For clinical diagnosis of patients with signs or symptoms of liver disease CDC recommends testing by using anti-HCV
]. However anti-HCV testing detects the presence of antibodies to the virus, indicating exposure to HCV and cannot distinguish between someone with an active or a previous HCV infection. Before 2004 when CDC developed a case definition for acute hepatitis, all studies searching for HCV infection risk factors were using anti-HCV testing to identify cases, this means that using this case definition might not reflect the accurate risk factors for infection because it is unclear when the patient was exposed. This is the first study to use the case definition developed by CDC in 2004
] to enroll the acute newly infected cases to help identify accurately the true risk factors for HCV infection.
Primary prevention of HCV infection remains the most important strategy to prevent HCV complications. This is particularly important due to absence of vaccine and cost effective medical therapy. The impact of any effort to prevent and control HCV infections relies on accurate epidemiological data, particularly the identification of risk factors associated with new infections. Egypt, like other countries with a similar disease burden, have limited funds to support wide-scale prevention programs. Therefore, targeting and prioritizing prevention activities are essential
Most seroprevalence studies in Egypt suggest community-acquired practices account for the bulk of HCV transmission in Egypt
]. This has lead to considerable investment in communication strategies directed at the public to promote behavior changes to decrease sharing razors and toothbrushes, getting tattoos and other risky behaviors. Identifying current risk factors for ongoing HCV transmission is challenging, as most HCV infections are initially asymptomatic and available assays do not distinguish acute from chronic or resolved infections. The US Centers for Disease Control and Prevention (CDC), in association with the Council of State and Territorial Epidemiologists (CSTE), recently developed a case definition for acute hepatitis C to differentiate between recent infections, old infections and disease exacerbation
]. The publication of this case definition encouraged us to conduct a case control study to explore risk factors for HCV infection among patients meeting the case definition of acute disease. Other methods to identify patients with newly acquired HCV infection include identification of patients who seroconvert from negative to positive anti-HCV antibody. Cohort studies have identified such patients in village-based studies. However, the number of patients is small and the ability to identify risk factors that are generalizable has been limited
The findings from this study highlight the importance of health care exposures as a source of ongoing HCV transmission in Egypt. The findings suggest both outpatient procedures and as well as exposures within the hospital play a role in transmission. The risks in the outpatient settings are apparent, particularly if providers reuse injection equipment e.g. syringes and IV line. Of particular concern is the apparent break in standard precautions during minor procedures such as administration of IV fluids, suturing, and conducting minimal surgeries. This suggests that primary care staff lack the basic skills for using safe procedures such as the use of aseptic techniques, or it could be due to a shortage of supplies. In this study, outpatient dental care was not found to be strongly associated with HCV infection. Population-based or larger case–control studies are needed before any firm conclusions can be inferred regarding the role of dental care and HCV transmission.
The possibility of acquiring acute HCV infections through hospitalization for any cause has been the subject of intense study
], particularly in developing countries. The rapid introduction of new technologies and invasive procedures in settings without well-developed infection control programs provides a unique ecologic niche for HCV transmission
]. This is particularly problematic in countries like Egypt where the prevalence of HCV infection among hospitalized patients is high and minor lapses in standard precautions can expose health care workers and patients to HCV-infected blood or body fluids
In this study, we observed that several invasive procedures were associated with acquiring new HCV infections. Prior studies have identified surgery or invasive medical procedures as main risk factors associated with transmission of HCV infection in developed countries
]. In a case–control study in Italy, Mele et al. identified an invasive procedure within 6 months of acute HCV infection onset in 25% of the patients
The association of HCV infection with endoscopy combined with interventional procedures such as biopsies or scelerotherapy, has also been described
]. In a 1994–1999 study performed by the Italian National Hepatitis Surveillance System
], endoscopy had been performed in 4.6% of the patients with acute HCV infection and the estimated OR for endoscopy was 2.1 (95% CI, 1.2–3.6). This has implications for Egypt, due to the high number of patients with chronic hepatitis from schistosomiasis and chronic hepatitis B requiring endoscopy. Risk of transmission of HCV through endoscopy is easily eliminated when the recommended cleansing, decontamination and sterilization procedures are followed
In addition to exposures in the health care setting, this study also identified injection drug use as an independent risk factor for HCV infection. In the developed world, there is accumulated evidence that injection drug use is the predominant source of new HCV infections over the past few decades which accounts for 68% and 80% of current infections
]. While this study also highlights the role of injecting drug use as a risk factor for HCV infection in Egypt, the percentage of patients reporting injection drug use (23%) is considerably low in comparison to developed countries. Egypt is among the African countries that recently reported experiencing injection drug use. Little information regarding drug use is available in Egypt not only because it is relatively new, but also because of the lack of funds to monitor it in a systematic way
]. This study also found that incarceration six months prior to start of illness was also a risk factor for disease. Further studies are needed to identify the specific source of HCV infection among incarcerated persons.
We did not identify any evidence of occupational or sexual risk factors associated with HCV transmission in Egypt. Numerous studies suggest that HCV transmission through occupational and sexual exposures is inefficient and that these exposures are unlikely to be major sources of new HCV infections, regardless of the population or geographic location
Egypt is now experiencing a wave of HCV-related morbidity with increasing numbers of patients with end stage cirrhosis or hepatocellular carcinoma. The cost of treatment or liver transplantation is a strain on the national health care budget. Many patients are presenting at the peak of their productive lives with considerable impact on their families and community. Preventing ongoing transmission is of paramount importance to the health of future generations. Therefore, national strategies should focus on primary prevention by reducing the numbers of new infections. Ideally, successful treatment of infected patients has the potential to help reduce the incidence of HCV infection by decreasing the reservoir of infected persons who can serve as a source of transmission
]. However, in Egypt the burden of disease is high and the capacity to treat large numbers of patients to reduce viral load is limited. This may reduce the possibility of having a meaningful impact on the reservoir of HCV-infected people in Egypt through treatment regimens.
Limitations of the study include selection of controls from the hospital visitors of the enrolled case patients or other patients in the same hospital; this may lead to selection bias because the cases and controls were not matched by place of residence.