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Original Investigation |

Using the Prevalence of an Elevated Serum Alanine Aminotransferase Level for Identifying Communities With a High Prevalence of Hepatitis C Virus Infection FREE

Chong-Shan Wang, MD, MPH; Shan-Tair Wang, PhD; Pesus Chou, DrPH
[+] Author Affiliations

From the A-Lein Community Health Center, Kaohsiung (Taiwan) County (Dr C.-S. Wang); Department of Public Health, College of Medicine, National Cheng Kung University, T'ai-nan, Taiwan (Drs C.-S. Wang and S.-T. Wang); and the Community Medicine Research Center and Institute of Public Health, National Yang-Ming University, Taipei, Taiwan (Dr Chou).


Arch Intern Med. 2001;161(3):392-394. doi:10.1001/archinte.161.3.392.
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Published online

Background  Antibody to hepatitis C virus (anti-HCV) is a widely accepted method for the diagnosis of HCV infection. However, it is too expensive to use in large-scale health surveys.

Objective  To investigate the use of the serum alanine aminotransferase (ALT) level to predict the prevalence of HCV infection.

Patients and Methods  A sample of 6095 residents aged 35 years old or older in a small township of southern Taiwan, Republic of China, were examined in a community health survey. These persons were walk-ins to the government-sponsored stations after an intensive health promotion for this survey. Blood samples were obtained and analyzed for serum ALT levels. The presence of hepatitis B surface antigen and anti-HCV were determined by enzyme immunoassay methods.

Results  The overall prevalences of hepatitis B surface antigens(+), anti-HCV(+), and elevated ALT levels were 11.8%, 15.0%, and 7.5%, respectively. Among the 13 villages in this community, the prevalence of hepatitis B surface antigen(+) ranged from 6.8% to 17.3%, anti-HCV(+) ranged from 7.2% to 37.6%, and an elevated ALT level ranged from 5.8% to 16.5%. A strong positive correlation was found between the prevalence of an elevated ALT level and anti-HCV(+) (r= 0.91, Spearman rank correlation; P<.001). However, nearly 0 correlation (r= −0.05, P= .87) was obtained between the prevalence of an elevated serum ALT level and hepatitis B surface antigen(+).

Conclusion  The prevalence of an elevated serum ALT level in a community is a strong indicator of its prevalence of anti-HCV(+), even in areas where there is a similar prevalence of hepatitis B virus infection. This result is useful for economically identifying hyperendemic communities with HCV infection.

Figures in this Article

HEPATITIS C VIRUS (HCV) infection is an important public health problem.1,2 This communicable disease is difficult to treat and frequently causes advanced liver diseases and related extrahepatic disorders13 and, thus, its effect on a community with high prevalence is potentially devastating. An effective way of minimizing the effect is to prevent the disease's further spread. Identifying the communities at high risk of HCV infection and the associated risk factors is an important first step.

Antibody to HCV (anti-HCV) test is the accepted method for the diagnosis of HCV infection. It is routinely used in the screening for HCV infection among blood donors. However, the anti-HCV test has not been widely used in routine health examination and community screening for 2 reasons: its high cost and the difficulty with performing the test in many communities where there is a lack of both necessary technicians and instruments. Cost and feasibility are primary considerations in such health surveillance and surveys. To identify the communities at high risk of HCV infection, there is a need for a much simpler, cost-effective tool.

The serum alanine aminotransferase (ALT) level test had been shown to be a viable and cost-effective screening test for HCV infection that could reduce the incidence of posttransfusion infection.4,5 However, with the invention of anti-HCV test, the serum ALT level test has been gradually phased out in blood donor screening because of its lower sensitivity, which can subject blood recipients to the unnecessary risk of HCV infection.6 Its effectiveness in large-scale screening of HCV infection also has been questioned because of its unsatisfactory sensitivity.7,8 Although the serum level test may not be ideal for the individual diagnosis of HCV infection, we will show that using the prevalence of an elevated serum ALT level (≥40 U/L) for identifying communities with high prevalence of HCV infection is valuable.

A sample of 6095 residents aged 35 years or older in a small township in southern Taiwan, Republic of China, were examined during a community health survey. These persons were walk-ins to the government-sponsored stations after an intensive health promotion for this survey. This community has 13 villages with a population of almost 31 000 people and has been known for its high prevalence of hepatitis B virus (HBV) and HCV infections.9,10 Of those living in this township, 8800 were 35 years old or older. Blood samples were obtained from the participants who were analyzed for serum ALT levels. The analysis was performed on a kinetic UV test for clinical chemistry analyzers (Olympus System Reagent, Mills, Ireland). The cutoff value of 40 U/L or higher was set for the diagnosis of an elevated serum ALT level. Hepatitis B virus infection was assessed for hepatitis B surface antigen (HBsAg) by optical density/cutoff ratios and enzyme immunoassay using Murex HBsAg Version I (London, England), and HCV infection was assessed by the third-generation Murex anti-HCV enzyme immunoassay, which contains the antigen from the HCV core, nonstructural 3 through 5 regions. For simplicity HBsAg(+) denotes HBsAg(+)/anti-HCV(−), and anti-HCV(+) denotes HBsAg(−)/anti-HCV(+). Seronegative cases were HBsAg(−)/anti-HCV(−). The correlation between the prevalence of an elevated serum ALT level and HBsAg(+) or anti-HCV(+) among the 13 villages was determined using the Spearman rank correlation.

The prevalence of HBsAg(+) was 11.8% (n = 719), anti-HCV(+) was 15.0% (n = 917), and elevated serum ALT level was 7.5% (n = 459) for the township. The village-specific prevalence of HBsAg(+) ranged from 6.8% to 17.3%, anti-HCV(+) ranged from 7.2% to 37.6%, and elevated serum ALT level ranged from 5.8% to 16.5%. Figure 1 shows the relation between the prevalence of an elevated serum ALT level and anti-HCV(+) among the 13 villages, and the relation between the prevalence of an elevated serum ALT level and HBsAg(+). Spearman rank correlation was calculated as 0.91 (P<.001), and −0.05 (P = .87), respectively.

Place holder to copy figure label and caption

A, The scatterplot of the prevalence of anti-hepatitis C virus (HCV)(+) vs elevated serum alanine aminotransferase (ALT) levels (≥40 U/L) (Spearman rank correlation coefficient, r = 0.91; P<.001). B, The scatterplot of the prevalence of hepatitis B surface antigens (HBsAg)(+) vs elevated serum ALT levels (Spearman rank correlation coefficient, r = −0.05; P = .87).

Graphic Jump Location

We found a strongly positive correlation between the prevalence of an elevated serum ALT level and anti-HCV(+) based on a sample of adults aged 35 years or older. This finding suggests that we can use the prevalence of an elevated serum ALT level for identifying the communities with high prevalence of HCV infection in this adult group. Considering that the per unit cost of the anti-HCV test is 5 to 25 times that of the serum ALT level test, the overall cost for conducting such a regional or national survey of HVC infection can be significantly reduced using the serum ALT level test. Moreover, the serum ALT level test is a routinely used liver function test in clinical practice and periodic health examination. Therefore, performing the serum ALT level test in the field is much more feasible than performing the anti-HCV test. Our data have important implications in terms of cost and feasibility for monitoring a communicable disease in communities, particularly in hyperendemic areas.

In contrast to HCV infection, we found no correlation between the prevalence of an elevated serum ALT level and HBsAg(+). Taiwan is a part of the world with high rates of HBV infection, so if HBV does not interfere with the use of the serum ALT level for the detection of HCV infection in Taiwan, it should not be a problem anywhere. In summary, the prevalence of an elevated serum ALT level is a valuable index for identifying the communities at the high risk of HCV infection. The increased population with an elevated serum ALT level is more likely to be attributed to HCV infection.

Accepted for publication July 28, 2000.

This investigation was supported in part by funds from the A-Lein Community Health Promotion Committee, and C. T. Hsu Cancer Research Foundation, Taipei, Taiwan.

We are indebted to Walter J. Rogan, MD, National Institute of Environmental Health Sciences, Triangle Park, NC, for his excellent comments on the manuscript during its preparation; to the staff and volunteers of the A-Lein Community Health Center, Kaoshsiung (Taiwan) County, for their assistance in data collection; and to the T'ai-nan Blood Center of Chinese Blood Service Foundation, T'ai-nan, Taiwan, for assistance with laboratory analysis.

Corresponding author and reprints: Pesus Chou, DrPH, National Yang-Ming University, Institute of Public Health, Shih-Pai, Taipei 112, Taiwan, Republic of China (e-mail: pschou@ym.edu.tw).

Di Bisceglie  AM Hepatitis C. Lancet. 1998;351351- 355
Link to Article
Hoofnagle  JH Hepatitis C: the clinical spectrum of disease. Hepatology. 1997;26 ((suppl 1)) 15S- 20S
Link to Article
Alter  MJKruszon-Moran  DNainan  OV  et al.  The prevalence of hepatitis C virus infection in the United States, 1988 through 1994. N Engl J Med. 1999;341556- 562
Link to Article
Friedman  LSDienstag  JLWatkins  E  et al.  Evaluation of blood donors with elevated serum alanine aminotransferase levels. Ann Intern Med. 1987;107137- 144
Link to Article
Aach  RDSzmuness  WMosley  JW  et al.  Serum alanine aminotransferase of donors in relation to the risk of non-A, non-B hepatitis in recipients: the transfusion-transmitted viruses study. N Engl J Med. 1981;304989- 994
Link to Article
Cable  RBadon  SPray  CPopovsky  MA Limited utility of alanine aminotransferase screening of hepatitis C antibody-screened blood donors. Transfusion. 1997;37206- 210
Link to Article
Allison  MCMills  PR Screening asymptomatic people at high risk for hepatitis C: the case against. BMJ. 1996;3121349- 1350
Link to Article
Seymour  CA Screening asymptomatic people at high risk for hepatitis C: the case for. BMJ. 1996;3121347- 1348
Link to Article
Wang  CSChang  TTChou  P Differing characteristics of hepatitis B and C risk factors among elders in a rural area in Taiwan. J Gerontol A Biol Sci Med Sci. 1998;53M107- M111
Link to Article
Wang  CSChang  TTChou  P Differences in risk factors for either a hepatitis B carrier or anti-hepatitis C+ in a hepatoma-hyperendemic area in rural Taiwan. J Clin Epidemiol. 1998;51733- 738
Link to Article

Figures

Place holder to copy figure label and caption

A, The scatterplot of the prevalence of anti-hepatitis C virus (HCV)(+) vs elevated serum alanine aminotransferase (ALT) levels (≥40 U/L) (Spearman rank correlation coefficient, r = 0.91; P<.001). B, The scatterplot of the prevalence of hepatitis B surface antigens (HBsAg)(+) vs elevated serum ALT levels (Spearman rank correlation coefficient, r = −0.05; P = .87).

Graphic Jump Location

Tables

References

Di Bisceglie  AM Hepatitis C. Lancet. 1998;351351- 355
Link to Article
Hoofnagle  JH Hepatitis C: the clinical spectrum of disease. Hepatology. 1997;26 ((suppl 1)) 15S- 20S
Link to Article
Alter  MJKruszon-Moran  DNainan  OV  et al.  The prevalence of hepatitis C virus infection in the United States, 1988 through 1994. N Engl J Med. 1999;341556- 562
Link to Article
Friedman  LSDienstag  JLWatkins  E  et al.  Evaluation of blood donors with elevated serum alanine aminotransferase levels. Ann Intern Med. 1987;107137- 144
Link to Article
Aach  RDSzmuness  WMosley  JW  et al.  Serum alanine aminotransferase of donors in relation to the risk of non-A, non-B hepatitis in recipients: the transfusion-transmitted viruses study. N Engl J Med. 1981;304989- 994
Link to Article
Cable  RBadon  SPray  CPopovsky  MA Limited utility of alanine aminotransferase screening of hepatitis C antibody-screened blood donors. Transfusion. 1997;37206- 210
Link to Article
Allison  MCMills  PR Screening asymptomatic people at high risk for hepatitis C: the case against. BMJ. 1996;3121349- 1350
Link to Article
Seymour  CA Screening asymptomatic people at high risk for hepatitis C: the case for. BMJ. 1996;3121347- 1348
Link to Article
Wang  CSChang  TTChou  P Differing characteristics of hepatitis B and C risk factors among elders in a rural area in Taiwan. J Gerontol A Biol Sci Med Sci. 1998;53M107- M111
Link to Article
Wang  CSChang  TTChou  P Differences in risk factors for either a hepatitis B carrier or anti-hepatitis C+ in a hepatoma-hyperendemic area in rural Taiwan. J Clin Epidemiol. 1998;51733- 738
Link to Article

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