Gianni Maggipinto

Hepatitis C virus transmission following invasive medical procedures

D S, Hepatitis C represents a major public health problem due to its prevalence and high incidence of chronic disease. Until now, most reported cases of hepatitis C infection have been associated with intravenous drug abuse or administration of untested blood products; many fewer cases have resulted from sexual or vertical transmission. In 40% of patients, however, the mode of viral transmission remains unknown. For some of these, a nosocomial origin has been suggested [1–3], with particular attention paid to transmission by gastrointestinal endoscopy [4–6]. However, the number of reported cases of patient-to-patient transmission associated with invasive medical procedures (IMPs) remains very low. Between 1994 and 1997, we diagnosed 20 cases of acute, icteric hepatitis C, nine of which were attributable to invasive medical procedures. Although sequencing or genotyping were not carried out to confirm the identity of the viral strains involved, we were convinced of a causal relationship by a series of chronological, clinical, biological and viral events (Table 1). Furthermore, these nine cases were subsequently traced to errors in disinfection procedures. Prior to IMP, all nine patients had normal levels of transaminases; none of them had ever received blood products or used intravenous drugs, and all sexual partners were seronegative for the C virus. The IMPs, which involved various medical specialities, were performed in several medical centres. Icteric hepatitis appeared an average of 50 days (range 32–91) after the procedure. The presence of viral HCV-RNA was confirmed by polymerase chain reaction (PCR) in all cases. Four of the nine patients were seropositive at the time of icterus, whilst five others converted to seropositivity within 4.5 months. Clinical evolution to chronic hepatitis was observed in four patients (patients 1, 3, 5 and 8), whilst in three patients (patients 2, 7 and 9), the hepatitis spontaneously resolved (with sustained biochemical resolution and undetectable serum hepatitis C virus RNA 32, 12 and 24 months, respectively, after the end of icterus). Two patients (patients 4 and 6), who were treated early after the resolution of icterus with interferon a-2b (5 million units day for 2 months), had apparent cure (normal transaminase levels and negative PCR 6 months after the end of treatment). LETTER TO THE EDITOR

Combination of Serological Markers to Predict the Presence or Absence of Viremia in HCV-Seropositive Blood Donors

Firstand second-generation anti-HCY screening assays have significantly contributed to the decline of posttransfusion hepatitis C (PTH-C) to a point where nosocomial transmission and iatrogenic procedures are currently being discussed as a possible remaining cause of hepatitis C in hospitalized patients [1]. This is excellent news for recipients but blood banks also have a responsibility towards their donors. Inthis regard the question ofinfectivity and its long-term consequences for HCY-seropositive donors begs for an answer. HCY-RNA assay by the polymerase chain reaction (PCR) is useful for the detection of viremia as a measure ofinfectivity [2]. However, PCR technology is still too complex and too costly for routine use in blood banks. Investigators have attempted to circumvent this difficulty by studying the predictive value ofmarkers readily available in blood banks for indirect detection of HCY viremia [3-5]. Several have noted an association between HCYRNA and abnormal alanine aminotransferase (ALT) levels [6], increased optical density (00) signals in anti-HCY screening tests [7], or the presence of complete antibody profiles in so-called supplemental assays [8]. Recent reports have documented an association between serum HCYRNA and HCY core IgM (lgM anti-HCc), and HCY core IgG antibodies (IgG anti-HCc) inpatients with chronic liver disease [9-11]. The aim of our study was to assess the predictive value, alone or incombination, ofanti-HCY seropositivity by thirdgeneration EIA (HCY EIA-3), the HCY antibody pattern by HCY supplemental EIA (HCY SA), HCY core IgG, HCY core IgM, and ALT as indirect markers of viremia ina cohort (n =131) of Belgian blood donors deferred from donating blood due to HCY seropositivity and/or elevated ALT.