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.

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.

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.

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.

Domestic violence among women attending out-patient clinics in Ain Shams University Hospitals, Cairo, Egypt.

Violence affects millions of women worldwide and it cuts across cultural and religious barriers, impeding the women's right to participate fully in the society. A descriptive cross sectional study was conducted to determine the prevalence of domestic violence among ever married females presenting to out patient clinics in Ain Shams university hospitals and to identify factors affecting it. Out of a total number of 509 women, 89.8% had experienced one or more episodes of violent behavior by their husbands of which 56%, 88.4% and 47.9% suffered physical, control and threat violence. Both univariate and multivariate analysis was done. The most common form of violence among the study group was husband's shouting followed by being kept short of money. About 34.2% had been beaten by their husbands and 17.1% were forced to do sex. Using multiple logistic regression it was found that smoking husband and economic problems were independent significant factors associated with all forms of violence. Suffering violence was significantly associated with different forms of health complaints and only 9.1% had been asked by their doctors on domestic violence exposure. This proposes the importance of effective screening, diagnosis and management of domestic violence victims.

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.

Effect of maternal diabetes and hypercholesterolemia on fetal liver of albino Wistar rats.

OBJECTIVE: The aim of this study was to predict the development of hepatic lesions and impairment of function during the development of fetuses (13-, 15-, 17-, and 19-d-old embryos) of diabetic and hypercholesterolemic mothers. METHODS: Eighty virgin and fertile male rats (one male/three females) of Wistar strain with an average body weight of 150 to 180 g were used. Mating was carried out, and pregnancy was determined by examining sperm in vaginal smears. Pregnant rats were arranged into three groups; control, diabetic (single intraperitoneal injection [i.p.] of 60 mg streptozotocin/kg) and hypercholesterolemic groups (fed on a diet containing 3% cholesterol for 6 wk before conception and throughout gestation) (n = 20). Pregnant rats were sacrificed and 13-, 15-, 17-, and 19-d-old embryos and livers were incised and subjected to histological and transmission electronic microscopical (TEM) investigations, assessments of alkaline phosphatase (Al-Pase) isoenzymes electrophoresis, DNA fragmentation, and comet assay. Flow cytometric analysis of apoptosis and caspases 3 and 9 in the livers of mother rats and their 19-d-old fetuses was determined. RESULTS: Histologic findings of diabetic and hypercholesterolemic mothers revealed apparent damage of hepatocytes, accumulation of lipid-laden cells, and vascular steatosis, while the 13-, 15-, 17- or 19-d-old fetuses of either diabetic or hypercholesterolemic mothers revealed disorganized hepatic architecture and massive cell damage. TEM of diseased mothers and their fetuses possessed increased incidence of pyknotic hepatocytes with massive vesicuolation of rough endoplasmic reticulum and degeneration of mitochondria. Al-Pase isoenzymes were altered and genomic DNA of both double and single helical structures were markedly damaged, especially in fetuses of maternally diabetic and hypercholesterolemic mothers. Flow cytometry revealed an increase in apoptosis and caspases 3 and 9 in diabetic and hypercholesterolemic mothers and their 19-d-old fetuses. CONCLUSION: These results suggested that maternal diabetes and hypercholesterolemia predicted early hepatitis and increased apoptosis in mothers and their fetuses as a result of oxidative stress and elevated apoptic markers caspases 3 and 9.

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.

Cardiomyopathy and angiogenesis defects of Wistar rat fetuses of diabetic and hypercholesterolemic mothers.

OBJECTIVE: We aimed to illustrate the histogenesis, lactic dehydrogenase isoenzymes electrophoresis, and DNA damage of cardiac muscles and blood vessels during prenatal life of maternal diabetic or hypercholesterolemic mother. METHODS: Eighty fertile male and virgin female Wistar rats (1 male/3 females), weighing approximately 130 g, were mated and zero date of gestation was determined. Diabetes was induced at the fifth day of gestation by intraperitoneal injection of a single dose of 60 mg streptozotocin/kg body weight in citrate buffer, pH 4.6. At the same time, hypercholesterolemia was carried out by feeding virgin rats a diet containing 3% cholesterol for 6 wk before the onset of conception. Pregnant rats were arranged into three groups: control, diabetic, and hypercholesterolemic (n = 20). The animals were sacrificed and embryos were separated at 7-, 13-, 15-, 17-, and 19 d old, respectively, and subjected to light and transmission electron microscopy, lactic dehydrogenases isoenzymes electrophoresis, DNA fragmentation, and comet assay. The sera of the mothers were examined for fasting glucose level, total cholesterol, triglycerides, low-density lipoprotein, high-density lipoprotein, and creatine phosphokinase levels. RESULTS: Diabetic and hypercholesterolemic mothers exhibited a significant increase of sera cholesterol level, low-density lipoprotein, and creatine phosphokinase activity. Histologic findings of embryos of diabetic and hypercholesterolemic mothers revealed cardiomyopathy and malformation of blood vessels with an apparent degeneration of their endothelium. Transmission electron microscopy possessed massive necrosis of muscle fibers, disorganization of Z and I bands, and mitochondrial damage. Lactic dehydrogenase isoenzyme electrophoresis was altered and genomic DNA fragmentation was markedly increased. CONCLUSION: Maternal diabetes or hypercholesterolemia led to marked alterations in blood vessel differentiation as well as to cardiomyopathy during prenatal growth as assessed by the disruption of fine structures, abnormal lactic dehydrogenase isoenzymes electrophoresis, and an increase of DNA damage. These may be attributed to the marked oxidative stress and liberation of free oxygen radicals, which interrupted the myocardium structure and function during organogenesis.

Protective effects of Allium sativum against defects of hypercholesterolemia on pregnant rats and their offspring.

Sixty fertile female and male albino rats of Wistar strain (I male/ 3 females) were used in the present study. The females were divided into four groups of ten rats each. Group 1 received water and standard feeds for thirty-four days. Group 2 was fed with a cholesterol-containing diet (1%) for two weeks prior to onset of gestation and maintained administration till parturition, produce atherosclerosis (34 days). Group 3 received intragastric administration of 100mg homogenate of garlic (Allium sativum)/kg body weight for three weeks prior to onset of gestation as well as throughout the gestation period. Group 4 intragastrically administered garlic for one week of group B and maintained with combined garlic-treatment for the mentioned period. At parturition, the pregnant were sacrificed and serum total cholesterol (TCL), triglycerides (TG), HDL, LDL and creatine kinase activity (CK) were determined. The total numbers of offspring were recorded and examined morphological for congenital abnormalities. Biopsies of heart and dorsal aorta of both pregnant and their offspring (1 day-age) were processed for investigation at light and transmission electron microscopy. The skeleton of the newborn of different experimental groups were stained with alizarin red s and mor-phometric assessment of mandibular and appendicular bone length. The study revealed that the myocardium of atherosclerotic mother exhibited leuhkocytic inflammatory cell infiltration associated with necrosis, eosinophilia of myocardiai fibers, and edema of blood vessels. Ultrastructural studies revealed swelling of mitochondria, disruption of cristae in the myocardiai muscle fibers. The dorsal aorta possessed accumulation of extra-cellular lipid in intima lining of endothelium. The collagenous fibrils in the tunica adventitia became fragile and loosely separated from each other. Numerous foamy lipid loaden cells were detected within the tunica intima causing deterioration of the elastic fibers, resulting in fibrinoid necrosis. Oral supplementation with Allium sativum (100 mg/ kg) ameliorated these effects in myocardium muscle of mothers and offspring; however the dorsal aorta of mothers showed partial amelioration. Hypercholesterolemic mothers exhibited marked alterations in serum TCL, TG, LDL and CK activity. Supplementation with Allium sativum ameliorated the drastic biochemical alterations. Concerning pregnancy, hypercholesterolemia increased the incidence of abortion and abnormalities of the newborn including decreased body weight, reduced ossification of axial (mandible) and appendicular bones. All these effects were markedly ameliorated by supplementation with Allium sativum. The author finally concluded that hypercholesterolemia exhibits pathological alterations of myocardiai muscles reducing its optimal capacity for pumping blood to different body organs along with atherosclerosis of dorsal aorta which intern affect the progress of gestation and development of both morphological and skeletal abnormalities. Allium sativum-supplementation leads to amelioration of both mother and their offspring investigated parameters as a result of its antioxidant activity.

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.