Epidemiology of Hepatitis C Iran

Transcription

1 Seyed Moayed Alavian M.D. Professor of Gastro & Hepatology Editor-in-chief of Glob Hepat Comm Editor-in-chief of Hepatitis Monthly E mail: editor@hepatmon.com Epidemiology of Hepatitis C Iran

2 Epidemiology of Hepatitis C HCV infection is widespread throughout the world. WHO estimation suggests that up to 3% of the world s population have been infected with HCV.

3 Relative Efficiency of HBV, HCV, HIV Transmission by Type of Exposure Type of exposure Efficiency of transmission to infected source HBV HCV HIV Transfusion Injecting drug use Unsafe injections Perinatal Needle stick Sexual Non-intact skin ++ +/- +/-

4 Risk Factors Associated With Acquiring HCV Infection Transfusion, transplant from infectious donor (1992) Injecting drug use and Incarceration Occupational blood exposure (needle sticks) Birth to an infected mother Infected sex partner Multiple heterosexual partners Tattooing Health-care related transmission:

5 Determining Who to Screen Primary care offices are the frontline in identifying patients with risk factors Anyone with a history of IDUs (even limited) should be tested Persons with a history of no injection drug use and/or multiple sexual partners should also be screened for HCV Persons infected with HIV should be screened for HCV Any abnormal ALT level warrants HCV testing All Thalassemia, Hemophilia and Hemodialysis patients periodically

6 Decrease or emerging infection? With the implementation of mandatory HCV screening of blood and blood products in the early 1990s, the number of post-transfusion infections has already decreased dramatically. However, intravenous drug use (IDU) has accelerated in the world.

7 Epidemiology of Hepatitis C First report in Iran is related to Rezvan et al in 1994 in IBTO: 0.3% of blood donors in Tehran. Rezvan et al. Vox Sang 1994

8 Hepatitis C in Iran Neonatal Blood Exchange and HCV Is Iran a low prevalence and Before screening of HCV in blood donors? Between , questionnaire to parents of students, eight different part of Tehran, randomly selected, Do you have children between 9-11 years ( screening started in 1995)? 465 children with history of blood exchange Two were HCV Ab positive and only one case with HCV RNA positive and genotype 1a Risk of HCV infection among transfused neonate is uncommon Nikbin, Alavian et al

9 Epidemiology of Hepatitis C Frequency of positive anti-hcv antibody in excluded cases were 9.2%. Prevalence of HCV infection in gypsies in Shahr-e-Kord was 3.1% Saneie-Moghadam 2003, Hosseini 2004

10 Alavian et al. J Gastro & Hepatology 2002( 0.12% were HCV positive)

11 Alavian et al. J Gastro & Hepatology 2002( 0.12% were HCV positive)

12 Risk Factor for HCV infection, Khuzestan, (Hajiani 2006)

13 IUDs / Prisoners and HCV in Iran First report in Prison by Prof Zali in 2001, IUDs in Ghasr prison in Tehran (study time spring 1995): 40.1% HCV Is it a serious problem? History of tattooing and cupping were important Zali 2003

14 Prevalence & Risk Factors of HIV, HBV, HCV in Drug Addicts among Zanjan Prisoners History and duration of addiction, kind and rout of drug use, shared syringe use, sexual behavior, tattooing Prevalence : HIV:1.2%, HBV: 3.8%, HCV: 47.4% Significant association between being single, heroin use, and Homosexuality and HCV infection (P=0.002) Significant association between IUDs and HCV (P=0.0001), HIV infections (P=0.04) Khani et al 2003

15 In a study in three prisons in three central provinces of Iran (Isfahan, Lorestan, Chaharmahal va Bakhtiari) in 2003 in male prisoners who were arrested because of their addiction 3.5% were HBsAg positive and 35.8% were HCV antibody. According the age, the infection with HBV and HCV were more common in younger than 30 yr old. Isfahan, Lorestan and Chaharmahal va Bakhtiari: Addicted arrested respectively, 28.5%, 50%, 53.% HCV infected IUDs, Tattooing history, In jail more than 5 years were important In Conclusion: Potentiating of harm reduction program,education for dangerous behavior,

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18 You are invited to visit: And receive the free articles regarding hepatitis from Iran and Middle East and Middle Asia

19 Strategies for control First we attended to the high risk groups such as hemodialysis, thalassemia and hemophilia patients. Harm reduction for IDUs Safety of blood and blood products More attention to other risk factors

20 Strategies for control Community-wide education initiatives are needed for alerting people to the modes of transmission and facilitating a social climate at-risk people feel comfortable to seek testing and where harm-reduction strategies can be implemented.

21 Epidemiology and Risk Factors of HCV Infection in Hemodialysis Alavian SM, et al. Epidemiology and risk factors of HCV infection among hemodialysis patients in countries of the Eastern Mediterranean Regional Office of WHO (EMRO)J Public Health (Oxf). 2011

22 The prevalence of HCV has decreased from 14.4% in 1999 to 4.5% in 2006 Less than 50% of anti-hcv positive are HCV RNA negative now. I would like to mention that we should evaluate the epidemiology of HCV infection in addition to serological tests, using molecular tests such as RT- PCR, and ask the history of antiviral therapy in hemodialysis patients with anti-hcv Ab-positive results and consider the RT-PCR negative results as cured cases, not positive ones. Alavian et al Hepatitis B and C in dialysis units in Iran: Changing the epidemiology. Hemodial Int Alavian SM. An Unbelievable Fact on Dialysis Centers Without Hepatitis C Infection. Nephro Urol Mon. 2014

23 Prevalence HCV among patients with thalassemia in Iran

24 Epidemiology and Risk Factors of HCV Infection in Thalassemia Alavian SM, et al. Epidemiology of HCV Infection among Thalassemia Patients in eastern Mediterranean Countries: a Quantitative Review of Literature. Iran Red Cres Med J. 2010

25 Hepatitis C in thalassemia patients After initiation of donors screening for HCV in 1995 and exclusion of high-risk groups from donation pool, the prevalence of HCV infection in thalassemia patients had decreased significantly Alavian SM, et al. The efficacy of blood donor screening in reducing the incidence of hepatitis C virus infection among thalassemic patients in Iran. Transfusion Today. 2002

26 Risk factors for acquiring the HCV infection in Thalassemia In 98 thalassemia patients in Markazi prov. In % (Elisa test) were positive, and 5.1% (Confirm) Seropositive subjects had higher mean number of blood transfusion units and longer duration of treatment than seronegative subjects Anti-HCV was not found positive among thalassemia patients who started receiving transfusion after Samimi-Rad K, Hepatitis C virus genotypes among patients with thalassemia and inherited bleeding disorders in Markazi province, Iran. Haemophilia. 2007

27 The current study aimed to investigate why patients still seroconvert to anti-hcv in thalassemia centers. Strains in seven clades were from nine patients infected between 1999 and 2005 and similar to strains from eight patients infected before 1996, indicating ongoing transmission at the centers. Further epidemiological investigation revealed that 28 patients infected with strains within the same clade had frequently been transfused at the same shift sitting on the same bed. An additional eight patients with related strains had frequently been transfused simultaneously in the same room. The results suggest nosocomial transmission at these thalassemia centers both before and after the introduction of blood screening. Further training of staff and strict adherence to preventive measures are thus essential to reduce the incidence of new HCV infections. Samimi-Rad Ket al. Patient-to-Patient Transmission of Hepatitis C at Iranian Thalassemia Centers Shown by Genetic Characterization of Viral Strains. Hepat Mon. 2013

28 Treatment of HCV infected pat9ents is important strategy for control of HCV infection in thalassemia group. Sustained virological response (SVR) was significantly higher in patients who received ribavirin (51 % vs. 38 % P = 0.02). In multivariate regression, OR of ribavirin for prediction of SVR was 2.2 (95 % CI )

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31 Hepatitis C in haemophilia patients Iran: 48.07% [(95%CI ) Bias may Affect Results of Reported Studies from Referral Centers

32 In an open-label single-treatment arm cohort study, 367 haemophilia patients seronegative for hepatitis B and human immunodeficiency virus markers and chronically infected with HCV infection received 180 microg of Pegasys and mg of ribavirin according to body weight. Genotypes 1 and 4, mixed and untypable infections were treated for 48 weeks, while genotypes 2 and 3 were treated for 24 weeks. Alavian SM, et al. Peginterferon alpha-2a and ribavirin treatment of patients with haemophilia and hepatitis C virus infection: a single-centre study of 367 cases. Liver Int Sep;30(8):

33 Two hundred and twenty-five subjects 61% achieved SVR, 66 patients relapsed and 30 subjects did not respond and nine patients developed breakthrough during treatment. Peginterferon alpha-2a in combination with weightbased ribavirin has SVR rate of 51% for genotype 1 and 71% for genotype non-1 infections in haemophilia patients. Alavian SM, et al. Peginterferon alpha-2a and ribavirin treatment of patients with haemophilia and hepatitis C virus infection: a single-centre study of 367 cases. Liver Int Sep;30(8):

34 Occult Hepatitis C Virus Infection in Iranian Patients With Cryptogenic Liver Disease Patients with chronic liver disease of unknown etiology may have occult HCV infection in the absence of anti-hcv antibodies and plasma HCV-RNA. It has been suggested that in the absence of liver biopsy specimens, analysis of PBMC sample for HCV-RNA would be informative. Bokharaei-Salim F, Keyvani H, Monavari SH, Alavian SM, Madjd Z, Toosi MN.et al. Occult hepatitis C virus infection in Iranian patients with cryptogenic liver disease. J Med Virol Jun;83(6):

35 A significant difference in the prevalence of positive HCV-RNA in PBMCs and history of blood transfusion