Co-morbidities and Non-B/Non-C Hepatitis Viruses

Tue, Nov 04 - 8:00 AM

 

HIV/HCV Coinfection – General

 

1931. Prospective evaluation by paired liver biopsy of HCV disease progression in patients (pts) co-infected with HIV.  

R. K. Sterling; P. G. Smith; J. Wegelin; M. L. Shiffman; R. T. Stravitz; V. A. Luketic; M. Fuchs; A. J. Sanyal.

Background and Aims:

The natural history of HCV may be accelerated in pts co-infected with HIV. However, most studies have been limited by either retrospective design of a single biopsy and estimated disease duration or part of HCV treatment trials. Consequently, the natural history of HCV disease progression in HIV remains ill defined. To address this, we performed a prospective longitudinal cohort study to define histologic progression of HCV by paired biopsy in pts co-infected with HIV.

 

Methods:

HIV/HCV co-infected pts with paired biopsy were included. Demographic, clinical and laboratory data were obtained at the time of biopsy and at intervening visits every 3-6 months. Liver histology was assessed by Ishak score for inflammation (0-18) and fibrosis (0-6) and for steatosis and cytologic ballooning (Kleiner 2005). AUC between 1st and 2nd LBx normalized per year for continuous variables and categorical variables at baseline were analyzed respectively by correlation and ANOVA for the primary outcomes, a ≥ 2 point increase in fibrosis and change per year in fibrosis and inflammation score.

 

Results:

Of 261 HIV/HCV pts who underwent biopsy, 47 without cirrhosis at baseline had at least 2 paired biopsies. The cohort had a mean(SD)age of 42(8.7)yrs, ALT 103(76) U/L, AST 104(102) U/L, CD4 597(411), 70% male, 77% African American, 95% GT 1, 49% HIV < 400 copies/ml, 83% on HAART and 33% underwent HCV therapy (NR 26%, SVR 6%, and relapse 2%). At baseline, inflammation and fibrosis scores were 6.4(2.5) and 1.5(1.1), respectively and 24% had >5% steatosis. The mean(SD) interval between biopsies was 52(23) months. Between 1st and 2nd biopsy, fibrosis progressed in 32% (19% by 1 point and 12% by ≥ 2 points), remained unchanged in 47%, and improved in 21% (by 1 point in 19%). Inflammation scores increased in > 2 points in 43%, decreased > 2 in 21%, and were within 2 points in 36%. The yearly mean (SD) rate of fibrosis and inflammation progression were 0.132(0.55) and 0.174(1.28) units/yr, respectively. There was no association between disease progression and demographics, CD4, AST or ALT, HAART use including D4T and ddI, response to HCV therapy, baseline FIB-4 or baseline histology including inflammation, fibrosis, or steatosis.

 

Conclusions:

In our coinfected cohort, 12% had a significant (≥ 2 point) increased fibrosis and 43% had increased inflammation over a mean interval of 52 months. Because there were no clinical or laboratory parameters that predicted disease progression, all coinfected pts should be considered for repeat assessment of disease severity by biopsy at periodic intervals in order to identify those who progress.

 


Disease Progression – General

 

1932. Selective up-regulation of interferon-inducible genes and type 1 and type 2 interferons in the brain of patients with hepatitis C and severe depression. 

M. Trippler; K. Truebner; T. Bajanowski; S. Bein; G. Gerken; J. F. Schlaak.

Background:

We have previously identified genes in the peripheral blood of HCV patients that were strongly associated the development of severe depressive side effects during therapy with IFN-α and ribavirin. In addition, we could demonstrate enhanced endogenous IFN production in HCV patients and patients with endogenous depression. This study was performed to validate this data in human brain tissue.

 

Methods:

Gene expression was analyzed in brain specimens from 19 persons who could be divided into three groups. 1. suicide (n=9), 2. fatal drug intoxication (n=5), 3. homocide without evidence of clinical depression prior to death (n=5). The distribution of HCV positive individuals among the three groups was: 3 /2 /1. Brain samples were taken from 4 different brain areas (hippocampus, amygdala, gyrus cinguli, pons) and stored in RNAlater. The brain tissue was homogenized using the TissueRuptor followed by RNA extraction using the RNeasy Lipid Tissue Mini Kit. Gene expression was measured by quantitative real-time PCR and normalized to three housekeeping genes (b-actin, YWHAZ, β2-microglobulin).

 

Results:

As previously found in the peripheral blood, DYNLT1, DISC1, TOR1B, GCH1, ST3GAL5 and MEF2A were detectable at significantly higher levels (2-3 fold, p<0,002) in brain tissue of individuals who committed suicide (group 1) and i.v. drug abusers with fatal drug intoxication (group 2) compared to brain specimens of individuals without evidence of clinical depression (group 3). In group 1 and 2, expression of IFN-α1, -β and –γ but not IFN-α2 was significantly enhanced (2-3 fold, p<0,003) compared to group 3. No significant differences in gene expression could be detected when the different brain areas were compared. Elevated expression of “depression genes” and IFNs in the brain of HCV-positive persons was found despite the absence of detectable HCV-RNA in the brain of these individuals.

 

Conclusions:

This study confirms that the genes that are associated with the development of depressive symptoms during IFN therapy in HCV patients are also relevant for IFN-unrelated depression. The data also suggest that the IFN-system plays a pivotal role in endogenous depression. Thus, these data could lead to the discovery of novel therapeutic approaches to treat IFN-induced and major depressive disorders.

 


HCV Disease Progression – General

 

1935. Prevalence and Predictors of Liver Fibrosis in Hepatitis C (HCV) Infected Hemophilic Men. 

M. Ragni; K. Soadwa; M. A. Nalesnik; Q. Dang.

Introduction:

Hepatitis C infection is the major cause of chronic liver disease and the leading cause of death in hemophilia. Although biopsy-proven liver fibrosis occurred in 20% before the AIDS epidemic, few data exist on current rates of fibrosis in this group, of whom 40% have HIV co-infection which is associated with more rapid HCV disease progression. As liver biopsy is not routinely performed in this group, there is increasing interest in the role of noninvasive predictors of liver fibrosis.

 

Aim:

We, therefore, conducted a prospective, cross-sectional NHLBI-funded multi-center study to determine the prevalence and risk factors for liver fibrosis in HCV(+) hemophilic men. Biopsies were reviewed independently by one pathologist, with fibrosis staging by Ishak, Metavir, and Knodell systems.

 

Methods:

Statistical analyses included Spearman rank correlation, logistic regression, and receiver operating curves (AUROC) for predictors of fibrosis.

 

Results:

Among 777 HCV(+) men enrolled at 34 U.S. centers, 220 (28.3%) underwent liver biopsy, including 91 (41.4%) with HIV co-infection, of whom 86(39.1%) had Ishak fibrosis (score 3-6), which was significantly more common in HIV(+), 44/91(48.3%) than in HIV(-), 42/129 (32.5%), p=0.034, and associated with a higher fibrosis score, 2.4 +/- 0.2(SEM), than in HIV(-), 1.8 +/- 0.2 in HIV(-), p=0.009. Those with significant fibrosis (Ishak 3-6) did not differ from those with minimal/no fibrosis (Ishak 0-2) in age, race, alcohol use, or past interferon/ ribavirin treatment, all p>0.05, and after controlling for HIV, only by age (43.2 vs 39.6 yr, p=0.03). Ishak, Metavir, and Knodell all showed good correlation with AST, AST/platelet ratio (APRI), and ALT in predicting fibrosis, all p<0.001. In the logistic regression model, the best predictors of Ishak fibrosis (3-6) were AST, r=0.304, p<0.001, and APRI score, r=0.302, p<0.001. Both the AST and APRI score, individually, predicted Ishak fibrosis with higher AUROC in HIV(-)than in HIV(+) men, 72.5% vs. 63.4% (AST), and 69.7% vs. 63.6% (APRI), respectively. In HIV(+), the Knodell score showed the best correlation with AST, r=0.326, p=0.002, while in HIV(-), the Metavir score showed best correlation with AST, r=0.380, p<0.001

 

Conclusion:

In conclusion, after 25+ years of HCV infection, nearly 40% of HCV(+) hemophilic men have liver fibrosis. AST and APRI score are potential surrogate markers for predicting liver fibrosis in HCV(+) hemophilic men, but less so in those with HIV/HCV co-infection. The reason for this finding is unknown, but may relate to the effects of HIV infection on liver and bone marrow.

 


Other Hepatitis Viruses

 

1936. A clinicopathological comparison of HIV/Hepatitis B co-infection and Hepatitis B mono-infection in Cape Town, South Africa. 

M. W. Sonderup; H. Wainwright; H. N. Hairwadzi; C. W. Spearman.

Introduction/Aim:

The adult HIV prevalence in South Africa of approximately 12% is one of the highest in the world. This is in a context where hepatitis B virus “HBV” infection is endemic. HBV surface antigen “HBsAg” carriage rate in South Africa is approximately 10%. The prevalence of HIV/HBV co-infection is estimated at between 5% and 17% from previous studies. Contradictory data exists, mostly from developed countries, as to the degree of necroinflammatory activity and fibrosis in the liver of co-infected patients. No such data from patients in developing countries, who acquire HIV in the setting of endemic HBV infection, exists.

 

Methods:

HIV positive patients co-infected with chronic HBV who had previously undergone a liver biopsy were selected. Similarly, a comparative group of patients with chronic HBV mono-infection who previously had also undergone liver biopsy were selected and matched to the co-infected group in terms of age and HBV serological profile. Clinical and demographic data was obtained from patient records and liver biopsies were assessed by a single experienced histopathologist using the Ishak modified Histological Activity Index. Statistical analyses using the paired sample t-test and Wilcoxon rank sum test were performed.

 

Results:

A total of 60 patients, 30 each in the co-infected and mono-infected group were assessed. Median age(years) in the co-infected and mono-infected groups was 34 [23–60] and 29 [17–66] respectively, p = NS. Serologically, both groups were identical. In each group 19(63%) were HBeAg positive and 11(37%) HBeAg negative. In the co-infected group, median CD4 count was 117 [2-1384]. The median HBV viral load (log cps/ml) in the co-infected and mono-infected group was log 7.2[0–9.3] and log 6.9[1.6–8.5] respectively, p = NS. Findings here were similar irrespective of HBeAg status. The median ALT (U/L) at the time of biopsy in the co-infected and mono-infected group was 118 [25-778] and 104 [104-1288] respectively, p = NS. The mean necroinflammatory activity was significantly greater in the co-infected group, 7.6±4.1 vs. 4.6±2.0, P = 0.0002. Similarly, median fibrosis scores were significantly greater in the co-infected group, 3.0[1–6] vs. 1[0–5], p <0.0076.

 

Conclusion:

Hepatitis B related necroinflammatory activity and fibrosis was significantly greater in HIV/HBV co-infected than in HBV mono-infected patients. This was despite advanced immunosuppression in the co-infected group and similar transaminase levels and HBV viral loads in both groups. This finding may predict for a worse long term liver morbidity and mortality outcome in co-infected patients in the setting of endemic HBV infection.

 


HIV/HCV Coinfection – General

 

1937. Increasing CD4 Percentage During Chronic HCV Treatment In An HIV/HCV Integrated Clinical Cohort.  

L. Beauchamps; J. S. Kalpoe; D. Tider; A. Stivala; D. A. Fishbein.

Background:

Absolute CD4 lymphocytes (CD4) have been shown to decrease during HCV treatment in HIV/HCV co-infected persons, yet CD4% is understudied. CD4% has been reported to predict HIV disease progression. Increases in CD4% during HCV treatment may be a more accurate assessment of immune function. We investigated these dynamics during HCV treatment in an on-site HIV/HCV co-infection clinic.

 

Methods:

One-hundred sixty HIV/HCV co-infected patients were enrolled as research participants in an integrated on-site co-infection clinic in New York City from 10/05 to 4/08. HIV and HCV viral loads (VL), CD4 and CD4% were monitored at baseline and at 4, 12, 24, 36 and 48 weeks on HCV treatment with pegylated interferon alpha2a and ribavirin. Absolute CD4 and CD4% were analyzed for change over time. Non-parametric statistical analyses were performed using SPSS, Inc. v. 16.

 

Results:

Twenty three subjects on HCV treatment had a mean age of 49.9 + 8.9; 13(56.5%) were Hispanic, 7(30.4%) black; 15(62%) male; 19(83%) HCV genotype 1; 22(96%) were on HAART; all had an HIV VL < 50. Median CD4 and CD4% at baseline were 524 (170-978) and 27% (12%-40%). CD4 and CD4% during treatment are depicted in Figure 1; HIV VL remained undetectable. Median CD4 decreased during HCV treatment to week 12 (z = -2.2, p = 0.028), and remained unchanged from 12 to 36 weeks; CD4% increased over time (z = 2.4, p = 0.018).

 

Conclusion:

CD4% increased throughout HCV treatment in contrast to absolute CD4, which decreased but then stabilized. This suggests that CD4% may be a preferred marker of HIV progression and may signify improved control over HIV once persons are treated for HCV. Long-term prospective studies are warranted to confirm this observation.

 

 


Extrahepatic Manifestations – General

 

1938. Effect of Rituximab on advanced liver disease in patients with HCV-related mixed cryoglobulinemia.  

A. Petrarca; L. Rigacci; U. Arena; F. Vizzutti; C. Giannini; P. Montalto; A. Bosi; S. Colagrande; P. Romagnoli; G. Laffi; A. Zignego.

Background.

HCV-related mixed cryoglobulinemia (MC) is frequently associated with advanced liver disease as well as with contraindications to antiviral treatment. The effectiveness of B-cell depletion by anti-CD20mAb (Rituximab= RIT) was described, but the possibility of an immunodepression-related increase in viral replication and ALT limits its use in patients with advanced liver disease.

 

Patients.

17 HCV+ patients (5 males, mean age: 67,7 yrs.) with invalidating MC and advanced liver disease who were excluded from antiviral therapy, were treated with RIT (4 weekly infusions of 375 mg/m2) and followed-up for 6 months.

 

Results.

Pre-treatment MC included, in addition to purpura, arthropathy and weakness, sensory-motor polyneuropathy in 15, nephropathy in 2, and leg ulcers in 2 cases. Cirrhosis was class A in 12, class B in 4, and class C in 1 patient (Child-Pugh classification). Five patients showed ascitic decompensation. A consistent improvement of MC symptoms and biohumoral data was evident at the end-of-treatment (EOT) and end-of-follow-up (EOFU). Some modification in mean viral titres (2.52 x106, 2.99 x106 and 2.72 x106 IU/mL at admission, EOT and EOFU, respectively) and in mean ALT values (81.9, 62.95 and 110 IU/L) were observed. Improvement of liver protidosyntetic activity, protrombin time, ascites, and encephalopathy was observed at EOT and EOFU, especially in advanced cases. In patients with Child-Pugh >A, the score improved from C11 to B7, B8 to A6, B7 to A5 and in two cases from B9 to B7, respectively.

 

Conclusions.

This study confirms the effectiveness of RIT in MC and, for the first time, shows its safety also in patients with advanced cirrhosis. This may imply a consistent extension of RIT use in MC with the possibility of its pre-transplantation (pre-LT) use to prevent MC worsening after LT. Moreover, the Rituximab-related depletion of CD20+ B-cells was followed by cirrhosis improvement in spite of a moderate and inconstant increase of both median viraemia and ALT values. The mechanisms involved are unknown. Interesting working hypotheses may implicate the contribution of B-cell infiltrates in conditioning liver damage (direct B-cell hepatotoxicity?). The improvement of Kuppfer cell function due to the cryocrit value reduction might also play a role.

 


Extrahepatic Manifestations – General

 

1941. Marginal zone lymphoma and HCV infection: role of antiviral treatment.  

A. M. Pellicelli; G. Barbaro; V. Zoli; D. Remotti; R. Villani; L. Nosotti; A. Picardi; U. Vespasiani Gentilucci; F. Soccorsi.

Background

The existence of an association between hepatitis C virus infection (HCV) and B cell non-Hodgkin lymphoma (B-NHL) is demonstrated in different reports. HCV infection persists chronically in host tissue and triggers a sustained lymphoid proliferation. Chronic antigen-dependent immune stimulation due to HCV infection can induce the development of a B-NHL over time. In particular, marginal zone lymphoma (MZL), a low grade lymphoma, seems to be strictly correlated to HCV infection and to other infectious agents. We have evaluated the role of antiviral treatment in HCV-associated MZL.

 

Methods

Seven consecutive patients with histologically proven MZL characterized by an indolent course and carring chronic HCV infection were enrolled in the study. All patients underwent antiviral treatment with pegylated interferon (180mcg or 1,5mcg/kg once a week) associated to ribavirin (800-1200 mg orally daily). Antiviral response was evaluated at 6 months (genotype 2) and 12 months (genotype 1) from the beginning of the treatment. A complete hematologic response or partial or no response was evaluated after 6 months from the completion of treatment.

 

Results

Of the seven patients with histologically proven MZL, six (85%) achieved a sustained virological response (SVR) with negative HCV-RNA assay after 6 months from the interruption of antiviral treatment. A complete hematological response was achieved in the six patients with SVR while a partial response was present in the patient non responder to antiviral treatment. All the data are reported in the Table.

 

Conclusion

This study strongly provides a role for antiviral treatment in the patients affected by HCV related low grade lymphoma. In particular, this study confirms the efficacy of antiviral treatment in the antigen dependent low grade lymphoma and confirms that chemotherapy should be reserved to more aggressive lymphoma (high grade lymphoma) in which the role of HCV stimulation could be marginal.

 

Table

Patient n°

Sex/Age

Histology

Stage

Genotype HCV

Treatment

Response to antiviral treatment

Remission of Lymphoma

1

F/68

Marginal extranodal (retro-orbital+BM)

IV

2a/2c

Peg180mcg/wk + ribavirin 800mg/die

SVR

CR

2

F/70

Marginal extranodal (Parotid gland+BM)

IV

2

Peg100mcg/wk + ribavirin 800mg/die

SVR

CR

3

M/22

Marginal splenic (spleen+BM

IV

2

Peg120mcg/wk + ribavirin 800 mg/die

SVR

CR

4

F/69

Marginal extranodal (Parotid gland+BM)

IV

2a

Peg100mcg/wk + ribavirin 800mg/die

SVR

CR

5

F/60

Marginal splenic (spleen+BM

IV

1b

Peg180 mcg/wk + ribavirin1000 mg

SVR

CR

6

F/58

Marginal extranodal (palatine tonsil+BM)

IV

1b

Peg180 mcg/wk + ribavirin1000 mg

SVR

CR

7

F/71

Marginal nodal (nodal+BM)

IV

1b

Peg180 mcg/wk + ribavirin1000 mg

NR

PR

BM= bone marrow, SVR= sustained virological response, NR= not responder, CR= complete response, PR=partial response

 


Diagnostic Tools – Biochemical/Imaging

 

1942. A Prospective Analysis of Fibrotest-Fibrosure (FT) Prognostic Value At 10 Years In Patients With Chronic Hepatitis C (CHC).  

Y. Ngo; M. Munteanu ; D. Messous; F. Charlotte; F. Imbert-Bismut; D. Thabut; P. Lebray; V. Thibault; Y. Benhamou; V. Ratziu; T. Poynard.

Background:

FT was a better predictor than histological staging at liver biopsy (LB) for HCV complications and deaths at 5-year follow-up (1).

 

Aim:

The aim was to compare the 10-year prognostic value of FT and LB for complications and survival in CHC. Methods: The survival time was calculated from the FT date to the first end-point date: complications of the disease (HCV-related death, liver transplantation, decompensation, hemorrage, hepatocellular carcinoma), overall death and HCV-related death. The prognostic values were compared by the areas under the ROC curves (AUROC).

 

Results:

537 prospective CHC patients had same day LB and FT; 157 had severe fibrosis (FT>0.58), 137 moderate fibrosis (FT 0.32-0.58) and 243 no/minimal fibrosis (FT<0.32): mean age 46yrs, 60%male, 85%caucasian, 52%genotype 1 and 9%HIV-coinfected. The prevalences of LB fibrosis stages were 13%F0, 43%F1, 22%F2, 12%F3 and 11%F4. In patients with FT>0.58, survival without HCV complications or HCV-related death was 71.0% (95%CI:63.0-79.1;39 complications or HCV death) significantly lower than in patients with moderate or no fibrosis (Figure 1), and survival without HCV death was 76.5%(66.8-86.2;24 HCV deaths) significantly lower than in patients with moderate or no fibrosis. In patients with FT=0.32-0.58, survivals were 97.0%(93.5-100;3 complications or HCV-death,P<0.0001) and 89.3%(73.6-100; 3 HCV-deaths;P<0.0001) respectively; in patients with FT<0.32, survivals were 99.5%(98.6-100;1 complication;P<0.0001) and 99.5%(98.6-100;1 HCV death ;P<0.0001) respectively. FT was a better predictor than LB for HCV complications or HCV-related death with AUROC(95%CI)=0.91(0.86-0.94) vs 0.77(0.66-0.85), P=0.0006 respectively; and for HCV related-death: 0.75(0.64-0.82) vs 0.56(0.44-0.66), P=0.0002, respectively.

 

Conclusion:

In CHC patients, FT is a surrogate marker of CHC severity with a very significant 10-year prognostic value, better than LB, for severe complications and HCV-related death.(1) Ngo Y et al. Clin Chem 2006;52:1887-96.

 

 


Diagnostic Tools – Biochemical/Imaging

 

1943. The presence of additional diagnoses in patients with chronic hepatitis B and C. Histological evaluation of liver biopsies used for correlation with Transient Elastography in 257 patients. 

C. Verveer; P. E. Zondervan; H. L. Janssen; R. J. de Knegt.

Background:

Transient Elastography (TE) is becoming an important tool to assess and monitor fibrosis in chronic liver disease. However, it remains the question whether qualitative assessment of liver tissue provides sufficient clinical information and whether clinical important diagnoses are missed. We studied the biopsy specimen of patients enrolled in our FibroScan validation study for histological signs of additional liver disease.

 

Methods:

a cohort of 257 patients with chronic viral hepatitis B or C underwent a liver biopsy with concomitant TE. Only biopsies with a minimal length of 25 mm were accepted and evaluated for the presence of an additional diagnosis.

 

Results:

137 patients with chronic viral hepatitis B, 117 with chronic viral hepatitis C and 3 patients with combined chronic viral hepatitis B and C were evaluated. In the majority of patients, 190 (73.9%), no histological signs of an additional diagnosis were present. In 67 (26.1%) patients we found histological abnormalities indicating additional disease. The predominant diagnoses were non-alcoholic steatohepatitis in 46 (17.9%) and non-alcoholic steatosis in 6 (2.3%) patients. In another 15 patients (5.8%) histological abnormalities were found classified as auto-immune hepatitis (3 patients), primary sclerosing cholangitis (1 patient), overlap autoimmune hepatitis/primary sclerosing cholangitis (1 patient), undefined cholangiopathy (1 patient), chronic hepatitis C (2 patients), hepatic granulomas (2 patients) and other (5 patients). In most of these 15 patients, neither clinical symptoms nor additional laboratory tests could confirm the additional diagnoses. However, in two cases the liver biopsy led to findings unknown before (granulomas after previous tuberculosis, and hepatic iron overload with heterozygous beta-thalassemia).

 

Conclusion:

In case TE (FibroScan) replaces the liver biopsy in the evaluation of patients with chronic hepatitis B or C, important additional liver disease might be missed, being non-alcoholic steatohepatitis or hepatic steatosis in the majority of these cases. Therefore a liver biopsy should still be considered in a new patient presenting with chronic hepatitis B or C.

 


HCV Treatment – General

 

1945. Association of Lipid Profiles with Hepatitis C Viral Load in Chronic Hepatitis C Patients with Genotype 1 and 2 Infection. 

C. Hsu; C. Liu; C. Liu; M. Lai; P. Chen; D. Chen; J. Kao.

Aims:

Metabolic profiles are correlated with hepatitis C virus infection and known as predictors of virologic responses in chronic hepatitis C patients with interferon-based treatment. However, the association of lipid profiles with hepatitis C viral load remains largely unknown.

 

Methods:

Five hundred and thirty-one chronic hepatitis C patients infected by HCV genotype 1 or 2 were consecutively enrolled. Univariate and multivariate approaches were used to estimate the associations between demographic, metabolic, viral variables and HCV RNA levels.

 

Results:

Higher serum triglyceride, total cholesterol and LDL correlated with HCV RNA level. In multivariate analysis, female gender, genotype 1 infection, severe hepatic inflammatory activity and higher triglyceride level are associated with higher HCV viral load (P<0.05). Sub-analysis on patients with lower BMI value showed higher HCV viral load was associated with higher total cholesterol and lower HDL level (P<0.05). After stratification by HCV genotype, lipid profiles were significantly associated with HCV viral load in genotype 2 infection (P<0.05), but not with genotype 1 infection.

 

Conclusions:

These data suggest dose-response relationships between serum lipid profiles and hepatitis C viral load in patients with genotype 2 but not in genotype 1 infection. Manipulation of lipid profiles may be beneficial to improve the response to current anti-HCV therapy.

 

Multivariate analysis identifying factors associated with HCV RNA levels in patients with different HCV genotype infection

 

 

Genotype 1 (n=323)

 

 

 

Genotype 2 (n=197)

 

 

Parameter Estimate

Standard Error

P value

 

Parameter Estimate

Standard Error

P value

BMI (kg/m2)

0.0224

0.0119

0.061

Age, years

-0.0092

0.0047

0.049

Sex, (M vs. F)

-0.3761

0.1020

<0.001

GGT, U/L

0.0025

0.0013

0.052

Steatosis

-0.1980

0.0568

0.001

Log10 (Total cholesterol), mg/dL

3.8190

1.5758

0.016

METAVIR activity

0.0931

0.0531

0.081

Log10 (LDL), mg/dL

-1.3180

0.8749

0.134

Log10 (Triglyceride), mg/dL

0.3948

0.2318

0.090

Log10 (HDL), mg/dL

-1.6030

0.7029

0.024

Constant

0.1271

1.1107

0.909

Constant

2.8930

1.6817

0.087

1. Stepwise estimation with backward-selection linear regression model using Log10 (HCV RNA levels) as the dependent variable and genotype, age, sex, body mass index, METAVIR activity, METAVIR fibrosis stage, steatosis, Log10 (WBC), Log10 (PMNs), Log10 (PLT), hemoglobin, Log10 (fasting blood glucose), AST, ALT, GGT, Log10 (Total cholesterol) , Log10 (Triglyceride), Log10 (LDL) and Log10 (HDL) as independent variables. 2. P ≥ 0.2 is the significant level for removal from the model and P <0.1 is the significant level for addition to the model.

 


Extrahepatic Manifestations – General

 

1947. HCV infection and carotid atherosclerosis: evidence in favor of a local viral action inside the plaque. 

M. Boddi; B. Chellini; R. Marcucci; F. Sofi; C. Giannini; L. Gragnani; A. Piluso; D. Prisco; R. Abbate; A. Zignego.

Background.

Infectious pathogens can induce macrophage foam-cell formation and/or potentiate the immune inflammatory reaction underlying atherosclerosis. A link between HCV and increased risk of atherosclerotic disease has been recently suggested. This study was aimed to evaluate the association between HCV infection and carotid atherosclerosis.

 

Methods.

161 patients with atherosclerotic disease, including 31 asymptomatic (normal ALT) anti-HCV+ (17 males, medium age 74±8 yrs ) and 130 age-matched anti-HCV– patients (90 males, 67.6±10 yrs), were evaluated for the status of carotid arteries (number of carotid plaque and carotid intima-media thickness) by high resolution B-mode ultrasonography. The prevalence of both traditional (smoke, hypertension, diabetes, dyslipidemia, family history of premature coronary artery disease (CHD)), and new risk factors for carotid atherosclerosis (fibrinogen, C reactive protein, Lp(a) lipoprotein and homocysteine) was evaluated. The presence of HCV RNA sequences was investigated in the carotid plaque tissue and in the corresponding serum from 10 anti-HCV positive patients who underwent carotid revascularization. HCV RNA (+ and -) sequences were detected by both home-made and Real Time PCR, as previously described. HCV genotype was evaluated in serum or plaque samples by INNO LiPA and/or direct sequencing.

 

Results.

The prevalence of carotid lesions was significantly higher in HCV+ (80.6%) than in HCV- patients (51%, p<0.01). At multivariate regression analysis HCV infection remained as an independent risk factor for carotid atherosclerosis. Aspecific markers of inflammation showed similar pattern in HCV+ and HCV- patients. Interestingly, HCV RNA sequences (+ and -) were detected in the majority (7/10) of plaque tissues, including cases who scored serum HCV RNA negative. The analysis of the HCV sequences detected in the plaque and/or serum samples showed HCV genotype 2 in 5 out of 7 cases.

 

Conclusions.

This study strengthen the possible role of HCV infection in facilitating the occurrence of carotid atherosclerotic lesions, independently of the classic risk factors for atherosclerosis. A finding of special importance was the demonstration of HCV RNA sequences in carotid plaque tissues, even in the absence of serum HCV RNA positivity and systemic markers of inflammation, suggesting that HCV does act by a local action inside the plaque and strengthens the opportunity for further studies investigating the molecular mechanisms involved. These data also suggest that HCV genotype 2, which was previously shown to be more closely associated with lipoproteins, may be also more associated than other genotypes to CHD.

 


Epidemiology – General

 

1950. Epidemiology and genetic analysis of Hepatocellular Carcinoma in Morocco. 

S. Benjelloun; A. Essaid El Feydi; A. Marchio; A. Akil; L. ElKihal; R. Afifi; M. Hassar; M. Benazzouz; S. Ezzikouri; P. Pineau.

Background and Objectives:

The aetiology and molecular pathogenesis of hepatocellular carcinoma (HCC), a tumour characterized by an important molecular heterogeneity throughout the world, remains unclear in Morocco. The aim of this study is to assess the role of hepatitis B virus (HBV), hepatitis C virus (HCV) and to document the genetic processes taking place in liver tumours from Morocco, an intermediate risk area.

 

Methods:

A total 89 patients with HCC and 168 control subjects not affected with hepatic diseases were recruited to analyse the viral aetiology of HCC. Point mutational analysis of three genes (bęta-catenin, p53, KRAS) and loss of heterozygosity (LOH) assay on 13 chromosomes were thus undertaken to identify genetic alterations that may play a role in the development of thirty-four HCC collected in Morocco.

 

Results:

In the present cohort, the main risk factor for HCC, hepatitis C, was present in 59.6 % of cases. 14.7 % of patients were positive for HBsAg and 61.4 % for total anti-HBc. Occult HBV infection was observed in 16 % patients. Diabetes was detected in 11.4 %. Dual infection B and C was observed in 5 HCC cases. Most of anti-HCV positive patients were positive for viral RNA and 3 genotypes were detected (1a, 1b and 2) with predominance of genotype 1b. HCC was associated with cirrhosis in 80% of patients. 13.6 % of HCC patients were negative for the risk factors studied.

 

Moreover, Moroccan HCCs exhibited a mean fractional allelic loss (FAL) of 15% with most frequent LOH affecting chromosomes 1p, 8p and 17p (>25%). The p53 gene was mutated in 20% of samples. Remarkably, p53 mutations were only observed among patients homozygote for Arg72 on p53 gene. Bęta-catenin was infrequently altered (9%). No mutation was observed for KRAS gene. We observed that allelic loss of chromosome 1p was higher in HCC without risk factors (p<0.03) and in younger patients (<52 years old, p<0.006). On the opposite, p53 mutations were more likely in older patients (>60 years old, p<0.05) with bigger tumours (>4cm, p<0.01) and high FAL (>15%, p<0.005).

 

Conclusion:

Diabetes, infection with HCV and HBV are the major risk factors for the development of HCC in Moroccan population. According to our data, the overall molecular profile of HCC in Morocco presents some peculiarities when compared with others countries.

 


Disease Progression – General

 

1951. Diabetes Mellitus is Associated with more Advanced Stage of Liver Fibrosis in Patients with Chronic Hepatitis C Infection. 

M. Sanon; E. Bou Assaf; S. Kirtich; G. Bahtiyar; S. I. McFarlane; A. Aytaman.

Background:

It is estimated that 170 million people worldwide are currently infected with HCV. This epidemic is a major cause of liver cirrhosis and hepatocellular carcinoma. Diabetes mellitus (DM) has also reached epidemic proportions in the USA and worldwide. Despite the increasingly recognized association between these two epidemics, the effect of DM on the stage of liver fibrosis is not well established.

 

Objective:

To evaluate the association of type 2 diabetes with stage of liver fibrosis in patients with HCV.

 

Methods:

We evaluated the interactions between hepatitis C and diabetes mellitus in a cross sectional analysis of 5266 US veterans followed at the NY metropolitan area. We identified the patients with HCV, who underwent liver biopsies between 2000 to 2007. In our database 332 patients had biopsies of whom 303 (91%) had complete data. Among the 303 patients demographic, clinical and laboratory data were collected. All liver biopsies were read by 3 pathologists and reviewed with one hepatopathologist as per routine protocol. Modified Ishak score was used for the degree of fibrosis (0-4).

 

Results:

Of the 303 patients with hepatitis C and liver biopsies mean age (years) was 52.6 ±0.35 (±SEM), BMI was 29.4 ±1.3 Kg/m2 . 40.8% of the patients were white, 42.1% black, 13.8% Hispanic and 1% Asian. Type 2 DM was present in 80 patients (26%). The odds Ratio (OR) for having advanced fibrosis (stage 3 or 4) was 2.27 (1.35 to1.384) (p<0,01). After adjusting for age and BMI, the presence of diabetes continued to confer a higher risk for advanced fibrosis with an OR of 2.16 (1.22 to 3.84) (p<0.002).

 

Conclusions:

Chronic hepatitis C patients with type 2 DM tend to have more advanced liver fibrosis compared to non-diabetics. Further studies are needed to confirm our findings as well as explore the effect of interventions related to tight DM control or DM prevention on liver fibrosis in chronic hepatitis C patients.

 


Other Hepatitis Viruses

 

1952. Hepatocellular Carcinoma associated to chronic Hepatitis Delta.  

R. Romeo; A. Russo; A. Sangiovanni; E. Del Ninno; M. Rumi; M. Colombo.

Introduction:

The role of HDV in hepatocellular carcinoma (HCC) is poorly defined. We aimed at defining risk and natural history of HCC developing in patients with HDV.

 

Methods:

299 consecutive anti-HDV positive patients (230 males, mean age 30yrs, 272 [91%] anti-HBe positive), followed for 233 months (range 8-518). Infection was of unknown origin in 222 (74%). Cirrhosis was either histologically or clinically diagnosed in 186. All patients were under surveillance for HCC with US every 6 months. HDV was defined by serum IgM anti-HDV , HDV-RNA by PCR and/or HDV antigen detection.

 

Results:

HCC developed in 60 cirrhotics (39 Child A, 17 child B, 4 child C), after 86 months (range 3-432) from diagnosis of cirrhosis (annual rates: 0.9%). 55 (92%) patients were anti-HBe positive, 5 (8%) anti-HCV positive, HCV-RNA negative. HBV-DNA and/or IgM-antiHBc were repeatedly positive in 27 (45%), HDV replication was present in 46 (77%). 22 patients (37%) had a past history of IFN treatment, 15 (25%) of corticosteroids, 4 (6%) of nucleoside analogues and 19 (32%) were never treated. Alcohol consumption was higher than 40 gr/day in 18 (30%). HCC was detected as a single nodule in 28 patients (47%, 24 with maximum diameter <3cm), two nodules in 15 patients (25%, <3cm in 11), 3 nodules in 8 (13%, <3 cm in 5) and >3 nodules in 9 (15%). Portal thrombosis was diagnosed in 6 (10%). 12 patients (20%) underwent OLT. Independent risk factors for HCC were IFN treatment (OR 2.18; 95% CI 1.10-4.32) and HBV replication (OR 5.15; 95% CI 2.57-10.32). After 45 months (range 3-204) from HCC diagnosis, 34 patients are still alive (57%), 1 (1%) was lost to follow-up and 25 (42%) died of liver failure (n=17=, HCC (n=5), primary non function (n=2), metastasis from other cancer (n=1).

 

Conclusions:

chronic hepatitis delta is a long-lasting disease with a substantial risk of developing into HCC. HCC risk is higher in the presence of HBV replication.

 


Other Hepatitis Viruses

 

1953. HBeAg-Positive Delta Hepatitis: Virological; Biochemical And Clinical Features In A Large European Multicenter Data Base. 

B. Heidrich; H. Wedemeyer; M. Bektas; R. Idilman; F. Önder; A. Bozdayi; K. Zachou; K. Deterding; R. Raupach; H. Bozkaya; M. P. Manns; C. Yurdaydin.

Introuction:

Delta hepatitis represents the most severe form chronic viral hepatitis. HDV infection is usually associated with HBeAg-negative, anti HBe-positive hepatitis B serology. However, 10-30% of HDV-RNA-positive patients have been described as being HBeAg-positive but the course of HBe-Ag positive delta hepatitis is largely unknown.

 

Methods:

We studied a cohort of 534 delta hepatitis patients recruited at Hannover Medical School, Germany, Ankara University, Turkey and in the European Hep-Net HIDIT-1 treatment trial.

 

Results:

HBeAg was detectable in 71 of anti-HDV-positive patients (13.3%). HbeAg-positive and HBeAg-negative delta hepatitis patients did not differ in sex distribution and country of origin (Turkey vs. Germany vs. Eastern Europe) but were significantly younger (mean age 36.4 ± 14.2 vs. 43.1 ± 12.9, p<0.001). Importantly, biochemical activity of liver disease was much more severe in HBeAg-positive delta hepatitis than in HBeAg negative patients (p<0.001 for ALT and p<0.0001 for AST). However, the frequency of patients with advanced liver disease defined as platelets below 90.000/ml, bilirubin more than two times of the upper limit of normal (ULN) or albumin lower than 35g/l was similar in the two groups (platelets <90.000/ml 17.3 vs. 21.1% p= 0.649; bilirubin >2x ULN 20.0 vs. 14.8% p= 0.450 ; albumin < 35g/l 12.8 vs. 15.8% p= 0.750). HBeAg-positive patients had significantly higher HBsAg levels (2.8*10^4 ± 3.2*10^4 vs. 1.0*10^4 ± 1.2*10^4; p<0.0001), had more frequently high HBV-DNA levels above 1x10^6 copies/ml (32.4% vs. 4.4%, p<0.001), and were more often anti-HCV positive (36.4% vs. 21.4% p= 0.028). Interestingly, HBeAg positive delta hepatitis was not always associated with high HBV viremia as 51% of the patients presented with HBV-DNA levels <300.000 IU/mL and 24.3% with even with <2000 IU/ml.

 

Conclusion:

In conclusion, HBeAg-positive delta hepatitis is not infrequent. These patients are younger, have higher mean HBV DNA and HBsAg levels and are associated with more severe disease activity than HBeAg-negative delta hepatitis patients.. However; HBeAg-positive delta hepatitis is not a homogenous group and can be associated with very low HBV DNA levels.. Our data strongly support the assessment of antiviral treatment of hepatitis B in HBeAg-positive delta hepatitis. Future trials need to investigate the efficacy of currently available treatment options for this group of patients.

 


Other Hepatitis Viruses

 

1954. Description of Hepatitis A Virus Specimens from Enhanced Surveillance Sites. 

K. Iqbal; E. S. Din; M. Klevens; A. Cronquist; H. Hanson; Q. Phan; E. Rocchio; K. Sweet; A. Thomas; Y. Khudyakov; G. Xia.

Background:

Characterization of the genetic heterogeneity among isolates of hepatitis A virus (HAV) can be used at the local level to inform outbreak investigations. Worldwide, most human HAV strains belong to genotype I or III; 80% are of genotype I. We describe the genetic characteristics of specimens from surveillance case data for six US sites.

 

Methods:

Connecticut, Colorado, Oregon, Minnesota, New York State, and New York City conducted enhanced, population-based surveillance for hepatitis A from 2006 to 2007. A convenience sample of specimens was available from cases reported in each site and sent to CDC for HAV RNA isolation, amplification, and sequencing. A 315-nt segment of HAV at the VP1-P2B junction was amplified by nested reverse-transcription polymerase chain reaction (RT-PCR). The HAV sequences were classified into genotypes by comparing each sequence with the reference sequences from GenBank.

 

Results:

During 2006-2007, 42% (287/683) of reported cases of hepatitis A had serum specimens available. Of the 287 specimens, 80% (229/287) had a positive PCR result. No differences were found in PCR results by site, report year, or sex (p>0.05). However, there were differences in PCR results by age and by race. Cases with PCR- positive specimens were younger than those with PCR- negative specimens [median age=30 years vs 43 years respectively (p=0.004)]. Most positive PCR results [80% (125/157)] were among white cases compared to other race groups.

 

Three genotypes were identified: IA (87%), IB (12%), and IIIA (1%). No differences were found in genotype by sex and by year of report (p>0.05). Compared to other sites, NYC had the highest proportion of genotype IB/IIIA [24% (18/75)] and MN had the highest proportion of genotype IA [96% (46/48)]. Race differed among cases by genotype (p<0.001); genotype IA was more prevalent among whites [94% (117/125)], whereas genotype IB/IIIA was more prevalent among blacks [66% (6/9)]. Cases with genotype IA were older (median age=32 years) than those with genotype IB/IIIA (median age=14 years) (p=<0.001).

 

Conclusions:

Specimens differed phylogenetically by site and by race. These differences may reflect variability across sites in collaborations with laboratories at the local level. Overall, 99% were of genotype I; additional sequence analysis will be needed to further characterize these HAV infections. Enhanced surveillance including collecting additional specimen samples will support development of a library to better describe the molecular epidemiology of HAV.

 


Other Hepatitis Viruses

 

1955. Clinical Impact of Hepatitis E Virus (HEV) on Acute Hepatitis of Unknown Etiology During 10 Years in Sapporo, Japan. 

J. Kang; H. Mizuo; Y. Karino; T. Matsui; J. Koyama; S. Honjo; T. Arakawa; H. Okamoto; S. Mishiro.

Background and aims:

In recent, there have been increasing reports of acute sporadic hepatitis E (HE) from industrialized countries including Japan. However, in these countries, the trend of incidence has not become clear (and infection routes remained to be uncovered). In Japan, Sapporo was considered as one of prevalent regions for HEV indigenous to community. The aim of this study is to clarify clinical impact of HE on non A, non B, non C acute hepatitis in the last 10 years in Sapporo.

 

Methods:

During 1998 through 2007, 391 patients with acute hepatitis of unknown etiology were registered in 3 hospitals located in Sapporo. Acute infection of hepatitis A, B, C virus, cytomegalovirus or EB virus was excluded and drug-induced hepatitis was also exempted. HEV infection was diagnosed by detectable HEV RNA or anti IgM and IgG against virus in sera.

 

Results:

HE was diagnosed in 64 patients (16.4%) out of 391 patients registered. During 10 years, the frequencies of HE in the cases of unknown etiology were annually 4/33, 2/25, 5/36, 16/55, 12/53, 11/47, 2/49, 5/33, 4/34, 3/26, respectively. In 64 HE patients, median age was 53-years and 48 were male. Seventeen patients developed severe hepatitis, defined to be 2.0 or more in prothrombin time INR, and among them, 6 presented fulminant form and 3 died of hepatic failure. HEV genotypes were 4 in 44 patients (72%), 3 in 16 (26%), and co-infection of genotype 3 and 4 was found in 1 (2%). Sixty-three patients had no history of traveling to endemic country during 3 months before onset. Genotype 4 infection was correlated with occurrence of severe or fulminant hepatitis (p<0.05). Among 57 patients underwent minute interview, ingestion of undercooked pig intestine or liver in latent period or habitual ingestion of them was suspected in 35 patients (61%). Two patients were molecularly confirmed to infect with HEV by transfusion transmission. However, in 20 patients (35%), the infection routes remained to be obscure.

 

Conclusion:

This study shows the recent decrease in incidence of HE in Sapporo, but confirms HEV accounts for at least 10% of cases of acute hepatitis of unknown etiology. Moreover, serious disease progression was observed in a quarter of patients with HE. Therefore, HEV seems to be one of significant agents responsible for sporadic hepatitis in Japan.

 


Other Hepatitis Viruses

 

1956. 39 PCR-documented cases of acute or chronic hepatitis E over a 2-year period in Marseilles, south-eastern France. 

P. Colson; V. Moal; A. Motte; P. Borentain; M. Henry; C. Dhiver; E. Ressiot; S. Garcia; P. Brouqui; C. Tamalet; R. Gérolami.

Purpose:

Seroprevalence data suggest that HEV might be endemic in developed countries, where an increasing number of sporadic autochthonous hepatitis E (HE) has been recently reported. Concurrently, there is increasing evidence that hepatitis E is a zoonosis in swine, which might be a source of contamination to humans. We aimed at studying the epidemiological, clinical, and virological features of PCR-documented hepatitis E diagnosed in public hospitals of Marseilles, in south-eastern France.

 

Methods:

From 04/2006 untill 03/2008, HE was diagnosed in Marseilles public hospitals in patients (pts) with liver cytolysis by using detection in serum of HEV RNA (in-house real-time PCR and sequencing assays) and anti-HEV IgG and IgM antibodies (Ab) (Adaltis assays).

 

Results:

39 HE were diagnosed in 38 adults (30 male (79%); mean age=50+/-16 (range, 20-80)), and a 7-year-old boy. 36 were autochthonous cases. 2 were diagnosed in HIV-infected pts, concurrently with HBV reactivation in 1 case. 5 pts were renal transplant-recipients (TR), and one was a heart-TR. Transfusion, exposure to piglets during surgical training, and pork sausage consumption were risk factors identified in 1, 1, and 4 cases, respectively. HE were significantly more frequent during spring and winter than during autumn (13 and 12 cases, respectively, vs 4 cases), and in January-June than in July-December (25 vs 13 cases) (p<0.05). At time of diagnosis, IgG anti-HEV antibodies were found negative from 24% of pts, whereas IgM anti-HEV Ab were detected in all but 1 case (blood donor). Mean ALT level and prothrombin index (PI) were 1,073+/-1,075 IU/L and 77+/-24%, respectively. ALT were <200 IU/L in all but 1 organ-TR. Jaundice and asthenia were the most frequently observed clinical signs. Liver failure (LF), as indicated by PI<80%, occurred in 13 pts (41%), whereas severe LF (PI <50%) occurred in 6 (19%; all were male adults). Fatal fulminant hepatitis occurred in 2 pts. Chronic HE occurred in 3 renal-TR, as defined by a >6 months elevation of ALT and persistence of HEV RNA associated with histologically-proven chronic active hepatitis. Chronic HE-associated cirrhosis was found in 1 pt. Protracted HEV infection (10 months) was observed in another pt. HEV genotypes in autochthonous cases were 3f, 3c, and 3e from 28, 5, and 2 pts, respectively. One phylogenetic cluster involved 3 family members who ate the same pork sausage, and another one help identifying transfusion-associated HE.

 

Conclusions:

Incidence of hepatitis E is not negligible in south-eastern France, and transmission is autochthonous in 92% of cases. Fatal outcome and chronic hepatitis were observed in 5% and 8% of diagnosed cases.

 


Other Hepatitis Viruses

 

1959. 11-year Change of Hepatitis A Prevalence in Single City of Korea. 

J. Lee; D. Son; H. Park; H. Park; J. Park; J. Lee; S. Jung; D. Lee; H. Kim; Y. Shin; Y. Kim.

Background & Aim:

Hepatitis A virus(HAV) is spread via the fecal-oral route, and is more prevalent in low socioeconomic areas in which a lack of adequate sanitation and poor hygienic practices facilitate spread of the infection. The manifestations vary with age. HAV infection is usually silent or subclinical in children. However, infection in adults can vary in severity from a mild flu-like illness to fulminant hepatitis. Hepatitis A had occurred epidemically in Korea. Because HAV was infected in childhood, most population of Korean adults over 40 had protective antibodies against HAV. So, HAV infection was not clinical problems. However, Korean epidemiology of HAV infection is changing, due to the improvement of living conditions. As a result, fewer children are infected, leading to a larger population of adults who lack protective antibodies against HAV. Accordingly, we observe the epidemic changes of HAV infection in Incheon port that is located on the west coast of Korea, and assess the need for HAV vaccination.

 

Method:

The medical records at the Inha University Hospital from January 1997 through December 2007 inclusive were reviewed to identify patients who were positive of anti-HAV IgM.

 

Results:

516 Patients were diagnosed as HAV hepatitis during 11 years, male were 287(55.6%) and female were 229(44.4%). Number of patient was increasing every year: 1 in 1997; 51 in 1998; 16 in 1999; 4 in 2000; 7 in 2001; 32 in 2002; 33 in 2003; 38 in 2004; 100 in 2005; 106 in 2006; 128 in 2007. Their ages ranged from 14 to 65 years: 54(10.47%) patients in their 10s, 256(49.61%) in their 20s, 180(34.88%) in their 30s, 22(4.26%) in their 40s, 2(0.39%) in their 50s, and 2(0.39%) in their 60s.

 

Conclusion:

Attacks of HAV infection were increasing yearly. The most common ages of HAV infection was 20s and the next common ages was 30s. A few attacks of HAV infection were in 40s and no attack was in 0s. Over the age of 40s, most population were infected with HAV in their childhood and acquired protective antibodies against HAV. However, young adults lack protective antibodies against HAV because they were not exposed to HAV. The decrease in young adults’ immunity in Korea has resulted in an increasingly large group of adults who are at risk for outbreaks of infection. Accordingly, young adults in Korea should be vaccinated against HAV. Large scaled epidemiologic study will be needed to examine the cause of recent out breaks in the western part of Korea.