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
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.
Prof. SM Alavian
Relative Efficiency of HBV, HCV, HIV
Transmission by Type of Exposure
Type of exposure
to infected source
Transfusion
Injecting drug use
Unsafe injections
Perinatal
Needle stick
Sexual
Non-intact skin
Prof. SM Alavian
Efficiency of transmission
HBV
HCV
HIV
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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:
Prof. SM Alavian
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,
periodically
Hemophilia
Prof. SM Alavian
and
Hemodialysis
patients
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.
Prof. SM Alavian
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
Prof. SM Alavian
Hepatitis C in Iran
Neonatal Blood Exchange and HCV
▪ Is Iran a low prevalence and Before screening of HCV in blood donors?
▪ Between 2000-2002, questionnaire to 47227 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
Prof. SM Alavian
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
Prof. SM Alavian
Alavian et al. J Gastro & Hepatology 2002( 0.12% were HCV positive)
Prof. SM Alavian
Alavian et al. J Gastro & Hepatology 2002( 0.12% were HCV positive)
Prof. SM Alavian
Risk Factor for HCV infection, Khuzestan, (Hajiani 2006)
Prof. SM Alavian
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
Prof. SM Alavian
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
Prof. SM Alavian
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,
Prof. SM Alavian
Prof. SM Alavian
Prof. SM Alavian
▪ You are invited to visit:
www.hepmon.ir
▪ And receive the free articles regarding hepatitis from Iran and
Middle East and Middle Asia
Prof. SM Alavian
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
Prof. SM Alavian
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.
Prof. SM Alavian
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
Prof. SM Alavian
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 RTPCR, 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. 2008
Alavian SM. An Unbelievable Fact on “Dialysis Centers Without Hepatitis C Infection”. Nephro Urol Mon. 2014
Prof. SM Alavian
Prevalence HCV among patients with
thalassemia in Iran
Prof. SM Alavian
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
Prof. SM Alavian
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
Prof. SM Alavian
Risk factors for acquiring the HCV infection
in Thalassemia
▪ In 98 thalassemia patients in Markazi prov. In 2004.
▪ 7.1% (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 1996.
▪
Samimi-Rad K, Hepatitis C virus genotypes among patients with thalassemia and inherited bleeding disorders in
Markazi province, Iran. Haemophilia. 2007
Prof. SM Alavian
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
Prof. SM Alavian
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 1.243.91)
Prof. SM Alavian
Prof. SM Alavian
Prof. SM Alavian
Hepatitis C in haemophilia patients
▪ Iran: 48.07% [(95%CI 35.06-60.48)
▪ Bias may Affect Results of Reported Studies
from Referral Centers
Prof. SM Alavian
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 800–1200 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. 2010 Sep;30(8):1173-80.
Prof. SM Alavian
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. 2010 Sep;30(8):1173-80.
Prof. SM Alavian
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. 2011 Jun;83(6):989-95.
Prof. SM Alavian
A significant difference in the prevalence of positive HCV-RNA in
PBMCs and history of blood transfusion
Prof. SM Alavian