Is there Failure to Screen for Hepatitis C in Newborns Suffering from Neonatal Abstinence Syndrome?

Abstract Background Enormous advances in treating/curing patients suffering from Hepatitis C (HepC) infection have occurred; resulting in many states mandating screening for HepC for older individuals. Unfortunately, no protection of screening exists for newborns. In Kentucky, rates of HepC among pregnant women are the second highest within the U.S., which has been associated to high intravenous drug use. Infants born to those women are at risk of HepC infection and other conditions such as neonatal abstinence syndrome (NAS). The current study examined the rate of HepC screening in a high-risk cohort (newborns suffering from NAS) and it’s impact on policy-making for this vulnerable population. Methods Kentucky Medicaid records, from 2015, were obtained to develop a detailed demographic, behavioral, clinical, and diagnostic data set (n = 152,749). NAS was defined by ICD-9 code 779.5 and ICD-10 code P96.1. HepC screening was defined by CPT codes (CPT 87520 [HCV, direct probe], 87521 [HCV, amplified probe], and 87522 [HCV RNA, Quantitative] or antibody [CPTs 86803–4]). Initially a descriptive study was performed, then multiple logistic regression techniques were used to test what variables impacted the odds of not being screened for HepC. Results A total of 1234 newborns with NAS were identified. The majority showed signs of NAS within 24 hours (64%), were white (68%) and were admitted to the hospital for an average of 24.8 days. Only one-in-three newborns with NAS (n = 412, 33.4%) were screened for HepC. Non-Whites (OR = 1.58, 95% CI 1.45–1.71, P < 0.001) and those living in non-urban areas (OR = 1.42, 95% CI 1.28–1.56, P < 0.001) were the only study variables to significantly impact the odds of not being screened for HepC (for newborns suffering from NAS). Conclusion A high-risk and vulnerable population for HepC may not be getting screened for HepC and thus are being underserved by the health care system. Non-Whites and those in rural areas are the most affected. Solutions and policies need to be focused on this population and area where screening is lacking. Optimization of maternal screening for HepC is crucial in high-risk populations. Disclosures All authors: No reported disclosures.

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Description of a pharmacist-led clinical video telehealth group clinic for opioid overdose prevention and naloxone education

Mental Health Clinician ◽

10.9740/mhc.2019.07.294 ◽

2019 ◽

Vol 9 (4) ◽

pp. 294-297

Author(s):

Aimee N. Jensen ◽

Candace M. Beam ◽

Amber R. Douglass ◽

Jennifer E. Brabson ◽

Michelle Colvard ◽

...

Keyword(s):

At Risk ◽

High Risk ◽

Rural Areas ◽

Urban Areas ◽

Patient Specific ◽

Opioid Overdose ◽

Overdose Prevention ◽

Innovative Practice ◽

Risk Patients ◽

Urban And Rural Areas

Abstract To achieve the nationwide goal of reducing opioid-related deaths, a clinical pharmacy specialist–led clinical video telehealth (CVT) clinic was created at a Veterans Affairs medical center (VAMC) to deliver opioid overdose prevention and naloxone education to at-risk patients. The purpose of this innovative practice was to improve access to this potentially life-saving intervention to patients across urban and rural areas. This study is a single-center, descriptive analysis of adult patients across 2 VAMC campuses and 4 community-based outpatient clinics from July 11, 2016, through December 31, 2016. The purpose of this innovative practice was to increase access to overdose education and naloxone distribution (OEND) to at-risk patients across urban and rural areas. Patient-specific factors were also examined among those receiving naloxone through the CVT clinic compared to other prescribers. During the first 6 months from the initiation of the clinic, 1 pharmacist prescribed 21% of the health care system's naloxone. These patients identified by the pharmacist-led CVT clinic were more likely to be considered high-risk due to concomitant use of opioids and benzodiazepines. In conclusion, the pharmacist-led CVT group clinic has been an efficient strategy to extend OEND services to high-risk patients beyond central, urban areas.

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Hepatitis C Virus Screening of High-Risk Patients in a Canadian Emergency Department

Canadian Journal of Gastroenterology and Hepatology ◽

10.1155/2020/5258289 ◽

2020 ◽

Vol 2020 ◽

pp. 1-6

Author(s):

Kelsey Ragan ◽

Anjali Pandya ◽

Tristan Holotnak ◽

Katrina Koger ◽

Neil Collins ◽

...

Keyword(s):

Emergency Department ◽

Hepatitis C Virus ◽

Hepatitis C ◽

High Risk ◽

Drug Use ◽

Hcv Rna ◽

High Risk Patients ◽

Risk Patients ◽

History Of ◽

Hcv Screening

Background. Approximately 0.7% of the Canadian population is infected with hepatitis C virus (HCV), and many individuals are unaware of their infection. Our objectives were to utilize an emergency department (ED) based point-of-care (POC) HCV screening test to describe our local population and estimate the proportion of high-risk patients in our population with undiagnosed HCV. Methods. A convenience sample of medically stable patients (≥18 years) presenting to a community ED in Calgary, AB, between April and July 2018 underwent rapid clinical screening for HCV risk factors, including history of injection drug use, healthcare in endemic countries, and other recognized criteria. High-risk patients were offered POC HCV testing. Antibody-positive patients underwent HCV-RNA testing and were linked to hepatology care. The primary outcome was the proportion of new HCV diagnoses in the high-risk population. Results. Of the 999 patients screened by survey, 247 patients (24.7%) were high-risk and eligible for testing. Of these, 123 (49.8%) were from HCV-endemic countries, while 63 (25.5%) and 31 (12.6%) patients endorsed a history of incarceration and intravenous drug use (IVDU), respectively. A total of 144 (58.3%) eligible patients agreed to testing. Of these, 6 patients were POC-positive (4.2%, CI 0.9–7.4%); all 6 had antibodies detected on confirmatory lab testing and 4 had detectable HCV-RNA viral loads in follow-up. Notably, 103 (41.7%) patients declined POC testing. Interpretation. Among 144 high-risk patients who agreed to testing, the rate of undiagnosed HCV infection was 4.2%, and the rate of undiagnosed HCV infection with detectable viral load was 2.8%. Many patients with high-risk clinical criteria refused POC testing. It is unknown if tested and untested groups have the same disease prevalence. This study shows that ED HCV screening is feasible and that a small number of previously undiagnosed patients can be identified and linked to potentially life-changing care.

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Survival Disparities in Patients with Lymphoma According to Place of Residence and Treatment Provider: A Population-Based Study

Blood ◽

10.1182/blood.v112.11.874.874 ◽

2008 ◽

Vol 112 (11) ◽

pp. 874-874

Author(s):

Fausto R Loberiza ◽

Anthony J Cannon ◽

Dennis D Weisenburger ◽

Julie M. Vose ◽

Matt J. Moehr ◽

...

Keyword(s):

Overall Survival ◽

High Risk ◽

Rural Areas ◽

Urban Areas ◽

Population Based ◽

Place Of Residence ◽

Community Based ◽

Risk Levels ◽

Risk Of Death ◽

Risk Patients

Abstract Objectives: We evaluated the association of the primary area of residence (urban vs. rural) and treatment (trt) provider (university-based vs. community-based) with overall survival in patients with lymphoma, and determined if there are patient subgroups that could benefit from better coordination of care. Methods: We performed a population-based study in 2,330 patients with centrally confirmed lymphoma from Nebraska and surrounding states reported to the Nebraska Lymphoma Study Group between 1982 and 2006. Patient residential ZIP codes at the time to trt were used to determine rural/urban designation, household income and distance to trt center; while trt providers were categorized into university-based or community based. Multivariate analyses were used to group patients into risk levels based on 8 factors found to be associated with survival at the time of trt (age, performance score, Ann Arbor stage, presence of B symptoms, LDH levels, tumor bulk, nodal and extranodal involvement). The following categories were identified: low-risk (1–3 factors), intermediate risk (4–5 factors), and high-risk (≥6 factors). Cox proportional regression analyses, stratified by type of lymphoma (low-grade NHL, high-grade NHL and Hodgkin) were used to evaluate the association between place of residence and trt provider with overall survival. Results: Among urban residents, 321 (14%) were treated by university-based providers (UUB) and 816 (35%) were treated by community-based providers (UCB). Among rural residents, 332 (14%) were treated by university-based providers (RUB) and 861 (37%) were treated by community-based providers (RCB). Patients from rural areas were more likely to be older and Caucasian, with a lower median household income, greater travel distance to seek trt, and more likely to have high-risk disease when compared to patients from urban areas. In multivariate analysis, using all patients regardless of risk level, the relative risk of death (RR) among UUB, UCB and RUB was not statistically different. However, RCB had a higher risk of death RR 1.37, 95% CI 1.14–1.65, p=0.01; RR 1.18, 95% CI 1.04–1.33, p<0.01; and RR 1.26, 95% CI 1.06–1.49, p=0.01 when compared with UUB, UCB and RUB, respectively. This association remained true in both low- and intermediate-risk patients. Among high-risk patients, both RUB and RCB were at higher risk of death when compared with UUB or UCB, while UCB were not different from UUB. We found no differences in progression-free survival according to place of residence and trt provider. The use of stem cell transplantation was significantly higher in patients coming from urban and rural areas treated by university-based providers (UUB 19%, RUB 16%) compared to urban and rural patients treated by community-based providers (UCB 11%, RCB 10%, p < 0.01). Patients from rural areas (RUB and RCB) were slightly less likely to die from lymphoma-related causes than patients from urban areas (75% versus 80%, p=0.04). Conclusion: Overall survival in patients with lymphoma is inferior in patients coming from rural areas. This relationship varies according to treatment provider and pretreatment risk levels. Further studies in patients from rural areas are needed to understand how coordination of care is carried to design appropriate interventions that may improve the disparity noted.

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Drivers and Projections of Global Surface Temperature Anomalies at Sub-City Scale

10.31219/osf.io/a8rfx ◽

2021 ◽

Author(s):

Susanne A. Benz ◽

Steven J. Davis ◽

Jennifer Burney

Keyword(s):

Energy Balance ◽

Surface Energy ◽

Rural Areas ◽

Urban Areas ◽

Surface Energy Balance ◽

Urban Migration ◽

Data Set ◽

Surface Temperatures ◽

Summer Temperatures ◽

Surrounding Areas

More than half of the world’s population now lives in urban areas, and trends in rural-to-urban migration are expected to continue through the end of the century. Although cities create efficiencies that drive innovation and economic growth, they also alter the local surface energy balance, resulting in urban temperatures that can differ dramatically from surrounding areas. Here we introduce a global 1-km resolution data set of seasonal and diurnal anomalies in urban surface temperatures relative to their rural surroundings, and use satellite-observable parameters in a simple model informed by the surface energy balance to understand the dominant drivers of present urban heating, the heat-related impacts of projected future urbanization, and the potential for policies to mitigate those damages. At present, urban populations live in areas with daytime surface summer temperatures that are 3.21°C (-3.97 - 9.24, 5th-95th percentiles) warmer than surrounding rural areas, such that 1.2 billion people are exposed to average surface summer temperatures in excess of 35°C that might put them at risk of heat-related illness. If design and infrastructure of cities remain unchanged, increased urban heat anomalies will add 0.19°C (-0.01, 0.47) to the daytime summer surface temperatures in urban areas in 2100 -- in addition to warming due to climate change. Such urban heating will increase the number of urban population living under extreme and potentially health-threatening temperatures by approximately 20% compared to current numbers. However we also find a significant potential for mitigation: 82% of all urban areas can optimize vegetation and/or surface albedo and reduce urban daytime summer surface temperatures for the affected population on average by -0.81°C (-2.55, -0.05).

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Development and Implementation of a Mobile Tool for High-Risk Pregnant Women to Deliver Effective Caregiving for Neonatal Abstinence Syndrome: Protocol for a Mixed Methods Study (Preprint)

10.2196/preprints.27382 ◽

2021 ◽

Author(s):

Ekaterina Burduli ◽

Hendrée E Jones ◽

Olivia Brooks ◽

Celestina Barbosa-Leiker ◽

Ron Kim Johnson ◽

...

Keyword(s):

Mixed Methods ◽

High Risk ◽

Data Collection ◽

Pregnant Women ◽

The United States ◽

Neonatal Abstinence Syndrome ◽

Abstinence Syndrome ◽

Semistructured Interviews ◽

Stage 1 ◽

Perinatal Women

BACKGROUND The United States continues to experience an alarming rise in opioid use that includes women who become pregnant and related neonatal abstinence syndrome (NAS) in newborns. Most newborns experiencing NAS require nonpharmacological care, which entails, most importantly, maternal involvement with the newborn. To facilitate positive maternal-newborn interactions, mothers need to learn effective caregiving NAS strategies when they are pregnant; however, an enormous gap exists in the early education of mothers on the symptoms and progression of NAS, partly because no education, training, or other interventions exist to prepare future mothers for the challenges of caring for their newborns at risk for NAS. OBJECTIVE In this paper, we describe a mixed methods, multistage study to adapt an existing mobile NAS tool for high-risk pregnant women and assess its usability, acceptability, and feasibility in a small randomized controlled trial. METHODS Stage 1 will include 20 semistructured interviews with a panel of neonatology experts, NAS care providers, and mothers with experience caring for NAS-affected newborns to gather their recommendations on the management of NAS and explore their perspectives on the care of these newborns. The findings will guide the adaptation of existing mobile NAS tools for high-risk pregnant women. In stage 2, we will test the usability, acceptability, and feasibility of the adapted mobile tool via surveys with 10 pregnant women receiving opioid agonist therapy (OAT). Finally, in stage 3, we will randomize 30 high-risk pregnant women receiving OAT to either receive the adapted mobile NAS caregiving tool or usual care. We will compare these women on primary outcomes—maternal drug relapse and OAT continuation—and secondary outcomes—maternal-newborn bonding; length of newborn hospital stays; readmission rates; breastfeeding initiation and duration; and postpartum depression and anxiety at 4, 8, and 12 weeks postpartum. RESULTS This project was funded in July 2020 and approved by the institutional review board in April 2020. Data collection for stage 1 began in December 2020, and as of January 2021, we completed 18 semistructured interviews (10 with NAS providers and 8 with perinatal women receiving OAT). Common themes from all interviews will be analyzed in spring 2021 to inform the adaptation of the NAS caregiving tool. The results from stage 1 are expected to be published in summer 2021. Stage 2 data collection will commence in fall 2021. CONCLUSIONS The findings of this study have the potential to improve NAS care and maternal-newborn outcomes and lead to commercialized product development. If effective, our new tool will be well suited to tailoring for other high-risk perinatal women with substance use disorders. CLINICALTRIAL ClinicalTrials.gov NCT04783558; https://clinicaltrials.gov/ct2/show/NCT04783558 INTERNATIONAL REGISTERED REPORT DERR1-10.2196/27382

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Low-Positive Anti-Hepatitis C Virus Enzyme Immunoassay Results: An Important Predictor of Low Likelihood of Hepatitis C Infection

Clinical Chemistry ◽

10.1373/49.3.479 ◽

2003 ◽

Vol 49 (3) ◽

pp. 479-486 ◽

Cited By ~ 36

Author(s):

D Robert Dufour ◽

Mageli Talastas ◽

Maria D A Fernandez ◽

Barbara Harris ◽

Doris B Strader ◽

...

Keyword(s):

Hepatitis C ◽

High Risk ◽

Screening Program ◽

Core Antigen ◽

Hcv Rna ◽

Hepatitis C Infection ◽

Immunoblot Assay ◽

Recombinant Immunoblot Assay ◽

Hepatitis B Core Antigen ◽

Alt Activity

Abstract Background: Tests for hepatitis C antibodies (anti-HCV enzyme immunoassays) are usually described as positive or negative. Several studies, mainly in blood donors, have found that specimens with low signal/cutoff (S/C) ratios are commonly negative when tested with a recombinant immunoblot assay (RIBA) or for HCV RNA. Methods: We retrospectively reviewed 17 418 consecutive anti-HCV results from a screening program for high-risk veterans; 2986 (17.1%) samples were anti-HCV-positive, and 490 (16.4%) had S/C ratios ≤3.7 (low positive). Additional tests were performed in 1814 anti-HCV-positive individuals. Results: RIBA was performed in 263 patients with low-positive anti-HCV; results were negative in 86%, indeterminate in 12%, and positive in 2%. Only 16 of 140 individuals (11%) with low-positive anti-HCV values were HCV RNA-positive, whereas HCV RNA was positive in 90% of 1435 individuals with high-positive anti-HCV values (P <0.0001). Compared with those with high-positive anti-HCV, individuals with low-positive anti-HCV values were older (P <0.0001) and were less likely to have risk factors for HCV (P <0.0001 for most), multiple increased alanine aminotransferase (ALT) activity values (30% vs 81%; P <0.0001), or positive anti-hepatitis B core antigen (19% vs 59%; P <0.0002). Among 634 individuals with high anti-HCV titers and multiple increased ALT activity values, 95% were HCV RNA-positive. Conclusions: The S/C ratio is important even in high-risk individuals; laboratories should report the S/C ratio along with anti-HCV EIA results and perform supplemental RIBA testing in those with low-positive values to avoid reporting false-positive results.

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Hepatitis C Virus Prevalence and Incidence in a Large Nationwide Sample of Patients in Opioid Substitution Treatment in Germany: A Prospective Cohort Study

Clinical Infectious Diseases ◽

10.1093/cid/ciz661 ◽

2019 ◽

Vol 70 (10) ◽

pp. 2199-2205 ◽

Cited By ~ 2

Author(s):

Bernd Schulte ◽

Christiane Sybille Schmidt ◽

Lisa Strada ◽

Moritz Rosenkranz ◽

Ingo Schäfer ◽

...

Keyword(s):

Hepatitis C Virus ◽

Hepatitis C ◽

High Risk ◽

Incidence Rates ◽

Hcv Rna ◽

High Risk Population ◽

Substitution Treatment ◽

Opioid Substitution Treatment ◽

Hcv Antibody ◽

Opioid Substitution

Abstract Background Hepatitis C virus (HCV) infection is highly prevalent among people who inject drugs (PWID). Accurate data on HCV prevalence and incidence rates among patients receiving opioid substitution treatment (OST) are needed to estimate the current and future burden of HCV infections in this high-risk population. Methods Baseline data from routine care were collected between October 2014 and June 2016 from randomly selected OST facilities in Germany. The primary outcome measure was the HCV status (antibody and RNA prevalence). Patients who were HCV antibody–negative at baseline were followed up after 12 months to calculate the HCV incidence rate. Results Sixty-three facilities from 14 German Federal States provided clinical data for a total of 2466 OST patients. HCV antibody and HCV RNA prevalence were 58.8% (95% confidence interval [CI], 56.8%–60.8%) and 27.3% (95% CI, 25.5%–29.2%), respectively. At baseline, a total of 528 patients (21.4%) had previously undergone antiviral treatment. Moreover, lower HCV RNA prevalence was associated with female gender, employment, younger age, and shorter duration of OST and opioid dependence. The HCV incidence rate was 2.5 cases per 100 person-years. Conclusions The low HCV RNA prevalence and HCV incidence rates confirm that OST in Germany is an effective setting both for treating chronic HCV infections and for preventing new infections among PWID. Scaling up the provision of OST, HCV testing, and HCV treatment among OST patients are important public health strategies for reducing HCV infections in this high-risk population.

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Atmospheric number size distributions of soot particles and estimation of emission factors

Atmospheric Chemistry and Physics ◽

10.5194/acp-6-1021-2006 ◽

2006 ◽

Vol 6 (4) ◽

pp. 1021-1031 ◽

Cited By ~ 94

Author(s):

D. Rose ◽

B. Wehner ◽

M. Ketzel ◽

C. Engler ◽

J. Voigtländer ◽

...

Keyword(s):

Size Distribution ◽

Atmospheric Aerosols ◽

Rural Areas ◽

Urban Areas ◽

Emission Factor ◽

Emission Factors ◽

Rural Site ◽

Passenger Cars ◽

Data Set ◽

Soot Particles

Abstract. Number fractions of externally mixed particles of four different sizes (30, 50, 80, and 150 nm in diameter) were measured using a Volatility Tandem DMA. The system was operated in a street canyon (Eisenbahnstrasse, EI) and at an urban background site (Institute for Tropospheric Research, IfT), both in the city of Leipzig, Germany as well as at a rural site (Melpitz (ME), a village near Leipzig). Intensive campaigns of 3–5 weeks each took place in summer 2003 as well as in winter 2003/04. The data set thus obtained provides mean number fractions of externally mixed soot particles of atmospheric aerosols in differently polluted areas and different seasons (e.g. at 80 nm on working days, 60% (EI), 22% (IfT), and 6% (ME) in summer and 26% (IfT), and 13% (ME) in winter). Furthermore, a new method is used to calculate the size distribution of these externally mixed soot particles from parallel number size distribution measurements. A decrease of the externally mixed soot fraction with decreasing urbanity and a diurnal variation linked to the daily traffic changes demonstrate, that the traffic emissions have a significant impact on the soot fraction in urban areas. This influence becomes less in rural areas, due to atmospheric mixing and transformation processes. For estimating the source strength of soot particles emitted by vehicles (veh), soot particle emission factors were calculated using the Operational Street Pollution Model (OSPM). The emission factor for an average vehicle was found to be (1.5±0.4)·1014 #(km·veh). The separation of the emission factor into passenger cars ((5.8±2)·1013} #(km·veh)) and trucks ((2.5±0.9)·1015 #(km·veh)) yielded in a 40-times higher emission factor for trucks compared to passenger cars.

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Global combustion sources of organic aerosols: model comparison with 84 AMS factor-analysis data sets

Atmospheric Chemistry and Physics ◽

10.5194/acp-16-8939-2016 ◽

2016 ◽

Vol 16 (14) ◽

pp. 8939-8962 ◽

Cited By ~ 24

Author(s):

Alexandra P. Tsimpidi ◽

Vlassis A. Karydis ◽

Spyros N. Pandis ◽

Jos Lelieveld

Keyword(s):

Factor Analysis ◽

Atmospheric Chemistry ◽

Rural Areas ◽

Urban Areas ◽

Model Comparison ◽

Climate Model ◽

Organic Aerosol ◽

Analysis Data ◽

Chemical Transformations ◽

Data Set

Abstract. Emissions of organic compounds from biomass, biofuel, and fossil fuel combustion strongly influence the global atmospheric aerosol load. Some of the organics are directly released as primary organic aerosol (POA). Most are emitted in the gas phase and undergo chemical transformations (i.e., oxidation by hydroxyl radical) and form secondary organic aerosol (SOA). In this work we use the global chemistry climate model ECHAM/MESSy Atmospheric Chemistry (EMAC) with a computationally efficient module for the description of organic aerosol (OA) composition and evolution in the atmosphere (ORACLE). The tropospheric burden of open biomass and anthropogenic (fossil and biofuel) combustion particles is estimated to be 0.59 and 0.63 Tg, respectively, accounting for about 30 and 32 % of the total tropospheric OA load. About 30 % of the open biomass burning and 10 % of the anthropogenic combustion aerosols originate from direct particle emissions, whereas the rest is formed in the atmosphere. A comprehensive data set of aerosol mass spectrometer (AMS) measurements along with factor-analysis results from 84 field campaigns across the Northern Hemisphere are used to evaluate the model results. Both the AMS observations and the model results suggest that over urban areas both POA (25–40 %) and SOA (60–75 %) contribute substantially to the overall OA mass, whereas further downwind and in rural areas the POA concentrations decrease substantially and SOA dominates (80–85 %). EMAC does a reasonable job in reproducing POA and SOA levels during most of the year. However, it tends to underpredict POA and SOA concentrations during winter indicating that the model misses wintertime sources of OA (e.g., residential biofuel use) and SOA formation pathways (e.g., multiphase oxidation).

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Incident Hepatitis C Virus Genotype Distribution and Multiple Infection in Australian Prisons

Journal of Clinical Microbiology ◽

10.1128/jcm.00287-16 ◽

2016 ◽

Vol 54 (7) ◽

pp. 1855-1861 ◽

Cited By ~ 7

Author(s):

Melanie R. Walker ◽

Hui Li ◽

Suzy Teutsch ◽

Brigid Betz-Stablein ◽

Fabio Luciani ◽

...

Keyword(s):

Hepatitis C Virus ◽

Hepatitis C ◽

High Risk ◽

Drug Users ◽

Multiple Infection ◽

Complex Nature ◽

Hcv Rna ◽

Genotype Distribution ◽

Virus Genotype ◽

Antiviral Therapies

Hepatitis C virus (HCV) is a highly diverse pathogen that is classified into seven distinct genotypes. Simultaneous or sequential reinfection with multiple HCV genotypes is recognized in high-risk populations, such as injecting drug users (IDUs). Multiple infection is of clinical concern as different genotypes have various sensitivities to current antiviral therapies. Therefore, a better understanding of the frequency of multiple infection and of the genotypes currently being transmitted is clinically relevant. An Australian cohort of IDUs (n= 123), identified with primary incident infection, was followed for multiple infection by regular HCV RNA testing between 2005 and 2013. A total of 354 samples were tested. Sequencing of primary incident infections revealed that genotype 3a was the most common circulating genotype, followed by genotype 1a. Examination of longitudinally collected samples identified complex patterns of multiple infection, including reinfection and superinfection. In those with multiple infection, there was no apparent evidence of homotypic immunity conferring protection against reinfection of the same subtype. This study revealed frequent multiple infection in a high-risk prisoner cohort, illustrating the complex nature of HCV infection and reinfection and highlighting the need for pan-genotypic antiviral therapies.

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