Parenteral Antischistosomal Therapy Research Articles

Characterizing the historical role of parenteral antischistosomal therapy in hepatitis C virus transmission in Egypt.

BackgroundEgypt is the nation most affected by hepatitis C virus (HCV) infection, following an epidemic of historic proportions. We aimed to characterize the epidemic’s historical evolution and to delineate the role of parenteral antischistosomal therapy (PAT) campaigns in transmission.MethodsA mathematical model was constructed and analysed in order to understand HCV-transmission dynamics. The model was fitted to Egypt’s Demographic and Health Survey data and to a systematic database of HCV-prevalence data.ResultsThe incidence rate peaked in 1966 at 15.7 infections per 1000 person-years—a period of time that coincides with the PAT campaigns—and rapidly declined thereafter, beginning the mid-1990s. The annual number of new infections peaked in 1993 at 581 200 (with rapid demographic growth), leading to a high-incidence-cohort effect, and declined to 67 800 by 2018. The number of individuals ever infected (1950–2018) was 16.4 million, with HCV prevalence peaking in 1979. The number of individuals ever exposed to PAT was 8.3 million; however, of these individuals, 7.3 million were alive in 1980 and only 3.5 million alive in 2018. The number of individuals ever infected due to PAT exposure was 963 900, with 850 200 individuals alive in 1980 and only 389 800 alive in 2018. The proportion of PAT-attributed prevalent infections peaked at 19.9% in 1972, declining to 5.5% by 2018.ConclusionsPAT campaigns played an important role in HCV transmission, yet explain only 6% of infections—they appear to be a manifestation, rather than a cause, of the epidemic. A possible driver of the epidemic could be the mass expansion of inadequate-quality healthcare during PAT campaigns and subsequent decades. Despite a historic toll, the epidemic has been rapidly diminishing since the mid-1990s.

Geospatial epidemiology of hepatitis C infection in Egypt 2017 by governorate

BackgroundGeographic Information Systems (GIS) and spatial epidemiological methods may provide a basis for disease investigation through which hotspots and disease determinants can be identified. Applying these methods for hepatitis C virus (HCV) in Egypt would support a more effective strategy to control its transmission. Therefore, this study used GIS software to draw one of the first HCV maps in Egypt elucidating and analyzing geographical and epidemiological differences in HCV distribution within the country. MethodsA cross-sectional survey of 21 governorates (n = 12169, 8080 rural, 3733 urban and 356 slums areas) was completed. All participants were interviewed regarding potential exposures to HCV. Third generation ELISA was used to test serum for HCV antibody. Quantitative real-time RT-PCR was used to test anti-HCV positive subjects for HCV-RNA. ResultsThe participants ranged in age from 14-90 years. Overall, anti-HCV sero-prevalence was 14.8%. The prevalence of HCV-RNA, was 9.5%. Proportionally, 65.8% of anti-HCV positives were positive for HCV-RNA. The map of Egyptian governorates highlighted the darkest spot of HCV infection in Menoufeya (37.8%) followed by Beni Suef (29.2%) and Minya (28.6%). Anti-HCV prevalence was higher among males and logistic regression models revealed a strong independent association with increasing age, rural residence and parenteral anti-schistosomal therapy. ConclusionsRural residences and HCV hotspots should be prioritized for HCV prevention programs. The unique age distribution first shown in this study shows that the older age groups (≥60 years old) constitutes a considerable reservoir of infection and must not be neglected.

Household Contacts of HCV Patients at Beltag Village, Egypt; Seropositivity and Habits

Background : Hepatitis C virus (HCV) is a major cause of chronic hepatitis and is considered as a worldwide problem. Egypt has the highest HCV prevalence in the world. The Centers for Disease Control and Prevention (CDC) recommend HCV screening for all adults at high risk of infection. Aim of the study: To determine the prevalence of HCV seropositivity among household contacts of HCV positive patients and study their habits. Methods: A cross sectional study was conducted in Beltag; a rural village affiliated to Nile Delta. Interviewed questionnaire was used including sociodemographic data and HCV risk factors information. All household contacts were assessed for HCV infection by testing for anti-HCV antibody using a commercial ELISA. Results: 102 of HCV hepatitis patients and 360 of their household contacts were included in the study. The prevalence of HCV seropositivity among household contacts was 35%. 78(61.9%) of seropositive contacts were over forty years old, 42(33.3%) received parenteral anti-schistosomal therapy, 72(57.1%) helped family HCV patients during bleeding episodes. Logistical regression showed that the most significant variable associated independently to HCV seropositivity in patients' contacts was helping HCV patients during bleeding episodes (OR = 7.262; 95% CI: 3.588– 14.698 p 0.000). Conclusion: This study approximates the findings of other studies which reported a high prevalence seropositivity among HCV patient’s contacts. Help HCV patients during bleeding episodes is the most significant risk factor for intrafamilial HCV transmission. Keywords HCV Patients , Seropositivity , Household contacts.

Coinfection of Schistosoma Species with Hepatitis B or Hepatitis C Viruses.

Coinfection of Schistosoma Species with Hepatitis B or Hepatitis C Viruses.

Viral transmission risk factors in an Egyptian population with high hepatitis C prevalence.

BackgroundEgypt has the world’s highest prevalence of infection with hepatitis C virus (HCV), which is a major cause of hepatocellular carcinoma. The high HCV prevalence is largely attributed to the parenteral antischistosomal therapy (PAT) campaigns conducted from the 1950s through the 1980s; however, the primary modes of transmission in the post-PAT period are not well known. In this study we examined the associations between HCV prevalence and exposures to risk factors, including PAT, in a high HCV prevalence population.MethodsUsing a cross-sectional design, we examined the associations between demographic characteristics and risk factors for HCV transmission and HCV positivity prevalence among a sample of Egyptian residents. Data were collected through an interview-administered survey, and the association estimates were determined using χ2 and logistic regression.ResultsThe highest HCV positivity prevalence was observed in cohorts born before 1960, and declined precipitously thereafter; whereas the proportion of subjects reporting PAT remained relatively stable. Being male, having a rural residence, and having received PAT were all associated with HCV positivity; however, PAT alone could not account for the high prevalence of HCV.ConclusionsIn Egypt, PAT and other transmission factors yet to be identified, as well as cohorts born before the 1960s and infected with HCV, are most likely the main contributors to the current HCV endemic.

Seroprevalence, Immunostatus and Factors Associated with Blood Borne Viral Infections Among Egyptian Municipal Solid Waste Workers

Abstract Objectives Waste collectors have a potential risk of infectious diseases. The high prevalence of viral hepatitis B and C in Egypt has elevated the concern regarding the potential for disease transmission among municipal solid waste workers (MSWWs) from solid waste stream sources. Such transmission has never been epidemiologically demonstrated. This study aimed to explore the occurrence of HIV, Hepatitis B and C and to describe possible ways of virus transmission among MSWWs in Egypt. Methods A descriptive cross-sectional study was conducted among 346 MSWWs recruited from the main municipality in Alexandria, Egypt. Study procedure entailed interviews using a predesigned questionnaire and blood testing for the blood borne viral markers. Analytical statistics were used to identify independent factors correlated with HCV and HBV infections. Results: Overall seroprevalences were: hepatitis B; 36.1%; hepatitis C; 8.4%; and HIV; 0.0%. About 50% of the participants were at risk of HBV infection. Subjects were characterized by a predominance of males with low educational and economic levels. HBV infection was found to be significantly associated with younger age, folk circumcision, and the presence of genital complains suggestive of STDs while HCV infection was primarily associated with past history of parenteral anti-schistosomal therapy, intravenous infusion and direct exposure to solid waste. Conclusion The present work provides a strong evidence of increased occupational risk of blood borne viral infections among MSWWs. This mandates the need of compulsory HBV immunization proph.

Reexamination of the relationship between the prevalence of hepatitis C virus and parenteral antischistosomal therapy among Egyptians resident in Qatar.

Egypt has the highest prevalence of recorded hepatitis C virus (HCV) worldwide, estimated nationally at 14.7%, which is attributed to extensive iatrogenic transmission during the era of parenteral antischistosomal therapy (PAT) mass-treatment campaigns. The objective of our study was to attempt to highlight to what extent HCV transmission is ongoing and discuss the possible risk factors. We studied the prevalence of HCV among 7.8% of Egyptians resident in Qatar in relation to age, socioeconomic status, and PAT and discuss the possible risk factors. HCV testing was conducted in 2,335 participants, and results were positive for 13.5%, and 8.5% for those aged below 35 years. The prevalence of HCV in the PAT-positive population was 23.7% (123 of 518, 95% confidence interval [CI] 20.2%–27.6%) compared with 11.2% in the PAT-negative group. Significantly higher HCV prevalence occurred in participants who were older than 50 years (23%, 95% CI 19.3%–27.1%) compared to those aged 45–50 years (19.3%, 95% CI 15.2%–23.8%), 35–45 years (11.1%, 95% CI 8.9%–13.7%), and less than 35 years (8.5%, 95% CI 6.8%–10.4%) (P<0.0001). Insignificant higher prevalence occurred in the low socioeconomic group (14.2%, 95% CI 11.3%–17.4%). Logistic regression analysis revealed that increasing age, history of PAT, bilharziasis, and praziquantel were common risk factors, but there was no relation with dental care. Host genetic predisposition seems to be a plausible underlying factor for susceptibility among Egyptians and intense ongoing infection.

Spatial epidemiology of hepatitis C virus infection in Egypt: Analyses and implications

Egypt has the highest hepatitis C virus (HCV) prevalence in the world (14.7%). The drivers of the HCV epidemic in Egypt are not well understood, but the mass parenteral antischistosomal therapy (PAT) campaigns in the second half of the 20th century are believed to be the determinant of the high prevalence. We studied HCV exposure in Egypt at a microscale through spatial mapping and epidemiological description of HCV clustering. The source of data was the 2008 Egypt Demographic and Health Survey. We identified clusters with high and low HCV prevalence and high and low PAT exposure using Kulldorff spatial scan statistics. Correlations across clusters were estimated, and each cluster age-specific HCV prevalence was described. We identified six clusters of high HCV prevalence, three clusters of low HCV prevalence, five clusters of high PAT exposure, and four clusters of low PAT exposure. HCV prevalence and PAT exposure were not significantly associated across clusters (Pearson correlation coefficient [PCC] = 0.36; 95% confidence interval [CI] −0.12 to 0.71). Meanwhile, there was a strong association between HCV prevalence in individuals older than 30 years of age (who could have been exposed to PAT) and HCV prevalence in individuals 30 years of age or younger (who could not have been exposed to PAT) (PCC = 0.81; 95% CI 0.55-0.93). Conclusion: The findings illustrate a spatial variation in HCV exposure in Egypt. The observed clustering was suggestive of an array of iatrogenic risk factors, besides past PAT exposure, and ongoing transmission. The role of PAT exposure in the HCV epidemic could have been overstated. Our findings support the rationale for spatially prioritized interventions. (Hepatology 2014;60:1150–1159)

The epidemiology of hepatitis C virus in Egypt: a systematic review and data synthesis.

BackgroundEgypt has the highest prevalence of hepatitis C virus (HCV) in the world, estimated nationally at 14.7%. Our study’s objective was to delineate the evidence on the epidemiology of HCV infection among the different population groups in Egypt, and to draw analytical inferences about the nature of HCV transmission in this country.MethodsWe conducted a systematic review of all data on HCV prevalence and incidence in Egypt following PRISMA guidelines. The main sources of data included PubMed and Embase databases. We also used a multivariate regression model to infer the temporal trend of HCV prevalence among the general population and high risk population in Egypt.ResultsWe identified 150 relevant records, four of which were incidence studies. HCV incidence ranged from 0.8 to 6.8 per 1,000 person-years. Overall, HCV prevalence among pregnant women ranged between 5-15%, among blood donors between 5-25%, and among other general population groups between 0-40%. HCV prevalence among multi-transfused patients ranged between 10-55%, among dialysis patients between 50-90%, and among other high risk populations between 10% and 85%. HCV prevalence varied widely among other clinical populations and populations at intermediate risk. Risk factors appear to be parenteral anti-schistosomal therapy, injections, transfusions, and surgical procedures, among others. Results of our time trend analysis suggest that there is no evidence of a statistically significant decline in HCV prevalence over time in both the general population (p-value: 0.215) and high risk population (p-value: 0.426).ConclusionsEgypt is confronted with an HCV disease burden of historical proportions that distinguishes this nation from others. A massive HCV epidemic at the national level must have occurred with substantial transmission still ongoing today. HCV prevention in Egypt must become a national priority. Policymakers, and public health and medical care stakeholders need to introduce and implement further prevention measures targeting the routes of HCV transmission.

Screening for hepatitis B and C in first‐generation Egyptian migrants living in the Netherlands

Egypt has high prevalence of hepatitis C virus (HCV) infection and intermediate prevalence of hepatitis B virus (HBV) infection; however, infection prevalence among Egyptian migrants is unknown. Considering the asymptomatic onset and development of disease in chronically-infected patients, many may remain undiagnosed. To evaluate an HCV- and HBV-screening programme designed to identify undetected infections among first-generation Egyptian migrants in Amsterdam, the Netherlands. In 2009 and 2010, viral hepatitis educational and screening sessions were established at Egyptian meeting places. Data regarding demographics and HCV risk factors were collected. Chronically infected participants were referred and followed up. Phylogenetic analyses were used to ascertain the geographic origin of infections. Eleven of 465 (2.4%; 95% CI = 1.3-4.2%) migrants had HCV antibodies; 10/11 were HCV RNA positive. All had genotype 4a, and strains were typical of those of Egypt and the Middle East. Older age and exposure to parenteral antischistosomal therapy (PAT) were significantly associated with HCV. Anti-HBc prevalence was 16.8% (95% CI = 13.7-20.4%); HBsAg prevalence was 1.1% (95% CI = 0.5-2.5%). All had genotype D, typical of those of the Middle East. Most (9/10 HCV; 3/5 HBV) chronic infections were newly diagnosed; four of the HCV-infected individuals started treatment. Anti-HCV and HBsAg prevalence among Egyptian migrants was lower compared with the general Egyptian population, but higher than the general population of Western countries. Phylogenetic analyses suggest that all infections were from the region of origin. HCV-screening programmes should target first-generation Egyptian migrants, especially those of older age and those who received PAT.

Burden of pediatric hepatitis C

Hepatitis C virus (HCV) is a major health burden infecting 170-210 million people worldwide. Additional 3-4 millions are newly-infected annually. Prevalence of pediatric infection varies from 0.05%-0.36% in the United States and Europe; up to 1.8%-5.8% in some developing countries. The highest prevalence occurs in Egypt, sub-Saharan Africa, Amazon basin and Mongolia. HCV has been present in some populations for several centuries, notably genotypes 1 and 2 in West Africa. Parenteral anti-schistosomal therapy practiced in the 1960s until the early 1980s had spread HCV infection throughout Egypt. Parenteral acquisition of HCV remains a major route for infection among Egyptian children. Insufficient screening of transfusions, unsterilized injection equipment and re-used needles and syringes continue to be major routes of HCV transmission in developing countries, whereas vertical transmission and adolescent high-risk behaviors (e.g., injection drug abuse) are the major routes in developed countries. The risk of vertical transmission from an infected mother to her unborn/newborn infant is approximately 5%. Early stages of HCV infection in children do not lead to marked impairment in the quality of life nor to cognitive, behavioral or emotional dysfunction; however, caregiver stress and family system strain may occur. HCV slowly progresses to serious complications as cirrhosis (1%-2%) and hepatocellular carcinoma (HCC) especially in the presence of risk factors as hemolytic anemias, obesity, treated malignancy, and concomitant human immune deficiency and/or hepatitis B virus co-infection. HCV vaccine remains elusive to date. Understanding the immune mechanisms in patients who successfully cleared the infection is essential for vaccine development. The pediatric standard of care treatment consists of pegylated interferon-α 2a or b plus ribavirin for 24-48 wk. The new oral direct acting antivirals, approved for adults, need further evaluation in children. Sustained virologic response varies depending on the viral load, genotype, duration of infection, degree of aminotransferase elevation, adiposity and single nucleotide polymorphisms of interleukin (IL)-28B locus. The goals of treatment in individual patients are virus eradication, prevention of cirrhosis and HCC, and removing stigmatization; meanwhile the overall goal is decreasing the global burden of HCV. IL-28B polymorphisms have been also associated with spontaneous clearance of vertically acquired HCV infection. The worldwide economic burden of HCV for children, families and countries is estimated to be hundreds of millions of US dollars per year. The United States, alone, is estimated to spend 199-336 million dollars in screening, monitoring and treatment during one decade. The emotional burden of having an HCV infected child in a family is more difficult to estimate.

Persistance of HBsAg, liver enzyme changes and risk factors of hepatitis B infection among chronic carriers of hepatitis B

as high as 58.2% in multi-transfused children, 51.6% in children on hemodialysis and 87.5% in adult dialysis patients. Among populations at indirect risk, family contacts of HCV positive individuals had a prevalence of 5.7%, diabetic children a prevalence of 3.1%, select professions such as barbers 12.3%, and health care workers 15.7%, while Injection drug users and prisoners had a prevalence of 63% and 31.4%, respectively. Common risk factors appear to be increasing age, parenteral anti-schistosomal therapy, frequent transfusions, injections or surgical procedures. Conclusion: With the highest HCV prevalence in the world, Egypt appears to be experiencing an HCV epidemic. High HCV prevalence levels especially among select clinical populations, is indicative of ongoing iatrogenic transmission. Therefore, prevention programs need to be developed targeting HCV transmission routes suchasbetter infection control practices inhospitals, healthcare and dental care facilities.

Abstract 1812: Urban-rural distribution of cancer profiles in Gharbiah, Egypt

Abstract In our previous studies, we observed higher incidence for certain malignancies in urban areas in Gharbiah, Egypt compared to rural areas. Here we present the results of our further investigations on urban-rural differences for other cancer sites in the same population. Using data from the Gharbiah population-based cancer registry, we compared urban-rural incidence rates of the ten most common cancers in men and women over four years (1999-2002). Census data provided accurate denominators and standard urban-rural definitions. Crude and adjusted incidence rates (IRs), incidence rate ratios (IRRs) and 95% confidence intervals (CIs) were estimated using Poisson regression. Comparing genders, incidence of all cancer sites was higher among men than women for both urban and rural areas with laryngeal cancer (IRR = 13.75, 95% CI = 4.96, 38.10) and liver cancer (IRR = 4.50, 95% CI = 3.63, 5.68) in rural men being much higher than rural women. Also, bladder cancer among urban men was much higher than in urban women (IRR = 5.12, 95% CI = 4.13, 6.35). Among both males and females, urban incidence was higher than rural incidence for all cancer sites. Among males, urban-rural incidence difference was highest for prostate cancer (IRR = 4.85, 95% CI = 3.76, 6.26) followed by larynx (IRR = 4.19, 95% CI = 3.06, 5.73), and brain and CNS (IRR = 3.95, 95% CI = 3.00, 5.20). Among females, urban-rural incidence difference was highest for uterus (IRR = 6.05, 95% CI = 4.17, 8.78) followed by larynx (IRR = 5.54, 95% CI = 1.74, 17.61), and breast (IRR = 4.87, 95% CI = 4.50, 5.27). Analysis of the urban-rural differences by district revealed that among males and females, urban incidence was higher than rural incidence in most of the 8 districts of Gharbiah, for all cancer sites. The highest urban-rural difference within districts for males was seen for laryngeal cancer in El Santa (IRR = 29.45, 95% CI = 10.63, 81.61) followed by prostate cancer in Kafr-El-zayat (IRR = 15.58, 95% CI = 5.20, 46.69). Noticeably, we discovered that El-Santa had the highest difference of urban-rural incidence for most cancer sites except prostate and pancreas. Among females, the highest urban-rural difference within districts was seen for uterine cancer in El Santa (IRR = 15.98, 95% CI = 2.69, 95.10) followed by lung cancer in Kotoor (IRR = 10.78, 95% CI = 3.14, 37.06). High smoking and higher exposure to S. hematobium followed by parenteral anti-schistosomal therapy among men in Egypt may have led to an increase in laryngeal, bladder, and liver cancer. Better healthcare access and more awareness are most likely responsible for high ascertainment of prostate, brain &amp; CNS in urban males. Among urban women, higher exposure to environmental risks and better access might be responsible for higher rates of uterine and breast cancer. Urban-rural differences within districts need to be investigated with respect to industrial pollution, pesticide use, and other toxins to further define the etiology of various cancers in this population. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 1812.

Emergence of Hepatitis C Virus Genotype 4: Phylogenetic Analysis Reveals Three Distinct Epidemiological Profiles

Hepatitis C virus (HCV) genotype 4 (HCV-4) infection is considered to be difficult to treat and has become increasingly prevalent in European countries, including The Netherlands. Using a molecular epidemiological approach, the present study investigates the genetic diversity and evolutionary origin of HCV-4 in Amsterdam, The Netherlands. Phylogenetic analysis of the NS5B sequences (668 bp) obtained from 133 patients newly diagnosed with HCV-4 infection over the period from 1999 to 2008 revealed eight distinct HCV-4 subtypes; the majority of HCV-4 isolates were of subtypes 4d (57%) and 4a (37%). Three distinct monophyletic clusters were identified, with each one having a specific epidemiological profile: (i) Egyptian immigrants infected with HCV-4a (n = 46), (ii) Dutch patients with a history of injecting drug use infected with HCV-4d (n = 44), and (iii) Dutch human immunodeficiency virus (HIV)-positive men who have sex with men (MSM) infected with HCV-4d (n = 26). Subsequent molecular clock analyses confirmed that the emergence of HCV-4 within these three risk groups coincided with (i) the parenteral antischistosomal therapy campaigns in Egypt (1920 to 1960), (ii) the popularity of injecting drug use in The Netherlands (1960 to 1990), and (iii) the rise in high-risk sexual behavior among MSM after the introduction of highly active antiretroviral therapy (1996 onwards). Our data show that in addition to the influx of HCV-4 strains from countries where HCV-4 is endemic, the local spread of HCV-4d affecting injecting drug users and, in recent years, especially HIV-positive MSM will further increase the relative proportion of HCV-4-infected patients in The Netherlands. HCV-4-specific agents are drastically needed to improve treatment response rates and decrease the future burden of HCV-4-related disease.

Epidemiology of viral hepatitis in Sudan

Hepatitis virus infections are the most common cause of liver disease worldwide. Sudan is classified among the countries with high hepatitis B virus seroprevalence. Exposure to the virus varied from 47%-78%, with a hepatitis B surface antigen prevalence ranging from 6.8% in central Sudan to 26% in southern Sudan. Studies pointed to infection in early childhood in southern Sudan while there was a trend of increasing infection rate with increasing age in northern Sudan. Hepatitis B virus was the commonest cause of chronic liver disease and hepatocellular carcinoma and was the second commonest cause of acute liver failure in the Sudan. Studies of hepatitis C virus showed a low seroprevalence of 2.2%-4.8% and there was no association with schistosomiasis or with parenteral antischistosomal therapy. Hepatitis E virus was the commonest cause of acute hepatitis among pediatric, adult, and displaced populations. Recent introduction of screening of blood and blood products for hepatitis B virus and hepatitis C virus infections and the introduction of hepatitis B virus vaccine as part of the extended program of immunization is expected to reduce the infection rate of these viruses in the Sudan.

Prevalence and common genotypes of HCV infection in Sudanese patients with hepatosplenic schistosomiasis

A cross-sectional hospital based study was carried out at the National Center for Gastrointestinal and Liver Disease in Khartoum, Sudan to determine the prevalence, common genotypes and risk factors for hepatitis C virus infection in Sudanese patients with hepatosplenic schistosomiasis. A total of 176 patients with hepatosplenic schistosomiasis were tested for HCV antibodies and 4.5% of the samples were reactive. PCR was positive in 2.3% of cases and genotype 4 was the major genotype isolated with subtypes 4, 4e, and 4c/4d. It is concluded that HCV was of low seroprevalence in the study population and that parenteral antischistosomal therapy was not a significant risk factor in transmission of infection in the Sudan.

Epidemiology of HCV infection in Gezira state of central Sudan

This is a cross sectional study carried out in Gezira state of central Sudan, an area with a high prevalence of Schistosoma mansoni infection, to determine the prevalence of hepatitis C virus (HCV) antibodies and risks factors for HCV infection. A total of 410 subjects in Um Zukra village were tested for HCV antibodies, 2.2% were reactive. The prevalence was highest in those between 11 and 20 years old with equal prevalence among males and females. No correlation was found between HCV infection and S. mansoni infection or parenteral antischistosomal therapy. It was concluded that HCV infection is of low seroprevalence and that schistosomiasis and parenteral antischistosomal therapy are not major risk factors for infection in the population studied.

High Rate of Infection with Hepatitis C Virus Genotype 4 in a District of Galicia, Spain

It is estimated that 170 million individuals are infected with hepatitis C virus (HCV) worldwide (6). The genetic heterogeneity of the virus has revealed six major genotypes. Most of the information on treatment of chronic hepatitis C comes from genotypes 1, 2, and 3, the predominant strains in the United States and Europe. Genotype 4 is more prevalent in Africa and the Middle East and has been frequently associated with evolution to cirrhosis and a poor response to conventional alpha interferon-based regimens (2, 8). The aim of this study is to evaluate epidemiological factors, liver histology, and response to combination therapy with interferon and ribavirin of a series of patients infected with genotype 4. From a total of 350 patients with hepatitis C referred to our Liver Unit from January 1999 to June 2004, 33 patients infected with genotype 4 (9.4%) were identified. Information about their demographics, mode of transmission, and laboratory data was collected. The date of transmission of infection was established by the year of first use of drugs in the case of intravenous drug use and snorting of cocaine and the year of the transfusion, surgery, or tattoo for the remaining forms of transmission. Serum HCV RNA levels were quantified by reverse transcription-PCR assay (Amplicor Monitor HCV 2.0; Roche). HCV genotyping was carried out using a line probe assay (INNO-LIPA HCV II; Innogenetics, Ghent, Belgium). Liver histology was available for 25 patients, and the histological fibrosis stage was assessed according to the score of Scheuer. Thirteen patients were treated with alpha-2b interferon and ribavirin in combination at standard doses. Six were treated with pegylated interferon and ribavirin. HCV RNA was assessed at baseline and at 3, 12, and 18 months after starting treatment. Sustained virologic response was defined as negative HCV RNA 6 months after treatment was stopped. The baseline demographics, liver histology, and biochemical data from these patients are summarized in Table ​Table1.1. All the patients were natives of Galicia and denied having traveled to areas of endemicity. A risk factor for exposure to HCV was noted for most of the patients (90.9%), and the main route of infection was intravenous drug use. The estimated mean age at the moment of infection was 22.4 ± 9.8 years. TABLE 1. Characteristics of genotype 4 patients The baseline HCV RNA level was above 2 × 106 copies/ml in nine cases. Most of the patients had mild to moderate liver disease on biopsy. Only one patient had cirrhosis by clinical, endoscopic, and ultrasonographic criteria. Mixed-genotype HCV infection was not detected in this population. Twelve patients have completed 12 months of therapy. Only one patient discontinued therapy because of side effects. Ten of the patients who completed treatment were considered sustained responders, whereas one was a nonresponder and one relapsed. Overall, 10 of the 13 patients who initiated therapy (76.9%) had a sustained response. Six of them were treated with pegylated interferon and four with standard interferon in combination with ribavirin. Patients with pretreatment HCV-RNA levels lower than 2 × 106 copies/ml had a significantly higher rate of sustained virologic response than patients with a higher viral load (P = 0.03), whereas the liver fibrosis score did not affect the response. The rate of 9.4% for this genotype in our area is noteworthy for a Western country, though it has been found in other districts of northern and southern Spain, in the latter with an even higher frequency (4, 3). Epidemiological and clinical characteristics found in this series differ from those for African and Middle Eastern countries. All patients were white, and, as expected in the Occidental world, the predominant mode of acquisition of the infection was intravenous drug use in almost two-thirds of the cases. This is in agreement with reports from other Western countries. In contrast, a high proportion of HCV infection from an unknown source was observed in Egypt, a country with one of the highest prevalences of genotype 4, and in Kuwait (2). An iatrogenic route was suggested by a study in Egypt, with a major role for parenteral antischistosomal therapy in the spread of HCV (1). The histological stage assessment reflects mild to moderate liver disease. On the other hand, studies with African and Middle Eastern populations suggest a frequent association with cirrhosis and a rapid fibrosis progression rate following liver transplantation (5, 7). Although this genotype was previously categorized as difficult to treat, our results are in accordance with the more recent trials that suggest a response intermediate between those of genotype 1 and non-1 genotypes. In conclusion, the prevalence of genotype 4 in our area is high in comparison with that for other Western countries. The majority of patients acquired the infection through intravenous drug use and had a histological assessment of mild to moderate liver disease.

Expected increase in hepatitis C-related mortality in Egypt due to pre-2000 infections

Egypt has the highest prevalence of Hepatitis C Virus (HCV) in the world, apparently due to mass parenteral antischistosomal therapy. Estimating the future burden of HCV in Egypt is important to support health policies to combat the epidemic. A previous back calculation model was adapted to the situation in Egypt. It combines a model of the natural history of HCV infections with available epidemiological data to back calculate the past HCV incidence from observed 1980-1999 hepatocellular carcinoma (HCC) mortality. In turn, the HCV-related mortality burden is projected in the future due to pre-2000 infections. Compared with the observed number of HCC deaths in 1999, the model predicts a 3.5-fold increase in this mortality in the next 20 years. Globally, the model predicts a 2.4-fold increase in the HCV-related mortality. These predictions do not take into account the new infections that may occur after 2000, which would still increase the estimated future mortality burden. HCV-related mortality is expected at least to double in the next 20 years. The use of antiviral therapies can lower these predictions. Efficient prevention policies are needed to avoid these predictions being exceeded.

Low prevalence of hepatitis C virus antibodies in HIV-endemic area of Zimbabwe support sexual transmission as the major route of HIV transmission in Africa.

Medical injections have recently been suggested to cause a large proportion of African HIV infections. If this hypothesis is true, high prevalences of other infections transmitted by injections should be expected. In a cohort of 145 HIV-negative and 124 HIV-positive individuals from a rural area of Zimbabwe with a high HIV prevalence we only found one with antibodies to hepatitis C virus. This does not support injections playing a major role in HIV transmission in sub-Saharan Africa.