Loreta A. Kondili

Hepatitis C virus infection and alanine transaminase levels in the general population : a survey in a southern Italian town

BACKGROUND/AIM The aim of the study was to estimate the prevalence, risk factors and genotype distribution of hepatitis C virus (HCV) in the general population older than 5 years of age in a southern Italian town. The positive predictive value of alanine transaminase (ALT) screening in identifying HCV positive subjects was also assessed. METHODS Cluster random sampling from the census of the general population was used. ELISA and RIBA tests assessed the presence of anti-HCV; nested reverse transcription polymerase chain reaction (RT-PCR) was used to identify HCV-RNA; genotyping was performed by INNO-LIPA III. The association linking anti-HCV seropositivity with potential risk factors was assessed by multiple logistic regression analysis. RESULTS Among the 488 subjects enrolled, 79 (16.2%) were anti-HCV positive. The prevalence increased from 1.2% in subjects 6-29 years of age to 42.1% in those > or = 60 years. Forty percent of these positive subjects also had abnormal ALT level and 54.4% were HCV RNA positive by PCR. The positive predictive value of the ALT test in identifying anti-HCV positive subjects was 65%; however, it was 46.7% in subjects younger than 60 years of age and 90.5% in those 60 or older. Genotype 1b was detected in 74% of subjects, type 2c in 23.3%, and type 1a in 2.3%. The only two variables significantly associated with HCV seropositivity in multivariate analysis were age older than 45 years (O.R. 8.5; CI 95%=3.0-24.1) and past use of glass syringes (O.R. 3.4; CI 95%=1.5-7.6). CONCLUSIONS These findings confirm that HCV infection is endemic in southern Italy, particularly among the elderly. Percutaneous exposure, such as injections with nondisposable, multiple-use, glass syringes used in the past for medical purposes may have played a major role in the spread of HCV infection. ALT screening is not useful in detecting HCV positive subjects in the general population, particularly among subjects who could benefit from antiviral therapy.

Seroprevalence and anti‐HEV persistence in the general population of the Republic of San Marino

The prevalence of anti‐HEV was assessed in 2,233 subjects aged 20–79 years in the Republic of San Marino in the years 1990–1991. The sera were tested by ELISA and further confirmed by Western blot (WB) analysis. The overall anti‐HEV prevalence was 1.5%. A significant trend by age was observed. Anti‐HEV prevalence was 0.6% in subjects <30 years and 3.3% in those older than 70 years of age. Family size larger than four persons (OR = 3.8; 95% CI = 1.8–13.2) was the sole independent predictor of anti‐HEV positivity in the multivariate analysis. Anti‐HAV and anti‐HEV prevalences did not show a parallel trend by age. No association was found either between hepatitis E virus (HEV) or hepatitis C virus (HCV) infections. Follow‐up samples 5 years apart were available for 38 out of 54 (70%) anti‐HEV ELISA‐positive subjects. Eight out of 22 (37%) WB‐confirmed anti‐HEV–positive subjects were still anti‐HEV–positive after 5 years. However, anti‐HEV remained positive in all but two (75%) of the subjects with WB‐confirmed ELISA positivity value of S/CO ≥ 2 (cutoff 1.2), but in only 2 out of the 14 subjects (14%) with a WB‐con‐ firmed ELISA positivity value of S/CO < 2 (P < 0.005). None of the 16 subjects ELISA‐positive but not WB‐confirmed was anti‐HEV–positive 5 years apart. Therefore, only a relative proportion of subjects once infected with HEV maintain for at least 5 years anti‐HEV antibodies. J. Med. Virol. 58:49–53, 1999.

High dosage alpha-interferon for treatment of children and young adults with chronic hepatitis C disease.

BACKGROUND There are limited data on the use of high interferon (IFN) dosage for treatment of children and young adults with hepatitis C virus infection and in those affected by thalassemia major (TM). OBJECTIVES To assess the response of children and young adults with chronic hepatitis C disease, including those affected by TM, to high dose natural alpha-interferon (IFN-alpha). To evaluate the effect of iron overload in response to high dose IFN-alpha in young chronic hepatitis C virus thalassemia patients. METHODS We conducted a therapeutic trial of natural IFN-alpha, using 10 million units/m2 three times a week for 6 months in 14 chronic hepatitis C patients ages 5 to 28 years; 7 also had TM. The follow-up period lasted 12 months. RESULTS Ten patients (73%) showed normal or nearly normal alanine aminotransferase values at the end of follow-up (biochemical response), but only five (35%) were negative for serum hepatitis C virus-RNA (complete responders). Four of the patients (57%) with TM were sustained complete responders. No correlation was found between the initial serum concentration of ferritin and response to IFN therapy. Patients infected with genotype 1b showed a poor response although high dose of natural IFN was used. CONCLUSIONS These results indicate that IFN-alpha can be used in children and young patients with chronic hepatitis C disease as well as in those affected by TM. Treatment with high dosage natural IFN-alpha in children and young adults with hepatitis C infection does not appear to be more effective than dosages previously used.

Identification of low HBV-DNA levels by nucleic acid amplification test (NAT) in blood donors

OBJECTIVE To evaluate the presence of HBV-DNA in 22,765 consecutive blood donors, who donated blood in the period from January 2006 to August 2007 at a transfusion centre in Lazio, a region in central Italy with low HBV endemicity. METHODS Each donation was individually tested using immunoenzymatic assays and nucleic acid amplification technologies (NAT). Samples that were reactive to generic NAT, Procleix Ultrio Assay were tested for HBV-DNA, HCV-RNA and HIV1-RNA by Discriminatory Procleix Ultrio NAT Assay. In samples that were reactive to generic NAT and negative for HBsAg, HCV-RNA and HIV1-RNA, HBV-DNA was further tested using Cobas TaqMan and an in-house nested PCR following an ultracentrifugation step. Sequence analysis confirmed HBV-DNA positivity. RESULTS Generic NAT identified 31 (0.13%) reactive sera. HBV-DNA discriminatory NAT identified 15 positive sera; HBsAg was positive in 12 sera. Of the 5 generic NAT-reactive/discriminatory NAT-negative/HBsAg-negative sera and of the 3 HBsAg-negative/HBV-DNA discriminatory NAT-positive sera, 7 were positive to Cobas TaqMan or the in-house PCR after ultracentrifugation. The overall HBV-DNA positivity was 0.083% [19 of 22,765 donors: 12 HBsAg-positive (HBV-DNA range 10(2)-10(4) IU/mL), 7 HBsAg-negative/anti-HBc positive (HBV-DNA< 6 IU/mL)]. CONCLUSIONS For blood transfusion safety, the significance of the finding of very low HBV-DNA levels should be further investigated. Our data indicate that in areas with a low HBV endemicity, single NAT assays may not always identify blood donations with very low HBV-DNA levels.

Hepatitis B Virus Infection in Health Care Workers in Albania: a Country still Highly Endemic for HBV Infection

Background:Health care workers (HCW) have an elevated risk of acquiring and transmitting parenteral infections. The aim of this study was to evaluate the prevalence of hepatitis B virus (HBV) and hepatitis C virus (HCV) markers with the final goal to encourage HBV vaccination of the non-immune Albanian HCW.Methods:Among 480 HCW enrolled, 92 were physicians, 246 were nurses/techniques, 120 were auxiliary workers and 22 were office workers.Results:The HBsAg, anti-HBc and anti-HCV prevalence were 8.1%, 70% and 0.6%, respectively. The highest (11.4%) HBsAg prevalence was observed in the youngest age group (20–30 years of age). High HBsAg prevalence (7.2–7.5%) was detected also in age groups above 30 years. The highest HBsAg prevalence (12.6%) was found in the auxiliaries. The anti-HBc prevalence increased significantly with age from 59% in HCWs younger than 39 years to 87% among those older than 50 years. After adjustments for different job categories, age older than 40 years remained independently associated with anti-HBc positivity (OR = 2.9; 95% CI 1.9–4.6) and inversely associated with the lack of HBV immunity or infection markers (OR = 0.4; 95% CI 0.2–7). Of 142 HBsAg negative and/or anti-HBc Ab negative sera, 28 (20%) tested positive for anti-HBs. The 114 remaining individuals with no HBV infection or immunity markers were vaccinated against HBV infection.Conclusions:A high HBV infection rate and low HBV vaccination coverage were found in Albanian HCW. Albania is a Mediterranean country still highly endemic for HBV infection and new strategies to promote HBV vaccination are to be adopted.

Correlation of alcohol consumption with liver histological features in non-cirrhotic patients.

Background and aims The association between alcohol consumption and the risk of liver disease remains unclear. The aim of our study was to determine liver morphological features directly related to the mean lifetime daily alcohol intake (LTDAI) in non-cirrhotic patients. Methods Medical records of all consecutive patients who reported alcohol consumption up to the time of hospital admission and who had undergone a liver biopsy in the Gastroenterology Unit of the University Hospital Centre of Tirana (Albania), were reviewed. Patients with established cirrhosis and/or with other possible causes of liver damage were excluded by the study. Results The histological features revealed in the biopsy samples of 51 non-cirrhotic patients were: steatosis in 46 patients (91%), six of whom (13%) showed also alcoholic foamy degeneration; alteration of hepatocytes in 40 patients (78%), diffuse mononuclear inflammation in 37 patients (73%), polymorphonuclear inflammation in 11 patients (22%) and perivenular fibrosis in 18 patients (35%). Diffuse steatosis was directly correlated with alcohol consumption (P<0.01). No association was found between alcohol consumption and the presence of degenerative alterations of hepatocytes, Mallory bodies or hepatocellular necrosis. Fibrosis was more prevalent in patients who reported a LTDAI ≥80 g in comparison with patients who reported a LTDAI ≥40 to <80 g (48% vs 25%; P<0.05). Conclusion In non-cirrhotic patients liver steatosis and fibrosis were more common features among patients who reported a higher alcoholic consumption, but no clear-cut association between typical histological features of alcoholic liver disease and alcohol consumption was found.

The relationships of chronic hepatitis and cirrhosis to alcohol intake, hepatitis B and C, and delta virus infection: a case- control study in Albania

The present study examined the effect of hepatitis B virus (HBV) and alcohol intake, and the role of hepatitis delta virus (HDV) and hepatitis C virus (HCV) in the aetiology of chronic liver disease in Albania. A total of 106 cases of liver cirrhosis or chronic hepatitis were compared to 195 control patients without these or other liver diseases. Adjusted odds ratios were 52.7 (95% CI 22.7-122) for HBV surface antigen, 26.9 (95% CI 4.9-147) for anti-HCV, 26.2 (95% CI 3-1-221) for anti-HDV, 2.4 (95% CI 1.3-4.4) for lifetime alcohol intake and 2.3 (95% CI 1-5.5) for duration of alcohol intake. Although not significant, an interaction was suggested between HBsAg and anti-HCV and between HBsAg and alcohol intake. Our study underlines the role of hepatitis viruses in the development of chronic liver diseases. Additionally, it suggests that heavy alcohol intake may magnify the effect of HBV on these diseases. HBV vaccination and alcohol abstention appear to be important strategies to reduce the risk of liver cirrhosis and chronic hepatitis in Albania.

Seroprevalence of hepatitis E virus (HEV) antibody and the possible association with chronic liver disease: a case-control study in Albania

A case-control study involving 109 in-patients with chronic liver disease and 190 in-patients with no apparent liver disease was conducted to evaluate the seroprevalence of anti-HEV antibodies and the possible association with chronic liver disease. Among cases, the anti-HEV prevalence was 36.6% which increased significantly by age; among controls, the prevalence was 12.1% (P<0.05) and was similar among age groups <60 years. Among cases, aged >50 years (OR 4.0, 95% CI 1.4-11) and the presence of end stage liver disease (ESLD) (OR 4.3, 95% CI 1.4-12.8) were associated independently with anti-HEV positivity. The mean optical density, determined by anti-HEV immunoenzymatic test, was significantly higher among patients with ESLD, compared to the other patients. These results indicate that there is a high seroprevalence of anti-HEV in patients with chronic liver disease and a possible association between HEV infection and/or anti-HEV production and advanced stage chronic liver disease.

Genotyping HCV isolates from Italy by type-specific PCR assay in the core region

A revision of the polymerase chain reaction (PCR) core procedure was performed for genotyping hepatitis C virus (HCV) in 139 patients from Italy. This procedure, developed prior to the identification of new genotypes, may be inadequate in several geographical areas. We proposed a new typing mixture in which primers for types 2c and 4, that are reported to be circulating in Italy, were added and a primer for type 2b was substituted. Using the modified procedure, 139 HCV-positive patients were analysed. The HCV genotype was identified in 96.4% of the cases. We observed double infections and unclassified genotypes in 5 (3.6%) and 5 (3.6%) patients, respectively. The classification of isolates into genotypes and subtypes 2b, 2c and 4 was confirmed by sequence analysis. Furthermore, the efficiency and accuracy of the modified core procedure were evaluated by parallel testing of 107 out of 139 samples using the line probe assay, and demonstrated a 98.9% degree of concordance. The results demonstrated the specificity of the selected primers for type 2c, 2b and 4 and confirmed the circulation of types 2c and 4 in Italy. In conclusion, the proposed modified PCR procedure is the only primer-specific PCR genotyping method available for identification of the 2c and 4 genotypes reported to be circulated in Italy and other European countries.

Incidence of DAA failure and the clinical impact of retreatment in real-life patients treated in the advanced stage of liver disease: Interim evaluations from the PITER network

Background Few data are available on the virological and clinical outcomes of advanced liver disease patients retreated after first-line DAA failure. Aim To evaluate DAA failure incidence and the retreatment clinical impact in patients treated in the advanced liver disease stage. Methods Data on HCV genotype, liver disease severity, and first and second line DAA regimens were prospectively collected in consecutive patients who reached the 12-week post-treatment and retreatment evaluations from January 2015 to December 2016 in 23 of the PITER network centers. Results Among 3,830 patients with advanced fibrosis (F3) or cirrhosis, 139 (3.6%) failed to achieve SVR. Genotype 3, bilirubin levels >1.5mg/dl, platelet count <120,000/mm3 and the sofosbuvir+ribavirin regimen were independent predictors of failure by logistic regression analysis. The failure rate was 7.6% for patients treated with regimens that are no longer recommended or considered suboptimal (sofosbuvir+ribavirin or simeprevir+sofosbuvir±ribavirin), whereas 1.4% for regimens containing sofosbuvir combined with daclatasvir or ledipasvir or other DAAs. Of the patients who failed to achieve SVR, 72 (51.8%) were retreated with a second DAA regimen, specifically 38 (52.7%) with sofosbuvir+daclatasvir, 27 (37.5%) with sofosbuvir+ledipasvir, and 7 (9.7%) with other DAAs ±ribavirin. Among these, 69 (96%) patients achieved SVR12 and 3 (4%) failed. During a median time of 6 months (range: 5–14 months) between failure and the second DAA therapy, the Child-Pugh class worsened in 12 (16.7%) patients: from A to B in 10 patients (19.6%) and from B to C in 2 patients (10.5%), whereas it did not change in the remaining 60 patients. Following the retreatment SVR12 (median time of 6 months; range: 3–12 months), the Child-Pugh class improved in 17 (23.6%) patients: from B to A in 14 (19.4%) patients, from C to A in 1 patient (1.4%) and from C to B in 2 (2.9%) patients; it remained unchanged in 53 patients (73.6%) and worsened in 2 (2.8%) patients. Of patients who were retreated, 3 (4%) had undergone OLT before retreatment (all reached SVR12 following retreatment) and 2 (2.8%) underwent OLT after having achieved retreatment SVR12. Two (70%) of the 3 patients who failed to achieve SVR12 after retreatment, and 2 (2.8%) of the 69 patients who achieved retreatment SVR12 died from liver failure (Child-Pugh class deteriorated from B to C) or HCC complications. Conclusions Failure rate following the first DAA regimen in patients with advanced disease is similar to or lower than that reported in clinical trials, although the majority of patients were treated with suboptimal regimens. Interim findings showed that worsening of liver function after failure, in terms of Child Pugh class deterioration, was improved by successful retreatment in about one third of retreated patients within a short follow-up period; however, in some advanced liver disease patients, clinical outcomes (Child Pugh class, HCC development, liver failure and death) were independent of viral eradication.