Hepatitis C: an epidemiological review

Hepatitis C: an epidemiological reviewM. I. Memon1 and M. A. Memon2 1Department of Community Health, Guild NHS Trust, Honorary Lecturer Lancashire Post

Graduate Medical School, Preston and Professor of Ethnicity and Community Health, Bolton Institute, Bolton, and 2Department of Surgery, Queen's

Medical Centre, Nottingham, UK

Received March 2001; accepted for publication July 2001

EPIDEMIOLOGY OF HEPATITIS C VIRUS

Hepatitis C virus (HCV), a positive strand RNA virus which is

related to ¯avi and pestiviruses family, was ®rst identi®ed in

the USA in 1989 as a major causative agent of post trans-

fusion non-A, non-B hepatitis [1]. According to WHO esti-

mates, approximately 3% of the world population, or about

170 million people, may be infected with hepatitis C virus

[2,3]. In the USA, antibodies to HCV are encountered in

between 0.1% to 1.8% of the general population (Table 1).

In healthy volunteer blood donors the incidence of HCV in

the USA varies between 0.17% to 1.4% and in the UK is

0.35% (Table 2). However in other parts of the world the

incidence HCV infection both in the general population and

blood donors may be much higher (Tables 1 and 2).

Although the annual incidence of newly acquired HCV has

declined substantially in the USA, from 180 000 to 30 000

in the past decade, there still remains a large reservoir of

chronically infected Americans (estimated to be 3.9 million)

who can serve as a source of transmission to others and who

are at risk of severe consequences of chronic liver disease [4].

HCV infections leads to acute hepatitis in 20% of cases and

chronic hepatitis in 50% of cases, 20% of who develop cir-

rhosis [5,6]. There is also a strong relationship between HCV

and hepatocellular carcinoma [7,8].

HCV is transmitted primarily by exposure to infected

blood. However, in up to 50% of cases no recognizable

transmission factor/route could be identi®ed [9]. Therefore, a

number of other routes of transmission such as sexual or

household exposure to an infected contact are postulated but

not widely accepted. This is because con¯icting data has

emerged regarding the presence of HCV in body ¯uids other

than blood. Some authors have found total absence of the

virus in sperm, saliva, vaginal secretions and other body

¯uids [9]. However, others have documented the presence of

HCV-speci®c antigens in semen of infected individuals

[10,11]. Risk factors for HCV infection include intravenous

drug abuse, haemodialysis, transfusion of blood products,

tattooing, high sexual behaviour, exposure to healthcare

and organ transplants from HCV-positive donors and use of

blood contaminated straws for cocaine snorting [12,13].

As far back as 1981, two separate American studies showed

that there was increased risk of acquiring post-transfusion

non-A, non-B infection (PTH-NANB) following blood trans-

fusion if the donors have elevated ALT levels compared with

normal ALT levels [14±16]. Furthermore the exclusion of

blood donors with antibodies to the hepatitis B core antigen

was found to prevent another 20±30% of the PTH-NANB,

Abbreviations: HCC, hepatocellular carcinoma; HCV, hepatitis C

virus; PTH-NANB, post-transfusion non-A, non-B infection.

Correspondence: Professor M. I. Memon, Oakwood, Whitehall

Road, Darwen, Lancashire BB3 2LH, UK.

E-mail: [email protected]

Journal of Viral Hepatitis, 2002, 9, 84±100

Ó 2002 Blackwell Science Ltd

SUMMARY. The aim of the study was to analyse the current

literature regarding the mode of transmission of HCV and its

global prevalence in different groups of people. A systematic

review of the literature on the epidemiology of hepatitis C

from 1991 to 2000 using computerized bibliographic data-

bases which include Medline, Current Content and Embase.

The prevalence of hepatitis C virus (HCV) varies tremen-

dously in different parts of the world, with the highest inci-

dence in the Eastern parts of the globe compared with the

Western parts. Furthermore, certain groups of individuals

such as intravenous drug users are at increased risk of ac-

quiring this disease irrespective of the geographical location.

Although the main route of transmission is via contamin-

ated blood, curiously enough in up to 50% of the cases no

recognizable transmission factor/route could be identi®ed.

Therefore, a number of other routes of transmission such as

sexual or household exposure to infected contacts have

been investigated with con¯icting results. Hepatitis C in-

fection is an important public health issue globally. Better

understanding of routes of transmission will help to combat

the spread of disease. In order to prevent a world wide

epidemic of this disease, urgent measures are required to (i)

develop a strategy to inform and educate the public re-

garding this disease and (ii) expedite the efforts to develop a

vaccine.

Keywords: epidemiology, etiology, hepatitis C, prevention

and control, risk factors, statistics and numerical data.

Table 1 Global Prevalence of Anti-HCV in the general population of different geographical locations

Author(s) Year(s)

Geographical

location

Type of

subjects

Number

tested

Percentage

positive (%)

Fairley et al. [127] 1990 Australia Antenatal women 252 0.4

Garner et al. [128] 1997 Australia Pregnant women 1537 1.1

Tao et al. [129] 1991 China Normal subjects 438 2.1

Darwish et al. [130] 1996 Egypt Nonrandom selected

residents

155 51

Dubois et al. [131] 1997 France Randomly selected

individuals undergoing

routine medical check-up

in social security

medical centres

6283 1.1

Richard-Lenoble et al. [132] 1995 Gabon Cross-sectional study 109 22

Martinson et al. [133] 1996 Ghana Cross-sectional children

and adolescence study

803 5.4

Jeannel et al. [134] 1998 Guinea Urban and rural population 459 1.1

Burkina Faso 965 4.9

Nekata et al. [135] 1994 Ho Chi Minh Pregnant women and

tropical disease patients

292 3.8

Chan et al. [136] 1992 Hong Kong Health exhibition attendants 382 0.5

Reddy et al. [137] 1995 India Random sample 91 5.5

Marranconi et al. [138] 1994 Italy Pregnant women 5672 0.7

Osella et al. [139] 1997 Italy Random sample of

population of a small town

in southern Italy

1969 26

Guadagnino et al. [140] 1997 Italy General population of a town 1352 14.4

Tajima et al. [141] 1991 Japan Normal subjects 971 5.1±49

Tibbs et al. [142] 1991 Kiribati Tropical communities 385 4.8

Vanuatu 138 <1

Zaire 173 6.4

Kim et al. [143] 1992 Korea Normal subjects > 20-year-old 4917 1.7

Morvan et al. [144] 1994 Madagascar Healthy subjects 643 3.3

Ahmed et al. [145] 1998 Malawi Descriptive study, Pregnant

women (both HIV positive

and negative)

150 16.5

Miller et al. [146] 1993 New Zealand Maori and Paci®c islanders 3483 0.49

Perez et al. [147] 1996 Nicaragua Cross-sectional study 399 0

Oshita et al. [148] 1993 Osaka Normal subjects 298 2

Luby [149] 1997 Pakistan Randomly selected subjects 309 6.5

Baumgart et al. [150] 1993 Papua New Guinea,

Central

Leprosy and HBV survey 253 1

Turner [151] 1993 Papua New Guinea,

Western

Remote, rural and

capital subjects

180 1±12

Hyams et al. [152] 1992 Peru Northern jungle region 2111 0

Bahakim et al. [153] 1991 Saudi Arabia Pregnant women 260 4.6

Healthy subjects 760 5.3

al-Faleh et al. [154] 1991 Saudi Arabia Children 4496 0.9

al Nasser et al. [155] 1992 Saudi Arabia Healthy subjects 380 3.6

al Karawi et al. [156] 1992 Saudi Arabia Antenatal women 385 1

al-Faleh et al. [157] 1995 Saudi Arabia Healthy subjects 1482 1.8

Chen et al. [158] 1991 Taiwan Pregnant women 294 0.34

Lee et al. [159] 1991 Taiwan Hepatitis B vaccination

program

1419 0.28

Ó 2002 Blackwell Science Ltd, Journal of Viral Hepatitis, 9, 84±100

Epidemiological review of hepatitis C 85

though this was not con®rmed by other European studies

[16±18]. The screening of donors for ALT and anti-HBc for

prevention of PTH-NANB was termed surrogate testing.

Before 1986, the incidence of post-transfusion HCV ran-

ged from 5% to 13% which declined to between 1.5% to 9%

from 1986 to 1990 [19±25]. Since 1990, when anti-HCV

screening of blood donors became mandatory, the incidence

of post-transfusion HCV declined to < 1% but not completely

eliminated. This is because the ®rst generation ELISA may

not become positive for months after infection with HCV

[26]. Furthermore, seronegative HCV carriers were respon-

sible for 10±15% of HCV transmission [26]. The new gen-

eration of various tests will further reduce the risk of

transfusion-transmitted HCV as they are able to detect a

number of additional antigens and are more sensitive.

It has been suggested that HCV can down-regulate the

pace of replication in order to escape viral clearance by the

host immune system, yet can still exist in a quiescent or low

replicative state within hepatocytes which in part is

responsible for the high degree of viral persistence in HCV

infection [26]. HCV displays a high mutation rate like many

RNA viruses which (i) provides protection against immu-

nological detection and destruction which leads to its per-

sistence, ¯are up and transmission of disease; (ii) can lead to

unreliability of antibody tests; (iii) higher reinfection rate due

to incomplete immunity; (iv) variable clinical expression;

(v) variable and unpredictable response to treatment; and,

lastly, (vi) dif®culty in development of a reliable vaccine

[27±29].

RECIPIENTS OF BLOOD AND BLOOD PRODUCTS

The incidence of acquiring post-transfusion HCV infection is

directly related to the number and amount of blood products

received [30±32]. Therefore, haemophilics have a very high

incidence of HCV infection, 46±90% [33±35]. Similarly

patients receiving > 100 000 U of cryoprecipitate per year

compared with those receiving < 100 000 U have a signi®-

cantly higher chance of become infected (76% vs 46%) [35].

Although virucidal procedures for blood products such as

heat treatment, pasteurization and solvent-detergent treat-

ment have nearly totally eliminated the risk of HCV trans-

mission, they nonetheless do not guarantee complete

security [35±37]. This is because there have been a number

of incidences of HCV transmission via intravenous immu-

noglobulin preparations [36,38±40]. However, a recent

Dutch study [41], failed to show any seroconversion

amongst 57 patients who received clotting products between

1989 and 1993 following virucidal treatment.

In children receiving multiple blood transfusion for tha-

lassemia, the incidence of HCV infection varies from 55% to

83% [30±42]. The outcome of HCV infection in these chil-

dren was variable; resolution in 20%, chronic infection in

69% and recurrent attacks of acute infection in 11%. In a

European multicentre study [43] of paediatric population

with chronic hepatitis C with no underlying systemic

disease, with a mean period of follow-up of 6 years, it

emerged that most children remain asymptomatic and some

even achieved sustained biochemical remission. This study

Table 1 Continued

Author(s) Year(s)

Geographical

location

Type of

subjects

Number

tested

Percentage

positive (%)

Pregnant women 793 0.4

Chien et al. [160] 1993 Taiwan Check-up program 108 5.6

Chang et al. [161] 1993 Taiwan Healthy infants 748 0

Chuang et al. [162] 1993 Taiwan Healthy subjects 275 2.9

Chang et al. [163] 1996 Taiwan Bunun aboriginal community 712 16.9

Triki et al. [164] 1997 Tunisia Young male military recruits,

healthy individuals (all age

groups from 6 Months onward)

33 363 0.4

Doganci et al. [165] 1992 Turkey High socioeconomic group in

Belgium

116 0

Hyams et al. [166] 1992 USA Military recruits 1538 0.3

Jonas et al. [167] 1997 USA Adolescent medicine clinic

or school-based clinics

869 0.1

Alter et al. [168] 1999 USA 3rd National health and

nutrition examination

survey (1998±94)

21 241 1.8

Blitz-Dorfman et al. [169] 1996 Venezuela Randomly selected subjects 293 0

Scott et al. [170] 1992 Yemen Cross-sectional survey 348 2.6

Oshitani et al. [171] 1995 Zambia Adult hospital patients with

and without jaundice

495 0.6


86 M. I. Memon & M. A. Memon

Table 2 Prevalence of anti-HCV in both volunteer and professional blood donors

Author(s) Year(s)

Geographical

location Type of donors

Number

of donors

Percentage

positive (%)

Allain et al. [172] 1991 Australia Voluntary 167 511 0.78

Archer et al. [173] 1992 Australia Not speci®ed (all) 94 970 0.45

Mison [174] 1997 Australia Voluntary 34 725 0.29

Khan et al. [175] 1993 Bangladesh Professional 163 2.4

Voluntary 83 0

Japanese voluntary 7479 0.6

Jeannel et al. [134] 1998 Benin (W. Africa) Not speci®ed 582 1.4

Vasconcelos et al. [176] 1994 Brazil Not speci®ed ±random selection 5000 1.14

Ito et al. [177] 1993 China Not speci®ed 451 0.7

Wang et al. [178] 1994 China Voluntary 1909 0.3

Professional 1017 5.7

Arthur et al. [179] 1997 Egypt Not speci®ed 2644 24.8

Schottstedt et al. [180] 1998 Germany Not speci®ed 428 896 0.005

Song et al. [181] 1994 Ho Chi Minh Not speci®ed 491 20.6

Hanoi Not speci®ed 499 0.8

Lin et al. [182] 1992 Hong Kong Voluntary 5000 0.4,1.2,3.8*

Panigrahi et al. [183] 1997 India Voluntary 15 922 1.85

Budihusodo et al. [184] 1991 Indonesia Voluntary 243 24.3

Amirudin et al. [185] 1991 Indonesia Not speci®ed 196 3.1

Sulaiman et al. [186] 1995 Indonesia Voluntary 7572 2.1

Darmadi et al. [187] 1996 Indonesia Voluntary 2233 2.3

Prati et al. [188] 1997 Italy Not speci®ed (repeat donors) 16 515 0.03

Tanaka et al. [189] 1992 Japan Voluntary 34 989 0.56

Watanabe et al. [190] 1993 Japan Not speci®ed (all) 16 500 2.2

Sasaki et al. [191] 1996 Japan Not speci®ed (all) 114 266 0.19

Tanaka et al. [192] 1998 Japan Not speci®ed (four age groups) 448 020 0.3

Kim et al. [193] 1993 Korea Not speci®ed 150 1.3

Araj et al. [194] 1995 Lebanon Not speci®ed (random selection) 536 0.7

Morris et al. [195] 1998 Northern Ireland Not speci®ed (all) 231 321 0.01

Kakepoto et al. [196] 1996 Pakistan Voluntary 16 705 1.18

Arguillas et al. [197] 1991 Philippines Not speci®ed 392 2.2

Abdourakhmanov et al. [198] 1998 Russia Voluntary 10 682 0.93

Paid 267 7.5

al Karawi [156] 1992 Saudi Arabia Voluntary 4818 1.5

Abdelaal et al. [199] 1994 Saudi Arabia Not speci®ed (random selection) 744 3.2

Crawford et al. [200] 1994 Scotland Not speci®ed (all) 180 658 0.088

Wang [201] 1995 Singapore Not speci®ed (all) 65 208 0.37

Tucker et al. [202] 1997 South Africa Voluntary 66 314 0.41

Lissen et al. [203] 1993 Spain Voluntary 400 1.2

Munoz-Gomez et al. [204] 1996 Spain Voluntary 55 587 0.93

Chen et al. [205] 1990 Taiwan Voluntary 420 0.95

Lee et al. [159] 1991 Taiwan Paid 500 0.4

Songsivilai et al. [206] 1997 Thailand Voluntary 3255 5.6

Mutimer et al. [207] 1995 UK Voluntary 287 332 0.35

Stevens et al. [208] 1990 USA Voluntary 874 1.4

Anderson et al. [209] 1995 USA Voluntary 21 431 0.5

Murphy et al. [210] 1996 USA Voluntary 862 398 0.36

Chuang et al. [211] 1999 USA Voluntary 149 756 0.17

el Guneid et al. [212] 1993 Yemen Not speci®ed (all) 294 1

Oshitani et al. [171] 1995 Zambia Not speci®ed (all) 240 0

*ALT £ SD, ALT raised 2±3 SD, ALT > 3 SD.



concluded on the basis of repeated liver biopsies, that severe

hepatitis and cirrhosis are infrequently encountered with

chronic hepatitis C infection in children and adolescence.

The risk of developing hepatic decompensation in HCV

patients in the presence of coinfection with HIV is 21 times

higher compared with those who are HIV negative [44,45].

OTHER IATROGENIC ROUTESOF TRANSMISSION

There is increased prevalence of HCV infections amongst

certain groups of patients which include: (i) long-term can-

cer survivors (20%); (ii) bone marrow transplant recipients

(29%); (iii) renal dialysis patients (15±20%); (iv) renal

transplant patients ± which is directly related to the fre-

quency and duration of haemodialysis received prior to their

transplant [29,32,46±54]. However, the prevalence of HCV

infection differs greatly between different countries and even

between different dialysis centres in the same country, the

highest has been reported from Brazil (82%) and the lowest

from Europe (4%) [55]. There is a direct correlation with the

duration of dialysis and number of blood transfusions

received and the incidence of acquiring HCV infection [55].

Other possible mechanisms of transmission include sharing

dialysis machines between HCV positive and negative

patients [56,57] and nosocomial transmission by the dialysis

staff [58±61]. It is clear from various studies that rigorously

applied universal infection precautions during dialysis by the

staff signi®cantly decrease the nosocomial transmission of

HCV infections [55,59,60,62,63]. The nosocomial trans-

mission has also been documented from a cardiac surgeon

(to ®ve patients), via anaesthetic tubing, and via syringes for

intravenous catheter ¯ushing [64±66].

RISK TO HEALTHCARE PROFESSIONALS

Healthcare professionals dealing with blood and blood

products are at a greater risk of contracting HCV via need

stick injury. The risk of acquiring HCV infection following a

single needle stick injury with contaminated blood is low as

determined by anti-HCV seroconversion using second gen-

eration assay and PCR [67±69]. High risk groups include

surgeons, obstetricians, haemodialysis nurses/technicians,

oral surgeons, emergency department workers and intensive

care workers (Table 3). The risk factors include: (i) type of

needle, i.e. hollow vs solid; (ii) the frequency of occupational

blood contacts; (iii) the type of patients, i.e. acute infection vs

chronic carriers; and (iv) prevalence of HCV amongst

patients. Three European studies [70±72] failed to show any

HCV seroconversion in healthcare workers following anti-

HCV positive needle prick injuries following at least

10 months of follow-up. In contrast, two Japanese pros-

pective studies revealed a seroconversion rate of between

3.3% and 5.6% amongst 90 and 56 healthcare workers,

respectively, following needle-stick injury [73,74]. Use of

blunt needles, use of double gloving in high-risk patients, use

of protective goggles and passing of sharp instruments via a

tray rather than directly are important precautionary

measures in minimizing iatrogenic transmission of HCV. It is

clear from the various studies that the risk of occupational

risk of HCV transmission does exist and preventive measures

as outlined above are currently the mainstay of healthcare

workers against HCV infection.

INTRAFAMILIAL TRANSMISSION

There is some evidence that intrafamilial spread of HCV also

occur as seropositivity for anti-HCV is 5±10-fold in individ-

uals living with an HCV-positive patient compared with

general population (Table 4). A number of studies [75±80]

totalling 335 patients, found the prevalence of HCV infection

in household (nonsexual) contacts to be between 0% to 11%

(average 3.6%). Children are less effected than spouses. The

nonsexual household transmission of HCV is speculative and

include sharing of toothbrushes, dental appliances, razors

and nail-grooming equipment.

The low rates of transmission may be due to low serum

titre of virus in HCV carriers during HCV infection [81].

However, no conclusive data exists as to the threshold

concentration of HCV required to transmit infection [29].

The prevalence of anti-HCV among the sexual and

household contacts of chronic hepatitis C patients ranges

between 0% to 27% (Table 4). Caporaso et al. [82] published

one of the largest studies evaluating the intrafamilial spread

of HCV among 1370 household contacts of 585 HCV pos-

itive subjects (index cases). By using third generation ELISA

and PCR techniques they found the incidence of anti-HCV to

be 7.3% (15.6% spouses, 3.2% in other relatives). After

adjusting for various confounders, the study failed to show

any correlation between spouses vs other relatives and

length of marriage and acquiring HCV infection. The

authors concluded that sexual transmission does not seem to

play a role in the intrafamilial spread of HCV infection. In

contrast to this study Guadagnino et al. [83] showed that

spouses who had been married to the index cases longer

than 20 years had a 7.5-fold risk of HCV seropositivity as

compared with those married less than 20 years. They

concluded that sexual contact plays an independent role in

the spread of HCV infection in the family setting.

A study from Japan [84] found spouses with anti-HCV-

positive partners to be twice as likely to have anti-HCV than

spouses with anti-HCV-negative partners. However, 50% of

the couples presented discordant HCV genotypes. The authors

concluded that the clustering of HCV infection among speci®c

couples within this endemic population may not be attribut-

able to heterosexual transmission. In contrast a study from

Taiwan [85] showed direct correlation with the duration of

marriage (> 20 years vs < 20 years) and duration of actual

exposure to the index patients but not with serum HCV titres.

The infected couples had more frequent sexual contacts and



more commonly shared toothbrushes than those with unin-

fected spouses. The authors concluded that spouses of patients

with chronic hepatitis C have a higher risk of acquiring HCV

that increases with longer marriage and duration of exposure,

and they should be educated about how to avoid contracting

HCV infection from their spouses.

One study showed a higher prevalence of anti-HCV in

female partners for positive males but not vice versa [86]. As

the data is so con¯icting, some experts believe that in long-

standing monogamous relationships no modi®cation in

sexual practices is required except during menstruation and

if one or the other partners have overt genital ulceration. In

other situations safe sex practices may help prevent the

transmission of HCV.

SEXUAL TRANSMISSION IN HIGH-RISK GROUPS

Sexual transmission of HCV occurs, but infrequently. The

prevalence of HCV infection is higher amongst heterosexual

individuals attending sexually transmitted diseases clinics,

male homosexuals, prostitutes and partners of intravenous

drug abusers (Table 5). There seems to be a positive

correlation with the overall number of sexual partners, not

using a condom, receptive anal intercourse, sexual activity

Table 3 Prevalence of anti-HCV in the healthcare professional of different geographical locations

Author(s) Year(s)

Geographical

location Type of subject

Number

tested

Percentage

positive (%)

Frider et al. [213] 1994 Argentina Healthcare workers 439 2.7

Jadoul et al. [214] 1994 Belgium Dialysis nurses 120 4.1

Vanderborght et al. [215] 1995 Brazil Healthcare workers 242 2.7

Germanaud [216] 1994 France Healthcare workers 430 0.9

Schlipkoter et al. [217] 1992 Germany Dialysis staff 121 1.6

Jochen et al. [218] 1992 Germany Hospital staff 1033 0.6

Ribero et al. [219] 1991 Italy Dentists 526 6.3

Campello et al. [220] 1992 Italy Healthcare workers 407 1.2

Petrosillo et al. [221] 1995 Italy Healthcare workers 5813 2

Nakashima et al. [222] 1993 Japan Hospital staff & acupuncturist 1077 1

Fujiyama et al. [223] 1995 Japan Dialysis staff 216 2.3

Rehman et al. [224] 1996 Pakistan Healthcare workers 95 4

Mujeeb et al. [225] 1998 Pakistan Operating room personnel 104 4.4

Hyams et al. [152] 1992 Peru Healthcare workers 148 0

Arguillas et al. [197] 1991 Philippines Physicians and lab staff 123 1.6

Soni et al. [226] 1993 South Africa Healthcare workers 212 0

Struve et al. [227] 1994 Sweden Healthcare staff 880 0.7

Liaw et al. [228] 1991 Taiwan Hospital administrative staff 123 0.8

Oge et al. [229] 1998 Turkey Urologist 24 12.5

Mortimer et al. [230] 1989 UK Healthcare workers 100 0

Herbert et al. [231] 1992 UK Dentist 94 0

Zuckerman et al. [70] 1994 UK Healthcare workers 1053 0.3

Neal et al. [232] 1997 UK Healthcare workers 1949 0.2

Lodi [233] 1997 UK Dental healthcare workers 167 1.2

Klein [69] 1991 USA Dentists 456 1.8

Abb [234] 1991 USA Healthcare workers 1018 0.6

Shapiro et al. [235] 1992 USA Orthopaedic surgeons 3262 0.8

Cooper et al. [236] 1992 USA Hospital staff 243 1.6

Thomas et al. [237] 1993 USA Teaching hospital healthcare personnel 943 0.7

Polish et al. [238] 1993 USA Community hospital healthcare

personnel

1677 1.4

Niu et al. [239] 1993 USA Dialysis staff 142 1.4

Forseter et al. [240] 1993 USA Dialysis nurses 51 1.9

Gerberding [241] 1994 USA Hospital care providers 976 1.4

Goetz et al. [242] 1995 USA Liver transplantation personnel 57 5.3

Panlilio et al. [243] 1995 USA Hospital-based Surgeons in moderate

to high AIDS areas

770 0.9

Tokars et al. [244] 1998 USA Dialysis staff 54 194 2



involving a trauma, history of other sexually transmitted

diseases and those coinfected with HIV [81,86±89].

PERINATAL OR VERTICAL OR MOTHER-TO-OFFSPRING TRANSMISSION

Perinatal transmission of HCV infection occurs between 0

and 15% of cases [55]. There remains a debate as to the exact

role of this route of HCV spread [90]. Vertical transmission

from mother to child has been reported in a number of studies

[91±100] on the basis of asymptomatic biochemical abnor-

malities of liver function tests in particular ALT and transient

anti-HCV seropositivity using either ELISA or PCR in the

majority of infants born to mothers with HCV infection.

Persistence of anti-HCV has been noted with HIV coinfection

suggesting facilitatory role of HIV in HCV transmission

[91,92,94,97,101]. RT-PCR although have con®rmed ver-

tical transmission of HCV infection, has also generated a

contradictory data when mother-infant pairs were evaluated.

Some studies have shown no detectable anti-HCV despite

detectable anti-HCV [102±106], whereas others have shown

the prevalence of anti-HCV to be between 5% and 80%

[94,96,100,107±113]. There is a positive correlation with

HCV-RNA titre in the mother and subsequent development of

HCV infection in children [110,111,114,115]. Furthermore,

acute HCV infection during pregnancy even in the absence of

HIV carries an increased risk of vertical transmission

[101,107,114]. What remain controversial is the route and

timing of HCV transmission. It seems logical to think that

selective vertical transmission of certain subsets of HCV

variants either in utero or in the immediate postnatal period is

a possibility [116]. A study from Taiwan showed that elective

cesarean sections were associated with lowest microtrans-

fusion from mother to fetus compared with spontaneous

vaginal delivery or emergency cesarean sections [111,117].

In the light of the current available knowledge, no effective

way of preventing transmission of HCV infection from mother

to child exists. Similarly, transmission of HCV by breast milk

has been suggested but never proved [93,118,119]. It has

been insinuated that there might be some correlation be-

tween the duration of breastfeeding by HCV-RNA-positive

mother and the acquiring of HCV infection by the baby. In

view of this inconclusive data, it is premature to advise anti-

HCV-positive mothers against breastfeeding.

INTRAVENOUS DRUG USERS

Intravenous drug abusers not only have the highest pre-

valence of HCV infection but also constitute a potential

reservoir of HCV in the community. The incidence varies

between 31% to as high as 98% in different parts of the

world (Table 6). The prevalence of HCV infection increases

proportionally with the duration of intravenous drug abuse

[120±122]. Other risk factors include male gender, being

older, sex trade worker, risky sexual behaviour, multiple

sexual partners, needle sharing and history of being in pri-

son [120,122±126]. Oral drug abusers, when compared

with intravenous drug abusers, were found to have far less

incidence of HCV infections in two studies, one from New

Zealand (4% vs 73%) and Taiwan (5.4% vs 53%) [123].

CONCLUSIONS

Better understanding of the mode of spread of the disease will

assist in minimizing HCV spread globally. The overall burden

on the society both ®nancially and socially to support and

manage individuals with HCV is a time bomb waiting to

explode unless urgent measures are undertaken to (i) develop

Table 4 Prevalence of anti-HCV in sexual partners

Author(s) Year(s) Geographical location Number tested Percentage positive (%)

Davis et al. [245] 1996 Australia 19 0

Kolho et al. [246] 1991 Finland 30 3.3

Meisel et al. [247] 1995 Germany 94 0

Brettler et al. [248] 1992 International 106 2.7

Power et al. [249] 1995 Ireland 393 0.5

Scotto et al. [250] 1996 Italy 83 8.4

Caporaso et al. [82] 1998 Italy 11 379 15.6

Guadagnino et al. [83] 1998 Italy 267 11.3

Akahane et al. [251] 1994 Japan 154 27

Koda et al. [252] 1996 Japan 121 17.4

Mauser-Bunschoten et al. [253] 1995 Netherlands 75 0

Win et al. [254] 1994 Scotland 75 5.3

Diago et al. [255] 1996 Spain 394 7.6

Kao et al. [85] 1996 Taiwan 100 17

Saltoglu et al. [256] 1998 Turkey 38 7.8

Gordon et al. [257] 1992 UK 42 4.7



a strategy to inform and educate the lay public and press

regarding this disease (HCV awareness programs); (ii) set up

clinical information system(s) to monitor trends, occurrence

and effectiveness of intervention programs; (iii) identify the

route of spread for sporadic cases of HCV which accounts for

almost 50% of cases; (iv) develop inexpensive sensitive and

speci®c tests for detection of HCV infection at an early stage;

(v) make available these diagnostic tests universally and in

particular for the poorer countries where HCV is reaching

epidemic proportions; and (vi) lastly to expedite the efforts to

develop a vaccine. Individuals who have been unfortunate to

have acquired the HCV can be supported by appropriate

therapeutic drug regimes, which at present vary from centre

to centre. Therefore, multicentre clinical trials are needed

urgently to de®ne the role of interferon alone or in combi-

nation with other antiviral agents for both symptomatic

and asymptomatic individuals. Furthermore, the exact

interaction of interferon with the virus, host and the inter-

feron regimens (dynamic tripartite interaction) in producing

a variable response needs to be elucidate so that optimal

Table 5 Prevalence of anti-HCV in the high sexual risk groups of different geographical locations

Author(s) Year(s)

Geographical

location Type of subjects

Number

tested

Percentage

positive (%)

Fairley et al. [127] 1990 Australia STD subjects 177 6.2

Quaranta et al. [258] 1994 France Heterosexual STD subjects 82 18

van Doornum et al. [259] 1991 Holland Heterosexual STD subjects 468 1.3

Corona et al. [260] 1991 Italy Heterosexual STD subjects 1130 1.7

Weinstock et al. [261] 1993 USA Heterosexual STD subjects 1162 3.4

Weinstock et al. [261] 1993 USA Inner city clinics for STD 1292 7.7

Thomas et al. [262] 1994 USA Heterosexual STD subjects 1257 10

Gust et al. [263] 1989 Australia Homosexual men 148 9

Fairley et al. [127] 1990 Australia Homosexual men 330 22.7

Bodsworth et al. [89] 1996 Australia Homosexual men 1038 7.6

Melbye et al. [264] 1990 Denmark Homosexual men 259 4.1

Westh et al. [265] 1993 Denmark Homosexual men 147 1

Westh et al. [265] 1993 Denmark Homosexual men 147 1.4

Quaranta et al. [258] 1994 France Homosexual men 68 3

Hadziyannis et al. [266] 1993 Greece Homosexual men 426 4±9

Corona et al. [260] 1991 Italy Homosexual men 195 2

Gasparini et al. [267] 1991 Italy Homosexual men 212 4

Ricchi et al. [268] 1992 Italy Homo-bisexual men 622 6.9

Donahue et al. [269] 1991 North America Homosexual men 926 1.6

Hyams et al. [152] 1992 Peru Homosexual men 103 1

Tor et al. [270] 1990 Spain Homosexual men 105 17

Sanchez-Quijano et al. [271] 1990 Spain Homosexual men 146 5.4

Lissen et al. [203] 1993 Spain Homosexual men 168 4.2

Sonnerborg et al. [272] 1990 Sweden Homosexual men 48 0

Osmond et al. [273] 1993 USA Homosexual men 589 1.5

Buchbinder et al. [274] 1994 USA Homosexual men 343 5

Thomas et al. [86] 1995 USA Homosexual men 35 18

Ndimbie et al. [275] 1996 USA Homosexual men 1058 2.9

Osella et al. [276] 1998 USA Homosexual men 228 12.7

Fairley et al. [127] 1990 Australia Prostitutes 212 10.4

Wu et al. [277] 1993 China Prostitutes 622 12

Hadziyannis et al. [266] 1993 Greece Prostitutes 203 4

Develoux et al. [278] 1994 Niger Prostitutes 250 7.6

Mast et al. [3] 1991 North America Prostitutes 535 12

Hyams et al. [152] 1993 Peru Prostitutes 966 0.7

Sanchez-Quijano et al. [271] 1990 Spain Prostitutes 78 8.9

Gutierrez et al. [279] 1992 Spain Prostitutes 227 9

Lissen et al. [203] 1993 Spain Prostitutes 310 6.4

STD, sexually transmitted disease.



anti-HCV therapy can be formulated. This coupled with

patients orientated surveys to identify quality of life issues

whilst on treatment will guide the physicians in tailoring a

treatment regime most suitable for these patients. Because

there is a wide variation in the disease prevalence rate which

may re¯ect (i) small sample size and (ii) variation in meth-

odology and serological testing, it is paramount that multi-

centre trials address the issue of the true global prevalence of

HCV infection in various groups of people using an up to

date single most sensitive and speci®c test. This task can only

be undertaken through the auspices of WHO, Center for

communicable diseases in Atlanta, GA, USA and the health

Departments of various countries which one hopes will

achieve an effective control of global spread of HCV.

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Hepatitis C: an epidemiological review

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