ObjectiveChronic hepatitis C (HCV) infection is associated with diabetes and favourable lipids. We studied the effect of this paradox on atherosclerosis and cardiometabolic response to HCV clearance. DesignCross-sectional study. Setting Egypt.Participants 329 chronically infected, 173 with cleared infection, and 795 never infected participants aged ≥35 attended for baseline investigations. A subsample of 192, 115, and 187 respectively underwent ultrasound. Main outcome measuresDiabetes, fasting glucose, lipids and fat deposition on ultrasound. Carotid intima media thickness (IMT) measured atherosclerosis. ResultsDiabetes prevalence was elevated (10.1% (95% CI 6.6,13.6), p=0.04) in HCV chronic, and cleared (10.1% (5.6,14.8), p=0.08) individuals versus 6.6% (4.9,8.3) in those never infected. Mesenteric fat was elevated in chronic (36.4 mm (34.5,38.2)), p=0.004, and cleared infection (37.8 (35.6,40.0)), p<0.0001 versus never infected (32.7 (31.0,34.4)). LDL cholesterol was lower in chronic (2.69 mmol/l (2.53,2.86) p<0.001), but similar in cleared (3.56 (3.34,3.78) p=0.4) versus never infected ConclusionsHepatic function normalisation with HCV clearance may account for reversal of favourable lipids observed with HCV infection. Hyperglycaemia and visceral adiposity appear less amenable to HCV 3 resolution. These different cardiovascular risk patterns may determine equivalent atherosclerosis risk by infection status. However, once these factors were accounted for, those with chronic infection had elevated IMT, suggesting a direct effect of infection. Word count 247 4 SummaryWhat is known about this subject?1. Chronic HCV infection is associated with an elevated prevalence of diabetes and insulin resistance, yet lipid profiles are favourable, compared to people never infected with HCV.2. Reports of the effect of this paradoxical risk factor profile on atherosclerosis are conflicting, due to limitations of previous study designs, either due to biased sampling, or lack of power.3. The effect of HCV clearance on both diabetes and lipid profiles and downstream effect on atherosclerosis has not been studied.What are the new findings?1. Chronic HCV infection is associated with central fat deposition on ultrasound, in addition to the known elevated risk of diabetes and insulin resistance.

ObjectiveTo identify current risk factors for hepatitis C virus (HCV) transmission in Greater Cairo.Design and SettingA 1∶1 matched case-control study was conducted comparing incident acute symptomatic hepatitis C patients in two “fever” hospitals of Greater Cairo with two control groups: household members of the cases and acute hepatitis A patients diagnosed at the same hospitals. Controls were matched on the same age and sex to cases and were all anti-HCV antibody negative. Iatrogenic, community and household exposures to HCV in the one to six months before symptoms onset for cases, and date of interview for controls, were exhaustively assessed.ResultsFrom 2002 to 2007, 94 definite acute symptomatic HCV cases and 188 controls were enrolled in the study. In multivariate analysis, intravenous injections (OR = 5.0; 95% CI = 1.2–20.2), medical stitches (OR = 4.2; 95% CI = 1.6–11.3), injection drug use (IDU) (OR = 7.9; 95% CI = 1.4–43.5), recent marriage (OR = 3.3; 95% CI = 1.1–9.9) and illiteracy (OR = 3.9; 95% CI = 1.8–8.5) were independently associated with an increased HCV risk.ConclusionIn urban Cairo, invasive health care procedures remain a source of HCV transmission and IDU is an emerging risk factor. Strict application of standard precautions during health care is a priority. Implementation of comprehensive infection prevention programs for IDU should be considered.

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.

In this study, HBV transmission took place primarily in the community, whether as a result of recent marriage (presumably first sexual intercourse), shaving at barbershops or IDU, and was more common among illiterates. Health promotion campaigns should be carried out to increase awareness about community transmission of HBV. In addition to routine immunization for infants and other populations, premarital screening might be useful to identify at-risk spouses in order to propose targeted immunization.

While three new HCV infections out of 100 could be linked to intra-familial transmission, parenteral iatrogenic transmission (dental care included) was accountable for 34.6% of these new infections. Thus, the relative contribution of intrafamilial transmission to HCV spread seems to be limited.

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.

The aim of the study was to describe the characteristics of acute hepatitis E in Greater Cairo. Patients with acute hepatitis E were identified through a surveillance of acute hepatitis using the following definition: recent (<3 weeks) onset of fever or jaundice, alanine aminotransferase at least three times the upper limit of normal (uln), negative markers for other causes of viral hepatitis and detectable hepatitis E virus (HEV) RNA. Comparison of the liver tests between acute hepatitis E and hepatitis A virus (HAV), case-control analysis (four sex-matched and age-matched (±1 year) HAV controls per case) to explore risk factors and phylogenetic analyses were performed. Of the 17 acute HEV patients identified between 2002 and 2007, 14 were male. Median age was 16 years (interquartile range 13-22). Compared with HAV (n = 68 sex-matched and ±1 year age-matched), HEV patients had higher bilirubin (mean (SD) 10.9 (5.7) uln versus 7.5 (4.4) uln, p 0.05) and aspartate aminotransferase levels (38.6 (27.1) uln versus 18.3 (18.1) uln, p 0.02). Co-infection (hepatitis C virus RNA or hepatitis B surface (HBs) -antigen positive/IgM anti-hepatitis B core (HBc) anitgen negative) was diagnosed in four patients. In univariate matched analysis (17 cases, 68 matched controls), HEV cases were more likely to live in a rural area than HAV controls (matched OR 7.9; 95% CI 2.0-30.4). Of the 16 isolates confirmed as genotype 1, 15 belonged to the same cluster with 94-98.5% identity in the open-reading frame 2 region. Our findings documented the sporadic nature of HEV in Greater Cairo, characterized a large number of Egyptian HEV genotype 1 strains and identified living in a rural area as a potential risk factor for infection.

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