Hepatitis C Virus Infection and Risk of Stroke: A Systematic Review and Meta-Analysis

Background/Aims

Several studies analyzed the association between hepatitis C virus (HCV) infection and the risk of stroke or cerebrovascular death, but their findings were inconsistent. Up to date, no systematic review about the association between HCV infection and stroke was performed. We conducted a meta-analysis to examine whether HCV infection dose increase stroke risk in comparison to the population without HCV infection.

Methods

We followed standard guidelines for performance of meta-analysis. Two independent investigators identified eligible studies through structured keyword searches in several databases. Random-effects and fixed-effects models were used to synthesize the data. Heterogeneity between studies and publication bias were also accessed.

Results

Combining the data from the eligible studies, we calculated the pooled multi-factor adjusted Odds Ratio (OR) with 95% confidence interval (CI). Upon the heterogeneity found between studies, the result was 1.58 (0.86, 2.30) by random-effects model. However, after omitting the study which induced heterogeneity, the pooled OR with 95% CI was 1.97 (1.64, 2.30).

Conclusions

This meta-analysis suggested that HCV infection increased the risk of stroke. More prospective cohort studies will be needed to confirm this association with underlying biological mechanisms in the future.     

用PCR分析HCV－RNA NS5部分序列变异

用ＰＣＲ分析ＨＣＶ－ＲＮＡＮＳ５部分序列变异魏来,王宇,陈红松,陶其敏（北京医科大学人民医院肝病研究所,北京１０００４４）对丙型肝炎病毒（ＨＣＶ）ｃＤＮＡ的序列分析是验证ＨＣＶ基因分型,确定新的型与亚型的基础￣［１］．经典的序列分析方法需经繁琐的分子...     

Diagnostic Accuracy of Point-of-Care Tests for Hepatitis C Virus Infection: A Systematic Review and Meta-Analysis

Background

Point-of-care tests provide a plausible diagnostic strategy for hepatitis C infection in economically impoverished areas. However, their utility depends upon the overall performance of individual tests.

Methods

A literature search was conducted using the metasearch engine Mettā, a query interface for retrieving articles from five leading medical databases. Studies were included if they employed point-of-care tests to detect antibodies of hepatitis C virus and compared the results with reference tests. Two reviewers performed a quality assessment of the studies and extracted data for estimating test accuracy.

Findings

Thirty studies that had evaluated 30 tests fulfilled the inclusion criteria. The overall pooled sensitivity, specificity, positive likelihood-ratio, negative likelihood-ratio and diagnostic odds ratio for all tests were 97.4% (95% CI: 95.9–98.4), 99.5% (99.2–99.7), 80.17 (55.35–116.14), 0.03 (0.02–0.04), and 3032.85 (1595.86–5763.78), respectively. This suggested a high pooled accuracy for all studies. We found substantial heterogeneity between studies, but none of the subgroups investigated could account for the heterogeneity. Genotype diversity of HCV had no or minimal influence on test performance. Of the seven tests evaluated in the meta-regression model, OraQuick had the highest test sensitivity and specificity and showed better performance than a third generation enzyme immunoassay in seroconversion panels. The next highest test sensitivities and specificities were from TriDot and SDBioline, followed by Genedia and Chembio. The Spot and Multiplo tests produced poor test sensitivities but high test specificities. Nine of the remaining 23 tests produced poor test sensitivities and specificities and/or showed poor performances in seroconversion panels, while 14 tests had high test performances with diagnostic odds ratios ranging from 590.70 to 28822.20.

Conclusions

Performances varied widely among individual point-of-care tests for diagnosis of hepatitis C virus infection. Physicians should consider this while using specific tests in clinical practice.     

The Epidemiology of Hepatitis C Virus in the Maghreb Region: Systematic Review and Meta-Analyses

Objective

To systematically review and synthesize available epidemiological data on hepatitis C virus (HCV) prevalence and incidence in the Maghreb region and to estimate the country-specific population-level HCV prevalence.

Methods

We conducted a systematic review of HCV antibody prevalence and incidence in the Maghreb countries as outlined by the PRISMA guidelines. Meta-analyses were conducted using DerSimonian-Laird random-effect models with inverse variance weighting to pool HCV prevalence estimates among general population groups.

Results

We identified 133 HCV prevalence measures and two HCV incidence measures. Among high risk groups, HCV prevalence ranged between 22% and 94% among people who inject drugs, 20% and 76% among dialysis patients, and 2% and 51% among hemophiliacs. Among intermediate-risk groups, considerable but widely variable HCV prevalence was found. Most common risk factors cited across studies were the duration of dialysis, number of transfusions, and having a history of surgery or dental work. The national HCV prevalence in Algeria was estimated at 0.3% (95%CI: 0.1–0.5), Libya 1.2% (95%CI: 1.1–1.3), Mauritania 1.1% (95%CI: 0–2.3), Morocco 0.8% (95%CI: 0.5–1.2), and Tunisia 0.6% (95%CI: 0.5–0.8).

Conclusions

HCV prevalence in the Maghreb region of the Middle East and North Africa is comparable to that in developed countries of about 1%. HCV exposures appear often to be linked to medical care and are suggestive of ongoing transmission in such settings. Injecting drug use appears also to be a major, though not dominant, contributor to HCV transmission. Further research is needed to draw a more thorough understanding of HCV epidemiology, especially in the countries with limited number of studies. HCV prevention policy and programming in these countries should focus on the settings of exposure.     

Treatment of Hepatitis C in Children: A Systematic Review

Background

Current guidelines recommend children be treated for hepatitis C virus (HCV) using the same principles applied in adults. There are however few published studies which assess the efficacy and safety of HCV therapy in children.

Methodology/Principal Findings

A systematic review of the literature was completed for studies of any design that evaluated HCV therapy in children. The primary outcome was sustained virologic response (SVR), with sub-group analysis of response rates by genotype. There were 4 randomized controlled trials (RCTs) and 31 non-randomized studies, all involving interferon, pegylated interferon (PEG-IFN), or combinations of these drugs with ribavirin. The SVR rate could not be directly compared as the populations and interventions differed across studies. Genotype was not reported or differed substantially from study to study. The overall SVR rate for PEG-IFN and ribavirin ranged from 30 to 100% which is comparable to the rate in adults. Similar to adults, the SVR rates were significantly higher in children with genotype 2 or 3 compared to genotype 1. Adverse effects were primarily flu-like symptoms and neutropenia. There were insufficient data to assess the applicability of the week 12 stop rule (stopping therapy at week 12 if there is less than a 2 log drop in HCV RNA) or the efficacy of shortening therapy to 24 weeks in children with genotype 2 and 3.

Conclusions/Significance

Current guidelines for the treatment of HCV in children are based on limited data. Further research is needed to define the optimal therapy for HCV in children.     

The Epidemiology of Hepatitis C Virus in the Fertile Crescent: Systematic Review and Meta-Analysis

Objective

To characterize hepatitis C virus (HCV) epidemiology in countries of the Fertile Crescent region of the Middle East and North Africa (MENA), namely Iraq, Jordan, Lebanon, Palestine, and Syria.

Methods

We systematically reviewed and synthesized available records of HCV incidence and prevalence following PRISMA guidelines. Meta-analyses were implemented using a DerSimonian-Laird random effects model with inverse weighting to estimate the country-specific HCV prevalence among the various at risk population groups.

Results

We identified eight HCV incidence and 240 HCV prevalence measures in the Fertile Crescent. HCV sero-conversion risk among hemodialysis patients was 9.2% in Jordan and 40.3% in Iraq, and ranged between 0% and 3.5% among other populations in Iraq over different follow-up times. Our meta-analyses estimated HCV prevalence among the general population at 0.2% in Iraq (range: 0–7.2%; 95% CI: 0.1–0.3%), 0.3% in Jordan (range: 0–2.0%; 95% CI: 0.1–0.5%), 0.2% in Lebanon (range: 0–3.4%; 95% CI: 0.1–0.3%), 0.2% in Palestine (range: 0–9.0%; 95% CI: 0.2–0.3%), and 0.4% in Syria (range: 0.3–0.9%; 95% CI: 0.4–0.5%). Among populations at high risk, HCV prevalence was estimated at 19.5% in Iraq (range: 0–67.3%; 95% CI: 14.9–24.5%), 37.0% in Jordan (range: 21–59.5%; 95% CI: 29.3–45.0%), 14.5% in Lebanon (range: 0–52.8%; 95% CI: 5.6–26.5%), and 47.4% in Syria (range: 21.0–75.0%; 95% CI: 32.5–62.5%). Genotypes 4 and 1 appear to be the dominant circulating strains.

Conclusions

HCV prevalence in the population at large appears to be below 1%, lower than that in other MENA sub-regions, and tending towards the lower end of the global range. However, there is evidence for ongoing HCV transmission within medical facilities and among people who inject drugs (PWID). Migration dynamics appear to have played a role in determining the circulating genotypes. HCV prevention efforts should be targeted, and focus on infection control in clinical settings and harm reduction among PWID.     

The Treatment Cascade for Chronic Hepatitis C Virus Infection in the United States: A Systematic Review and Meta-Analysis

Background

Identifying gaps in care for people with chronic hepatitis C virus (HCV) infection is important to clinicians, public health officials, and federal agencies. The objective of this study was to systematically review the literature to provide estimates of the proportion of chronic HCV-infected persons in the United States (U.S.) completing each step along a proposed HCV treatment cascade: (1) infected with chronic HCV; (2) diagnosed and aware of their infection; (3) with access to outpatient care; (4) HCV RNA confirmed; (5) liver fibrosis staged by biopsy; (6) prescribed HCV treatment; and (7) achieved sustained virologic response (SVR).

Methods

We searched MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews for articles published between January 2003 and July 2013. Two reviewers independently identified articles addressing each step in the cascade. Studies were excluded if they focused on specific populations, did not present original data, involved only a single site, were conducted outside of the U.S., or only included data collected prior to 2000.

Results

9,581 articles were identified, 117 were retrieved for full text review, and 10 were included. Overall, 3.5 million people were estimated to have chronic HCV in the U.S. Fifty percent (95% CI 43–57%) were diagnosed and aware of their infection, 43% (CI 40–47%) had access to outpatient care, 27% (CI 27–28%) had HCV RNA confirmed, 17% (CI 16–17%) underwent liver fibrosis staging, 16% (CI 15–16%) were prescribed treatment, and 9% (CI 9–10%) achieved SVR.

Conclusions

Continued efforts are needed to improve HCV care in the U.S. The proposed HCV treatment cascade provides a framework for evaluating the delivery of HCV care over time and within subgroups, and will be useful in monitoring the impact of new screening efforts and advances in antiviral therapy.     

Hepatitis C Virus Transmission Bottlenecks Analyzed by Deep Sequencing

Hepatitis C virus (HCV) replication in infected patients produces large and diverse viral populations, which give rise to drug-resistant and immune escape variants. Here, we analyzed HCV populations during transmission and diversification in longitudinal and cross-sectional samples using 454/Roche pyrosequencing, in total analyzing 174,185 sequence reads. To sample diversity, four locations in the HCV genome were analyzed, ranging from high diversity (the envelope hypervariable region 1 [HVR1]) to almost no diversity (the 5′ untranslated region [UTR]). For three longitudinal samples for which early time points were available, we found that only 1 to 4 viral variants were present, suggesting that productive infection was initiated by a very small number of HCV particles. Sequence diversity accumulated subsequently, with the 5′ UTR showing almost no diversification while the envelope HVR1 showed >100 variants in some subjects. Calculation of the transmission probability for only a single variant, taking into account the measured population structure within patients, confirmed initial infection by one or a few viral particles. These findings provide the most detailed sequence-based analysis of HCV transmission bottlenecks to date. The analytical methods described here are broadly applicable to studies of viral diversity using deep sequencing.Hepatitis C virus (HCV) is a positive-strand enveloped RNA virus of the flavivirus family. HCV infects ∼170 million people worldwide with a high rate of persistence (1, 2) and is a major etiological agent of chronic hepatitis, liver cirrhosis, and hepatocellular carcinoma. The current standard of therapy is the combined use of pegylated alpha interferon (IFN-α) and ribavirin (9), although there are substantial limitations due to toxicity and resistance profiles (47). Recent development of various small-molecule inhibitors that specifically target HCV offer some promise (13), but challenges still remain because the size and diversity of viral populations promote rapid development of drug resistance (28, 42). In an infected individual, serum HCV RNA levels can reach 10 to 100 million IU/ml (40). The viral RNA polymerase is estimated to make 1 error per 10,000 to 100,000 bp copied (22), but the viral genome is only 9,600 bases, resulting in diversification of the viral population, so that most viral genomes differ in sequence from the population consensus (16, 20, 21). Thus, when antiviral pressure is exerted on a viral population, sequence variants with reduced sensitivity may expand in the presence of the selective pressure (30, 41) and cause resistance (37). Consistent with this, differential sequence diversity in HCV populations has been linked to clinical outcome (7, 8).The size and complexity of HCV populations has made their analysis challenging. However, new deep-sequencing and bioinformatics methods are well suited to analyzing this problem. Using the 454/Roche technology, it is possible to generate more than 10⁸ bases of DNA sequence in a single 1-day run, albeit in fragments 200 to 500 bases in length (24). In addition, many samples can be multiplexed in single experiments using DNA barcodes introduced in amplification primers to tag each sample (3, 12, 45, 46), allowing many viral sequences to be characterized in a single experiment.Here, we analyze HCV diversity by pyrosequencing a series of representative viral regions contained within PCR amplicons, and we use methods from the environmental microbiology field for data processing and analysis. In both virology and environmental microbiology, populations of interest commonly consist of many related but nonidentical sequences (e.g., viral lineages with related sequences or bacteria harboring related 16S rRNA gene sequences). Assembly of short pyrosequence reads into longer scaffolds is quite difficult in such a setting, because the related sequences present in the population can be assembled in many different ways. Complicated data-processing methods yield at best complex probabilistic models of variants likely to be present in the population (6). For this reason, in studies of bacterial 16S DNA from uncultured communities, many groups have used simplified analysis of single 16S amplicons that query short regions of the 16S rRNA gene (5, 11, 14, 23, 25, 38, 44). Extensive simulations and practical applications show that analysis of such “sequence tags” can disclose biologically meaningful clusters and gradients in collections of samples. Here, we apply a similar approach, using sequence tags for several regions of the HCV genome. This approach has the disadvantage of losing linkage information between amplicons, but it does allow the efficient analysis of large numbers of viral variants over many samples.A major challenge, however, is distinguishing variations authentically present in viral populations from artifactual mutations introduced as a result of the isolation procedure or sequencing error. Sequence recovery involves PCR steps that can result in base pair substitutions or artifactual chimera formation. The 454/Roche method, like any sequencing method, has a characteristic error rate and particularly elevated error rates at homopolymer runs (24). In this study, we took advantage of improved methods for error control using the PyroNoise program of Quince and colleagues, which was first used for analysis of 16S rRNA gene sequences (29). The PyroNoise program preclusters the raw light intensity data generated during pyrosequencing by the 454/Roche method, which removes most homopolymer errors. In reconstruction experiments, Quince and colleagues showed that 454/Roche sequence analysis of artificially constructed mock 16S rRNA gene communities yielded greatly inflated numbers of sequence types due to error, but preclustering using PyroNoise reduced the diversity to values much closer to the correct value. Here, we used a two-stage clustering method to remove noise. In the first stage, raw light intensity data were preclustered with PyroNoise (29); then, in the second stage, after interpretation of the sequence as base calls, sequences were clustered at 98.5% identity. The second step allowed us to take advantage of redundancy in the reads to improve sequence quality, though distinguishing genuine low-level variations in the viral populations from error is a challenge.We determined 174,185 high-quality HCV sequence reads to characterize (i) longitudinal variation in HCV populations following transmission, (ii) differences in HCV variation between HCV-monoinfected and HIV-HCV-coinfected subjects, and (iii) variation in a control HCV genome cloned in a bacterial plasmid to quantify variation arising during the isolation and analytical procedure. We developed amplicons to characterize four regions of the HCV genome (Fig. ​(Fig.1A)1A) and found that HCV sequence diversity ranged from almost nonexistent to extreme depending on the region of the viral genome studied. Using the deep-sequencing data, we estimate that only one or a few viral variants seeded initial infection, but after that, viral variants could expand to >100 in a single individual. Thus, these data specify the numbers of particles seeding productive infection and provide a general framework for the use of deep-sequencing data to characterize the structures of viral populations.Open in a separate windowFIG. 1.HCV genome and characteristics of three subjects studied longitudinally during acute HCV infection. (A) The HCV genome and the positions of amplicons studied. The amplicons are numbered 1 to 4 from left to right, and a letter is used to indicate the direction of sequence determination. For the E1E2 HVR1 (3) and E2 (4) amplicons, two slightly different primers were used in each direction in an effort to maximize the diversity of recovered sequence variants, and these are indicated by the two bars. (B) HCV load and ALT levels for patients 1 to 3 during acute HCV infection. The x axis shows the number of weeks after clinical presentation, which for these patients was close in time to initial infection. Further patient characteristics were as follows: patient 1, injecting drug user, anti-HCV negative on 18 June 2001, first ALT flare (ALT, 677) on 6 July 2001, anti-HCV positive on 11 October 2001; patient 2, possible medical exposure, anti-HCV negative on 16 May 2001, initial ALT flare (ALT, 467) on 9 January 2004, anti-HCV positive on 22 April 2004; patient 3, injecting drug user, anti-HCV negative on 31 January 2006 (slightly abnormal ALT, 73), initial ALT flare (ALT, 640) on 10 April 2006, anti-HCV positive on 11 April 2006.     

一株丙型肝炎病毒缺陷株NS5A基因片段的序列分析

Ｑ丙型肝炎是由丙型肝炎病毒（ＨＣＶ）引起的一种严重的传染病。丙型肝炎病毒主要通过输血和应用不洁的血液制品传播,所以利用敏感、特异的检测方法筛选献血员对丙型肝炎的预防尤为重要。现在第二代ＨＣＶ检测试剂已大批应用,加入ＮＳ５Ａ抗原的第三代试剂也正在研制中...     

Hepatitis C Virus Epidemiology in Djibouti,Somalia, Sudan,and Yemen: Systematic Review and Meta-Analysis

Objectives

To characterize hepatitis C virus (HCV) epidemiology and assess country-specific population-level HCV prevalence in four countries in the Middle East and North Africa (MENA) region: Djibouti, Somalia, Sudan, and Yemen.

Methods

Reports of HCV prevalence were systematically reviewed as per PRISMA guidelines. Pooled HCV prevalence estimates in different risk populations were conducted when the number of measures per risk category was at least five.

Results

We identified 101 prevalence estimates. Pooled HCV antibody prevalence in the general population in Somalia, Sudan and Yemen was 0.9% (95% confidence interval [95%CI]: 0.3%–1.9%), 1.0% (95%CI: 0.3%–1.9%) and 1.9% (95%CI: 1.4%–2.6%), respectively. The only general population study from Djibouti reported a prevalence of 0.3% (CI: 0.2%–0.4%) in blood donors. In high-risk populations (e.g., haemodialysis and haemophilia patients), pooled HCV prevalence was 17.3% (95%CI: 8.6%–28.2%) in Sudan. In Yemen, three studies of haemodialysis patients reported HCV prevalence between 40.0%-62.7%. In intermediate-risk populations (e.g.. healthcare workers, in patients and men who have sex with men), pooled HCV prevalence was 1.7% (95%CI: 0.0%–4.9%) in Somalia and 0.6% (95%CI: 0.4%–0.8%) in Sudan.

Conclusion

National HCV prevalence in Yemen appears to be higher than in Djibouti, Somalia, and Sudan as well as most other MENA countries; but otherwise prevalence levels in this subregion are comparable to global levels. The high HCV prevalence in patients who have undergone clinical care appears to reflect ongoing transmission in clinical settings. HCV prevalence in people who inject drugs remains unknown.     

乙型肝炎病毒全基因序列的测定

Seven cases of chronic hepatitis B virus carriers were included for sequencing of whole gene sequences of hepatitis B virus (HBV). The serotype of 4 strains of HBV were adr, and 3 strains were adw. Two strains were classified to genotype B, and the other 5 strains to genotype C. No significant mutations, such as A¹⁸⁹⁶, T¹⁷⁶²A¹⁷⁶⁴ were present. With other reported 2 complete sequences of HBV strains prevailing in mainland China, 7 strains of HBV whole sequences of genotype C from mainland China were analyzed to produce the consensus sequence of HBV of China. Comparing of the consensus sequence with that from Genbank, there were only 22 sites with different nucleotides.     

乙型肝炎病毒全基因序列的测定

测定７ 例慢性 Ｈ Ｂ Ｖ 携带者 Ｈ Ｂ Ｖ 基因组全序列,经同源性比较,确定基因型。２ 例基因型为 Ｂ 型,余均为 Ｃ 型;血清型ａｄｒ ４ 例,ａｄｗ ３ 例。各序列间 Ｘ 基因差异最大。未见 Ａ１８９６ 、 Ｔ１７６２ Ａ１７６４等重要位点的变异。结合已有的２ 株 Ｈ Ｂ Ｖ 中国流行株全基因序列,初步建立以中国流行株序列为基础的 Ｈ Ｂ Ｖ 标准序列,该标准序列与国外标准序列仅有２２ 个位点的差异     

Elucidation of Hepatitis C Virus Transmission and Early Diversification by Single Genome Sequencing

A precise molecular identification of transmitted hepatitis C virus (HCV) genomes could illuminate key aspects of transmission biology, immunopathogenesis and natural history. We used single genome sequencing of 2,922 half or quarter genomes from plasma viral RNA to identify transmitted/founder (T/F) viruses in 17 subjects with acute community-acquired HCV infection. Sequences from 13 of 17 acute subjects, but none of 14 chronic controls, exhibited one or more discrete low diversity viral lineages. Sequences within each lineage generally revealed a star-like phylogeny of mutations that coalesced to unambiguous T/F viral genomes. Numbers of transmitted viruses leading to productive clinical infection were estimated to range from 1 to 37 or more (median = 4). Four acutely infected subjects showed a distinctly different pattern of virus diversity that deviated from a star-like phylogeny. In these cases, empirical analysis and mathematical modeling suggested high multiplicity virus transmission from individuals who themselves were acutely infected or had experienced a virus population bottleneck due to antiviral drug therapy. These results provide new quantitative and qualitative insights into HCV transmission, revealing for the first time virus-host interactions that successful vaccines or treatment interventions will need to overcome. Our findings further suggest a novel experimental strategy for identifying full-length T/F genomes for proteome-wide analyses of HCV biology and adaptation to antiviral drug or immune pressures.     

丙型肝炎病毒北京株NS3基因的克隆及测序

用ＲＴ－ＰＣＲ方法从北京株丙型肝炎病毒中扩增出ＮＳ３区基因片段,该片段经ｐＧＥＸ－Ｔ载体克隆到大肠杆菌ＤＨ５α菌株中．经自动序列分析仪测出ＮＳ３基因的７２８ｂｐ长的核酸序列．发现在该片段中第３１位核苷酸发生Ａ→Ｔ突变,产生一个终止突变．这表明,丙型肝炎病毒北京株存在一定的变异,产生缺陷型病毒,这类缺陷型病毒的出现可能是丙型肝炎病毒持续性感染的原因之一．     

The Impact of Hepatitis A Virus Infection on Hepatitis C Virus Infection: A Competitive Exclusion Hypothesis

We address the observation that, in some cases, patients infected with the hepatitis C virus (HCV) are cleared of HCV when super-infected with the hepatitis A virus (HAV). We hypothesise that this phenomenon can be explained by the competitive exclusion principle, including the action of the immune system, and show that the inclusion of the immune system explains both the elimination of one virus and the co-existence of both infections for a certain range of parameters. We discuss the potential clinical implications of our findings.     

Next-Generation Sequencing Reveals Frequent Opportunities for Exposure to Hepatitis C Virus in Ghana

Globally, hepatitis C Virus (HCV) infection is responsible for a large proportion of persons with liver disease, including cancer. The infection is highly prevalent in sub-Saharan Africa. West Africa was identified as a geographic origin of two HCV genotypes. However, little is known about the genetic composition of HCV populations in many countries of the region. Using conventional and next-generation sequencing (NGS), we identified and genetically characterized 65 HCV strains circulating among HCV-positive blood donors in Kumasi, Ghana. Phylogenetic analysis using consensus sequences derived from 3 genomic regions of the HCV genome, 5''-untranslated region, hypervariable region 1 (HVR1) and NS5B gene, consistently classified the HCV variants (n = 65) into genotypes 1 (HCV-1, 15%) and genotype 2 (HCV-2, 85%). The Ghanaian and West African HCV-2 NS5B sequences were found completely intermixed in the phylogenetic tree, indicating a substantial genetic heterogeneity of HCV-2 in Ghana. Analysis of HVR1 sequences from intra-host HCV variants obtained by NGS showed that three donors were infected with >1 HCV strain, including infections with 2 genotypes. Two other donors share an HCV strain, indicating HCV transmission between them. The HCV-2 strain sampled from one donor was replaced with another HCV-2 strain after only 2 months of observation, indicating rapid strain switching. Bayesian analysis estimated that the HCV-2 strains in Ghana were expanding since the 16^th century. The blood donors in Kumasi, Ghana, are infected with a very heterogeneous HCV population of HCV-1 and HCV-2, with HCV-2 being prevalent. The detection of three cases of co- or super-infections and transmission linkage between 2 cases suggests frequent opportunities for HCV exposure among the blood donors and is consistent with the reported high HCV prevalence. The conditions for effective HCV-2 transmission existed for ~ 3–4 centuries, indicating a long epidemic history of HCV-2 in Ghana.     

Hepatitis C Virus Infection Epidemiology among People Who Inject Drugs in Europe: A Systematic Review of Data for Scaling Up Treatment and Prevention

Background

People who inject drugs (PWID) are a key population affected by hepatitis C virus (HCV). Treatment options are improving and may enhance prevention; however access for PWID may be poor. The availability in the literature of information on seven main topic areas (incidence, chronicity, genotypes, HIV co-infection, diagnosis and treatment uptake, and burden of disease) to guide HCV treatment and prevention scale-up for PWID in the 27 countries of the European Union is systematically reviewed.

Methods and Findings

We searched MEDLINE, EMBASE and Cochrane Library for publications between 1 January 2000 and 31 December 2012, with a search strategy of general keywords regarding viral hepatitis, substance abuse and geographic scope, as well as topic-specific keywords. Additional articles were found through structured email consultations with a large European expert network. Data availability was highly variable and important limitations existed in comparability and representativeness. Nine of 27 countries had data on HCV incidence among PWID, which was often high (2.7-66/100 person-years, median 13, Interquartile range (IQR) 8.7–28). Most common HCV genotypes were G1 and G3; however, G4 may be increasing, while the proportion of traditionally ‘difficult to treat’ genotypes (G1+G4) showed large variation (median 53, IQR 43–62). Twelve countries reported on HCV chronicity (median 72, IQR 64–81) and 22 on HIV prevalence in HCV-infected PWID (median 3.9%, IQR 0.2–28). Undiagnosed infection, assessed in five countries, was high (median 49%, IQR 38–64), while of those diagnosed, the proportion entering treatment was low (median 9.5%, IQR 3.5–15). Burden of disease, where assessed, was high and will rise in the next decade.

Conclusion

Key data on HCV epidemiology, care and disease burden among PWID in Europe are sparse but suggest many undiagnosed infections and poor treatment uptake. Stronger efforts are needed to improve data availability to guide an increase in HCV treatment among PWID.