Incidence of hepatitis c virus seroconversion among hemodialysis patients in the Nile Delta of Egypt: A single-center study.

Egypt has the highest worldwide prevalence of hepatitis C virus (HCV) infection, caused in part by nosocomial transmission. Patients on hemodialysis (HD) are at especially high risk of infection. We aimed to estimate the incidence of seroconversion among HCV-negative patients undergoing regular HD at a unit in a large public hospital in the Nile Delta of Egypt, which implements the Egyptian Ministry of Health guidelines for infection control, and an isolation policy for hepatitis-positive patients. We also assessed the adherence to infection control practices and evaluated nurses and physicians' knowledge and attitude toward infection control procedures. Records of HCV-negative patients undergoing regular HD at the unit from August 2008 to August 2010 were reviewed retrospectively for data on HCV status. Patients were then followed up until September 2011, when polymerase chain reaction was performed for all patients. Infection control practices were evaluated by four checklists applied monthly and analyzed by control charts. Nurses and physicians' knowledge and attitudes toward infection control were assessed by interview questionnaires. Of 60 patients followed up, there was one case of HCV seroconversion giving an incidence rate of 0.676/100 person-years of follow-up (95% confidence interval: 0.017-3.76). There were no cases of hepatitis B virus seroconversion. The mean scores of all the infection control practices' checklists were very high and generally remained above the lower control limit over the 12-month period. Physicians and nurses achieved very high scores on knowledge and attitude on infection control (mean score >95%). This public facility had a low seroconversion rate and high adherence to infection control guidelines.

Excess mortality rate associated with hepatitis C virus infection: A community-based cohort study in rural Egypt.

BACKGROUND & AIMS: >80% of people chronically infected with hepatitis C virus (HCV) live in resource-limited countries, yet the excess mortality associated with HCV infection in these settings is poorly documented. METHODS: Individuals were recruited from three villages in rural Egypt in 1997-2003 and their vital status was determined in 2008-2009. Mortality rates across the cohorts were compared according to HCV status: chronic HCV infection (anti-HCV antibody positive and HCV RNA positive), cleared HCV infection (anti-HCV antibody positive and HCV RNA negative) and never infected (anti-HCV antibody negative). Data related to cause of death was collected from a death registry in one village. RESULTS: Among 18,111 survey participants enrolled in 1997-2003, 9.1% had chronic HCV infection, 5.5% had cleared HCV infection, and 85.4% had never been infected. After a mean time to follow-up of 8.6years, vital status was obtained for 16,282 (89.9%) participants. When compared to those who had never been infected with HCV in the same age groups, mortality rate ratios (MRR) of males with chronic HCV infection aged <35, 35-44, and 45-54years were 2.35 (95% CI 1.00-5.49), 2.87 (1.46-5.63), and 2.22 (1.29-3.81), respectively. No difference in mortality rate was seen in older males or in females. The all-cause mortality rate attributable to chronic HCV infection was 5.7% (95% CI: 1.0-10.1%), while liver-related mortality was 45.5% (11.3-66.4%). CONCLUSIONS: Use of a highly potent new antiviral agent to treat all villagers with positive HCV RNA may reduce all-cause mortality rate by up to 5% and hepatic mortality by up to 40% in rural Egypt.

Skin Prick Test Reactivity to Aeroallergens among Egyptian Patients with Isolated Allergic Conjunctival Disease.

Allergic conjunctival disease (ACD) is a type of ocular allergy, which includes seasonal allergic conjunctivitis (SAC), perennial allergic conjunctivitis (PAC), and vernal keratoconjunctivitis (VKC). Little is known about the pattern of sensitization or prevalent aeroallergens among patients with isolated ACD in Egypt We aimed to evaluate the prevalence of skin prick test positivity to common aeroallergens among Egyptian patients with isolated allergic conjunctival disease. The study included 75 patients with isolated ACD recruited from a tertiary Egyptian outpatient clinic. Skin prick test (SPT) was performed for all patients with common aeroallergens. Total serum immunoglobulin E (IgE) was measured by ELISA. A positive SPT reaction was present among 32 patients (42.7%). The most prevalent aeroallergens among all patients were mites and pollens (12% respectively), followed by grass (8%) and hay dust (6.7%). Eight patients (10.7%) had SAC, 19 patients (25.3%) had PAC, and 48 patients (64%) had VKC. Prevalence of SPT positivity to indoor allergens was significantly more common among PAC (52.6%) than among SAC (25%) and VKC (16.7%), P= 0.011. Outdoor allergen sensitization did not differ significantly between the 3 subgroups, P= 0.614. Elevated IgE levels were observed among 62.5%, 73.7% and 66.7% of patients with SAC, PAC and VKC, respectively, with no statistically significant difference between them, P= 0.806. In conclusion aeroallergen sensitization is common among Egyptian patients with isolated ACD. Accordingly, SPT should be included in the diagnostic workup of these patients.

Effect of preventive and curative interventions on hepatitis C virus transmission in Egypt (ANRS 1211): a modelling study.

BACKGROUND: Most hepatitis C virus (HCV) transmission in Egypt is related to medical injections and procedures. To control the spread of HCV, the Egyptian Ministry of Health initiated awareness and education campaigns, strengthened infection control in health-care facilities, and subsidised anti-HCV treatment. We aimed to investigate the effect of these interventions on the spread of HCV by mathematical modelling. METHODS: We developed a mathematical model of HCV transmission in Zawyat Razin, a typical rural community. Our model assumes that each individual has two distinct types of medical procedures: injections and more invasive medical procedures. To quantify the severity of the spread of HCV, we used the notion of the basic reproduction number R0, a standard threshold parameter signalling whether transmission of an infectious disease is self-sustained and maintains an epidemic. If R0 is greater than 1, HCV is self-sustained; if R0 is 1 or less, HCV transmission is not self-sustained. We investigated whether heterogeneity in the rate of injection or invasive medical procedures is the determinant factor for HCV transmission and whether most iatrogenic transmission is caused by a small group of individuals who receive health-care interventions frequently. We then assessed whether interventions targeted at this group could reduce the spread of HCV. FINDINGS: The R0 of the spread of HCV without treatment was 3·54 (95% CI 1·28-6·18), suggesting a self-sustained spread. Furthermore, the present national treatment programme only decreased R0 from 3·54 to 3·03 (95% CI 1·10-5·25). Individuals with high rates of medical injections seem to be responsible for the spread of HCV in Egypt; the R0 of the spread of HCV without treatment would be 0·64 (95% CI 0·41-0·93) if everybody followed the average behaviour. The effect of treatment on HCV transmission is greatly enhanced if treatment is provided a mean of 2·5 years (95% CI 0·1-9·2) after chronic infection and with drug regimens with more than 80% efficacy. With these treatment parameters, preventive and curative interventions targeting individuals with high rates of medical injections might decrease R0 below 1 for treatment coverage lower than 5%. INTERPRETATION: Targeting preventive and curative interventions to individuals with high rates of medical injections in Egypt would result in a greater reduction the spread of HCV than would untargeted allocation. Such an approach might prove beneficial in other resource-limited countries with health-care-driven epidemics. FUNDING: Agence Nationale de Recherche sur le SIDA et les Hépatites Virales (ANRS 1211), ANR grant Labex Integrative Biology of Emerging Infectious Diseases.

A novel method to identify routes of hepatitis C virus transmission.

BACKGROUND: We propose a new approach based on genetic distances among viral strains to infer about risk exposures and location of transmission at population level. METHODS: We re-analysed 133 viral sequences obtained during a cross-sectional survey of 4020 subjects living in a hepatitis C virus (HCV) endemic area in 2002. A permutation test was used to analyze the correlation between matrices of genetic distances in the NS5b region of all pairwise combinations of the 133 viral strains and exposure status (jointly exposed or not) to several potential HCV risk factors. RESULTS: Compared to subjects who did not share the same characteristics or iatrogenic exposures, the median Kimura genetic distances of viral strains were significantly smaller between brothers and sisters (0.031 versus 0.102, P<0.001), mother and child (0.044 versus 0.102, P<0.001), father and child (0.045 versus 0.102, P<0.001), or subjects exposed to periodontal treatment (0.084 versus 0.102, P = 0.02). Conversely, viral strains were more divergent between subjects exposed to blood transfusions (0.216 versus 0.102, P = 0.04) or tooth filling or extraction (0.108, versus 0.097, P = 0.05), suggesting acquisition of the virus outside of the village. CONCLUSION: This method provided insights on where infection took place (household, village) for several socio-demographic characteristics or iatrogenic procedures, information of great relevance for targeting prevention interventions. This method may have interesting applications for virologists and epidemiologists studying transmission networks in health-care facilities or among intravenous drug users.

Prolactin and dehydroepiandrosterone sulfate: are they related to the severity of chronic urticaria?

BACKGROUND AND AIMS: Elevated prolactin and reduced dehydroepiandrosterone sulfate (DHEA-S) levels are associated with autoimmune diseases. A limited number of studies have investigated these hormones in chronic urticaria (CU). The autologous serum skin test (ASST) reaction has also been linked to autoimmune diseases, and a positive reaction is usually associated with a more severe disease. We aimed to compare serum prolactin and DHEA-S levels between female CU patients with positive and negative ASST reactions and healthy controls. METHODS: The study included 30 female CU patients with a positive ASST reaction, 30 female CU patients with a negative ASST reaction, and 30 healthy female controls. All identifiable causes of urticaria were excluded. Serum prolactin and DHEA-S levels were measured in all subjects. RESULTS: Prolactin was significantly higher among ASST positive patients than among ASST negative patients and controls but did not differ between ASST negative patients or controls. Higher prolactin levels were associated with increasing disease severity among ASST positive patients. DHEA-S levels did not differ between ASST positive or negative patients but were significantly lower among both patient subgroups than controls. DHEA-S levels did not differ according to the severity of disease among either of the patient subgroups. DHEA-S levels did not correlate with prolactin among any group. CONCLUSION: We demonstrate for the first time a possible role for prolactin in ASST-positive CU patients and its association with disease severity. We recommend larger prospective studies to assess changes in prolactin and DHEA-S levels after complete disease remission.

Women in Cairo, Egypt and their risk factors for unmet contraceptive need: a community-based study.

BACKGROUND AND METHODOLOGY: Although modern family planning methods are readily available in Egypt at low cost, a considerable proportion of women still have an unmet contraceptive need. The aim of this study was to detect the risk factors of unmet contraceptive need among married women in the childbearing period in an underprivileged area in Cairo with high population density. A survey of 2340 women in the Marg district of Eastern Cairo was conducted by means of home interviews. For every woman identified as having an unmet contraceptive need (n=174), the next two women identified with met contraceptive need were selected as controls (n=348). RESULTS: The prevalence of unmet need was 7.4%. Risk factors identified were: belief that contraception is religiously prohibited (OR 2.08, 95% CI 1.06-4.09); poor interspousal communication about the desired number of children (OR 2.59, 95% CI 1.40-4.79); husband opposition to contraceptive use (OR 2.96, 95% CI 1.47-5.97); a previous history of unwanted pregnancy (OR 2.98, 95% CI 1.73-5.14); and experiencing side effects from previous contraceptive use (OR 5.69, 95% CI 3.46-9.37). CONCLUSIONS: The authors propose training physicians to identify and counsel women who experience contraceptive side effects and/or a previous unwanted pregnancy, as well as the transmission of clear media messages on the religious acceptability of contraceptive use.

Study of folate status among Egyptian asthmatics.

OBJECTIVE: To compare serum folate levels between atopic asthmatics, non-atopic asthmatics, and healthy controls. METHODS: This case-control study included 60 asthmatics with at least one positive skin prick test (SPT) reaction (atopic asthma group), 60 asthmatics with negative SPT reactions (non-atopic asthma group), and 60 healthy controls with no history of asthma or other allergic diseases, and with negative SPT reactions. Serum folate and total IgE levels were measured in all subjects. In addition, lung functions were assessed by spirometry. RESULTS: Serum folate levels were significantly lower among the atopic asthma group [9.1 (4.9, 12.1) ng/mL] as compared to the non-atopic asthma group [11.3 (7.5, 14.8) ng/mL] and the control group [12.0 (8.3, 15.1) ng/mL], p= 0.001. Among atopic asthmatics, serum folate levels were inversely correlated with total serum IgE levels (r=-0.483, p<0.001), and the number of positive SPT reactions (r=-0.442, p<0.001). Atopic asthmatics with a total serum IgE ≤200 IU/mL had significantly higher levels of serum folate than those with a total serum IgE >200 IU/mL. Regression analysis showed that higher folate levels independently predicted lower total serum IgE levels. Folate was not found to be an independent predictor of asthma. No association was observed between serum folate levels and values of forced expiratory volume in 1s. CONCLUSION: Among asthmatics, serum folate levels are significantly lower among atopics, and correlate inversely with the degree of atopy.

Is the hepatitis C virus epidemic over in Egypt? Incidence and risk factors of new hepatitis C virus infections.

OBJECTIVES: To estimate hepatitis C virus (HCV) incidence rates and identify risk factors for current HCV transmission with emphasis on the role of living with infected household family members in rural Egypt. METHODS: A 4-year population-based, cohort study of seronegative villagers was conducted to identify incident HCV seroconversion cases. A risk factor questionnaire and blood samples for anti-HCV EIA-3 and HCV RNA polymerase chain reaction testing were collected at two rounds of follow-up. Incidence rates, relative risks and 95% confidence interval (CI) were calculated based on a Poisson distribution. A matched case-control analysis to explore specific behavioural predictors of infection was conducted and odds ratios were obtained by conditional logistic regression. RESULTS: Twenty-five participants (11 females) seroconverted in 10,578 person years of follow-up (PY), (incidence rate of 2.4/1000 PY; 95% CI: 1.6-3.5). The median age at seroconversion was 26 years [interquartile range (IQR) 19-35] among males and 20 years (IQR 13-24) among females. The only significant risk factor identified for these cases was receiving injections [adjusted odds ratio (OR(adj))=3.3; 95% CI: 1.1-9.8]. Two of the 17 viraemic seroconvertors were infected with the same strain as at least one of their family members. CONCLUSION: This study identified the important role of injections in spreading HCV infection in this rural community. National healthcare awareness and infection control programmes should be strengthened to prevent further transmission. Screening of families of infected HCV subjects should be an essential part of case management for early detection and management.

Assessment of the role of interleukin-6 in diagnosis of hepatocellular carcinoma.

Interleukin-6 (IL-6) is a promising tumor marker for hepatocellular carcinoma; HCC. IL-6 may help to identify a subset of HCC patients with low alpha-fetoprotein (AFP) level, and may serve as complementary tumor marker, however, this has to be clarified. This study assesses the value of measuring serum level of interleukin-6 in patients with chronic liver disease and HCC, and evaluates its sensitivity and specificity in comparison to AFP in early diagnosis of HCC. Seventy five patients with chronic liver disease (CLD) with or without HCC and 25 healthy controls were included. Patients were divided into Group I: 25 patients with CLD but no evidence of HCC. Group II: 25 patients with HCC on top of post-viral hepatitic with elevation in AFP (> 200 ng); and Group III: 25 patients with HCC on top of post-viral hepatitic but without elevation in AFP (< 200 ng). Analysis of the mean serum IL-6 levels revealed a statistically significant difference between all groups (P < 0.01). A significant positive correlation was found between mean levels of IL- 6 & AFP in HCC (P < 0.05), the mean IL-6 levels in patients with Child classification C was higher than in those with Child A and B.After adjustment using multiple logistic regressions, only loss of weight and AFP were found to be significantly associated with HCC (P < 0.05). It is concluded that the diagnostic value of IL-6 increased when it is associated with AFP measurement. Combining the two markers can provide a new perspective in the diagnosis of HCC.

Evidence for a dominant major gene conferring predisposition to hepatitis C virus infection in endemic conditions.

Hepatitis C virus (HCV), infecting 170 million people worldwide, is a major public health problem. In developing countries, unsafe injections and blood transfusions are thought to be the major routes of transmission. However, our previous work in a population from Egypt, endemic for HCV, revealed highly significant familial correlations, strongly suggesting the existence of both familial transmission of the virus and genetic predisposition to HCV infection. We investigated the hypothesis of genetic predisposition by carrying out a segregation analysis of HCV infection in the same population. We used a logistic regression model simultaneously taking into account a major gene effect, familial correlations and relevant risk factors. We analyzed 312 pedigrees (3,703 subjects). Overall HCV seroprevalence was 11.8% and increased with age. The main associated risk factors were previous parenteral treatment for schistosomiasis and blood transfusions. We found strong evidence for a dominant major gene conferring a predisposition to HCV infection. The frequency of the predisposing allele was 0.013, reflecting a strong predisposition to HCV infection in 2.6% of the subjects, particularly those under the age of 20. This study provides evidence for the involvement of host genetic factors in susceptibility/resistance to HCV infection in endemic conditions.

Prevalence of intestinal parasitosis in a rural population in Egypt, and its relation to socio-demographic characteristics.

A cross-sectional study was conducted in a village in Menoufia Governorate, Egypt where the majority of people had individual trenches in the houses for sewage disposal with absence of public sewage system. Out of 2292 stool samples 47.8% had at least a single infection. Multiple infections occurred in 14.9%. Entamoeba histolytica was 20%, E. coli 10%, Giardia lamblia 10%, Ascaris lumbricoides 27.31%, Hymenolepis nana 2.96%, Schistosoma mansoni 2.45% and Ancylostoma duodenale 2.23%. Males were significantly infected with S. mansoni than females. Younger age groups were significantly infected by H. nana than older ones. Working in agriculture was significantly at risk with S. mansoni and A. duodenale infections. On multiple logistic regression analysis; the risk factor most strongly associated with infection was the presence of another infected family member.

HCV-related morbidity in a rural community of Egypt.

The origin of the hepatitis C virus (HCV) epidemic in Egypt has been attributed to intravenous schistosomiasis treatment in rural areas in the 1960s to 70s. The objective of this study was to estimate the HCV-related morbidity in a rural area where mass schistosomiasis treatment campaigns took place 20-40 years before. The study sample included 2,425 village residents aged 18-65 years recruited through home-based visits. Overall, HCV antibody prevalence was 448/2,425 = 18.5% (95% CI = 16.9-20.1%), reaching 45% in males over 40 years, and 30% in females over 50 years. Of those with HCV antibodies, 284/448 (63.4%, 95% CI = 58.7-67.9%) had chronic HCV infection, among which 107/266 (40.2%, 95% CI = 34.3-46.4%) had elevated alanine aminotransferase (ALT). As part of pre-treatment screening, 26 consenting patients had a liver biopsy: 13 (50.0%) had a treatment indication. Thus, of all patients with HCV antibodies, 13 (2.9%) were eligible for treatment and willing to be treated. The relatively low level of morbidity observed in this study is discussed in view of co-factors of HCV infection progression, such as young age at infection, absence of alcohol intake, the prevalence of Schistosoma mansoni infection, and the prevalence of chronic hepatitis B.

Changing pattern of hepatitis C virus spread in rural areas of Egypt.

BACKGROUND/AIMS: To identify patterns of HCV spread in the Nile Delta of Egypt. METHODS: Residents in a Nile Delta village were invited to participate in a cohort study of HCV infection. Risk factors for past or current infection were identified at cohort intake using generalized estimated equations models. Attributable fractions were calculated for all independent risk factors. RESULTS: The prevalence of HCV antibodies increased from 2.7% in those <20 years of age to more than 40% in males aged 40-54 years. The peak in HCV prevalence in the 40-54 year age group corresponds to the aging of the cohort of children infected through schistosomiasis intravenous treatments in the 1960s-70s (accounting for 12.4% of all HCV infections observed today among adults). Following this initial founding event, the HCV epidemic has spread in the community through iatrogenic factors, and particularly injections (37.9% of the overall attributable fraction in adults). In children, however, no iatrogenic factors were associated with increased risk of infection, suggesting a change in the pattern of HCV spread. CONCLUSIONS: While HCV infections in adults could be attributed to iatrogenic factors, and particularly injections, infections in children could not be explained by similar routes of transmission.