Use of enhanced surveillance for hepatitis C virus infection to detect a cluster among young injection-drug users--new York, November 2004-April 2007

Infection with hepatitis C virus (HCV) is a leading cause of chronic liver disease in the United States. Chronic hepatitis B and C virus infections were added to the nationally notifiable diseases list in 2003. Approximately 3.2 million persons in the United States have chronic HCV infection. The most common risk factor for HCV infection is illicit drug use (specifically injection-drug use [IDU]), although approximately one third to one half of cases have no identified risk factor. Because approximately 80% of acute HCV infections are asymptomatic and no serologic markers for recent infection exist, distinguishing recent from distant infection based on serology alone is challenging and establishment of national HCV infection incidence is difficult. CDC provides funding to enhance surveillance for HCV infection and other forms of viral hepatitis in New York State (NYS) and seven other areas. One project of enhanced surveillance is to identify those HCV infections most likely to have been acquired recently. Since January 2006, NYSDOH has prioritized follow-up of positive laboratory markers for HCV infection among persons aged <30 years because they are more likely to be newly infected than older persons. In February 2007, NYSDOH detected a cluster of HCV infections among persons in this age group by using the prioritized algorithm. This report describes the subsequent investigation by NYSDOH and the Erie County Department of Health (ECDOH), which identified a group of patients with histories of IDU who were linked through a single high school that all the patients had attended at some time. The findings demonstrate how targeted enhanced surveillance can effectively detect clusters and outbreaks and guide appropriate interventions.     

Acute hepatitis C virus infection

Acute hepatitis C virus infection produces clinical and biochemical features that is non-specific and indistinguishable from those caused by other hepatotropic viruses. The specific diagnosis of acute hepatitis C virus infection is based on the detection of serum RNA-HCV through a technique of PCR whose result will be positive after 1-2 weeks of the initial contact with the virus. The anti-bodies against HCV are detected later (after 7-8 weeks on average), and are not useful, as an isolated determination, in distinguishing acute infection from chronic infection or in clearing the virus (spontaneous or following treatment). Fifty-five to eighty-five percent of patients with acute HCV infection do not clear the virus and develop a chronic infection with risk of evolution to cirrhosis and of developing hepatocellular carcinoma. For this reason, the present tendency is to treat with interferon all those patients in whom RNA-HCV remains positive after 3-4 months following diagnosis of acute infection     

Nosocomial transmission of hepatitis C virus associated with the use of multidose saline vials.

OBJECTIVE: To identify the source of an outbreak of acute hepatitis C virus (HCV) infection among 3 patients occurring within 8 weeks of hospitalization in the same ward of a Florida hospital during November 1998. DESIGN: A retrospective cohort study was conducted among 41 patients hospitalized between November 11 and 19, 1998. Patients' blood was tested for antibodies to HCV, and HCV RNA-positive samples were genotyped and sequenced. RESULTS: Of the 41 patients, 24 (59%) participated in the study. HCV genotype lb infections were found in 5 patients. Three of 4 patients who received saline flushes from a multidose saline vial on November 16 had acute HCV infection, whereas none of the 9 patients who did not receive saline flushes had HCV infection (P = .01). No other significant exposures were identified. The HCV sequence was available for 1 case of acute HCV and differed by a single nucleotide (0.3%) from that of the indeterminate case. CONCLUSION: This outbreak of HCV probably occurred when a multidose saline vial was contaminated with blood from an HCV-infected patient Hospitals should emphasize adherence to standard procedures to prevent blood-borne infections. In addition, the use of single-dose vials or prefilled saline syringes might further reduce the risk for nosocomial transmission of blood-borne pathogens.     

Chronic hepatitis C virus infection

Following acute hepatitis C virus infection (HCV), a significant percentage of patients do not clear the virus and develop a chronic hepatitis C. The symptoms, when they exist, are usually unspecific. Besides, approximately one third of the patients present extrahepatic manifestations of the infection, basically due to the lymphotropism of HCV. Outstanding amongst these, due to their clear association with HCV, are mixed cryoglobulinaemia and the production of autoantibodies (autoAb). Other diseases such as non-Hodgkin lynphoma (NHL) or autoimmune thyroiditis do not have a clearly established association. Although the majority of patients with chronic hepatitis C have slight or moderately high levels and fluctuations of transaminases, as many as one third of those infected can show persistently normal levels of transaminases. The diagnosis of chronic HCV infection is based on serological tests, which detect the presence of antibodies against HCV, and on virological tests that detect RNA of the HCV, which confirm the existence of active infection. Finally, an important topic of chronic HCV infection, following diagnosis, is to ascertain the stage of fibrosis and the degree of inflammation, since both characteristics are very important for predicting the natural evolution and the need for treatment. Nowadays, this information can only be obtained through liver biopsy, which is recommended in patients with chronic HCV infection and high transaminases. Whether liver biopsy should be performed in patients with normal transaminases is still subject of controversy.     

A large nosocomial outbreak of hepatitis C and hepatitis B among patients receiving pain remediation treatments.

BACKGROUND AND OBJECTIVE: In August 2002, the Oklahoma State Department of Health received a report of six patients with unexplained hepatitis C virus (HCV) infection treated in the same pain remediation clinic. We investigated the outbreak's extent and etiology. DESIGN, SETTING, AND PARTICIPANTS: We conducted a retrospective cohort study of clinic patients, including a serologic survey, interviews of infected patients, and reviews of medical records and staff infection control practices. Patients received outpatient pain remediation treatments one afternoon a week in a clinic within a hospital. Cases were defined as HCV or hepatitis B virus (HBV) infections among patients who reported no prior diagnosis or risk factors for disease or reported previous risk factors but had evidence of acute infection. RESULTS: Of 908 patients, 795 (87.6%) were tested, and 71 HCV-infected patients (8.9%) and 31 HBV-infected patients (3.9%) met the case definition. Multiple HCV genotypes were identified. Significantly higher HCV infection rates were found among individuals treated after an HCV-infected patient during the same visit (adjusted odds ratio [AOR], 6.2; 95% confidence interval [CI95], 2.4-15.8); a similar association was observed for HBV (AOR, 2.9; CI95, 1.3-6.5). Review of staff practices revealed the nurse anesthetist had been using the same syringe-needle to sequentially administer sedation medications to every treated patient each clinic day. CONCLUSIONS: Reuse of needles-syringes was the mechanism for patient-to-patient transmission of HCV and HBV in this large nosocomial outbreak. Further education and stricter oversight of infection control practices may prevent future outbreaks.     

Confirmation of nosocomial hepatitis C virus infection in a hemodialysis unit.

OBJECTIVES: To investigate a hepatitis C virus (HCV) outbreak in a hemodialysis unit and determine the source of transmission. METHODS: We have prospectively investigated the epidemiology of hemodialysis-related HCV infection in a single unit since 1989. In September 2000, acute hepatitis C (AH-C) was diagnosed in 5 patients by alanine aminotransferase elevation and HCV genotype 1b viremia without antibody to HCV. We surveyed the epidemiologic situation and performed polymerase chain reaction sequence analysis of the HCV 5'-noncoding (5'NC) region in the patients for comparison with 9 patients with chronic HCV genotype 1b viremia. RESULTS: Sequence analysis of the 5'NC region showed the consistency in the 5 independent clones from each AH-C patient and those from each chronic HCV viremia patient and no quasispecies over time in the clones of any of 14 analyzed patients. All AH-C patients had the same sequencing of the 6 variations in the region with the only other patient. A saline ampoule, used for heparin solution during hemodialysis, had a recap function. It was difficult to determine whether the ampoule was new or had already been used. The source-patient often underwent hemodialysis before the AH-C patients and most of their hemodialysis-related medicine was prepared during the source-patient's treatment. These findings suggested a high possibility that the AH-C patients shared a single heparin-saline solution ampoule contaminated by HCV from the source-patient. CONCLUSION: Nosocomial HCV infection occurred as a result of poor infection control practice when a patient with chronic HCV viremia received treatment prior to other hemodialysis patients.     

Retrospective investigation of patients exposed to possible transmission of hepatitis C virus by a capillary blood glucose meter

A 75-year-old female with no known risk factors for hepatitis C virus (HCV) infection was hospitalized and a diagnosis of HCV seroconversion was established (HCV immunoblot and a positive quantitative viral load). An epidemiological investigation revealed that, during a previous hospitalization resulting in a diagnosis of diabetes, she had shared a Glucotrend capillary blood glucose meter (CBGM; Roche Diagnostics, France) with a known HCV-positive diabetic patient. Poor hygiene practices were observed when using this device. Since the Glucotrend CBGM had been purchased, the suspected source patient had been hospitalized eight times and another 19 diabetic patients with known anti-HCV antibodies also regularly attended the same hospital. Consequently, 35 diabetic patients who had been hospitalized at the same time as the suspected source patient and 1305 patients who had used the Glucotrend CBGM were invited to undergo serum anti-hepatitis B virus, anti-HCV and anti-human immunodeficiency virus testing. Among the 35 diabetic patients, none of the 24 subjects tested were positive. Among the 1305 other patients, 995 were tested and 19 (2%) were anti-HCV positive. Although this prevalence is higher than that reported in the general French population, this excess risk cannot be attributed to use of the CBGM. Furthermore, molecular analysis showed that the two HCV strains isolated did not belong to the same phylogenetic cluster. However, as a result of this incident, measures were taken to minimize the transmission of bloodborne viruses in the hospital concerned. Other French hospitals were informed by a national alert message from the French Agency for the Safety of Health Products.     

Epidemic outbreak of acute hepatitis C--clinical course, histology and effectiveness of therapy

An epidemic outbreak of HCV infection was observed in the center of nonconventional therapy, when patients with stable coronary heart disease and arteriosclerosis obliterans were treated. They received drop infusions with chelate therapy with unknown medicine. We diagnosed acute hepatitis C in 15 patients (mean age 61). All were positive for HCV RNA, had known exposure to HCV within the preceding 3 months and elevated serum ALT value 2-10 ULN. 12 out of 15 patients had documented seroconversion to anti-HCV. In 6 patients liver biopsy was performed. Acute viral hepatitis was diagnosed in 4 cases (of mild activity in 2 cases and of moderate activity in the other two cases). In two remaining cases histology required differentiation diagnosis (one with non alcoholic steatohepatitis and one with exacerbation of chronic hepatitis). Different forms of hepatocyte degeneration and steatosis were observed in all cases. Considering the possibility to chronicity we decided to treat 10 patients, while remaining 5 had contraindications to interferon therapy. There was no control group. Patients were treated with pegylated alfa 2b interferon 1.5 mcg/kg/week and ribavirin 1000-1200 mg/d, for 12 weeks. Side effects appear minimal. In no case therapy was interrupted. Sustained viral response (SVR) and normalization of ALT were observed in 6 out of 10 treated patients (1 with jaundice and 5 asymptomatic). Two untreated subjects had spontaneous recovery. We found that administration of pegylated interferon alfa-2b and ribavirin 1-6 months after the appearance of jaundice or significant elevation of ALT activity could prevent progression to chronic infection. This therapy appears to be effective and safe in asymptomatic infection and among others in adult patients with stable coronary heart disease. Our results confirmed the previous observations mentioned by others that treatment of acute hepatitis C with pegylated interferon and ribavirin may lead to cure.     

乙型肝炎患者重叠感染丙型肝炎、庚型肝炎病毒的研究

[目的 ]了解乙型肝炎患者重叠感染丙型肝炎病毒 (HCV)、庚型肝炎病毒 (HGV)的情况。 [方法 ]应用 EL ISA法分别对 86 8例乙肝患者、5 17例乙肝病毒携带者检测血清抗 - HCV和抗 - HGV,应用逆转录聚合酶链反应法分别对HCV、HGV感染者进行血清 HCV- RNA、HGV- RNA检测 ,并与乙肝病毒携带者比较。 [结果 ]乙肝患者与乙肝病毒携带者 HCV感染率分别为 14.5 %、2 .3% ,HGV感染率分别为 15 .6 %、3.9% ,HCV和 HGV的重叠感染率分别为 2 .3%、0 .2 % ,两组间 HCV、HGV合并感染率均有非常显著性差异 (P<0 .0 1)。乙肝患者中 HCV感染者 HCV- RNA阳性率14.3% ,HGV感染者 HGV- RNA阳性率 11.9%。 [结论 ]乙型肝炎、丙型肝炎、庚型肝炎可以重叠感染。急慢性乙型肝炎患者的 HCV、HGV重叠感染率不同。     

Development of antibody to hepatitis C virus (HCV) in acute and chronic non-A,non-B post-transfusion hepatitis

The antibody to hepatitis C virus (anti-HCV) was measured by an immunoassay in 507 serum samples from 94 patients with acute and chronic post-transfusion non-A, non-B hepatitis (NANB) and in 436 healthy blood donors. Anti-HCV was found in 70.8 of patients with acute hepatitis, in 78.2 with chronic hepatitis, and in 1.4 of healthy blood donors. In acute hepatitis, anti-HCV appeared in the serum from 4 to 34 weeks after transfusion and from 1 to 30 weeks after the onset of the overt disease. Three patients with resolving hepatitis (21%) and 2 who developed chronic hepatitis (10%) lost anti-HCV during a mean follow-up period of 28 months. Among the 36 patients with chronic hepatitis, 2 (6%) lost anti-HCV after 12 months and 8 years respectively. These data indicate that in recent years HCV has been the major etiologic agent of acute and chronic transfusion-associated hepatitis (TAH) in our geographical area. The late appearance of anti-HCV from the onset of clinical and biochemical signs of acute hepatitis in more than 70% of patients limits the diagnostic utility of this assay for an earlier serological diagnosis of acute NANB hepatitis. Additional studies are required to determine the diagnostic significance of this antibody in chronic NANB hepatitis.Corresponding author.     

The treatment of chronic hepatitis C virus infection in children

A 9-year-old boy, a 15-year-old boy, and a 6-year-old girl were infected with chronic hepatitis C virus (HCV). They had no physical complaints and a virus genotype that was favourable to treatment with peginterferon-alpha and ribavirin. The younger boy and the girl had liver fibrosis and were treated for 6 months; the virus was eradicated from the boy's plasma and the fibrosis diminished, while the girl's plasma virus was again present shortly after the end of treatment. In the older boy with no fibrosis, treatment was temporarily suspended due to behaviour problems. HCV infection is a frequent cause of chronic hepatitis in children. A better understanding of its natural history, improvements in the efficacy of treatment, and more favourable outcomes seen in children compared with adults have gradually changed the consideration to treat children with chronic HCV infection over the last 10 years. The decision whether or not to treat depends primarily on the degree of liver damage, virus genotype, and the psychological condition and motivation of the patient. Screening patients at risk for chronic HCV infection and careful follow-up for liver damage in those with HCV infection have become even more important given the new insights regarding treatment.     

A cluster of hepatitis C virus infections associated with ozone-enriched transfusion of autologous blood in Rome, Italy.

OBJECTIVE: To describe an outbreak of hepatitis C virus (HCV). DESIGN: Retrospective cohort study. SETTING: Outpatient department of a hospital in Rome, Italy. PATIENTS: All 42 patients exposed to ozone therapy by autohemotherapy or intramuscular injection from January to June 2001. METHODS: Epidemiologic investigation, serologic analysis, and virus genotyping. RESULTS: Thirty-one (74%) of the patients agreed to participate in the study. Three (9.7%) had symptoms of HCV infection. This incidence rate was higher than the rate of 1.4 per 100,000 per year in the regional population. Six patients were positive for HCV antibodies and HCV RNA for a prevalence rate of 19.4%, which was much higher than the estimate of 0.9% in the population. Virus genotype 1b was found in two case-patients (one symptomatic) and 2c in four case-patients (two symptomatic), one of whom was known to have an HCV infection since 1986 and could have been the source of infection. The infected patients were all being exposed to ozone-enriched transfusions of autologous blood. Although the specific mode of transmission between patients was not detected, transmission probably occurred during one of the three busiest therapeutic sessions in the 6-month period. CONCLUSIONS: Transmission of HCV infection may occur during medical procedures with limited bleeding. Standard precautions must be applied in any healthcare setting; restricting the number of individuals treated during each therapeutic session could be an effective way of avoiding accidental transmission of infection.     

丙型肝炎病毒感染后慢性转化率的流行病学研究

笔者选择 1992～ 1996年间 ,安徽某乡“职业”供血员和 2所省级医院住院病人中 ,抗 -HCV( )和 /或 HCV RNA( )者为调查对象。追访了他们 HCV感染及其后的有关重要临床诊治和流行病学信息 ,同时调查了感染者的现况及相关实验室指标检测 ,描述了供血员人群丙型肝炎病毒感染后慢性转化率变化趋势。结果 HCV感染 6个月后慢性转化率为 55.93% ,1～ 4年慢性转化率依次为 50 %、4 8.54%、4 6.4 7%和 4 6.4 3%。表明其感染后慢性转化率一直持续高水平 ,下降缓慢 ,尤其 2年后基本稳定在 4 6%～ 4 8% ,远高于乙型肝炎 5%～ 10 %的慢性转化率。     

Sexual transmission of hepatitis C in homosexual men

An acute hepatitis C infection was diagnosed in three HIV-positive gay men, aged 43, 48 and 30 years, respectively. In all three, unprotected sexual intercourse and fisting was a universal risk factor for the infection. They all denied having used drugs intravenously, which is the most common risk factor. The third man had a documented proctitis (lymphogranuloma venereum) at the time when the HCV transmission must have taken place. No serious complications occurred during the acute HCV infection. Because the infection did not resolve spontaneously after a few months, all three men were treated with pegylated interferon and ribavirin. Recently, the number of cases of acute HCV infection has been seen to increase in The Netherlands. This may be due primarily to an increase in unprotected sexual intercourse and fisting. This hypothesis is supported by a documented increased prevalence of sexually transmissible diseases among gay men in The Netherlands. As acute infections may turn into chronic infections, treatment of an acute infection should be considered in order to prevent the chronic disease.     

Nosocomial risk factors of hepatitis C infection. A multicenter study in a hospital-based population

PURPOSE: Drug abuse and blood transfusion are well known risk factors for hepatitis C virus (HCV) infection. However, the route of transmission remains undetermined for 30% of HCV infections. The potential for nosocomial transmission of HCV in health care settings has been suggested but remains poorly estimated. The aim of the study was to assess the prevalence and to identify risk factors for hepatitis C virus (HCV) infection in hospitalized patients frequently exposed to invasive procedures. METHOD: A multi-center sero-prevalence study was conducted in hospitalized patients who underwent invasive procedures in interventional radiology wards in 6 University hospitals in Paris between 1998 and 1999. Each patient presenting in the ward was consecutively interviewed by a medical investigator. Data were collected on a standardized questionnaire including items on socio-demographic characteristics, past exposure to intravenous drug use, blood transfusions, underlying diseases and type and number of previous invasive procedures. Before procedure, HCV antibody testing (ELISA) was performed in all patients after informed consent. In all HCV-positive patients, HCV viremia was detected using polymerase chain reaction. RESULTS: Overall, 91 of 944 (9.7%) patients were HCV-positive, of whom 90% had positive viremia and 10 were identified HCV positive by the screening. HCV prevalence decreased with age and ranged from 4.5% to 22% according to center. Logistic regression analysis showed that intravenous drug use, history of blood transfusions and endoscopy were found as independent risk factors for HCV infection (odds ratio [CI95%]: 77.3 [23.3-256.3], 4.7 [2.7-8.2] et 1.20 [1.01-1.44]). No other risk factor for nosocomial or iatrogenic transmission was identified. CONCLUSION: The results suggest that, except for blood transfusions, other healthcare-related procedures may partly explain HCV transmission. This emphasizes the need to reinforce compliance with standard precautions of hygiene.     

187例维持性血液透析患者肝炎病毒感染的随访研究

目的 :了解维持性血液透析患者肝炎病毒的感染率及其有关因素。方法 :回顾分析 187例行维持性血液透析的慢性肾功能衰竭患者的实验室资料。结果 :维持性血液透析患者肝炎病毒感染率分别为乙型肝炎病毒 12 .3%、丙型肝炎病毒 46 .0 %、戊型肝炎病毒 3.4% ,感染率的高低与透析年限呈正相关。结论 :在 CHD患者肝炎病毒感染中 ,以丙型肝炎病毒感染率最高 ,同时应注意戊型肝炎病毒感染的动向。     

IgM responses to hepatitis-A virus and hepatitis-B core antigen in acute and chronic liver disease in Malawi; possible role of non-A, non-B, hepatitis

Of 33 patients with acute hepatitis in Malawi, 21 had infection by hepatitis-B virus (HBV), five by hepatitis-A virus (HAV) and seven, who had no markers of current HBV or HAV infections, were probably infected by the agent(s) of non-A, non-B, hepatitis. 87 of 88 sera from persons without liver disease contained antibody to HAV and 49 antibody to hepatitis-B surface antigen (anti-HBs) (six were positive for hepatitis-B surface antigen). The diagnosis of recent infection by HAV was made by detecting HAV-specific IGM in single serum samples and, although such tests showed that HAV caused acute hepatitis, its absence in patients with chronic liver disease suggests that, unlike HBV, infection by HAV does not play a role in chronic liver disease in Malawi. Anti-hepatis-B core antigen (anti-HBc)-specific IgM was detected in 19 of 21 patients with acute HBV infection, in three of five HbsAg-positive patients with cirrhosis, but in none of five HbsAg-positive patients with hepatoma.     

Biochemical and virological response (by PCR) to interferon therapy in chronic hepatitis C

Interferon-alpha has been established for the treatment of chronic hepatitis C virus infection. However, the complete responding rate is not higher than 20-25%. Our study was carried out on sixty patients with chronic HCV infection with the following criteria: elevated serum ALT levels, positive antibodies to HCV (by second generation ELISA and RIBA tests) and positive HCV in serum by PCR. All patients had negative tests for hepatitis B virus and liver histopathological findings consistent with chronic hepatitis +/- cirrhosis. Patients were treated with 3 Mu interferon-alpha thrice weekly for 6 months. The results showed response in 14 out of the 60 patients (23.3%) with normalization of the ALT levels within 2-3 months of IFN therapy. Complete response (CR) was present in 6/14 (42.9%) of the responders with negative PCR in serum up to 6 months after stoppage of therapy. Response with relapse (unsustained response) was noticed in 8/14 (57.1%) of the responders with elevation of ALT level 2 months after stoppage of treatment. Forty six patients 46/60 (76.7%) were non-responders (NR) with significant elevation of ALT level and positive PCR in serum all through the course of treatment. The response in cirrhotic patients was significantly lower than in noncirrhotic cases. In conclusion, prolonged treatment courses should be further evaluated in controlled studies.     

Patient notification exercise following a dentist's admission of the periodic use of unsterilized equipment

During 2001, Greater Glasgow National Health Service (NHS) Board undertook a patient notification exercise in a Glasgow dental practice following the admission, by the dentist, of the use of unsterilized dental equipment on patients. Four thousand and eighty-nine exposed patients were identified; of these, 1696 contacted the NHS helpline and 1005 were counselled and screened for hepatitis C virus (HCV), hepatitis B virus (HBV) and human immunodeficiency virus. One patient showed evidence of previous HBV infection and 13 had antibodies to HCV. Molecular investigation of the HCV isolates indicated no significant associations. The investigation found no evidence of patient-to-patient transmission of HCV among patients attending the practice of a dentist who admitted periodically using unsterilized equipment.