Hepatitis C in Arab world and Hepatitis C in Arab world and North AfricaNorth Africa

Dr. Khaled Mahmoud Abd ElazizDr. Khaled Mahmoud Abd Elaziz

Assistant professor of Public health Assistant professor of Public health & Preventive medicine & Preventive medicine

Faculty of Medicine -Ain Shams University Faculty of Medicine -Ain Shams University

DefinitionDefinitionPrevalence around the Arab countries and Prevalence around the Arab countries and

North AfricaNorth AfricaGenotypes Distribution of infectionGenotypes Distribution of infectionTransmission with blood transfusionTransmission with blood transfusionTransmission among health care workersTransmission among health care workers

Hepatitis C viral infectionHepatitis C viral infection

Hepatitis C virus (HCV) is a RNA virus known to infect humans and chimpanzees, causing similar disease in these 2 species. HCV is most often transmitted parentrally but is also transmitted vertically and sexually .HCV is up to 4 times more infectious than Human Immunodeficiency Virus.

Hepatitis C viral infectionHepatitis C viral infectionHCV is a leading cause of chronic liver disease in the world. The World Health Organization (WHO) estimates that 170 million people are infected with HCV globally and 3-4 million new infections occur each year, making it one of the leading public health problems in the world.

Hepatitis C viral infectionHepatitis C viral infection

With a prevalence of 5.3% and an estimated 32 million people infected with HCV, Sub Saharan Africa has the highest burden of the disease in the world. (Karoney 2013)

Hepatitis C viral infectionHepatitis C viral infection

WHO estimates 2.2% prevalence all over the world. It is estimated that 27% of the world burden of liver fibrosis and 25% of the HCC are due to hepatitis C viral infection

(Daw 2012)

Hepatitis C viral infection in arab Hepatitis C viral infection in arab countriescountries

Estimated 25 millions affected in the Arab world and without effective intervention the number will increase tremendously in the next two decades

(Daw 2012)

GenotypesGenotypes

There are 11 HCV genotypes: 1-11, with many subtypes: a, b, c, and about 100 different strains: 1,2,3 based on the sequence of the HCV genome Genotypes 1-3 are widely distributed globally, with genotypes 1a and 1 b accounting for 60% of infections worldwide. Genotype 4 is characteristic for the Middle East, Egypt and Central Africa.

Prevalence Countries Major genotypes

Minor

Low<1-1.9%

Lybia(1.2)Tunisia (0.4-0.7)

4/11b

2a,2b,2c2a,2c,1a

Moderate2-2.9%

Algeria (2%) NA NA

High3-3.9%

--- ---- -----

Very high>4%

Egypt,17.8(13-22)

Morocco 7%

41b

1a,1b2,2a2a,2c,1a

Prevalence of HCV infections in countries Prevalence of HCV infections in countries of North Africaof North Africa

Country Transmission

Egypt 40%

Lybia 20.5%

Algeria 63%

Tunisia 51%

Morrocco 76%

Transmission of HCV in hemodialysis Transmission of HCV in hemodialysis

Risk factor Low<5%

Moderate5-20%

High >20%

Blood transfusion

All countries

Hemodialysis All countries

Nosocomial transmissio

n

All countries

Health care workers

All countries

Risk factors for transmission of HCV Risk factors for transmission of HCV infection in North Africainfection in North Africa

Risk factor Low<5%

Moderate5-20%

High >20%

Invasive medical

procedure

All countries

Dental practice

Lybia, Tunisia Egypt, Algeria, Morocco

Hospital waste handling

Lybia, Tunisia Egypt, Algeria, Morocco

Intravenous Drug Abuse

All countries

Habiutal, high risk

behavior

Lybia, Tunisia Algeria, Egypt Morocco

Risk factors for transmission of HCV Risk factors for transmission of HCV infection in North Africainfection in North Africa

Habitual and community acquired Habitual and community acquired infectionsinfections

Around 50% of subjects deny any exposure to previous risk factors. We report that as community acquired infectionIt is likely that injections given in rural communities by both traditional and nontraditional health care providers are an important cause of HCV transmission, particularly in countries like Egypt, Morocco and Algeria,

Cases prevalence Suspected factors125

Tanta76% among cases HCV

Antibody40% PCR

family history, dental, minor

surgical procedures

150 Ain Shams

University

Only 66 done the testPrevalence 20%

Quality control and more

sensitive test for blood screening

strict pre transfusion blood testing

Transmission in cases with blood Transmission in cases with blood transfusion (children with B thalassemia)transfusion (children with B thalassemia)

Transmission within health care Transmission within health care settingsetting

Reported rates of HCV virus transmission to HCW exposed to HCV RNA positive patients inside hospitals range between 0 and 10%

Transmission within health care Transmission within health care settingsetting

A recent study done in Egypt to explore the transmission of HCV infection to HCWs.It included 597 health care workers that reported recent occupational blood born exposures.

Among the 73 HCWs enrolled in the prospective study,. Nine had evidence of transient viremia at one time point during follow-up, representing a cumulative incidence of 12.3% (95%CI, 5.8%–22.1%). Most(66.7%) HCWs had their viremic episode within 2 weeks after exposure.

The cumulative incidence of transient viremia was not significantly different between men and women. However, it was different according to the HCW’s age, with 35.7% (5/14) viremic HCWs among those aged below 24 years versus 6.8% (4/59)among HCWs aged 24 or above (p = 0.01). Also, the use of disinfectant after OBE was lower among HCWs who developed viremia than among those who did not (6.7% (3/45) and 26.3%(5/19), respectively; p =0.04).

HCWs of a general University hospital in Cairo were exposed to a highly viremic patient population. They experienced frequent occupational blood exposures, particularly in early stages of training. These exposures resulted in transient viremic episodes without established infection.

Mean viral load of index patientsdid not differ significantly between viremic and non viremicHCWs (5.1 and 4.8 logIU/ml, respectively, p= 0.36).

The first important finding of this study is the extremely high (37%) proportion of patients with HCV viremia among inpatients of a general hospital in Cairo.

Mounir et al 2013 (Diaa Marzouk)

Another study done in Al minia in upper egypt Abdel Wahab et al Journal of clinical virology

651 HCWS followed up for 18 months for seroconversion twice per year

Over all incidence of HCV sero convernsion 2.1/ 1000 person year

4.8% inicidence among subjects exposed to needle stick injuries.

Risk factors for acquiring HCV infection in referal center (liver institute) (central liver disease institute)

The prevalence of anti-HCV, hepatitis B surface antigen (HBsAg)and co-infection was 16.6%, 1.5% and 0.2%, respectively. Schistosoma mansoni antibodies were present in 35.1%. The anti-HCV rate increased sharplywith age and employment duration, but not among those with needlestick history.

After adjusting for other risk factors, the anti-HCV rate was higher among older HCWs[P < 0.001; risk ratio (RR) = 1.086, 95% CI 1.063–1.11], males (P = 0.002; RR = 1.911, 95% CI1.266–2.885) and those with rural residence (P < 0.001; RR = 2.876, 95% CI 1.830–4.52).Occupation (duration of employment or schistosomal antibody positivity) were not significant risk factors for anti-HCV positivity. In conclusion, although one in six HCWs had been infected with HCV, the infections were more likely tobe community-acquired and not occupationally related.

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