Where are people being tested for anti‐HCV in England? Results from sentinel laboratory surveillance

SUMMARY: Many people infected with hepatitis C virus (HCV) are unaware of their infection and are, therefore. potentially infectious to others. To enable effective case-finding policies to be developed, an understanding of where people, and injecting drug users (IDUs) in particular, are accessing HCV antibody testing is needed. HCV antibody testing data were collected electronically from 21 sentinel laboratories in England between 2002 and 2006 in this cross-sectional study. Service types of the physician requesting the HCV test were identified and classified. Differences in people being tested in each service type and over time were investigated. Over half a million people were tested in 5 years. Whilst most testing took place in hospital, a large proportion of people were tested in community care, particularly in general practice surgeries and genito-urinary medicine clinics. Younger people were more likely to be tested in community care, and there was evidence that testing differed according to ethnic status. IDUs were tested in all parts of the health services, although the highest proportion positive were from prisons and specialist services for drug users. Testing increased between 2002 and 2005 whilst the proportion of people testing positive declined. Routine laboratory data can provide valuable information on where people are being tested for HCV. Risk exposures should be investigated and testing targeted to people at higher risk for infection. Local laboratories should review data on testing locations and proportion positive to inform local initiatives to improve testing and yield.     

HCV In At Risk Populations: Who Can be Treated and How?

Hepatitis C virus (HCV), a major cause of chronic liver disease, affects an estimated 5 million people in the Unites States [1] and close to 170 million people worldwide. Certain subpopulations including injection drug users, prison inmates, the homeless, ethnic minorities, American veterans, and HIV co-infected patients are considered high risk for viral acquisition and are disproportionately affected by HCV. This review describes the prevalence of HCV in these at-risk populations including those with cirrhosis, chronic kidney disease (CKD), solid organ transplantation and presents current treatment options.     

北京市吸毒人群丙型肝炎病毒感染的流行病学监测

目的探讨吸毒人群丙型肝炎病毒(HCV)感染的流行率,并分析HCV感染的可能危险因素。方法 2006-2009年于在押吸毒人群中,采用标准化问卷收集人口学、危险行为等信息,采用酶联免疫吸附试验(ELISA)检测HCV抗体。结果 1 253名吸毒者中,总的HCV抗体阳性率为25.3%,注射吸毒者HCV抗体阳性率为66.6%。多因素Logistic回归分析提示,注射吸毒(调整OR=18.988,95%CI:13.860～26.013)为吸毒人群感染HCV的最主要危险因素;其次是共用注射器(调整OR=1.025,95%CI:0.604～1.739)。注射吸毒时间≥5年者感染HCV的危险性较<5年者高(调整OR=0.669,95%CI:0.084～1.089);没有职业的吸毒者感染HCV的危险性较有职业者高(调整OR=1.280,95%CI:0.866～1.893)。结论吸毒人群HCV流行水平较高,注射吸毒是流行的最主要原因。应采取有效措施预防该人群HCV的二代传播,为阳性患者提供治疗刻不容缓。     

Global epidemiology of hepatitis C virus infection

Hepatitis C virus (HCV) is a major cause of liver disease worldwide and a potential cause of substantial morbidity and mortality in the future. The complexity and uncertainty related to the geographic distribution of HCV infection and chronic hepatitis C, determination of its associated risk factors, and evaluation of cofactors that accelerate its progression, underscore the difficulties in global prevention and control of HCV. Because there is no vaccine and no post-exposure prophylaxis for HCV, the focus of primary prevention efforts should be safer blood supply in the developing world, safe injection practices in health care and other settings, and decreasing the number of people who initiate injection drug use.     

Hepatitis C virus in Pakistan： A systematic review of prevalence, genotypes and risk factors

In Pakistan more than 10 million people are living with Hepatitis C virus (HCV), with high morbidity and mortality. This article reviews the prevalence,genotypes and factors associated with HCV infection in the Pakistani population. A literature search was performed by using the keywords; HCV prevalence, genotypes and risk factors in a Pakistani population,in Pubmed, PakMediNet and Google scholar. Ninetyone different studies dating from 1994 to May 2009 were included in this study, and weighted mean and standard error of each population group was calculated.Percentage prevalence of HCV was 4.95% ± 0.53% in the general adult population, 1.72% ± 0.24% in the pediatric population and 3.64% ± 0.31% in a young population applying for recruitment, whereas a very high 57% ± 17.7% prevalence was observed in injecting drug users and 48.67% ± 1.75% in a multitransfused population. Most prevalent genotype of HCV was 3a. HCV prevalence was moderate in the general population but very high in injecting drug users and multi-transfused populations. This data suggests that the major contributing factors towards increased HCV prevalence include unchecked blood transfusions and reuse of injection syringes. Awareness programs are required to decrease the future burden of HCV in the Pakistani population.     

Factors related to screening of hepatitis C virus in general medicine

Despite the high prevalence of hepatitis C in France ( approximately 1.2%), a large proportion of people infected with hepatitis C virus (HCV) are not known aware of their status. The objective of this study was to investigate the factors related to screening in general medicine. MATERIAL AND METHODS: Three hundred and one general practitioners were interviewed by phone in South-Eastern France about their HCV screening practices, knowledge of the epidemic, of the natural course of the disease, and opinions about health care for people infected with HCV. RESULTS: While general practitioners often offered HCV screening to intravenous drug users, screening for people who had received blood transfusion, and identification of risk factors among patients were not satisfactory. Multivariate analysis showed that certain characteristics in general practitioners were negatively and independently related to the frequency of HCV screening, especially: general practitioners older than 40 (odds-ratio: 3.12), general practitioners who did not care for intravenous drug users (odds-ratio: 2.24) and did not prescribe human immunodeficiency virus tests (odds-ratio: 5.55). Other characteristics such as awareness of the course of hepatitis C and health care were also associated with HCV screening. Conversely knowledge of the size of the epidemic was not related to better HCV screening practices. CONCLUSION: Our study shows that knowledge about the size of the epidemic and the natural history of hepatitis C, HCV screening practices and investigation of risk factors among patients are not satisfactory among South-eastern French general practitioners. Although HCV screening and health care must be improved among intravenous drug users, hepatitis C should not be considered as a disease of injecting drug users only by general practitioners and the population. Efforts should be made so that hepatitis C is recognized as a global public health issue, and training of general practitioners should be improved to investigate risk factors and offer HCV screening instead of merely dramatizing the situation.     

不同人群丙型肝炎知识及行为和宣传材料需求调查

目的了解一般人群和高危人群对丙型肝炎（丙肝）防治知识的知晓情况及行为,对丙肝防治宣传材料的需求和喜好,为制定丙肝健康教育和宣传材料开发策略提供科学依据。方法采取随机整群抽样方法 ,对流动人口、城市居民、吸毒人员、暗娼4类人群进行匿名问卷调查和小组访谈。结果共回收有效问卷650份,调查流动人口155人,城市居民167人,吸毒人员219人,暗娼109人。丙肝传播途径知晓率依次为吸毒人员（8.3%）、暗娼（5.5%）、城市居民（1.8%）、流动人口（0.6%）。丙肝预防方法知晓率依次为城市居民（3.6%）、吸毒人员（0.9%）、流动人口（0%）、暗娼（0%）。丙肝高危行为普遍存在,一般人群主要为牙科治疗、内窥镜、手术等;高危人群主要为与他人共用注射器、多性伴等。绝大多数调查对象以往从未接触过丙肝防治宣传材料,对丙肝宣传材料喜好主要为科教片、读本、挂历台历、挂图等。结论各类人群丙肝知识知晓率普遍较低,亟需加强丙肝健康教育,开发适宜的传播材料。     

Centers for Disease Control and Prevention initiatives to prevent hepatitis C virus infection: a selective update

Hepatitis C virus (HCV) infection is a complex public health problem, characterized by a high prevalence of chronic infection, an increasing burden of HCV-associated disease, low rates of testing and treatment, and the prospect of increasing incidence associated with the epidemic of injection drug use. Three-quarters of chronic HCV infections occur among persons born from 1945 through 1965. Prevention efforts are complicated by limited knowledge among health care professionals, persons at risk and in the public at large. At the Centers for Disease Control and Prevention, efforts to improve primary and secondary prevention effectiveness center on policy development, education and training initiatives, and applied research. This report provides a brief overview of some of these efforts, including the development of testing recommendations for the 1945-1965 birth cohort, research and evaluation studies in settings where persons who inject drugs receive services, and a national viral hepatitis education campaign that targets health care professionals, the public, and persons at risk.     

Hepatitis B and C testing strategies in healthcare and community settings in the EU/EEA: A systematic review

An estimated 9 million individuals are chronically infected with hepatitis B virus (HBV) and hepatitis C virus (HCV) across the European Union/European Economic Area (EU/EEA), many of which are yet to be diagnosed. We performed a systematic review to identify interventions effective at improving testing offer and uptake in the EU/EEA. Original research articles published between 1 January 2008 and 1 September 2017 were retrieved from PubMed and EMBASE. Search strings combined terms for HBV/HCV, intervention, testing and geographic terms (EU/EEA). Out of 8331 records retrieved, 93 studies were selected. Included studies reported on testing initiatives in primary health care (9), hospital (12), other healthcare settings (31) and community settings (41). Testing initiatives targeted population groups such as migrants, drug users, prisoners, pregnant women and the general population. Testing targeted to populations at higher risk yielded high coverage rates in many settings. Implementation of novel testing approaches, including dried blood spot (DBS) testing, was associated with increased coverage in several settings including drug services, pharmacies and STI clinics. Community‐based testing services were effective in reaching populations at higher risk for infection, vulnerable and hard‐to‐reach populations. In conclusion, our review identified several successful testing approaches implemented in healthcare and community settings, including testing approaches targeting groups at higher risk, community‐based testing services and DBS testing. Combining a diverse set of testing opportunities within national testing strategies may lead to higher impact both in terms of testing coverage and in terms of reduction, on the undiagnosed fraction.     

Is Hepatitis C Infection Associated with Increased Risk of Depression in Persons with Methamphetamine Dependence?

The abuse of methamphetamine (MA) has increased in the United States over the past 15 years and is associated with considerable negative social, psychological, and health effects, including symptoms of depression. Infection with the hepatitis C virus (HCV), which is independently associated with increased risk of depression, is common among MA users, possibly due to high rates of transmission risk behaviors in this cohort (eg, injection drug use). Given the prevalence of depression among HCV-infected individuals and MA users separately, the current study aimed to determine whether HCV infection and MA dependence are associated with additive effects on depression. Focused psychiatric evaluations were conducted on 39 individuals with both MA dependence and HCV infection (MA + HCV +), 57 persons with only MA dependence (MA + HCV -), and a comparison sample of 46 participants with neither risk factor (MA - HCV -). Consistent with prior research, greater self-reported symptoms of depression were observed in the MA + groups relative to MA - HCV - participants; however, there was no evidence to suggest an additive effect of HCV infection. Surprisingly, the prevalence of current and lifetime diagnoses of Major Depressive Disorder (MDD) did not differ across the study groups. Results from this study suggest that HCV infection does not confer an additive effect on the severity of depressive symptoms or the prevalence of major depression in persons with MA dependence.     

Hepatitis C and HIV infections: implications for clinical care in injection drug users

Our objective is to provide a state-of-the-art review on hepatitis C (HCV) and the human immunodeficiency virus (HIV) in injection drug users (IDUs), highlighting important clinical issues. We performed a literature review from the MEDLINE database for research from 1966 to 2003, with an emphasis on recent consensus documents. Of the estimated 15 million illicit drug users in the U.S., approximately 1.0 to 1.5 million inject drugs. IDUs are at significant risk of contracting HCV and HIV, with IDUs accounting for 60% of new HCV cases and 25% of new HIV infections. It is a major risk factor for HCV/HIV coinfection, which significantly impacts on each disorder's progression. It appears that treatment response in IDUs with HCV or HIV is similar to non-IDUs with these viruses and that medication adherence and treatment outcomes are optimized when linked with substance abuse treatment. Providers caring for patients who are or were IDUs must be aware of the management of these diseases and make efforts to integrate their medical care with the treatment of their substance abuse.     

HIV,Hepatitis C,and Abstinence from Alcohol Among Injection and Non-injection Drug Users

Individuals using illicit drugs are at risk for heavy drinking and infection with human immunodeficiency virus (HIV) and/or hepatitis C virus (HCV). Despite medical consequences of drinking with HIV and/or HCV, whether drug users with these infections are less likely to drink is unclear. Using samples of drug users in treatment with lifetime injection use (n = 1309) and non-injection use (n = 1996) participating in a large, serial, cross-sectional study, we investigated the associations between HIV and HCV with abstinence from alcohol. About half of injection drug users (52.8 %) and 26.6 % of non-injection drug users abstained from alcohol. Among non-injection drug users, those with HIV were less likely to abstain [odds ratio (OR) 0.55; adjusted odds ratio (AOR) 0.58] while those with HCV were more likely to abstain (OR 1.46; AOR 1.34). In contrast, among injection drug users, neither HIV nor HCV was associated with drinking. However, exploratory analyses suggested that younger injection drug users with HIV or HCV were more likely to drink, whereas older injection drug users with HIV or HCV were more likely to abstain. In summary, individuals using drugs, especially non-injection users and those with HIV, are likely to drink. Age may modify the risk of drinking among injection drug users with HIV and HCV, a finding requiring replication. Alcohol intervention for HIV and HCV infected drug users is needed to prevent further harm.     

Prevention of hepatocellular carcinoma in the Asia–Pacific region: Consensus statements

Among approximately 650 000 people who die from hepatocellular carcinoma (HCC) each year, at least two‐thirds live in Asia. Efforts to improve early diagnosis and treatment have not yet impacted mortality. An Asia–Pacific Working Party convened in Hong Kong in June 2008 to consider ways to prevent HCC in this region. Separate reviews have summarized epidemiology of HCC, preventive approaches related to hepatitis B virus (HBV), hepatitis C virus (HCV) and non‐viral liver diseases, and the role of surveillance to detect HCC at a curative stage. We now present Consensus Statements from these deliberations and reviews. As chronic hepatitis B is the most common cause of HCC in Asia, effective hepatitis B vaccination programs are the most important strategy to reduce HCC incidence. Prevention of HCV by screening blood donors, universal precautions against blood contamination in health‐care settings and reducing HCV transmission from injection drug use are also vital. There is strong evidence that effective antiviral therapy to control HBV infection or eradicate HCV substantially reduces (but does not abolish) HCC risk. With hemochromatosis, family screening, early diagnosis and correcting iron overload to prevent liver fibrosis prevents HCC. There is currently insufficient evidence to give firm recommendations on alcohol, obesity/metabolic risk factors and other liver diseases. HCC surveillance for high‐risk groups is recommended in individual cases but cost‐effectiveness is not as high as infant hepatitis B vaccination and screening blood for HCV. Widespread application of HCC surveillance in Asia–Pacific countries depends on economic factors and health‐care priorities.     

The epidemiology of acute and chronic hepatitis C

Although the incidence of newly acquired acute hepatitis C virus (HCV) infection has declined, an estimated 3.9 million Americans are chronically infected with HCV, most of whom are young adults who will be at risk of the severe consequences of their infection in the next 10 to 20 years. The relative importance of the two most common exposures associated with the transmission of HCV has changed over time. Blood transfusions, which account for a substantial proportion of HCV infections acquired more than 10 years ago, account for only a small portion of recently acquired infections. In contrast, injection drug use has accounted for a substantial portion of HCV infections during both the remote and recent past. Sexual exposures, which have been poorly ascertained particularly among patients with chronic hepatitis C, may account for 10% to 20% of HCV transmissions. Physicians and other health care professionals need to be educated not only about the appropriate medical management of HCV infected patients, but also about the known and potential risks for HCV infection, the need to ascertain complete risk behavior histories from their patients, the appropriate evaluation of high-risk patients for evidence of infections, and the recommendations for prevention.     

Risk factors for hepatitis C virus infection among homeless adults

OBJECTIVE: To describe the prevalence of hepatitis C virus (HCV) infection in a sample of homeless and impoverished adults and examine risk factors for HCV infection in the overall sample and as a function of injection drug use. DESIGN: Assays were conducted on stored sera. Sociodemographic characteristics and risky sexual activity were measured by content-specific items. Substance use was measured by a structured questionnaire. HCV antibodies were tested by enzyme-linked immunosorbent assay; a confirmatory level was defined by recombinant immunoblot assay. SETTINGS: Shelters ( N = 36) and outdoor locations in Los Angeles. PARTICIPANTS: Eight hundred eighty-four homeless women and/or partners or friends. RESULTS: Among this sample of 884 homeless and impoverished adults, 22% were found to be HCV infected. Lifetime injection drug users (IDUs) (cocaine, crack, and methamphetamine) and recent daily users of crack were more likely than nonusers or less-frequent users of these drugs to be HCV-infected. Similar results were found for those who had been hospitalized for a mental health problem. Among non-injection drug users and persons in the total sample, those who reported lifetime alcohol abuse were more likely than those who did not to be HCV infected. Controlling for sociodemographic characteristics, multiple logistic regression analyses revealed IDUs have over 25 times greater odds of having HCV infection than non-IDUs. HCV infection was also predicted by older age, having started living on one's own before the age of 18, and recent chronic alcohol use. Males and recent crack users had about one and a half times greater odds of HCV infection when compared to females and non-chronic crack users. CONCLUSIONS: Targeted outreach for homeless women and their partners, including HCV testing coupled with referrals to HCV and substance abuse treatments, may be helpful.     

Hepatitis C virus infection in Western Europe

Hepatitis C virus (HCV) infection is now recognised as the most common infection causing chronic liver disease in Europe. Approximately 3% of the world population has been infected with HCV, which represents about 170 million chronic carriers at risk of developing serious complications with more than 5 million in Europe alone. In the general population, the prevalence varies geographically from about 0.5% in northern countries to 2% in Mediterranean countries. Among newly detected HCV cases, 40-60% have normal ALT levels, 80% are viraemic, while about 70% of newly detected HCV carriers present histologic liver disease. More than 75% of the cases remain to be identified. The residual risk for transmitting HCV by blood products is at present 1/200 000 units distributed. Intravenous drug users are currently the main risk group. The prevalence rate is about 80% and the yearly incidence varies between 4 and 6%. In haemodialysis patients, the prevalence ranges from 10% to 30% and the incidence from 3% to 7%. The source of infection for the 30% of cases without identifiable risk factor remains to be clarified and appropriate well-controlled case-control studies on large samples are necessary. Further training and information campaigns remain desirable to improve knowledge and awareness among health care professionals.     

Management of hepatitis C virus in special populations: patient and treatment considerations.

The most common chronic blood-borne infection in the United States is caused by hepatitis C virus. An estimated 3.9 million people (1.8%) in the United States have been infected with the hepatitis C virus, excluding certain subpopulations who are at high risk for hepatitis C virus infection. Among these subpopulations are an estimated 255,000 (15%) of prison inmates and 175,000 (22%) of homeless people. Prevalence of hepatitis C virus infection is also high among veterans (6.6% overall and even higher among homeless veterans). The single most important risk factor for hepatitis C virus infection is injection drug use; up to 90% of illicit injection drug users are infected with hepatitis C virus. This review describes the prevalence of hepatitis C virus in special populations and discusses the treatment options for patients with severe disease, transplant recipients, and patients at high risk for infection. Close monitoring and management of therapeutic side effects are required to assist these patients in adhering to therapy.     

Viral evolution of hepatitis C in injection drug users

Injection drug users represent the largest cohort of patients with established hepatitis C virus (HCV) infection as well as the group that is at highest risk for new infections. Most published studies have focused on the clinical consequences of established HCV infection and have not examined the consequences of new infection. The aim of the current study was to measure the virological consequences of HCV in patients with ongoing injection drug use that might pose a risk for new and/or for superinfection with additional strains of HCV. We examined the following groups: (a) those with resolved HCV infection with ongoing injection drug use, (b) those with chronic infection who continued to inject and (c) those with chronic infection who no longer injected. Our study demonstrated a spectrum of responses. The majority of patients appeared to be 'protected' from new infection. None of six patients with resolved infection had detectable HCV RNA by quantitative or qualitative PCR when followed for 1 year. Similarly, despite ongoing injection drug use, no patient with persistent infection had a 'switch' in HCV genotype indicative of possible superinfection. Virological analysis of HCV quasispecies to detect possible infection with new variants of HCV in patients with apparently 'stable' infection, indicated divergence of virus over time, divergence that was unrelated to injection drug behaviour. Thus, patients with ongoing or prior HCV infection appear to develop immunity that protects against further infection with HCV despite repeated exposure.     

Hepatitis C infection among drug users in northern Thailand

Illicit drug users are commonly infected with hepatitis C virus (HCV) and human immunodeficiency virus (HIV). We evaluated the prevalence, incidence, and risk behaviors associated with HCV infection in 1,859 drug users in northern Thailand. The HCV prevalence was 27.3%: 86.0% among drug injectors (IDUs) and 5.3% among those who did not inject. Sexual behavior was not significantly associated with HCV among IDUs or drug users who used but didn't inject illicit drugs; only injection behaviors were independently associated with HCV in multivariate analysis. Among men, a history and increasing frequency of injecting drugs, older age, and a history of incarceration were associated with HCV infection. Among 514 opiate users who were HCV and HIV seronegative at baseline, 41 incident HCV infections and 6 HIV infections occurred on follow-up; the HCV incidence was 5.43/100 person-years; it was 44.3/100 person-years in IDUs and 1.9/100 person-years in non-injectors. HCV and HIV among drug users in Thailand are common and primarily associated with injection behavior.