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Evolving epidemiology of hepatitis C virus

The publication of the Global Burden of Disease Study 2010 (GBD 2010) and the accompanying collection of Lancet articles in December 2012 provided the most comprehensive attempt to quantify the burden of almost 300 diseases, injuries, and risk factors, including neglected tropical diseases (NTDs) [1]–[3]. The disability-adjusted life year (DALY), the metric used in the GBD 2010, is a tool which may be used to assess and compare the relative impact of a number of diseases locally and globally [4]–[6]. Table 1 lists the major NTDs as defined by the World Health Organization (WHO) [7] and their estimated DALYs [1]. With a few exceptions, most of the NTDs currently listed by the WHO [7] or those on the expanded list from PLOS Neglected Tropical Diseases [8] are disablers rather than killers, so the DALY estimates represent one of the few metrics available that could fully embrace the chronic effects of these infections.

Table 1
Estimated DALYs (in millions) of the NTDs from the Global Burden of Disease Study 2010.

Disease	DALYs from GBD 2010 (numbers in parentheses indicate 95% confidence intervals) [1]	
NTDs	26.06 (20.30–35.12)	
Intestinal nematode infections	5.19 (2.98–8.81)	
Hookworm disease	3.23 (1.70–5.73)	
Ascariasis	1.32 (0.71–2.35)	
Trichuriasis	0.64 (0.35–1.06)	
Leishmaniasis	3.32 (2.18–4.90)	
Schistosomiasis	3.31 (1.70–6.26)	
Lymphatic filariasis	2.78 (1.8–4.00)	
Food-borne trematodiases	1.88 (0.70–4.84)	
Rabies	1.46 ((0.85–2.66)	
Dengue	0.83 (0.34–1.41)	
African trypanosomiasis	0.56 (0.08–1.77)	
Chagas disease	0.55 (0.27–1.05)	
Cysticercosis	0.50 (0.38–0.66)	
Onchocerciasis	0.49 (0.36–0.66)	
Trachoma	0.33 (0.24–0.44)	
Echinococcosis	0.14 (0.07–0.29)	
Yellow fever	<0.001	
Other NTDs *	4.72 (3.53–6.35)	


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* Relapsing fevers, typhus fever, spotted fever, Q fever, other rickettsioses, other mosquito-borne viral fevers, unspecified arthropod-borne viral fever, arenaviral haemorrhagic fever, toxoplasmosis, unspecified protozoal disease, taeniasis, diphyllobothriasis and sparganosis, other cestode infections, dracunculiasis, trichinellosis, strongyloidiasis, enterobiasis, and other helminthiases.



Even DALYs, however, do not tell the complete story of the harmful effects from NTDs. Some of the specific and potential shortcomings of GBD 2010 have been highlighted elsewhere [9]. Furthermore, DALYs measure only direct health loss and, for example, do not consider the economic impact of the NTDs that results from detrimental effects on school attendance and child development, agriculture (especially from zoonotic NTDs), and overall economic productivity [10], [11]. Nor do DALYs account for direct costs of treatment, surveillance, and prevention measures. Yet, economic impact has emerged as an essential feature of the NTDs, which may trap people in a cycle of poverty and disease [10]–[12]. Additional aspects not considered by the DALY metrics are the important elements of social stigma for many of the NTDs and the spillover effects to family and community members [13], [14], loss of tourism [15], and health system overload (e.g., during dengue outbreaks). Ultimately NTD control and elimination efforts could produce social and economic benefits not necessarily reflected in the DALY metrics, especially among the most affected poor communities [11].

/pdf/the-global-burden-of-disease-study-2010-interpretation-and-2s1owuc43r.pdf

The global burden of disease study 2010: interpretation and implications for the neglected tropical diseases.

https://aasldpubs.onlinelibrary.wiley.com/doi/pdf/10.1002/hep.20110

Chronic hepatitis B: update of recommendations.

Hepatitis B virus (HBV) prevalence has decreased dramatically in Iranian population during the last decade, and now our country is classified as having low endemicity for hepatitis B infection. Improvement of the people's knowledge about HBV risk factors, national vaccination program since 1993 for all neonates, and vaccination of high risk groups might justify this decrease. The HBV vaccination started in infants in two provinces (Zanjan and Semnan) in 1989, and in 1993 the vaccination was included in the Expanded Program on Immunization (EPI) countrywide. After 13 years of implementation, the coverage has reached an appropriate level from 62% in 1993 to 94% in 2005. Evaluation of risk factors in HBV infected people is important for designing the strategies to control the disease. Intensifying HB vaccination of high risk groups, surveillance of hepatitis B infected subjects, and control on health state of refugees will further decrease the frequency of the disease in our country. Considering all possible routes of transmission in subjects without risk factors for infection is necessary. Changes in the pattern of transmission of new cases of hepatitis B, inform us of changes in the epidemiology of viral hepatitis B infection.

The changing epidemiology of viral hepatitis B in Iran.

Pathogenesis and management of bacterial urinary tract infections in adult patients with diabetes mellitus.

Results: Fourteen studies met the inclusion criteria. They were from 7 (out of 30) provinces in which about 40 percent of the country population live. These provinces (HBsAg positive prevalence) were Golestan (6.3%), Tehran (2.2%), East Azarbaijan (1.3%), Hamedan (2.3%), Isfahan (1.3%), Kermanshah (1.3%) and Hormozgan (2.4%). The HBV infection prevalence in Iran is estimated to be 2.14 percent (95%CI: 1.92-2.35), in men and women 2.55 percent (95%CI: 2.252.85) and 2.03 percent (95%CI: 1.6-2.46 percent) respectively. Conclusions: About 1.5 million people in Iran are living with HBV infection (mild to moderate prevalence according to WHO classification) and it is assumed that 15% to 40% of them are at risk of developing cirrhosis and/or hepatocellular carcinoma (HCC) without intervention. The prevalence of HBV infection has been reported higher in more recent studies compared to the study in 2000-2001.

Hepatitis B Virus Infection in Iran: A Systematic Review

books by two independent reviewers. We also searched the research projects of 29 out of 40 Iranian universities of medical sciences from their websites. We contacted the Center for Disease Control (CDC) of the Iranian Ministry of Health and the Iranian Blood Transfusion Organization (IBTO) for searching national reports from the study time period. Medical students’ theses were also evaluated by two independent reviewers from the Iranian center for scientific documents and records (IranDoc). Finally, we consulted eight expert HCV researchers in Iran and searched their personal archives for additional citations. Forward and backward citations of searched items were also performed. Critical appraisal and selection of studies Two independent reviewers reviewed all citations thoroughly and checked for eligibility criteria to include the studies in the analysis. The inclusion criteria were all cross-sectional studies that specified temporal and geographic characteristics of the study; sufficiently declared objectives; and that used a valid 213 Seyed Moayed Alavian et al. Hepatitis Monthly, Summer 2009; 9(3): 211-223 sampling method that allowed for a generalization of the findings to the target population, valid measurement instruments for all study subjects, and appropriate analytic methods for the given sampling design and demographic characteristics. We revised the criteria developed by Sharifi et al. for this purpose (12). Data extraction After evaluating studies on these criteria, we extracted the findings of the included studies to Excel spreadsheets. The extracted data were year of the study, first author, province and district of the study, sample population, sampling method, sample size, HCV Antibody detection method, HCV Antibody kit name, mean age and standard error (SE) of subjects, percentage of male subjects, and HCV point prevalence in study subjects and/or in males/females and its SE. If there were other parameters reported other than SE, such as standard deviation, confidence interval, and/or P.value, the proper modifications were performed to calculate SE. Statistical analysis We analyzed the extracted data to estimate the point prevalence of HCV infection and its 95% confidence interval (CI) and used a Cochrane Q-test with a significance level of < 0.1 for checking the statistical heterogeneity of the results. We used a meta-analysis method with the “meta” command using fix/random model based on the results of the heterogeneity test. It seems that the meta-analysis method would not have been a suitable method to achieve the objectives of this systematic review because the weighting system of this method only considers sample size and not the size of the provincial population. We used a survey data analysis method to calculate the estimate of the nationwide prevalence rate considering the weight of each province as the ratio of the provincial population to the sample size(s), where the population of each province was retrieved from the Iranian national census at 2006 (7). In provinces with more than one prevalnce study (Tehran and Sistan-va-Baluchestan), the provincial prevalence was calculated by a meta-analysis of the studies, and the total sample size was determined by adding all study sample sizes. The analysis was performed with STATA 9.1 software (STATA Corp. LP). The results were shown in geographic maps using Arc View 3.2a software (ESRI Inc. NY).

Hepatitis C infection in the general population of Iran: a systematic review.

Background and Aims: In order to evaluate some possible risk factors for the spread of hepatitis B infection, a case-control study was undertaken. Methods: The study population consisted of subjects who came to Karaj Hepatitis Center. All subjects who met the inclusion criteria were considered as having chronic hepatitis and comprised our case group. Risk factors were evaluated using a questionnaire. Backward conditional logistic regression analysis was used. Results: The case group consisted of 500 chronic subjects, and 434 subjects with negative tests for hepatitis B, hepatitis C and HIV comprised the control group. Age, male sex, marital status (being married), history of contact with hepatitis, extramarital sexual activity, IV-drug use, major surgery, experimental dentist visit and some jobs (police, barber, and driver) were found to be independent risk factors of being chronically infected with hepatitis B virus (odds ratio: 0.9, 2.3, 2.1, 8.9, 6.5, 5.4, 1.6, 1.8 and 2.3, respectively). Conclusions: It seems to be of great importance to pay more attention to certain jobs, life styles and cultural matters in Iran that predispose people to a number of risk factors so as to implement measures to control HBV spread. Despite existence of a long list of risk factors, different epidemiological studies with alternative methodologies accompanied by meta-analysis of risk factors in each separate area seems to be helpful in providing information about transmission routes and surveillance of hepatitis B infection.

Risk Factors in Chronic Hepatitis B Infection: A Case-control Study

Background and Aims: The significance of hepatitis B virus (HBV) serum titers has been examined in several clinical situations. Although most studies addressing this question have shown a correlation between virus serum titer and severity of liver damage, some others have failed to show any correlation between them. The aim of the present study was to determine any correlation between HBV viral load and the severity of liver disease. Methods: 200 patients, including inactive carriers (n=104), patients with chronic active hepatitis (n=74: 55 HBeAg negative and 19 HBeAg positive) and with cirrhosis (n=22) entered the study. Quantitative serum HBV RNA assay was carried out using the PCR Amplicore technique. Results: The mean age of the patients was 37 ± 12 years. A significant correlation was observed between HBV DNA viral load and ALT in cirrhotic patients (p=0.035, r=0.451). No correlation was observed between serum HBV DNA viral load and the histopathological score or grade, ALT or AST level in other CLD types (p>0.05). Conclusions: Our results indicate that the severity of liver disease is independent of serum levels of hepatitis B virus. The correlation between serum titers of hepatitis B virus and severity of liver disease clearly require further investigation.

Alavian SeyedMoayed

Papers

Hepatitis B Virus Infection in Iran: A Systematic Review

Hepatitis C infection in the general population of Iran: a systematic review.

Risk Factors in Chronic Hepatitis B Infection: A Case-control Study

HBV DNA Viral Load and Chronic Hepatitis Infection in Different Stages

Hepatitis C Virus Genotypes