HCV Genotype 4 in EAST AFRICA
Francis SsaliSite Investigator, Joint Clinical Research Centre, Kampala,
Uganda
Valsa Madhava et al, The Lancet Infectious Diseases 2002; 2:293-302
General population HCV prevalence by country and region in Sub-Sahara Africa
This data was based on small studies, with mostly screening data of limited reliability
HCV Diagnostic pitfalls in East Africa
• There a discordance or variability in the results of the available testing methods
• Which tests to use (Kits) ?– In what Algorithm?
• Limited generalizability of the current prevalence data.
Screening of blood Bank Samples for HCV in Kampala, 1999
• 2592 blood donors (82% male) screened by EIA and and confirmed with RIBA HCV tests:– 107(4.1%) HCV EIA positive
15(0.6%) RIBA positive (overall)
47(44%) of 107 RIBA Indeterminate 45(42%) RIBA Negative
Hladik W. et al Tropical Medicine and International Health. 2006;11(6):951–954
HCV among pregnant women in Rwanda & Uganda,2001-2002
• Retrospective testing for HBV & HCV on Baseline samples from 247 HIV+ of 413 pregnant women in the SIMBA(Stopping Infection from Mother-to-child via Breastfeeding in Africa)
– 165 from Kampala, Uganda and 82 from Kigali, Rwanda
– HCV screening by 4th generation EIA (Innogenetics, Gent, Belgium) and positive samples were retested with a second EIA(Ortho-Clinical Diagnostics, Raritan,NJ)
Pirillo Maria F. et al, Journal of Medical Virology,2007;79:1797–1801
HCV prevalence In The SIMBA StudyHCV (n=247) HBV (n=266)
Kigali 4.9% 4.1% Kampala 0.6% 4.9%Overall prevalence
2.1%(95%CI=0.3-3.9)
4.1% (95%CI=1.7-6.8)
Viral hepatitis present in 6%
Comment:• The Initial HCV screening test kit is based antigens
derived from genotype 1a, 1b,2 & 3a• Potential for underestimate Genotype 4• Sera from 5 of 8 initially HCV positive were
positive on the second EIA.
HCV & IVDU in Nairobi, Kenya, 2000Anti HCV Positive Anti HIV 1
n (%) P Value n (%) P Value
Male (n=314)
61 19.4 0.0352 63 20 0.0005
Female (n=19)
8 42.1 11 57.9
• 74 (22.2%) of 333 Samples were Anti-HCV positive.– 38 (52.2%) of 69 Anti-HCV+ samples were HCV RNA PCR+
• 7 (27%)were Genotype 4• 19(73%) were Genotype 1a
T. Muasya, East African Medical Journal, 2008;85(7):318-325.
T. Muasya, East African Medical Journal, 2008;85(7):318-325.
Kenya Genotype1a Isolates
Kenya Genotype 4 Isolates
HCV in Nairobi, UVDUs
Viral Hepatitis Among 167 HIV Positive Children in Dar es Salaam, Tanzania
Safila P Telatela et al, BMC Public Health. 2007; 7: 338.
Overall HCV prevalence = 13.6%
HCV in Tanzania Children, Muhimbili Dar es Salaam
• Post transfusion HCV in Tanzania children aged 15-59 months
• Over all prevalence = 7.1%
• No increase risk of Paediatric HCV due to blood transfusion
HCV Serology Transfused No past Transfusion
Positive 5 (5.4%) 8 (8.6%)Negative 87 84
Total (n) 92 92
Kitundu J. et al Annals of Tropical Paediatrics2001;21(4):343-348
HCV results from Rural SW Tanzania.(Lugalawa Study)
General Population screened
• n=750
Number testing Positive by Elisa • 78 (10.4%)
Positive by RIBA
• 15 (2%)
Positive by RNA-PCR • 2 (0.2%)
Puato M. et al, Digestive and Liver Disease2007;39:891–892
? Favorable outcome or variable diagnostic specificity? Denaturation of Nucleic acids in Sample storage & Transportation
HIV Pos HCV Pos HCV+HIV Pos HBV Pos0
5
10
15
20
25
30
Prevalence of HCV, HIV & HBV Among MSMs in Zanzibar , 2007
% MSM IVDU(n=66)
% MSM Non IVDU (n=443)
% P
reva
lenc
e
P<0.05
L.G. Johnston et al. International Journal of Drug Policy 2010;21:485–492
P<0.001
Prevalence of HCV, HIV, HBV among 408 IVDUs in Zanzibar, 2012
Series10
5
10
15
20
25
30
11.3 25.4 5.9
Prevalence of HCV, HIV & HBV
HIV HCV HBV
%
Khatib A. et al. IAS, 2013 e-Poster TUPE339
All HIV All HCV All HBV0
5
10
15
20
25
30Hepatitis & HIV Co-infection
HBV & HCV only
HBV & HIV Only
HBV Only
HBV & HCV & HIV
HIV Only
HCV & HIV Only
HCV Only
HCV In Kampala, Uganda, 2008
• 500 hospitalized patients HIV positive and HIV- Negative (1:1) at Mulago Hospital
• Anti-HCV + Samples re-tested with HCV PCR– Overall HCV prevalence(Anti-HCV) of 13/500 (2.6%)– Only 3(23%) of the 13 Anti-HCV+ samples were
positive by RNA PCR.– No difference in HCV prevalence between HIV+ and
HIV- groups.– Age > 50 was the only significant risk factor.
O’Reill, J. I. et al Journal of Tropical Medicine, 2011. doi:10.1155/2011/598341
HCV Testing among Hospitalized patients in Kampala, Uganda, 2006
Seremba E. et al, Journal of Medical Virology,2010;82:1371-1378
• 380 (55.5% female) consecutive acute medical admissions(Median age 38yrs, Range 13-87yrs) screened for:
1. Anti HCV– Rapid Strip Assay (RSA)– Enzyme Immuno Assay(3rd Generation EIA)– Recombinant Immunoblot Assay(RIBA)
– Positive samples were tested for serum RNA– Nucleic Acid testing (NAT)
Reduced reliability of the HCV Screening Tests in Kampala
Seremba E. et al, Journal of Medical Virology,2010;82:1371-1378
• 14 (29.2%) of 48 Positive Screen (Anti HCV) samples were positive by RNA PCR.
• HIV positivity was associated with a higher rate of False positive HCV EIA.
Reliability of HCV Screening in Kampala…
– 12 ( 25%) of 48 Positive Anti HCV but PCR negative possibly had past infection that was no longer active
– RSA was falsely negative in 7 (50%) of 14 Positive samples by HCV-RNA
– EIA falsely negative in 4 (28.6%) of 14 HCV-RNA Positive samples.
– HCV genotyping done on 11 samples:• All were Genotype - 1a
Seremba E. et al, Journal of Medical Virology,2010;82:1371-1378
Why is there a high rate of False HCV test results in the East African Studies ?
• Background Flavivirus infections (e.g. West Nile Virus) , Recent Influenza vaccination & Autoimmune diseases?– Not evident in the Mulago Hospital, Kampala Samples.
• HIV Infection ?– was associated with a higher rate of false positive
HCV EIA, in Mulago Hospital Kampala• Insufficient Primer homology to adequately
detect HCV-RNA in East African Isolates?• Suboptimal Storage and shipping conditions?
Seremba E. et al, Journal of Medical Virology,2010;82:1371-1378
HCV genotype-4 in Uganda, Rwanda
Kato Kitondwe, Makerere University, (MSc Dissertation) 2011
• HCV RNA testing and Genotyping done on previously stored HCV EIA positive (151 of 2900) samples at the UVRI, Entebbe, for an East African population Hematology -normal range study, 2008 (Stevens).
Site EIA Used Number of Positive Number of Negative TotalKigali, Rwanda
Murex anti HCV Version 4.0 (Abbot) 13 2 15
Entebbe, Uganda
Innotest HCV Ab IV (Innogenetics) 10 1 11
Masaka, Uganda
Innotest HCV Ab IV (Innogenetics) 98 10 108
Kilifi, Kenya Innotest HCV Ab IV (Innogenetics) 30 3 33
Total 151 16 167
HCV genotype-4 in Uganda, Rwanda (Samples from UVRI)…
• Negative controls were from the same study population
• Only 9 of 151 had positive PCR• Viral load range 19 – 1,058,000 U/ml.
• All the 9 isolates were Genotype 4
Kato Kitondwe, Makerere University, (MSc Dissertation) 2011
Phylogenetic analysis of HCV Isolates from Rwanda and Uganda (n=9)
Kato Kitondwe, Makerere University, (MSc Dissertation) 2011
Uganda Isolates
HCV Clinical Cases. Two examples in Kampala, Uganda
• There is low clinical awareness and the diagnosis is often missed
CASE1• 42yr Female seen at JCRC in June 2013 with Jaundice
and a palpable spleen. – Labs:
• ALT 13.2 u/L(NR <40), AST 15.5u/L(NR<40) T.Bili 2.38mg/dl(NR<1). Malaria Smear negative. Hb 7.1g/dl, Plts141x103/μL
• HBSAg+, HBV-Anticore IgG+, Anti HCV+, HIV-Negative
– No further HCV tests done for reasons of cost.– Awaiting further HBV evaluation
CASE 2• 39yr Male seen Nov.2012 with 4mths of RUQ-
Abdominal pain. No physical exam signs. BMI 25.4– Labs:
• ALT 26, AST 19, T. Bilirubin 17.8μmol/L(NR<17)• HBSAg-Negative, HCV Elisa Positive• HCV RNA 185,252 U/ml (Taqman) (Jan 2013)• Genotype 4 (Lancet Lab, SA)
– Liver Biopsy:• Focal partial chronic inflammation limited to portal triads• No Steatosis /Necrosis/ Fibrosis.
Case 2 (cont)
• CASE 2 Continued– March 2013. Pegasys 180μg SC. Weekly + Ribavirine
600mg p.o. BID – Missed Wk4 VL (for reasons of cost)– Wk12 VL =Undetectable (<15 U, Taqman). • Complete Early Virologic Response
– Awaiting Wk 24 VL– Question:• Continue to 36 or 48 Wks of therapy?
Concluding Remarks
• There is considerable variability in the overall prevalence of HCV in East Africa, with higher rates emerging in special populations.
• There is need to have more reliable HCV testing methods.
• Genotype 4 and perhaps genotype 1 appear to be the dominant HCV infections.
• There is a paucity of HCV treatment outcome data in East Africa.
Top Related