Lu Yu Hwang

Risk Factors for Perinatal Transmission of Hepatitis C Virus (HCV) and the Natural History of HCV Infection Acquired in Infancy

BACKGROUNDnThe goal of the present study was to assess risk factors for perinatal hepatitis C virus (HCV) transmission and the natural history of infection among HCV-infected infants.nnnMETHODSnIn a cohort study, 244 infants born to HCV-positive mothers were followed from birth until age > or =12 months. Maternal serum was collected at enrollment and delivery; infant serum was collected at birth and at 8 well-child visits. Testing included detection of antibody to HCV, detection of HCV RNA (qualitative and quantitative), and genotyping. HCV-infected infants were followed annually until age 5 years.nnnRESULTSnOverall, 9 of 190 (4.7% [95% confidence interval (CI), 2.3%-9.1%]) infants born to mothers who were HCV RNA positive at delivery became infected, compared with 0 of 54 infants born to HCV RNA-negative mothers (P=.10). Among HCV RNA-positive mothers, the rate of transmission was 3.8% (95% CI, 1.7%-8.1%) from the 182 who were human immunodeficiency virus (HIV) negative, compared with 25.0% (95% CI, 4.5%-64.4%) from the 8 who were HIV positive (P<.05). Three infected infants resolved their infection (i.e., became HCV RNA negative). In multivariate analysis restricted to HCV RNA-positive mothers, membrane rupture > or =6 h (odds ratio [OR], 9.3 [95% CI, 1.5-179.7]) and internal fetal monitoring (OR, 6.7 [95% CI, 1.1-35.9]) were associated with transmission of HCV to infants.nnnCONCLUSIONnIf duration of membrane rupture and internal fetal monitoring are confirmed to be associated with transmission, interventions may be possible to decrease the risk of transmission.

The effect of HIV coinfection on the risk of cirrhosis and hepatocellular carcinoma in U.S. veterans with hepatitis C.

OBJECTIVES:This study was conducted to determine whether HIV coinfection increases the risk of cirrhosis in HCV-infected patients in the HAART and pre-HAART eras. Further, the risk of hepatocellular carcinoma was also examined.METHODS:This retrospective cohort study was conducted among HCV-infected veterans who were seen at one of the 172 Veterans Health Administration hospitals between October 1, 1991 and September 30, 2000. Patients with prerecorded advanced liver disease were excluded. Incidence rates, cumulative incidence, and Cox proportional hazard ratios were calculated.RESULTS:There were 26,641 patients with HCV-only and 4,761 patients with HCV–HIV coinfection. The unadjusted incidence rate of cirrhosis was lower in patients with coinfection than HCV-only (p < 0.01). After controlling for demographics and confounders (including alcoholism and chronic hepatitis B), coinfection was not significantly associated with cirrhosis. However, there was an increased risk of cirrhosis in patients with coinfection compared to HCV-only during the pre-HAART era (before October 1, 1996) (hazard ratio = 1.48, 1.06–2.07, p= 0.02), but not among patients who entered the cohort during the HAART era. The unadjusted incidence rate of hepatocellular carcinoma in patients with coinfection and HCV-only was 1.3 and 2/1,000 person-years, respectively (p= 0.04). In the multivariate model, coinfection was not associated with hepatocellular carcinoma (hazard ratio = 0.84, p= 0.40).CONCLUSIONS:Coinfection was a significant risk factor for cirrhosis only during the pre-HAART era and was not associated with hepatocellular carcinoma, irrespective of time period.

Prevalence of sexually transmitted infections and associated risk factors among populations of drug abusers.

A cross-sectional survey was conducted of sexually transmitted diseases (STDs) and risky behaviors among 407 drug abusers in treatment facilities in 1998. Infections with human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV), herpes simplex virus type 2 (HSV-2), and syphilis were detected by testing serum antibody levels; chlamydia and gonorrhea were detected by testing nucleic acid levels in urine. Logistic regression analysis was performed to measure associations. Prevalences of antibodies were as follows: to HSV-2, 44.4%; to HCV, 35.1%; to HBV, 29.5%; to HIV, 2.7%. The prevalence of syphilis was 3.4%; of chlamydia, 3.7%; and of gonorrhea, 1.7%. Of the 407 subjects, approximately 62% had markers for 1 of the STDs. HIV infection was associated with African American race, use of smokable freebase (crack) cocaine, and STD history. HBV infection was associated with age >30 years, injecting drugs, needle sharing, a history of treatment for drug abuse, and African American race. HCV infection was associated with an age >30 years, injecting drugs, and needle sharing, and HSV-2 infection with an age >30 years, female sex, and African American race. Syphilis was associated with a history of STDs. High prevalences of STDs among drug abusers indicate the need for integration of STD screening and treatment into drug treatment programs.

The role of hepatitis C in hepatocellular carcinoma: a case control study among Egyptian patients.

Background Egypt has one of the highest prevalence rates of hepatitis C virus (HCV) infection in the world; however, the risk and attribution related to HCV in Egyptian patients with hepatocellular carcinoma (HCC) remains unknown. Goals The current study was undertaken to estimate the risk of HCC in relation to HCV in Egypt. Study Thirty-three patients with HCC and 35 healthy controls who had a similar socioeconomic status were prospectively enrolled at the University of Cairo National Cancer Institute. Results Anti-HCV antibodies were present in 75.8% of the patients and in 42.9% of the controls (p = 0.01); hepatitis B surface antigen (HBsAg) was present in 15.2% of the patients and in 2.9% of the controls (p = 0.03). In addition, the sex-and age-adjusted odds ratio (OR) for anti-HCV antibodies was 5.1 (95% CI = 1.5–17.4) and for HBsAg was 13.2 (95% CI = 1.2–148.2). Concurrent Schistosoma mansoni and anti-HCV was associated with an OR of 10.3 (95% CI = 1.3–79.8), which was higher than that for anti-HCV (6.5; 95% CI = 1.6–26.6) and S. mansoni infection (0.2; 95% CI = 0.1–6.2) alone. Finally, we estimated the attributable fraction of HCC to HCV to be 64% in this study population and 48% in the general Egyptian population. Conclusions Both HCV and hepatitis B virus infection increase the risk of HCC in Egyptian patients, whereas isolated Schistosoma infection does not. Because of the very high prevalence rate of HCV in the general Egyptian population, it accounts for most HCC cases in Egypt.

Relationship of cosmetic procedures and drug use to hepatitis C and hepatitis B virus infections in a low‐risk population

We conducted an anonymous cross‐sectional seroprevalence study of a population with a low frequency of injection drug use to determine whether persons with a history of cosmetic procedures, such as tattooing and body piercing, or intranasal drug use were at increased risk for hepatitis C virus (HCV) or hepatitis B virus (HBV) infection. Students 18 years and older from eight college campuses in Houston, Texas, were invited to participate in the study. Of the 7,960 who completed a self‐administered questionnaire and provided a blood sample, 5,282 U.S.‐ or Canadian‐born participants were analyzed. Their median age was 21, 62% were female, 42% were white, 26% black, 22% Hispanic, and 10% Asian or other. Two percent reported injection drug use, 13.7% intranasal drug use, 21.2% body piercings, and 25.2% tattoos. The overall prevalence of HCV infection was 0.9% and of HBV infection was 5.2%. Higher HCV prevalence was independently associated with increasing age (odds ratio [OR] per year = 1.11; 95% confidence interval [CI] = 1.08‐1.14), history of injection drug use (OR = 18.24; 95% CI = 7.74‐42.92), blood transfusion before 1991 (OR = 3.21; 95% CI = 1.02‐10.12), and incarceration (OR = 3.48; 95% CI = 1.45‐8.37). Among 5,066 students who denied injecting drugs, HCV prevalence was 0.8% in those who reported intranasal drug use and 0.6% each in those who reported tattoos and those who reported body piercing. Increased HBV prevalence was associated with high‐risk sexual behaviors and black or Asian race. In conclusion, there was no increased risk for HCV or HBV infection in low‐risk adults based solely on history of cosmetic procedures or snorting drugs. However, proper infection control practices for cosmetic procedures should be followed, illegal drug use discouraged, and hepatitis B vaccination provided to adolescents and sexually active adults. (HEPATOLOGY 2006;44:341–351.)

Accelerated hepatitis B vaccination schedule among drug users: a randomized controlled trial.

BACKGROUNDnHepatitis B vaccine provides a model for improving uptake and completion of multidose vaccinations in the drug-using community.nnnMETHODSnThe Drugs, AIDS, STDs, and Hepatitis (DASH) project conducted a randomized controlled trial among not-in-treatment current drug users in 2 urban neighborhoods. Neighborhoods were cluster-randomized to receive a standard behavioral intervention (which provided information on human immunodeficiency virus [HIV]) or an enhanced behavioral intervention (designed to increase acceptance of or adherence to the hepatitis B vaccination protocol). Participants within clusters were randomized to a standard vaccination schedule (vaccines at 0, 1, and 6 months) or an accelerated vaccination schedule (vaccines at 0, 1, and 2 months). The outcomes were completion of the 3-dose vaccine and seroprotection against hepatitis B virus (HBV).nnnRESULTSnOf participants with negative screening results for HIV and HBV, 77% accepted hepatitis B vaccination, and 75% of vaccinees received all 3 doses. Injection drug users (IDUs) on the accelerated schedule were significantly more likely to receive 3 doses (76%) than those on the standard schedule (66%; P = .04), although for drug users as a whole the corresponding adherence rates were 77% and 73%, respectively. No difference in adherence was observed between the behavioral intervention groups. Predictors of adherence were older age, African American race, stable housing, and alcohol use. Cumulative HBV seroprotection (≥10 mIU/mL) was gained within 12 months by 65% of those completing the schedule. Seroprotection at 6 months was greater for those on the accelerated schedule.nnnCONCLUSIONnThe accelerated vaccination schedule improves hepatitis B vaccination adherence among IDUs.

Late HIV diagnosis in Houston/Harris County, Texas, 2000-2007.

Abstract This cross-sectional study aimed to evaluate the prevalence and predictive factors associated with late HIV diagnoses in Houston, Texas using surveillance data. Study subjects were Houston/Harris County residents, 13 years or older, diagnosed with HIV and reported to the Houston Department of Health and Human Services. Late HIV diagnosis was defined as an AIDS diagnosis within three months of an HIV diagnosis. Logistic regression was used to investigate the association between late HIV diagnoses and predictive factors. We found 31% of the study population had late HIV diagnoses. The Hispanic population, men, older individuals, heterosexuals, and those diagnosed in private facilities were more likely to receive late HIV diagnoses. Sensitivity analysis was conducted to evaluate the effect of time from HIV to AIDS diagnosis on the prevalence of a late diagnosis, and on the predictors of late diagnosis. The sensitivity analysis showed time affects prevalence, but not the odds ratios of the risk factors for late diagnosis. This finding suggests HIV prevention programs should specifically target these populations at risk for late HIV diagnosis to encourage frequent HIV testing.

Prevalence of infantile hypertrophic pyloric stenosis in Texas, 1999–2002

BACKGROUNDnThe cause of infantile hypertrophic pyloric stenosis (IHPS) is poorly understood. This descriptive study of IHPS focuses on the effect of maternal nativity, maternal Hispanic ethnicity, subtypes of maternal Asian ethnicity, and the timing of the infants surgery, that is, pyloromyotomy.nnnMETHODSnAll cases of IHPS born in Texas from 1999 through 2002 were retrieved from the Texas Birth Defects Registry. Crude prevalence ratios and adjusted prevalence ratios (aPRs) were calculated using logistic regression.nnnRESULTSnIHPS occurred predominantly in boys (aPR 4.21; 95% CI: 3.81, 4.65) compared with girls. Compared with Whites, there was a lower prevalence among Blacks (aPR 0.36; 95% CI: 0.30, 0.43), foreign-born Hispanics (aPR 0.61; 95% CI: 0.54, 0.69), Chinese (aPR 0.11; 95% CI: 0.01, 0.78), Vietnamese (aPR 0.17; 95% CI: 0.06, 0.46), Asian Indians (aPR 0.33; 95% CI: 0.15, 0.75), and Filipinos (aPR 0.22; 95% CI: 0.05, 0.91). In aggregate, foreign born Asians had a decreased risk of IHPS (aPR 0.20; 95% CI: 0.11, 0.37) compared to Whites. We observed no decrease in the risk of IHPS among US-born Asians (in aggregate) or US-born Hispanics. The strength of these risk factors did not vary according to the timing of the pyloromyotomy.nnnCONCLUSIONSnThis study confirmed previous findings that female infants and Black infants have a lower rate of IHPS. Large decreases in rates of IHPS were observed among foreign-born Hispanics and foreign-born Asians, but not among their US-born counterparts. These findings may be explained by differences in the frequency of behavioral risk factors for IHPS or differences in the frequency of ascertainment of mild cases of IHPS by ethnicity or nativity.

Immune response to hepatitis B vaccination in drug using populations: A systematic review and meta-regression analysis

Injecting and non-injecting drug users are at increased risk of contracting HBV infection, and show lower antibody response to hepatitis B vaccination compared to the general population. This systematic review and meta-regression analysis aimed to estimate seroprotection rates and identify host or vaccine factors associated with varying immune response following hepatitis B vaccination in drug using populations. Original research articles were searched using online databases (Medline, PubMed, and Embase) and from reference lists of eligible articles. HBV vaccine intervention studies reporting seroprotection rates in drug users, published in English during or after 1989 were eligible. Of 978 citations reviewed, 11 studies were eligible and included for final analysis. The reported seroprotection rates ranged from 54.5% to 97.1%. The studies were significantly heterogeneous (Q=180.850, p=0.000). Measurement of anti-HBs antibody at 2 months after the third vaccine dose (RR=2.62, 95%CI=1.16-5.94, p=0.026) was significantly associated with higher seroprotection rates compared to measurement at 1 month and 6 month following third vaccine dose. Age, gender, current drug use, vaccine dose and schedule, anti-HBc, anti-HCV and anti-HIV antibody seropositivity, and proportion of IDU study population did not show a significant association with seroprotection rates. Recommendations for future research include the definition of a standardized time point for the measurement of anti-HBs antibody levels, to enhance comparability of the immune response between different studies. Studies should strive to accurately report all potentially relevant factors affecting immune response to vaccine. Long-term follow up studies are needed to assess the seroprotection status in drug using populations receiving hepatitis B vaccine by standard or accelerated schedules.

Influence of trust on HIV diagnosis and care practices: a literature review.

Delays in accessing HIV health care and failure to adhere to providers’ advice are common. Patient trust is critical to an individual’s willingness to seek care and follow the physician’s advice. Conversely, patient distrust can diminish the patient’s health status. The trust literature is reviewed in an attempt to determine its effect on HIV care. In the HIV literature reviewed, greater trust in health care providers was associated with improved accessing of and remaining in care. Interventions to enhance patient trust have been tested, with no changes in the levels of trust being found. Few studies were rigorous enough to assess causality or temporal relation. It is not clear whether there is a causal association between patient trust and HIV health care outcomes. As these relationships are better understood, interventions can be designed to increase health-promoting behaviors.