Historical epidemiology of hepatitis C virus in select countries-volume 4

Due to the introduction of newer, more efficacious treatment options, there is a pressing need for policy makers and public health officials to develop or adapt national hepatitis C virus (HCV) control strategies to the changing epidemiological landscape. To do so, detailed, country-specific data are needed to characterize the burden of chronic HCV infection. In this study of 17 countries, a literature review of published and unpublished data on HCV prevalence, viraemia, genotype, age and gender distribution, liver transplants and diagnosis and treatment rates was conducted, and inputs were validated by expert consensus in each country. Viraemic prevalence in this study ranged from 0.2% in Hong Kong to 2.4% in Taiwan, while the largest viraemic populations were in Nigeria (2 597 000 cases) and Taiwan (569 000 cases). Diagnosis, treatment and liver transplant rates varied widely across the countries included in this analysis, as did the availability of reliable data. Addressing data gaps will be critical for the development of future strategies to manage and minimize the disease burden of hepatitis C.

Adjusted estimate of the prevalence of hepatitis delta virus in 25 countries and territories

BACKGROUND & AIMS

Hepatitis delta virus (HDV) is a satellite RNA virus that requires the hepatitis B virus (HBV) for assembly and propagation. Individuals infected with HDV progress to advanced liver disease faster than HBV-monoinfected individuals. Recent studies have estimated the global prevalence of anti-HDV antibodies among the HBV-infected population to be 5-15%. This study aimed to better understand HDV prevalence at the population level in 25 countries/territories.

METHODS

We conducted a literature review to determine the prevalence of anti-HDV and HDV RNA in hepatitis B surface antigen (HBsAg)-positive individuals in 25 countries/territories. Virtual meetings were held with experts from each setting to discuss the findings and collect unpublished data. Data were weighted for patient segments and regional heterogeneity to estimate the prevalence in the HBV-infected population. The findings were then combined with The Polaris Observatory HBV data to estimate the anti-HDV and HDV RNA prevalence in each country/territory at the population level.

RESULTS

After adjusting for geographical distribution, disease stage and special populations, the anti-HDV prevalence among the HBsAg+ population changed from the literature estimate in 19 countries. The highest anti-HDV prevalence was 60.1% in Mongolia. Once adjusted for the size of the HBsAg+ population and HDV RNA positivity rate, China had the highest absolute number of HDV RNA+ cases.

CONCLUSIONS

We found substantially lower HDV prevalence than previously reported, as prior meta-analyses primarily focused on studies conducted in groups/regions that have a higher probability of HBV infection: tertiary care centers, specific risk groups or geographical regions. There is large uncertainty in HDV prevalence estimates. The implementation of reflex testing would improve estimates, while also allowing earlier linkage to care for HDV RNA+ individuals. The logistical and economic burden of reflex testing on the health system would be limited, as only HBsAg+ cases would be screened.

IMPACT AND IMPLICATIONS

There is a great deal of uncertainty surrounding the prevalence of hepatitis delta virus among people living with hepatitis B virus at the population level. In this study, we aimed to better understand the burden in 25 countries and territories, to refine techniques that can be used in future analyses. We found a lower prevalence in the majority of places studied than had been previously reported. These data can help inform policy makers on the need to screen people living with hepatitis B virus to find those coinfected with hepatitis delta virus and at high risk of progression, while also highlighting the pitfalls that other researchers have often fallen into.

The present and future disease burden of hepatitis C virus infections with today's treatment paradigm: Volume 4

Factors influencing the morbidity and mortality associated with viremic hepatitis C virus (HCV) infection change over time and place, making it difficult to compare reported estimates. Models were developed for 17 countries (Bahrain, Bulgaria, Cameroon, Colombia, Croatia, Dominican Republic, Ethiopia, Ghana, Hong Kong, Jordan, Kazakhstan, Malaysia, Morocco, Nigeria, Qatar and Taiwan) to quantify and characterize the viremic population as well as forecast the changes in the infected population and the corresponding disease burden from 2015 to 2030. Model inputs were agreed upon through expert consensus, and a standardized methodology was followed to allow for comparison across countries. The viremic prevalence is expected to remain constant or decline in all but four countries (Ethiopia, Ghana, Jordan and Oman); however, HCV-related morbidity and mortality will increase in all countries except Qatar and Taiwan. In Qatar, the high-treatment rate will contribute to a reduction in total cases and HCV-related morbidity by 2030. In the remaining countries, however, the current treatment paradigm will be insufficient to achieve large reductions in HCV-related morbidity and mortality.

Strategies to manage hepatitis C virus infection disease burden-Volume 4

The hepatitis C virus (HCV) epidemic was forecasted through 2030 for 17 countries in Africa, Asia, Europe, Latin America and the Middle East, and interventions for achieving the Global Health Sector Strategy on viral hepatitis targets-"WHO Targets" (65% reduction in HCV-related deaths, 90% reduction in new infections and 90% of infections diagnosed by 2030) were considered. Scaling up treatment and diagnosis rates over time would be required to achieve these targets in all but one country, even with the introduction of high SVR therapies. The scenarios developed to achieve the WHO Targets in all countries studied assumed the implementation of national policies to prevent new infections and to diagnose current infections through screening.

Lamivudine induced stable reversal in HBV liver cirrhosis Child C: a case report

A 40-year-old viremic woman with HBV related liver cirrhosis (Child-Plugh - C) received 100 mg lamivudine daily for 24 months. Initially the patient was with hepato-splenomegaly, marked ascites and mild jaundice. There were no signs of portal encephalopaty and gastrointestinal haemorrhage. The baseline ALT was about 6 times above the upper limit of normal. Hypoalbuminemia of 29 g/l as well as hyperbilirubinemia of 40 mmol/L and decreased protrombin index of 47% was found. Serological tests showed positive serum HBsAg and anti-HBe antibodies. The patient was HBeAg negative, but with detectable serum HBV DNA (500 pg/mL) by dot-blot hybridization HDV, HCV and HIV co-infections were excluded. A marked improvement in liver function had been found at the end of the third month of therapy, with normalization of bilirubin and ALT activity. Serum albumin and protrombine index increased from 29 g/l to 36 g/l and from 47% to 92%, respectively. The patient was without ascites and Child-Plough score decreased from 10 to 5 points. Serum HBV DNA rapidly decreased at the end of first treatment month and was undetectable three months after the initiation of lamivudine therapy. We found two viremic episodes during the lamivudine treatment. However, Child-Pugh score did not increased and the patient remained with compensated liver disease and with lower ALT than baseline value. The main question is haw long such patients have to receive the lamivudine treatment.

Chronic HBV infection. Immunomodulation with levamisole in viremic HBeAg positive or anti-HBe positive patients--a pilot study

BACKGROUND/AIMS

We evaluated the effect of immunomodulatory treatment with levamisole in HBeAg positive or anti-HBe positive patients with chronic HBV infection and ongoing viral replication. The majority of patients had an expected poor response to IFN-alpha.

METHODOLOGY

Twenty-five viremic patients (15 males and 10 females) with chronic HBV infection were treated with Levamisole for 12 months or until negative serum HBV DNA occurred for at least 3 months. Viral replication and aminotransferase activity were controlled at the end of 3, 6, 9 and 12 months during the treatment.

RESULTS

A decrease of serum HBV DNA was noted when serum HBV DNA levels before and after treatment with levamisole were compared, by t-test for dependent samples (p < 0.05). There was a significant reduction of ALT activity, too. HBV DNA fell below the detection limit of our assay at the end of 3, 6, 9 and 12 months in 7, 7, 8 and 10 of the patients, respectively. In 3 of 16 initially HBeAg positive patients, seroconversion to anti-HBe antibody occurred. At the end of 12 months 10 patients were with negative serum HBV DNA and normal ALT activity. Two of them lost HBsAg during the treatment. Ten patients were without any effect from the therapy. The potential responder initially is anti-HBe positive, with low serum HBV DNA < 500 pg/ml and low ALT activity (< 3 times the upper limit of normal).

CONCLUSIONS

Immunomodulation with levamisole may benefit some patients with chronic ongoing viral replication including patients with expected poor response to IFN-alpha. This treatment could be used as an alternative therapeutic schedule in patients contraindicated for IFN-alpha, and also because it lowers treatment costs.