Conceived and designed the experiments: NSE CR MEH AF MKM. Performed the experiments: NSE SI HM SEA. Analyzed the data: NSE CR MEH AF. Contributed reagents/materials/analysis tools: SEK MAH. Wrote the paper: NSE MKM. Consultant clinician for the clinical trial: GE SP.
The authors have declared that no competing interests exist.
The aim of this study was to estimate the proportion of spontaneous viral clearance (SVC) after symptomatic acute hepatitis C and to evaluate the efficacy of 12 weeks of pegylated interferon alfa-2a in patients who did not clear the virus spontaneously.
Patients with symptomatic acute hepatitis C were recruited from two “fever hospitals” in Cairo, Egypt. Patients still viremic three months after the onset of symptoms were considered for treatment with 12 weeks of pegylated interferon alfa-2a (180 µg/week).
Between May 2002 and February 2006, 2243 adult patients with acute hepatitis were enrolled in the study. The SVC rate among 117 patients with acute hepatitis C was 33.8% (95%CI [25.9%–43.2%]) at three months and 41.5% (95%CI [33.0%–51.2%]) at six months. The sustained virological response (SVR) rate among the 17 patients who started treatment 4–6 months after onset of symptoms was 15/17 = 88.2% (95%CI [63.6%–98.5%]).
Spontaneous viral clearance was high (41.5% six months after the onset of symptoms) in this population with symptomatic acute hepatitis C. Allowing time for spontaneous clearance should be considered before treatment is initiated for symptomatic acute hepatitis C.
Management of acute hepatitis C is a complex issue. While studies have shown that treatment during the acute phase can achieve high (72%–98%) success rates
In Egypt, the epidemiological situation differs from that of Western countries. HCV prevalence is very high (estimated among adults at 10 and 20% in urban and rural areas respectively)
Among these patients, waiting for spontaneous clearance and treating only those still viremic three months after the onset of symptoms makes sense for two reasons: the higher rate of spontaneous clearance expected from patients with symptomatic compared to asymptomatic forms of acute hepatitis C (estimated at 31% versus 18%, respectively, 17); and the cost savings incurred by not treating all patients, an important consideration in countries with limited resources, including Egypt. In this paper, we present the results of the follow-up of 117 patients diagnosed with symptomatic acute hepatitis C in Cairo. Patients who failed to clear the virus three months after the onset of symptoms were considered for treatment with 12 weeks of pegylated interferon alfa-2a.
The recruitment of patients with symptomatic acute hepatitis C has already been described in our previous report of a pilot study performed in 2002 in Cairo
All patients were interviewed by trained medical doctors, using a questionnaire on socio-demographic characteristics and risk factors for HCV infection in the past six months. Risk factors were categorized as high risk and low risk exposures based on the magnitude of the associations with HCV transmission documented in previous studies
A 10 ml venous blood sample was collected for liver functions [ALT, aspartate aminotransferase (AST), total and indirect bilirubin, alkaline phosphatase], and exclusion of acute hepatitis A and B by serological analysis [IgM anti-hepatitis A virus (HAV) (HAVAB®, M EIA, Abbott Laboratories, Diagnostics Division, Abbott Park, IL); IgM anti-hepatitis B virus (HBV) core (CORZYME®, M rDNA, Abbott Laboratories, Diagnostics Division); hepatitis B surface antigen (AUSZYME MONOCLONAL®, third generation EIA, Abbott laboratories, Diagnostics Division, Abbott Park, IL)]. In patients with non-A non-B hepatitis, anti-HCV antibodies were assessed serologically (INNOTEST® HCV Ab IV, Innogenetics, Ghent, Belgium), and HCV RNA Extraction was performed using QIAmp Viral RNA Kit (QIAGEN, Santa Clarita, U.S.A.) according to manufacturer's recommendations. The Reverse Transcription and Polymerase Chain Reaction (RT-PCR) was done according to Abdel-Hamid et al, 1997
In patients with positive HCV antibodies and RNA, exacerbation of chronic hepatitis C by other infectious agents was ruled out using reverse transcriptase PCR for HEV-RNA (in house assay using ORF1 and ORF2 primers) and serological testing [anti Epstein-Barr virus (EBV) IgM (ETI-EBV-M reverse P001605, Dia Sorin, Vercelle, Italy), anti-cytomegalovirus (CMV) IgM (AXSYM® system-CMV-IgM, Abbott Laboratories, Wiesbaden, Delknheim, Germany), and anti-Toxoplasma IgM (AXSYM® system-Toxo-IgM, Abbott Laboratories, Wiesbaden, Delknheim, Germany)]. All tests were performed at the Viral Reference Hepatology Laboratory (VHRL).
The diagnosis of acute hepatitis C was based on epidemiological findings, clinical examination, and laboratory test results. Accordingly, patients were categorized as
All patients with acute hepatitis C were offered follow-up at the National Hepatology and Tropical Medicine Research Institute (NHTMRI) in Cairo. Visits were scheduled for clinical and biochemical assessment at 2, 3, 6, 12, 18 and 24 months, calculated from onset of symptoms. Antiviral treatment was not offered immediately in order to allow for spontaneous clearance of the virus; however, non-specific symptomatic treatment, such as antiemetics for nausea and vomiting, antipyretics for fever and analgesics for headache, were offered to all patients. Patients who were still HCV RNA positive three months after the onset of symptoms were screened for treatment eligibility. Exclusion criteria for treatment were age <18 years or >65 years; poorly controlled diabetes; thyroid disease (TSH outside the normal range); autoimmune diseases; alcoholism; liver cirrhosis; hepatocellular carcinoma; psychiatric disease such as history of severe depression, psychosis, suicidal ideas; epilepsy; non-stabilized medical or surgical condition; hemoglobin<11 g/dl, leucocytes <3000/µL, polynuclear neutrophils <1500/µL, platelets <100 000/µL, and blood creatinin >150 µmol/L. For females: pregnancy or breastfeeding were contra-indications (an effective contraception was requested during the treatment period).
Treatment with free pegylated interferon [PEG-IFNα-2a (PEGASYS®, Roche)] (180 µg/week) for 12 weeks was started 4–6 months after onset of symptoms in those still positive at that date, provided there were no contraindications. Injections were provided at the NHTMRI clinic under medical supervision. In patients still HCV RNA positive after 12 weeks of treatment, treatment was extended for another 12 weeks. Patients were seen weekly during the treatment period, and every six weeks afterwards until week 36 (end of follow-up for those treated for 12 weeks), or week 48 (end of follow-up for those treated for 24 weeks). The dosage of PEG-IFN α-2a was reduced for two weeks to 90 µg/week if neutrophil or platelet counts fell below 750/µL and 50,000/µL, respectively. After the 2 weeks, dose was raised back to 180 µg/week if neutrophil and platelet counts went above 750/µL and 50,000/µL, respectively. Treatment was discontinued if neutrophil or platelet counts fell below 500/µL and 25000/µL, respectively, or when serum hemoglobin concentrations decreased below 8.5 g/dL. Doctors' judgment was the basis for dose reduction and discontinuation of PEG-IFN α-2a if other commonly reported adverse events (such as flu-like symptoms and emotional side effects) were reported. The primary endpoint was sustained virological response (SVR), defined as negative serum HCV RNA 24 weeks after the end of treatment. Secondary endpoints were the absence of detectable levels of serum HCV RNA at the end of treatment and the normalization of ALT levels. Viral load was determined using the Cobas Amplicor HCV Monitor test, v 2.0 (Roche Diagnostic Systems).
All patients with acute hepatitis consulting or hospitalized in the two participating hospitals were included in the study after providing a written informed consent. A separate informed consent was required for the patients who were treated with pegylated interferon. The entire study protocol has obtained clearance from the Ministry of Health and Population in Egypt, and the Institutional Review Board for Human Subject Research at NHTMRI. The 12-week pegylated interferon trial protocol for patients with acute hepatitis C has been registered under the following number: NCT00158522 (ANRS1213).
Spontaneous viral clearance (SVC) was defined as no HCV RNA in serum, in the absence of treatment, for two consecutive HCV PCR tests during follow-up. Patients treated with pegylated interferon were censored at the time of treatment initiation. Date of clearance was chosen as the midpoint between the last positive PCR and the first negative PCR defining clearance. The SVC rate was estimated using Kaplan-Meier estimates, with time 0 equivalent to onset of symptoms. A Cox proportional hazards model was used to identify factors associated with SVC. Factors with p values less than 0.25 in univariate analysis were tested in the multivariate model, and p values less than 0.05 were considered significant. Statistical analyses were performed using Stata 8 statistical software (Stata Corporation, College Station, Texas, USA).
Between May 2002 and February 2006, 2243 consecutive adult patients with acute hepatitis were recruited from Abbassia and Imbaba Fever Hospitals. Of these, 647 (28.8%) were diagnosed with acute hepatitis A, 609 (27.2%) were diagnosed with acute hepatitis B, and 401 (17.9%) tested positive for HCV RNA by PCR. Of the patients positive for HCV RNA, those with negative HCV antibodies (n = 79; 3.5% of the initial 2243 patients) were considered as definite acute hepatitis C. Of the 322 with positive HCV antibodies, 114 had ALT levels lower than 10 times ULN, and were therefore no longer considered potential acute hepatitis C cases. Full assessment to determine final status (serologies/PCR; see Patients and
Follow-up data were available for 117 (73.1%) of the 160 patients with acute hepatitis C.
Characteristics | Completed Study (n = 117) | Lost to Follow up (n = 43) | P-value | |
≤35 years | 69 (59.0) | 29 (67.4) | 0.33 | |
>35 years | 48 (41.0) | 14 (32.6) | ||
Female | 48 (41.0) | 19 (44.2) | 0.75 | |
Male | 69 (59.0) | 24 (55.8) | ||
Urban | 89 (78.1) | 35 (81.4) | 0.65 | |
Rural | 25 (21.9 ) | 8 (18.6) | ||
Missing | 3 | 0 | ||
Ever married | 86 (73.5) | 26 (60.5) | 0.14 | |
Never married | 31 (26.5) | 17 (39.5) | ||
Illiterate | 46 (40.4) | 17 (39.5) | 0.14 | |
Read and write | 39 (34.2 ) | 9 (21.0) | ||
Formal education | 29 (25.4) | 17 (39.5) | ||
Missing | 3 | 0 | ||
Skilled labour | 13 (11.3) | 6 (14.0) | 0.21 | |
Unskilled labour | 61 (53.0 ) | 16 (37.2) | ||
Not working | 41 (35.7) | 21 (48.8) | ||
Missing | 2 | 0 | ||
Yes | 41 (35.0) | 16 (37.2) | 0.91 | |
No | 76 (65.0) | 27 (62.8) | ||
Yes | 113 (96.6) | 42 (97.7) | 0.81 | |
No | 4 (3.4) | 1 (2.30) | ||
Median (IQR) ALT (IU/L) | 684 (515–904) | 510 (299–650) | 0.001 |
|
Median (IQR) total bilirubin (mg/dl) | 7.2 (3.8–10.9) |
9.1 (4.7–11.8) | 0.29 |
Patients with probable acute hepatitis C were all in the group with follow-up since ascertainment of cases required follow-up to perform additional serological and PCR investigations (see Patients and
Two missing values for bilirubin
In total, 51 patients spontaneously cleared the virus, with the following Kaplan-Meier estimates (95% CI) at specific points during the follow-up period: 33.8% (25.9%–43.2%) at 3 months, 41.5% (33.0%–51.2%) at 6 months, 44.0% (35.2%–53.9%) at 12 months, 45.5% (36.5%–55.6%) at 18 months, and 47.3% (38.0%–57.6%) at 24 months (
Characteristics | SVC (n = 51) | Person-months | Crude HR (95%CI) | P-value | |
≤35 | 31 | 652 | 1.00 | 0.47 | |
>35 | 20 | 542 | 0.81 (0.46–1.43) | ||
Female | 21 | 527 | 1.00 | 0.80 | |
Male | 30 | 667 | 1.07 (0.61–1.88) | ||
No | 33 | 767 | 1 | 0.96 | |
Yes | 18 | 427 | 0.99 (0.55–1.75 ) | ||
No | 1 | 28 | 1 | 0.96 | |
Yes | 50 | 1166 | 1.05 (0.14–7.63) | ||
≤median |
23 | 616 | 1 | 0.26 | |
>median |
28 | 578 | 1.37 (0.79–2.39) | ||
≤median |
25 | 546 | 1 | 0.81 | |
>median |
25 | 647 | 0.93 (0.54–1.63) | ||
Medical | 31 | 804 | 1.00 | 0.69 | |
Dental | 3 | 75 | 1.51 (0.46–4.96) | ||
IVDU | 4 | 90 | 1.22 (0.43–3.46) | ||
Low risk | 11 | 168 | 1.61 (0.81–3.22) | ||
Unknown | 2 | 57 | 0.79 (0.19–3.31) |
Median ALT was 684 IU/L; median bilirubin was 7.2 mg/dl (two missing values for bilirubin).
Medical procedures included surgery, blood transfusion, hemodialysis, biopsy, endoscopy, Caesarean section, episiotomy, uterine curettage, injection, infusion, catheter, sclerotherapy of varicose veins. Low risk exposures included acupuncture, shaving at barber, tattooing, pedicure, manicure, and circumcision.
From the 77 patients still HCV RNA positive three months after the onset of symptoms, 17 were treated with pegylated interferon. Sixty patients were not treated for the following reasons: 16 had negative HCV RNA by PCR during the screening period (7 who definitely cleared the virus and 9 who turned positive again during follow-up), 14 had medical contra-indications to treatment, 20 did not show up at the pre-treatment screening visit but re-appeared at subsequent follow-up visits more than six months after the onset of symptoms, 6 were definitely lost to follow-up, and 4 refused treatment. Seventeen patients started treatment with pegylated interferon. Their baseline characteristics are summarized in
Characteristics | |
Age (in years), median (IQR) | 31 (27–38) |
Males, n (%) | 12 (70.6) |
Weight (in kilos) , median (IQR) | 85 (68–93) |
Duration between onset of symptoms and treatment (in months), median (IQR) | 5.2 (4.3–6.2) |
HCV genotype, n | |
4a | 11 |
1 | 1 |
untypable | 1 |
missing | 4 |
ALT at treatment initiation (in IU/L), median (IQR) | 85 (36–155) |
Viral load at treatment initiation (in IU/mL), median (IQR) | 74400 (7900, 444000) |
Between May 2002 and February 2006, approximately 7% of adult patients presenting with acute hepatitis in two hospitals of Cairo had acute hepatitis C. In absolute numbers, around 3 cases per month were diagnosed in these two hospitals during the study period. This figure contrasts with the rarity of acute hepatitis C diagnoses in Western countries. Most patients had recent exposure to invasive medical procedures, half of which were surgical cases, suggesting the need for strict preventive measures to control this source of infection.
In the ensuing cohort of 117 patients with symptomatic acute hepatitis C, 41% had spontaneously cleared the virus six months after onset of symptoms. This figure, found in a patient group infected primarily with HCV genotype 4, is similar to the 41% estimate obtained from a cohort of patients with symptomatic community-acquired acute hepatitis C in Italy whose infecting genotypes were: 1 (42%), 2 (20%), 3 (16%), 4 (2%), and unknown (20%)
One of the crucial issues in acute hepatitis C management is when to treat. While randomized trials comparing different timing of treatment initiation may be the most rigorous approach to the issue, more than 200 patients in each arm would be required to have 80% power to show a 10% difference (e.g., 80% versus 90% SVR rates) between two strategies. Such sample sizes will be difficult to achieve for a rare disease like acute hepatitis C. Descriptive studies like this one may therefore be useful in making educated guesses for patient management until the results of randomized trials are available. In this study of symptomatic acute hepatitis C, 80% of all SVC took place within three months after onset of symptoms (or five months after infection taking into account the two months average duration between infection and symptoms). Thus, waiting for three months after onset of symptoms to treat may be necessary in symptomatic acute hepatitis C to allow SVC to take place. The question arises of whether waiting so long after infection to provide treatment might compromise the response of the patients who will ultimately need it. A study in which treatment with interferon was initiated one year after the onset of symptoms achieved a disappointing 40% SVR rate
In conclusion, this study has documented the high spontaneous clearance rate of symptomatic acute hepatitis C, and shown that 80% of SVC had taken place three months after onset of symptoms. In patients who had not spontaneously cleared the virus by that time, SVR could be obtained in 88.2% with a short 12-week monotherapy with pegylated interferon alfa-2a.
We thank Dr. Yehia A. Abbas, Director of Imbaba Fever Hospital and Dr Yehia Sultan, Director of Abassaia Fever Hospital; Dr. Saad Abdel Monein, Dr. Tarek Lasheen, and Dr. Hamdi Mostafa, clinicians in charge of acute hepatitis patients at the two fever hospitals; Dr. Mohamed Atallah, clinician who examined the patients at NHTMRI clinic; Dr. Faten Osman, Director of the Laboratory at the Abassaia Hospital and her staff; all staff members of the Biochemistry and Hematology Laboratories at the two fever hospitals; Dr. Saeed Aoun, the previous director of the general administration for preventive affairs, and Dr Nasr Elsaid, the Deputy Minister of Health for preventive affairs, for their continuous support to the project.