil's comprehensive response

Hepatitis C is considered one of the most neglected diseases in world. Worldwide about 150 million people are chronically infected by hepatitis C virus (HCV), and 60% to 70% of them will develop severe liver disease. This article describes Brazil's response to hepatitis C, from the first steps in 1993 to a national program in 2002. We reviewed the available literature, most of it in Brazilian Portuguese, and compiled them in order to share this experience with those seeking some pragmatic solutions. After 12 years, the national program has achieved universal coverage of treatment, resulting in saved lives and resources for the health system. There is abundant evidence that the HCV epidemic deserves attention. The overall consequence of long-term HCV infection is a negative impact on the health care economy. The Brazilian experience can be adapted to many countries in the world, in compliance with the 2010 World Health Organization World Health Assembly Resolution.

Low IL10 serum levels as key factor for predicting the sustained virological response to IFNα/ribavirin in Brazilian patients with HCV carrying IL28B CT/TT genotype

PROPOSE

IL28B polymorphisms rs12979860 CC genotype was associated to protection of HCV infection and sustained virological response (SVR) in HCV infected patients treated with pegIFNα/ribavirin (IFNα/RIB), however, this polymorphism frequency varies depending on genetic components. Studies with larger number of Brazilian individuals, determining IL28B polymorphisms is lacking. Regarding to treatment response, the levels of IL10 seem to influence response to IFNα/RIB therapy. Thus, the IL28B polymorphism frequency was investigated in health controls and infected HCV patients, as well as, in patients who reach SVR vs Non-SVR. Also, to gain insight into the interplay between IL28B genotypes, IL10 levels and therapy response, a subgroup of genotyped HCV patients SVR and Non-SVR were analyzed regarding the IL10 production.

METHODS

It was enrolled 487 HCV infected patients and 234 healthy individuals. Patients with response to IFNα/RIB were classified as SVR (n = 81) and Non-SVR (n = 123). TAQMAN probes were used for genotyping the SNP rs12979860, resulting in CC, CT or TT genotypes. In one hundred one patients, the levels IL10 were measured at week 4 of IFNα/RIB.

RESULTS

CC genotype was associated to SVR (p = 0.029) and its frequency was higher in healthy individuals vs patients (p = 0.02). Patients carrying CT/TT with IL10<10 pg/mL, had a chance of 2.72 to achieve SVR in multivariate model (p = 0.043).

CONCLUSION

CC genotype was associated to SVR and protection to HCV infection. Moreover, IL28B genotyping and IL10 serum levels could be further explored as a useful algorithm for identify the CT/TT SVR patients.

Evidence of hepatitis A virus person-to-person transmission in household outbreaks

The person-to-person transmission of the hepatitis A virus primarily occurs in enclosed spaces, particularly in the presence of inadequate hygiene conditions and a high proportion of susceptible individuals. Thus, intimate family contact stands out as a risk factor for HAV infection dissemination. The present study aimed to evaluate the occurrence of household HAV transmission. Blood samples were collected from patients with hepatitis A (index cases) and their family members (contacts) that were referred to an ambulatory care clinic specializing in viral hepatitis. A total of 97 samples were collected from 30 families with a confirmed hepatitis A case (index case). Serological and molecular techniques for the diagnosis of hepatitis A were conducted on all samples. HAV infection (anti-HAV IgM + and/or HAV RNA +) was detected in 34.3% (23/67) of the contacts; 34.3% (23/67) of the contacts were immune to HAV, and 31.4% (21/67) were susceptible. In the household contacts, HAV immunity was significantly associated with older age; susceptibility to infection and HAV infection were associated with younger age. Household outbreaks were detected in 16/30 families studied. Co-circulation of subgenotypes IA and IB was found in the household outbreaks, and person-to-person transmission was evidenced in six of the household outbreaks, with 100% homology between the index case and contact strains. The results demonstrated the relevance of HAV household transmission, reaffirming the need for hepatitis A vaccine administration in susceptible contacts and effective infection control procedures to prevent the extension of household outbreaks.

Hepatitis C worldwide and in Brazil: silent epidemic--data on disease including incidence, transmission, prevention, and treatment

Hepatitis C virus (HCV) is endemic worldwide and according to the World Health Organization (WHO), there are about 150 million chronic carriers worldwide. The infection is a leading cause of liver diseases like cirrhosis and hepatocellular carcinoma (HCC); thus, HCV infection constitutes a critical public health problem. There are increasing efforts worldwide in order to reduce the global impact of hepatitis C through the implementation of programmatic actions that may increase the awareness of viral hepatitis and also improve surveillance, prevention, and treatment. In Brazil, about 1,5 million people have been chronically infected with HCV. The country has a vast territory with uneven population density, and hepatitis C incidence rates are variable with the majority of cases concentrated in the most populated areas. Currently, the main priorities of Brazilian Ministry of Health's strategies for viral hepatitis management include the prevention and early diagnosis of viral hepatitis infections; strengthening of the healthcare network and lines of treatment for sexually transmitted diseases, viral hepatitis, and AIDS; improvement and development of surveillance, information, and research; and promotion of universal access to medication. This review aims to summarize the available data on hepatitis C epidemiology and current status of efforts in prevention and infection control around the world and in Brazil.

Modelling the force of infection for hepatitis A in an urban population-based survey: a comparison of transmission patterns in Brazilian macro-regions

Background

This study aimed to identify the transmission pattern of hepatitis A (HA) infection based on a primary dataset from the Brazilian National Hepatitis Survey in a pre-vaccination context. The national survey conducted in urban areas disclosed two epidemiological scenarios with low and intermediate HA endemicity.

Methods

A catalytic model of HA transmission was built based on a national seroprevalence survey (2005 to 2009). The seroprevalence data from 7,062 individuals aged 5–69 years from all the Brazilian macro-regions were included. We built up three models: fully homogeneous mixing model, with constant contact pattern; the highly assortative model and the highly assortative model with the additional component accounting for contacts with infected food/water. Curves of prevalence, force of infection (FOI) and the number of new infections with 99% confidence intervals (CIs) were compared between the intermediate (North, Northeast, Midwest and Federal District) and low (South and Southeast) endemicity areas. A contour plot was also constructed.

Results

The anti- HAV IgG seroprevalence was 68.8% (95% CI, 64.8%–72.5%) and 33.7% (95% CI, 32.4%–35.1%) for the intermediate and low endemicity areas, respectively, according to the field data analysis. The models showed that a higher force of infection was identified in the 10- to 19-year-old age cohort (∼9,000 infected individuals per year per 100,000 susceptible persons) in the intermediate endemicity area, whereas a higher force of infection occurred in the 15- to 29-year-old age cohort (∼6,000 infected individuals per year per 100,000 susceptible persons) for the other macro-regions.

Conclusion

Our findings support the shift of Brazil toward intermediate and low endemicity levels with the shift of the risk of infection to older age groups. These estimates of HA force of infection stratified by age and endemicity levels are useful information to characterize the pre-vaccination scenario in Brazil.

Chronic Hepatitis C treatment for genotype 2 or 3 in Brazil: cost effectiveness analysis of peginterferon plus ribavirin as first choice treatment

Brazilian Guidelines to HCV treatment (2007) recommended that the first choice treatment for patients with chronic hepatitis C (CHC) and genotype 2 or 3 is interferon alpha (IFN) plus ribavirin (RBV) for 24 weeks. The aim of this study is compare the cost and effectiveness to Hepatitis C treatment in patients with genotype 2 or 3 of peginterferon alpha (PEG) as the first choice of treatment within PEG for those that do not respond to IFN. The target population is CHC patients with genotype 2 or 3 in Brazil. The interventions are: PEG-SEC (first IFN plus RBV for 24 weeks, after, for non-responders and relapsers subsequently PEG plus RBV for 48 weeks); PEG-FIRST24 (PEG+RBV for 24 weeks). The type of the study is cost-effectiveness analysis. The data sources are: Effectiveness data from meta-analysis conducted on the Brazilian population. Treatment cost from Brazilian micro costing study is converted into USD (2010). The perspective is the Public Health System. The outcome measurements are Sustained Viral Response (SVR) and costs. PEG-FIRST24 (SVR: 87.8%, costs: USD 8,338.27) was more effective and more costly than PEG-SEC (SVR: 79.2%, costs: USD 5,852.99). The sensitivity analyses are: When SVR rates with IFN was less than 30% PEG-FIRST is dominant. On the other hand, when SVR with IFN was more then 75% PEG-SEC is dominant (SVR=88.2% and costs USD $ 3,753.00). PEG-SEC is also dominant when SVR to PEG24 weeks was less than 54%. In the Brazilian context, PEG-FIRST is more effective and more expensive than PEG-SEC. PEG-SEC could be dominant when rates of IFN therapy are higher than 75% or rates of PEG24 therapy are lower than 54%.

Occult hepatitis B virus infection among blood donors from the Brazilian Amazon: implications for transfusion policy

BACKGROUND

Brazil requires the performance of both a test for hepatitis B surface antigen (HBsAg) and a test for antibodies to the core of hepatitis B for blood donor screening. Blood centres in regions of high HBV endemicity struggle to maintain adequate stocks in face of the high discard rates due to anti-HBc reactivity. We evaluated the potential infectivity of donations positive for anti-HBc in search of a rational approach for the handling of these collections.

STUDY DESIGN AND METHODS

We tested anti-HBc reactive blood donations from the state of Amazonas for the presence of HBV DNA and for titres of anti-HBs. The study population consists of village-based donors from the interior of Amazonas state.

RESULTS

Among 3600 donations, 799 were anti-HBc reactive (22·2%). We were able to perform real-time PCR for the HBV S gene on specimens from 291 of these donors. Eight of these samples were negative for HBsAg and positive for HBV DNA and were defined as occult B virus infections (2·7%). Six of those eight specimens had anti-HBs titres above 100 mIU/ml, indicating the concomitant presence of the virus with high antibody titres.

CONCLUSION

A small proportion of anti-HBc reactive donors carry HBV DNA and anti-HBs testing is not useful for predicting viremia on them. This finding indicates the possibility of HBV transmission from asymptomatic donors, especially in areas of high HBV prevalence. Sensitive HBV DNA nucleic acid testing may provide another level of safety, allowing eventual use of anti-HBc reactive units in critical situations.

[Mortality due to malignant neoplasms of the liver and intrahepatic bile ducts in Brazil, 1980-2010]

This study aimed to analyze trends in mortality due to malignant neoplasms of the liver and intrahepatic bile ducts in Brazil from 1980 to 2010. This was a time series study using data provided by the Mortality Information System. Crude and standardized mortality rates were calculated according to age, area of residence, and gender. Trends were analyzed using polynomial regression models. An increasing trend in mortality was observed for both males and females in Brazil. Mean overall mortality was 3.59, with a linear increase of 0.020 (R² = 0.588; p < 0.001). The rate for males was 4.20 deaths per 100,000 inhabitants with a linear annual increase of 0.044 (R² = 0.81; p < 0,001), and for females, 2.98 per 100,000 inhabitants with a linear annual increase of 0.0194 (R² = 0.35; p = 0.008). The article discusses possible explanations for this increase, as well as potential information bias.

Prevalence and risk factors of Hepatitis C virus infection in Brazil, 2005 through 2009: a cross-sectional study

BACKGROUND

Hepatitis C chronic liver disease is a major cause of liver transplant in developed countries. This article reports the first nationwide population-based survey conducted to estimate the seroprevalence of HCV antibodies and associated risk factors in the urban population of Brazil.

METHODS

The cross sectional study was conducted in all Brazilian macro-regions from 2005 to 2009, as a stratified multistage cluster sample of 19,503 inhabitants aged between 10 and 69 years, representing individuals living in all 26 State capitals and the Federal District. Hepatitis C antibodies were detected by a third-generation enzyme immunoassay. Seropositive individuals were retested by Polymerase Chain Reaction and genotyped. Adjusted prevalence was estimated by macro-regions. Potential risk factors associated with HCV infection were assessed by calculating the crude and adjusted odds ratios, 95% confidence intervals (95% CI) and p values. Population attributable risk was estimated for multiple factors using a case-control approach.

RESULTS

The overall weighted prevalence of hepatitis C antibodies was 1.38% (95% CI: 1.12%-1.64%). Prevalence of infection increased in older groups but was similar for both sexes. The multivariate model showed the following to be predictors of HCV infection: age, injected drug use (OR = 6.65), sniffed drug use (OR = 2.59), hospitalization (OR = 1.90), groups socially deprived by the lack of sewage disposal (OR = 2.53), and injection with glass syringe (OR = 1.52, with a borderline p value). The genotypes 1 (subtypes 1a, 1b), 2b and 3a were identified. The estimated population attributable risk for the ensemble of risk factors was 40%. Approximately 1.3 million individuals would be expected to be anti-HCV-positive in the country.

CONCLUSIONS

The large estimated absolute numbers of infected individuals reveals the burden of the disease in the near future, giving rise to costs for the health care system and society at large. The known risk factors explain less than 50% of the infected cases, limiting the prevention strategies. Our findings regarding risk behaviors associated with HCV infection showed that there is still room for improving strategies for reducing transmission among drug users and nosocomial infection, as well as a need for specific prevention and control strategies targeting individuals living in poverty.

Cost-effectiveness analysis of universal childhood hepatitis A vaccination in Brazil: regional analyses according to the endemic context

OBJECTIVE

To conduct a cost-effectiveness analysis of a universal childhood hepatitis A vaccination program in Brazil.

METHODS

An age and time-dependent dynamic model was developed to estimate the incidence of hepatitis A for 24 years. The analysis was run separately according to the pattern of regional endemicity, one for South+Southeast (low endemicity) and one for the North+Northeast+Midwest (intermediate endemicity). The decision analysis model compared universal childhood vaccination with current program of vaccinating high risk individuals. Epidemiologic and cost estimates were based on data from a nationwide seroprevalence survey of viral hepatitis, primary data collection, National Health Information Systems and literature. The analysis was conducted from both the health system and societal perspectives. Costs are expressed in 2008 Brazilian currency (Real).

RESULTS

A universal immunization program would have a significant impact on disease epidemiology in all regions, resulting in 64% reduction in the number of cases of icteric hepatitis, 59% reduction in deaths for the disease and a 62% decrease of life years lost, in a national perspective. With a vaccine price of R$16.89 (US$7.23) per dose, vaccination against hepatitis A was a cost-saving strategy in the low and intermediate endemicity regions and in Brazil as a whole from both health system and society perspective. Results were most sensitive to the frequency of icteric hepatitis, ambulatory care and vaccine costs.

CONCLUSIONS

Universal childhood vaccination program against hepatitis A could be a cost-saving strategy in all regions of Brazil. These results are useful for the Brazilian government for vaccine related decisions and for monitoring population impact if the vaccine is included in the National Immunization Program.

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

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

Seroprevalence of HBV and HCV markers among young adult males in the Air Force in Florianópolis, South Brazil

We investigated the prevalence of hepatitis B virus (HBV) and hepatitis C virus (HCV) serological markers of infection in young adults from the metropolitan region of Florianópolis who were conscripts of the Air Base of Florianópolis in the state of Santa Catarina, Brazil. A population-based cross-sectional seroprevalence study was conducted with 371 young males during a one year period starting in June 2009. Demographic characteristics, socio-economic characteristics and possible risk factors to HBV and HCV were assessed. Blood samples were analyzed for HBsAg, anti-HBc, anti-HCV and anti-HBs through automated microparticle enzymatic immunoassays (Abbott®, AxSYM System, Wiesbaden, Germany). None of the participants showed positivity to HBsAg or anti-HCV. The prevalence of anti-HBc was 1.6% (95% CI 0.6 - 3.5), and the prevalence of anti-HBs was 40.7% (95% CI 35.7 - 45.9). Unsafe sex was associated with positive anti-HBc in a bivariate analysis. There was a very low prevalence of past HBV infection and no cases of past HCV infection in a young adult population in the metropolitan region of Florianópolis. The very low prevalence of markers of infection and risk factors indicates a very optimistic future with respect to HBV and HCV infection in this population.

Successes and failures in the control of infectious diseases in Brazil: social and environmental context, policies, interventions, and research needs

Despite pronounced reductions in the number of deaths due to infectious diseases over the past six decades, infectious diseases are still a public health problem in Brazil. In this report, we discuss the major successes and failures in the control of infectious diseases in Brazil, and identify research needs and policies to further improve control or interrupt transmission. Control of diseases such as cholera, Chagas disease, and those preventable by vaccination has been successful through efficient public policies and concerted efforts from different levels of government and civil society. For these diseases, policies dealt with key determinants (eg, the quality of water and basic sanitation, vector control), provided access to preventive resources (such as vaccines), and successfully integrated health policies with broader social policies. Diseases for which control has failed (such as dengue fever and visceral leishmaniasis) are vector-borne diseases with changing epidemiological profiles and major difficulties in treatment (in the case of dengue fever, no treatment is available). Diseases for which control has been partly successful have complex transmission patterns related to adverse environmental, social, economic, or unknown determinants; are sometimes transmitted by insect vectors that are difficult to control; and are mostly chronic diseases with long infectious periods that require lengthy periods of treatment.