Diagnosis of patients with suspected chronic hepatitis C infection

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"documento" => "article" "crossmark" => 0 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "fla" "cita" => "Ann Hepatol. 2010;9 Supl 1:S39-42" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 51 "formatos" => array:3 [ "EPUB" => 12 "HTML" => 19 "PDF" => 20 ] ] "en" => array:10 [ "idiomaDefecto" => true "titulo" => "Usefulness of liver biopsy in chronic hepatitis C" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "S39" "paginaFinal" => "S42" ] ] "contieneResumen" => array:1 [ "en" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Edna Strauss" "autores" => array:1 [ 0 => array:2 [ "nombre" => "Edna" "apellidos" => "Strauss" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1665268119317223?idApp=UINPBA00004N" "url" => "/16652681/00000009000000S1/v1_201906221034/S1665268119317223/v1_201906221034/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S166526811931720X" "issn" => "16652681" "doi" => "10.1016/S1665-2681(19)31720-X" "estado" => "S300" "fechaPublicacion" => "2010-01-01" "aid" => "71382" "copyright" => "Fundación Clínica Médica Sur, A.C." "documento" => "article" "crossmark" => 0 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "fla" "cita" => "Ann Hepatol. 2010;9 Supl 1:S30-3" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 56 "formatos" => array:3 [ "EPUB" => 10 "HTML" => 20 "PDF" => 26 ] ] "en" => array:11 [ "idiomaDefecto" => true "titulo" => "Routes of transmission of hepatitis C virus" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "S30" "paginaFinal" => "S33" ] ] "contieneResumen" => array:1 [ "en" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "f0005" "etiqueta" => "Figure 1." "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 644 "Ancho" => 1003 "Tamanyo" => 31289 ] ] "descripcion" => array:1 [ "en" => "Seroprevalence of HCV infection in a representative sample of the general population of Santiago older than 20 years. N = 1115. Adapted from.<a class="elsevierStyleCrossRef" href="#bib0030">6</a>This pattern of age-specific prevalence is suggestive of infection in the distant past, mainly by unsafe injection practices and blood transfusion." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Alejandro Soza, Arnoldo Riquelme, Marco Arrese" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Alejandro" "apellidos" => "Soza" ] 1 => array:2 [ "nombre" => "Arnoldo" "apellidos" => "Riquelme" ] 2 => array:2 [ "nombre" => "Marco" "apellidos" => "Arrese" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S166526811931720X?idApp=UINPBA00004N" "url" => "/16652681/00000009000000S1/v1_201906221034/S166526811931720X/v1_201906221034/en/main.assets" ] "en" => array:16 [ "idiomaDefecto" => true "titulo" => "Diagnosis of patients with suspected chronic hepatitis C infection" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "S34" "paginaFinal" => "S38" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Adrián Gadano, Omar Galdame, Sebastián Marciano" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Adrián" "apellidos" => "Gadano" "email" => array:1 [ 0 => "adrian.gadano@hospitalitaliano.org.ar" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "aff1" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor1" ] ] ] 1 => array:3 [ "nombre" => "Omar" "apellidos" => "Galdame" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "aff1" ] ] ] 2 => array:3 [ "nombre" => "Sebastián" "apellidos" => "Marciano" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "aff1" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:3 [ "entidad" => "Sección Hepatología. Hospital Italiano de Buenos Aires - Argentina." "etiqueta" => "*" "identificador" => "aff1" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor1" "etiqueta" => "*" "correspondencia" => "Correspondence and reprint request:" ] ] ] ] "textoCompleto" => "IntroductionThere is an important population of patients who are currently infected with hepatitis C virus (HCV) but who are undiagnosed and asymptomatic. The optimal approach to detecting HCV infection involves screening for risk factors of exposure to the virus and only testing selected individuals at a risk.Throughout the world, blood transfusions from infectious donors, unsafe therapeutic injection practices, and illegal intravenous drug use have been the predominant modes of transmission of HCV infection. In most developed countries, blood donor testing has virtually eliminated transfusion-related transmission of HCV, and nosocomial and iatrogenic transmission is uncommon. In these countries, illegal intravenous drug use has been identified as the major risk factor during the past 40 years and the highest prevalence of infection is found in young to middle-aged adults. In many developing countries, unsafe therapeutic injection practices appears to be responsible for the geographic clustering of high rates of infection because of inadequate or nonexistent supplies of sterile syringes, administration of injections by nonprofessionals outside the medical setting, and administration of medications by injection. In some countries, the risk from unsafe therapeutic injections has decreased, as indicated by high prevalence rates of HCV infection only in older people. In other countries, this transmission mode continues to be a major source of HCV infection, with high prevalence rates of HCV infection found among people in all age groups.Characterizing the epidemiology of hepatitis C in individual countries is crucial to developing and implementing effective preventive measures. For some countries, ensuring safe blood supplies and healthcare-related procedures is the highest priority. For others, the priorities are the prevention of illegal injection drug use, harm reduction counseling, and testing to identify HCV-infected people for medical evaluation and management.<a class="elsevierStyleCrossRef" href="#bib0005">1</a>,<a class="elsevierStyleCrossRef" href="#bib0010">2</a>Because symptoms are generally absent in individuals with chronic HCV infection, recognition of infection requires risk factor screening, which should be performed, when indicated, in combination with appropriate HCV testing and counseling.<a class="elsevierStyleCrossRef" href="#bib0015">3</a><a class="elsevierStyleCrossRef" href="#t0005">Table 1</a> lists people who should be routinely screened for HCV infection.<a class="elsevierStyleCrossRef" href="#bib0020">4</a><elsevierMultimedia ident="t0005"></elsevierMultimedia>Diagnosis of Chronic Hepatitis CLaboratory testingThe repertoire of virological markers currently used for the clinical management of patients with hepatitis C includes serologic assays (ELISA or immunoblot assays), which detect specific antibodies (IgG) to HCV, and virological assays, which detect serum, HCV RNA by highly sensitive qualitative and quantitative techniques. These assays play no role in the assessment of disease severity or prognosis.The use of serologic and virological tests has become essential in the management of HCV infection in order to:<ul class="elsevierStyleList" id="li0020"><li class="elsevierStyleListItem" id="list0075">•Diagnose infection.</li><li class="elsevierStyleListItem" id="list0080">•Assess the virological response to therapy and guide treatment decisions.</li></ul>Serologic assaysTests that detect anti-HCV are used both to screen for and to diagnose HCV infection. Such tests detect antibodies directed against various HCV epitopes in plasma or in serum. Three enzyme immunoassays (EIAs) that have been approved by the US Food and Drug Administration (FDA) for clinical use are the Abbott HCV EIA 2.0 (Abbott Laboratories, Abbott Park, IL), ORTHO HCV Version 3.0 ELISA (Ortho-Clinical Diagnostics, Raritan, NJ), and the enhanced chemiluminescence immunoassay (CIA) VITROS Anti-HCV assay (Ortho-Clinical Diagnostics, Raritan, NJ). The specificity of current EIAs for anti-HCV is greater than 99%;<a class="elsevierStyleCrossRef" href="#bib0025">5</a> however, sensitivity is more difficult to evaluate.These tests can occasionally provide false positive results, which is why confirmation using virological assays to determine HCV RNA may be necessary. Undertaking confirmation tests is essential in patients with normal alanino aminotransferase (ALT) levels and in patients with elevated levels of gamma globulin. Outside these circumstances, as for the great majority of patients who are anti-HCV positive with elevated ALT levels, it is not essential to carry out confirmation tests.<a class="elsevierStyleCrossRef" href="#bib0030">6</a>,<a class="elsevierStyleCrossRef" href="#bib0035">7</a>The recombinant immunoblot assay Chiron RIBA HCV 3.0 SIA is also FDA approved. However, the widespread availability of nucleic acid testing has rendered RIBA testing for HCV clinically obsolete.<a class="elsevierStyleCrossRef" href="#bib0040">8</a>,<a class="elsevierStyleCrossRef" href="#bib0045">9</a>Virological assaysHistorically, the qualitative assays have been more sensitive. With the recent availability of realtime polymerase chain reaction (PCR)-based assays and transcription-mediated amplification (TMA) assays, with a sensitivity of 10–50 IU/mL, qualitative assays are being replaced in most settings by highly sensitive quantitative real-time PCR assays.<a class="elsevierStyleCrossRef" href="#bib0050">10</a>,<a class="elsevierStyleCrossRef" href="#bib0055">11</a>Another virological assay is the HCV core antigen EIA assay, which can detect total HCV core antigen in serum. The HCV core antigen levels are expressed in pg/mL and closely correlate with HCV RNA levels. One picogram of HCV core antigen is equivalent to approximately 8,000 IU of HCV RNA. Although the HCV core antigen assay can be used as a surrogate marker of HCV replication to monitor the early virological response during antiviral therapy, its clinical use is limited by the low sensitivity as the current version of the assay does not detect HCV core antigen below an HCV RNA level of 20,000 IU/mL.<a class="elsevierStyleCrossRef" href="#bib0060">12</a>All currently available assays have excellent specificity, in the range of 98 to 99%. Since the IUs have been refined and standardized across laboratories throughout the world, they are now the preferred unit for reporting test results, rather than viral copy number.<a class="elsevierStyleCrossRef" href="#bib0065">13</a>,<a class="elsevierStyleCrossRef" href="#bib0070">14</a>These assays are mainly used in the early monitoring of the virological response to antiviral therapy and in the prediction of treatment outcome. For monitoring purposes, it is important to use the same laboratory test before and during therapy.The commercial assays available for the detection (qualitative assays) or quantification (quantitative assays) of HCV RNA are listed in <a class="elsevierStyleCrossRef" href="#t0010">Tables 2</a> and <a class="elsevierStyleCrossRef" href="#t0015">3</a>.<elsevierMultimedia ident="t0010"></elsevierMultimedia><elsevierMultimedia ident="t0015"></elsevierMultimedia>Diagnosis of chronic HCV infection and interpretation of assaysIn patients with clinical or biological signs of chronic liver disease, screening for chronic HCV infection generally requires testing for antibodies against both HCV (anti-HCV) and HCV RNA. A sensitive quantitative HCV RNA assay is recommended for diagnosis because it also provides information on the viremia. Although here we recommend the use of quantitative assays, their use in Latin American countries will depend on the availability of tests.The differentiation between acute and chronic HCV infection depends on the clinical presentation, namely the presence of symptoms, such as jaundice, and whether or not there is a prior history of prolonged elevated ALT levels. After acute exposure, detection of HCV RNA usually precedes the detection of antibody reactivity in serum; HCV RNA can be identified as early as two weeks following exposure whereas anti-HCV antibodies are generally not detected before 8–12 weeks. The positive response may vary between these two markers of HCV infection, requiring careful analysis for interpretation <a class="elsevierStyleCrossRef" href="#t0020">(Table 4)</a>.<elsevierMultimedia ident="t0020"></elsevierMultimedia>It is possible for both anti-HCV and HCV RNA to be positively identified in a patient with a recent elevation of ALT levels. This scenario is consistent with either acute HCV infection when there is a recent risk of exposure, with an exacerbation of a chronic HCV infection, or with an acute hepatitis of other etiology in a patient with chronic HCV infection. Another possibility is the detection of anti-HCV but not HCV RNA. This scenario most commonly represent a recovery from HCV infection. Less likely it may represent an acute HCV infection during a period of transient clearance of HCV RNA, an anti-HCV false positive or an HCV RNA false negative result. The reverse scenario, a negative anti-HCV with a positive HCV RNA, can be seen in the early stage of an acute infection prior to the development of antibodies and in cases of chronic infection in immunosuppressed patients. Alternatively, it may represent a false positive the HCV RNA result. For all cases, retesting for anti-HCV and HCV RNA 4–6 months later should resolve the issue. Finally, if the patient has elevated ALT levels but the tests for anti-HCV and HCV RNA are negative, both acute and chronic hepatitis C may be excluded and another diagnosis should be considered.Approximately 30% of the patients with chronic HCV infection have normal ALT levels at diagnosis, regardless of the age and gender, and many of them maintain normal liver function tests during prolonged follow-up. Reactivation of liver disease with ALT flares may be seen in a significant number of these cases over time. Some of these HCV patients with normal ALT levels have significant fibrosis or cirrhosis, as shown by liver biopsy. Virological or biochemical testing cannot predict the presence of significant liver disease or the risk of future ALT flares.<a class="elsevierStyleCrossRef" href="#bib0075">15</a>Recommendations<ul class="elsevierStyleList" id="li0025"><li class="elsevierStyleListItem" id="list0085">1.Patients suspected of having acute or chronic HCV infection should first be tested for anti-HCV (Class I, Level B).</li><li class="elsevierStyleListItem" id="list0090">2.HCV RNA testing should be performed in:<ul class="elsevierStyleList" id="li0030"><li class="elsevierStyleListItem" id="list0095">a)Patients who test positive for anti-HCV (Class I, Level B).</li><li class="elsevierStyleListItem" id="list0100">b)Patients for whom antiviral treatment is being considered, using a sensitive quantitative assay (Class I, Level A).</li><li class="elsevierStyleListItem" id="list0105">c)Patients with unexplained liver disease whose anti-HCV test is negative and who are immunosuppresed or suspected of having acute HCV infection (Class I, Level B).</li></ul></li><li class="elsevierStyleListItem" id="list0110">3.HCV genotyping should be performed in all HCV-infected patients prior to interferon-based treatment in order to determine the dose and duration of therapy and to estimate the likelihood of response (Class I, Level A).</li></ul>Indiscriminate screening is not recommended for:<ul class="elsevierStyleList" id="li0035"><li class="elsevierStyleListItem" id="list0115">a)The general population.</li><li class="elsevierStyleListItem" id="list0120">b)Non household contacts of HCV infected patients.</li><li class="elsevierStyleListItem" id="list0125">c)Pregnant women.</li><li class="elsevierStyleListItem" id="list0130">d)Health care workers who are not at significant risk.</li></ul>" "textoCompletoSecciones" => array:1 [ "secciones" => array:6 [ 0 => array:3 [ "identificador" => "xres1210331" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abs0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1126748" "titulo" => "Key words" ] 2 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 3 => array:3 [ "identificador" => "sec0010" "titulo" => "Diagnosis of Chronic Hepatitis C" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Laboratory testing" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Serologic assays" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Virological assays" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Diagnosis of chronic HCV infection and interpretation of assays" ] ] ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Recommendations" ] 5 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2010-03-20" "fechaAceptado" => "2010-04-20" "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Key words" "identificador" => "xpalclavsec1126748" "palabras" => array:4 [ 0 => "Hepatitis C" 1 => "Diagnosis" 2 => "Risk factors" 3 => "Serologic tests" ] ] ] ] "tieneResumen" => true "resumen" => array:1 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "The current optimal approach to detecting hepatitis C virus (HCV) infection involves screening people for risk factors and only testing selected individuals at risk. Blood transfusion from infectious donors, unsafe therapeutic injection practices, and illegal intravenous drug use have been the predominant modes of transmissiom of HCV infection. Virological markers that are currently used for the clinical management of patients with hepatitis C include serologic assays (ELISA or immunoblot assays), which detect specific antibodies (IgG) to HCV, and virological assays, which detect serum HCV RNA, by highly sensitive qualitative and quantitative techniques. The applicability of these tests is for the diagnoses and monitoring of the treatment but they have no role in the assessment of disease severity or prognosis. Patients diagnosed with HCV infection must be educated in order to avoid the spread of the disease to other people." ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "t0005" "etiqueta" => "Table 1." "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "Ghany MG, Strader DB, Thomas DL, Seeff LB. Diagnosis, Management and treatment of Hepatitis C: an update. Hepatology 2009; 49(4):1335–74." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle"><ul class="elsevierStyleList" id="li0005"><li class="elsevierStyleListItem" id="list0005">•People who have injected illicit drugs in the recent or remote past, including those who have injected only once and do not consider themselves to be drug users.</li><li class="elsevierStyleListItem" id="list0010">•People with conditions associated with a high prevalence of HCV infection including those:<ul class="elsevierStyleList" id="li0010"><li class="elsevierStyleListItem" id="list0015">°With HIV infection.</li><li class="elsevierStyleListItem" id="list0020">°With hemophilia who received clotting factor concentrates prior to 1987.</li><li class="elsevierStyleListItem" id="list0025">°Who have ever received hemodialysis.</li><li class="elsevierStyleListItem" id="list0030">°With unexplained abnormal liver function tests.</li></ul></li><li class="elsevierStyleListItem" id="list0035">•Recipients of transfusions or organ transplants prior to July 1992 including persons who:<ul class="elsevierStyleList" id="li0015"><li class="elsevierStyleListItem" id="list0040">°Were notified that they had received blood from a donor who later tested positive for HCV infection.</li><li class="elsevierStyleListItem" id="list0045">°Received a transfusion of blood or blood products.</li><li class="elsevierStyleListItem" id="list0050">°Received an organ transplant.</li></ul></li><li class="elsevierStyleListItem" id="list0055">•Children born to HCV-infected mothers.</li><li class="elsevierStyleListItem" id="list0060">•Healthcare, emergency medical, and public safety workers after a needle stick injury or mucosal exposure to HCV-positive blood.</li><li class="elsevierStyleListItem" id="list0065">•People who are or have been in prison.</li><li class="elsevierStyleListItem" id="list0070">•Current sexual partners of HCV-infected people.</li></ul> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2066280.png" ] ] ] ] "descripcion" => array:1 [ "en" => "People for whom HCV screening is recommended." ] ] 1 => array:7 [ "identificador" => "t0010" "etiqueta" => "Table 2." "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "RT-PCR: Reverse transcription polymerase chain reaction. TMA: Transcription-mediated amplification. Ghany MG, Strader DB, Thomas DL, Seeff LB. Diagnosis, Management and treatment of Hepatitis C: an update. Hepatology 2009;49(4):1335–1374." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="middle" scope="col">Assay and manufacturer \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="middle" scope="col">Method of detection \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="middle" scope="col">Lower limit IU/mL \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="middle" scope="col">Setting \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="middle">Amplicor HCV v2.0 (Roche Molecular Systems) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">Manual RT-PCR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">Diagnosis and monitoring \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="middle">Cobas Amplicor HCV v2.0 (Roche Molecular Systems) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">Semiautomated RT-PCR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">Diagnosis and monitoring \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="middle">Ampliscreen (Roche Molecular Systems) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">Semiautomated RT-PCR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">< 50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">Blood screening \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="middle">Versant HCV RNA Qualitative Assay (Siemens) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">Semiautomated TMA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">Diagnosis and monitoring \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="middle">Procleix HIV-1/HCV Assay (Chiron Corporation) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">Manual TMA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">< 50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">Blood screening \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2066281.png" ] ] ] ] "descripcion" => array:1 [ "en" => "FDA-approved qualitative assays for detection of HCV RNA." ] ] 2 => array:7 [ "identificador" => "t0015" "etiqueta" => "Table 3." "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "RT-PCR: Reverse transcription polymerase chain reaction. TMA: Transcription-mediated amplification. Ghany MG, Strader DB, Thomas DL, Seeff LB. Diagnosis, Management and treatment of Hepatitis C: an update. Hepatology 2009;49(4):1335–1374." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="middle" scope="col">Assay \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="middle" scope="col">Method \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="middle" scope="col">IU/mL Conversion factor \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="middle" scope="col">Dynamic range (IU/mL) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="middle" scope="col">FDA approved \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="middle">• Amplicor HCV Monitor (Roche Molecular Systems) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">Manual RT-PCR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">0.9 copies/mL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">600-500,000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="middle">• Cobas Amplicor HCV Monitor V2.0 (Roche Molecular Systems) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">Semiautomated RT-PCR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">2.7 copies/mL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">600-500,000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="middle">• Versant HCV RNA 3.0 Assay (bDNA) (Siemens Diagnostics) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">Semiautomated bDNA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">5.2 copies/mL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">615-7,700,000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="middle">• LCx HCV RNA-Quantitative Assay (Abbott Diagnostics) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">Semiautomated RT-PCR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">3.8 copies/mL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">25-2,630,000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="middle">• SuperQuant (National Genetics Institute) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">Semiautomated RT-PCR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">3.4 copies/mL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">30-1,470,000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="middle">• Cobas Taqman HCV Test (Roche Molecular Systems) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">Semiautomated real-time PCR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">43-69,000,000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="middle">• Abbott RealTime (Abbott Diagnostics) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">Semiautomated RT-PCR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">12-100,000,000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">No \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2066283.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Available assays for quantification of HCV in serum/plasma." ] ] 3 => array:7 [ "identificador" => "t0020" "etiqueta" => "Table 4." "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "Ghany MG, Strader DB, Thomas DL, Seeff LB. Diagnosis, Management and treatment of Hepatitis C: an update. Hepatology 2009;49(4):1335–1374." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="middle">Interpretation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="middle">Positive-Positive: acute or chronic HCV depending on the clinical context. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="middle">Positive-Negative: resolution of HCV; acute HCV during period of low-level viremia. False Anti-HCV positive. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="middle">Negative-Positive: early acute HCV infection; chronic HCV in immunosuppressed patients; false positive HCV RNA test. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="middle">Negative-Negative: absence of HCV infection. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2066282.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Interpretation of HCV assays: anti-HCV vs HCV RNA." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bs0005" "bibliografiaReferencia" => array:15 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hepatitis C: fact vs. fiction." "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "Alter MJ" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "LibroEditado" => array:5 [ "editores" => "MargolisHS, AlterMJ, LiangTJ, DienstagJL" "titulo" => "Viral Hepatitis and Liver Disease." "paginaInicial" => "310" "paginaFinal" => "315" "serieFecha" => "2002" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prevalence of hepatitis C virus infection in the United States." "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "Alter MJ" 1 => "Kruszon MD" 2 => "Nainan OV" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJM199908193410802" "Revista" => array:6 [ "tituloSerie" => "N Engl J Med" "fecha" => "1999" "volumen" => "341" "paginaInicial" => "556" "paginaFinal" => "562" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10451460" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Testing for hepatitis C virus infection should be routine for persons at increased risk for infection." "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "Alter MJ" 1 => "Seeff LB" 2 => "Bacon BR" 3 => "Thomas DL" 4 => "Rigsby MO" 5 => "Di Bisceglie AM" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.7326/0003-4819-141-9-200411020-00013" "Revista" => array:6 [ "tituloSerie" => "Ann Intern Med" "fecha" => "2004" "volumen" => "141" "paginaInicial" => "715" "paginaFinal" => "717" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15520428" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Recommendations for prevention and control of hepatitis C virus (HCV) infection and HCV related chronic disease." "autores" => array:1 [ 0 => array:2 [ "colaboracion" => "Centers for Disease Control and Prevention." "etal" => false ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "MMWR Recomm Rep" "fecha" => "1998" "volumen" => "47" "paginaInicial" => "1" "paginaFinal" => "39" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9809743" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sensitivity and specificity of third-generation hepatitis C virus antibody detection assays: an analysis of the literature." 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Adrián Gadano

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adrian.gadano@hospitalitaliano.org.ar

Correspondence and reprint request:

, Omar Galdame*, Sebastián Marciano*

* Sección Hepatología. Hospital Italiano de Buenos Aires - Argentina.

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In these countries&#44; illegal intravenous drug use has been identified as the major risk factor during the past 40 years and the highest prevalence of infection is found in young to middle-aged adults&#46; In many developing countries&#44; unsafe therapeutic injection practices appears to be responsible for the geographic clustering of high rates of infection because of inadequate or nonexistent supplies of sterile syringes&#44; administration of injections by nonprofessionals outside the medical setting&#44; and administration of medications by injection&#46; In some countries&#44; the risk from unsafe therapeutic injections has decreased&#44; as indicated by high prevalence rates of HCV infection only in older people&#46; In other countries&#44; this transmission mode continues to be a major source of HCV infection&#44; with high prevalence rates of HCV infection found among people in all age groups&#46;</p><p id="p0085" class="elsevierStylePara elsevierViewall">Characterizing the epidemiology of hepatitis C in individual countries is crucial to developing and implementing effective preventive measures&#46; For some countries&#44; ensuring safe blood supplies and healthcare-related procedures is the highest priority&#46; For others&#44; the priorities are the prevention of illegal injection drug use&#44; harm reduction counseling&#44; and testing to identify HCV-infected people for medical evaluation and management&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="p0090" class="elsevierStylePara elsevierViewall">Because symptoms are generally absent in individuals with chronic HCV infection&#44; recognition of infection requires risk factor screening&#44; which should be performed&#44; when indicated&#44; in combination with appropriate HCV testing and counseling&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a><a class="elsevierStyleCrossRef" href="#t0005">Table 1</a> lists people who should be routinely screened for HCV infection&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><elsevierMultimedia ident="t0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Diagnosis of Chronic Hepatitis C</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Laboratory testing</span><p id="p0095" class="elsevierStylePara elsevierViewall">The repertoire of virological markers currently used for the clinical management of patients with hepatitis C includes serologic assays &#40;ELISA or immunoblot assays&#41;&#44; which detect specific antibodies &#40;IgG&#41; to HCV&#44; and virological assays&#44; which detect serum&#44; HCV RNA by highly sensitive qualitative and quantitative techniques&#46; These assays play no role in the assessment of disease severity or prognosis&#46;</p><p id="p0100" class="elsevierStylePara elsevierViewall">The use of serologic and virological tests has become essential in the management of HCV infection in order to&#58;<ul class="elsevierStyleList" id="li0020"><li class="elsevierStyleListItem" id="list0075"><span class="elsevierStyleLabel">&#8226;</span><p id="p0105" class="elsevierStylePara elsevierViewall">Diagnose infection&#46;</p></li><li class="elsevierStyleListItem" id="list0080"><span class="elsevierStyleLabel">&#8226;</span><p id="p0110" class="elsevierStylePara elsevierViewall">Assess the virological response to therapy and guide treatment decisions&#46;</p></li></ul></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Serologic assays</span><p id="p0115" class="elsevierStylePara elsevierViewall">Tests that detect anti-HCV are used both to screen for and to diagnose HCV infection&#46; Such tests detect antibodies directed against various HCV epitopes in plasma or in serum&#46; Three enzyme immunoassays &#40;EIAs&#41; that have been approved by the US Food and Drug Administration &#40;FDA&#41; for clinical use are the Abbott HCV EIA 2&#46;0 &#40;Abbott Laboratories&#44; Abbott Park&#44; IL&#41;&#44; ORTHO HCV Version 3&#46;0 ELISA &#40;Ortho-Clinical Diagnostics&#44; Raritan&#44; NJ&#41;&#44; and the enhanced chemiluminescence immunoassay &#40;CIA&#41; VITROS Anti-HCV assay &#40;Ortho-Clinical Diagnostics&#44; Raritan&#44; NJ&#41;&#46; The specificity of current EIAs for anti-HCV is greater than 99&#37;&#59;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> however&#44; sensitivity is more difficult to evaluate&#46;</p><p id="p0120" class="elsevierStylePara elsevierViewall">These tests can occasionally provide false positive results&#44; which is why confirmation using virological assays to determine HCV RNA may be necessary&#46; Undertaking confirmation tests is essential in patients with normal alanino aminotransferase &#40;ALT&#41; levels and in patients with elevated levels of gamma globulin&#46; Outside these circumstances&#44; as for the great majority of patients who are anti-HCV positive with elevated ALT levels&#44; it is not essential to carry out confirmation tests&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="p0125" class="elsevierStylePara elsevierViewall">The recombinant immunoblot assay Chiron RIBA HCV 3&#46;0 SIA is also FDA approved&#46; However&#44; the widespread availability of nucleic acid testing has rendered RIBA testing for HCV clinically obsolete&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Virological assays</span><p id="p0130" class="elsevierStylePara elsevierViewall">Historically&#44; the qualitative assays have been more sensitive&#46; With the recent availability of realtime polymerase chain reaction &#40;PCR&#41;-based assays and transcription-mediated amplification &#40;TMA&#41; assays&#44; with a sensitivity of 10&#8211;50 IU&#47;mL&#44; qualitative assays are being replaced in most settings by highly sensitive quantitative real-time PCR assays&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="p0135" class="elsevierStylePara elsevierViewall">Another virological assay is the HCV core antigen EIA assay&#44; which can detect total HCV core antigen in serum&#46; The HCV core antigen levels are expressed in pg&#47;mL and closely correlate with HCV RNA levels&#46; One picogram of HCV core antigen is equivalent to approximately 8&#44;000 IU of HCV RNA&#46; Although the HCV core antigen assay can be used as a surrogate marker of HCV replication to monitor the early virological response during antiviral therapy&#44; its clinical use is limited by the low sensitivity as the current version of the assay does not detect HCV core antigen below an HCV RNA level of 20&#44;000 IU&#47;mL&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="p0140" class="elsevierStylePara elsevierViewall">All currently available assays have excellent specificity&#44; in the range of 98 to 99&#37;&#46; Since the IUs have been refined and standardized across laboratories throughout the world&#44; they are now the preferred unit for reporting test results&#44; rather than viral copy number&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="p0145" class="elsevierStylePara elsevierViewall">These assays are mainly used in the early monitoring of the virological response to antiviral therapy and in the prediction of treatment outcome&#46; For monitoring purposes&#44; it is important to use the same laboratory test before and during therapy&#46;</p><p id="p0150" class="elsevierStylePara elsevierViewall">The commercial assays available for the detection &#40;qualitative assays&#41; or quantification &#40;quantitative assays&#41; of HCV RNA are listed in <a class="elsevierStyleCrossRef" href="#t0010">Tables 2</a> and <a class="elsevierStyleCrossRef" href="#t0015">3</a>&#46;</p><elsevierMultimedia ident="t0010"></elsevierMultimedia><elsevierMultimedia ident="t0015"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Diagnosis of chronic HCV infection and interpretation of assays</span><p id="p0155" class="elsevierStylePara elsevierViewall">In patients with clinical or biological signs of chronic liver disease&#44; screening for chronic HCV infection generally requires testing for antibodies against both HCV &#40;anti-HCV&#41; and HCV RNA&#46; A sensitive quantitative HCV RNA assay is recommended for diagnosis because it also provides information on the viremia&#46; Although here we recommend the use of quantitative assays&#44; their use in Latin American countries will depend on the availability of tests&#46;</p><p id="p0160" class="elsevierStylePara elsevierViewall">The differentiation between acute and chronic HCV infection depends on the clinical presentation&#44; namely the presence of symptoms&#44; such as jaundice&#44; and whether or not there is a prior history of prolonged elevated ALT levels&#46; After acute exposure&#44; detection of HCV RNA usually precedes the detection of antibody reactivity in serum&#59; HCV RNA can be identified as early as two weeks following exposure whereas anti-HCV antibodies are generally not detected before 8&#8211;12 weeks&#46; The positive response may vary between these two markers of HCV infection&#44; requiring careful analysis for interpretation <a class="elsevierStyleCrossRef" href="#t0020">&#40;Table 4&#41;</a>&#46;</p><elsevierMultimedia ident="t0020"></elsevierMultimedia><p id="p0165" class="elsevierStylePara elsevierViewall">It is possible for both anti-HCV and HCV RNA to be positively identified in a patient with a recent elevation of ALT levels&#46; This scenario is consistent with either acute HCV infection when there is a recent risk of exposure&#44; with an exacerbation of a chronic HCV infection&#44; or with an acute hepatitis of other etiology in a patient with chronic HCV infection&#46; Another possibility is the detection of anti-HCV but not HCV RNA&#46; This scenario most commonly represent a recovery from HCV infection&#46; Less likely it may represent an acute HCV infection during a period of transient clearance of HCV RNA&#44; an anti-HCV false positive or an HCV RNA false negative result&#46; The reverse scenario&#44; a negative anti-HCV with a positive HCV RNA&#44; can be seen in the early stage of an acute infection prior to the development of antibodies and in cases of chronic infection in immunosuppressed patients&#46; Alternatively&#44; it may represent a false positive the HCV RNA result&#46; For all cases&#44; retesting for anti-HCV and HCV RNA 4&#8211;6 months later should resolve the issue&#46; Finally&#44; if the patient has elevated ALT levels but the tests for anti-HCV and HCV RNA are negative&#44; both acute and chronic hepatitis C may be excluded and another diagnosis should be considered&#46;</p><p id="p0170" class="elsevierStylePara elsevierViewall">Approximately 30&#37; of the patients with chronic HCV infection have normal ALT levels at diagnosis&#44; regardless of the age and gender&#44; and many of them maintain normal liver function tests during prolonged follow-up&#46; Reactivation of liver disease with ALT flares may be seen in a significant number of these cases over time&#46; Some of these HCV patients with normal ALT levels have significant fibrosis or cirrhosis&#44; as shown by liver biopsy&#46; Virological or biochemical testing cannot predict the presence of significant liver disease or the risk of future ALT flares&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Recommendations</span><p id="p0175" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="li0025"><li class="elsevierStyleListItem" id="list0085"><span class="elsevierStyleLabel">1&#46;</span><p id="p0180" class="elsevierStylePara elsevierViewall">Patients suspected of having acute or chronic HCV infection should first be tested for anti-HCV <span class="elsevierStyleBold">&#40;Class I&#44; Level B&#41;&#46;</span></p></li><li class="elsevierStyleListItem" id="list0090"><span class="elsevierStyleLabel">2&#46;</span><p id="p0185" class="elsevierStylePara elsevierViewall">HCV RNA testing should be performed in&#58;<ul class="elsevierStyleList" id="li0030"><li class="elsevierStyleListItem" id="list0095"><span class="elsevierStyleLabel">a&#41;</span><p id="p0190" class="elsevierStylePara elsevierViewall">Patients who test positive for anti-HCV <span class="elsevierStyleBold">&#40;Class I&#44; Level B&#41;&#46;</span></p></li><li class="elsevierStyleListItem" id="list0100"><span class="elsevierStyleLabel">b&#41;</span><p id="p0195" class="elsevierStylePara elsevierViewall">Patients for whom antiviral treatment is being considered&#44; using a sensitive quantitative assay <span class="elsevierStyleBold">&#40;Class I&#44; Level A&#41;&#46;</span></p></li><li class="elsevierStyleListItem" id="list0105"><span class="elsevierStyleLabel">c&#41;</span><p id="p0200" class="elsevierStylePara elsevierViewall">Patients with unexplained liver disease whose anti-HCV test is negative and who are immunosuppresed or suspected of having acute HCV infection <span class="elsevierStyleBold">&#40;Class I&#44; Level B&#41;&#46;</span></p></li></ul></p></li><li class="elsevierStyleListItem" id="list0110"><span class="elsevierStyleLabel">3&#46;</span><p id="p0205" class="elsevierStylePara elsevierViewall">HCV genotyping should be performed in all HCV-infected patients prior to interferon-based treatment in order to determine the dose and duration of therapy and to estimate the likelihood of response <span class="elsevierStyleBold">&#40;Class I&#44; Level A&#41;&#46;</span></p></li></ul></p><p id="p0210" class="elsevierStylePara elsevierViewall">Indiscriminate screening is not recommended for&#58;<ul class="elsevierStyleList" id="li0035"><li class="elsevierStyleListItem" id="list0115"><span class="elsevierStyleLabel">a&#41;</span><p id="p0215" class="elsevierStylePara elsevierViewall">The general population&#46;</p></li><li class="elsevierStyleListItem" id="list0120"><span class="elsevierStyleLabel">b&#41;</span><p id="p0220" class="elsevierStylePara elsevierViewall">Non household contacts of HCV infected patients&#46;</p></li><li class="elsevierStyleListItem" id="list0125"><span class="elsevierStyleLabel">c&#41;</span><p id="p0225" class="elsevierStylePara elsevierViewall">Pregnant women&#46;</p></li><li class="elsevierStyleListItem" id="list0130"><span class="elsevierStyleLabel">d&#41;</span><p id="p0230" class="elsevierStylePara elsevierViewall">Health care workers who are not at significant risk&#46;</p></li></ul></p></span></span>"
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              "titulo" => "Virological assays"
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              "identificador" => "sec0030"
              "titulo" => "Diagnosis of chronic HCV infection and interpretation of assays"
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        "resumen" => "<span id="abs0005" class="elsevierStyleSection elsevierViewall"><p id="sp0025" class="elsevierStyleSimplePara elsevierViewall">The current optimal approach to detecting hepatitis C virus &#40;HCV&#41; infection involves screening people for risk factors and only testing selected individuals at risk&#46; Blood transfusion from infectious donors&#44; unsafe therapeutic injection practices&#44; and illegal intravenous drug use have been the predominant modes of transmissiom of HCV infection&#46; Virological markers that are currently used for the clinical management of patients with hepatitis C include serologic assays &#40;ELISA or immunoblot assays&#41;&#44; which detect specific antibodies &#40;IgG&#41; to HCV&#44; and virological assays&#44; which detect serum HCV RNA&#44; by highly sensitive qualitative and quantitative techniques&#46; The applicability of these tests is for the diagnoses and monitoring of the treatment but they have no role in the assessment of disease severity or prognosis&#46; Patients diagnosed with HCV infection must be educated in order to avoid the spread of the disease to other people&#46;</p></span>"
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          "leyenda" => "<p id="npara0005" class="elsevierStyleSimplePara elsevierViewall">Ghany MG&#44; Strader DB&#44; Thomas DL&#44; Seeff LB&#46; Diagnosis&#44; Management and treatment of Hepatitis C&#58; an update&#46; Hepatology 2009&#59; 49&#40;4&#41;&#58;1335&#8211;74&#46;</p>"
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                  \t\t\t\t  " align="center" valign="middle"><ul class="elsevierStyleList" id="li0005"><li class="elsevierStyleListItem" id="list0005"><span class="elsevierStyleLabel">&#8226;</span><p id="p0005" class="elsevierStylePara elsevierViewall">People who have injected illicit drugs in the recent or remote past&#44; including those who have injected only once and do not consider themselves to be drug users&#46;</p></li><li class="elsevierStyleListItem" id="list0010"><span class="elsevierStyleLabel">&#8226;</span><p id="p0010" class="elsevierStylePara elsevierViewall">People with conditions associated with a high prevalence of HCV infection including those&#58;<ul class="elsevierStyleList" id="li0010"><li class="elsevierStyleListItem" id="list0015"><span class="elsevierStyleLabel">&#176;</span><p id="p0015" class="elsevierStylePara elsevierViewall">With HIV infection&#46;</p></li><li class="elsevierStyleListItem" id="list0020"><span class="elsevierStyleLabel">&#176;</span><p id="p0020" class="elsevierStylePara elsevierViewall">With hemophilia who received clotting factor concentrates prior to 1987&#46;</p></li><li class="elsevierStyleListItem" id="list0025"><span class="elsevierStyleLabel">&#176;</span><p id="p0025" class="elsevierStylePara elsevierViewall">Who have ever received hemodialysis&#46;</p></li><li class="elsevierStyleListItem" id="list0030"><span class="elsevierStyleLabel">&#176;</span><p id="p0030" class="elsevierStylePara elsevierViewall">With unexplained abnormal liver function tests&#46;</p></li></ul></p></li><li class="elsevierStyleListItem" id="list0035"><span class="elsevierStyleLabel">&#8226;</span><p id="p0035" class="elsevierStylePara elsevierViewall">Recipients of transfusions or organ transplants prior to July 1992 including persons who&#58;<ul class="elsevierStyleList" id="li0015"><li class="elsevierStyleListItem" id="list0040"><span class="elsevierStyleLabel">&#176;</span><p id="p0040" class="elsevierStylePara elsevierViewall">Were notified that they had received blood from a donor who later tested positive for HCV infection&#46;</p></li><li class="elsevierStyleListItem" id="list0045"><span class="elsevierStyleLabel">&#176;</span><p id="p0045" class="elsevierStylePara elsevierViewall">Received a transfusion of blood or blood products&#46;</p></li><li class="elsevierStyleListItem" id="list0050"><span class="elsevierStyleLabel">&#176;</span><p id="p0050" class="elsevierStylePara elsevierViewall">Received an organ transplant&#46;</p></li></ul></p></li><li class="elsevierStyleListItem" id="list0055"><span class="elsevierStyleLabel">&#8226;</span><p id="p0055" class="elsevierStylePara elsevierViewall">Children born to HCV-infected mothers&#46;</p></li><li class="elsevierStyleListItem" id="list0060"><span class="elsevierStyleLabel">&#8226;</span><p id="p0060" class="elsevierStylePara elsevierViewall">Healthcare&#44; emergency medical&#44; and public safety workers after a needle stick injury or mucosal exposure to HCV-positive blood&#46;</p></li><li class="elsevierStyleListItem" id="list0065"><span class="elsevierStyleLabel">&#8226;</span><p id="p0065" class="elsevierStylePara elsevierViewall">People who are or have been in prison&#46;</p></li><li class="elsevierStyleListItem" id="list0070"><span class="elsevierStyleLabel">&#8226;</span><p id="p0070" class="elsevierStylePara elsevierViewall">Current sexual partners of HCV-infected people&#46;</p></li></ul>&nbsp;\t\t\t\t\t\t\n
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          "leyenda" => "<p id="npara0010" class="elsevierStyleSimplePara elsevierViewall">RT-PCR&#58; Reverse transcription polymerase chain reaction&#46; TMA&#58; Transcription-mediated amplification&#46; Ghany MG&#44; Strader DB&#44; Thomas DL&#44; Seeff LB&#46; Diagnosis&#44; Management and treatment of Hepatitis C&#58; an update&#46; Hepatology 2009&#59;49&#40;4&#41;&#58;1335&#8211;1374&#46;</p>"
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">Blood screening&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle">Versant HCV RNA Qualitative Assay &#40;Siemens&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">Semiautomated TMA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">Diagnosis and monitoring&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle">Procleix HIV-1&#47;HCV Assay &#40;Chiron Corporation&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">Manual TMA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">&#60; 50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">Blood screening&nbsp;\t\t\t\t\t\t\n
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          "leyenda" => "<p id="npara0015" class="elsevierStyleSimplePara elsevierViewall">RT-PCR&#58; Reverse transcription polymerase chain reaction&#46; TMA&#58; Transcription-mediated amplification&#46; Ghany MG&#44; Strader DB&#44; Thomas DL&#44; Seeff LB&#46; Diagnosis&#44; Management and treatment of Hepatitis C&#58; an update&#46; Hepatology 2009&#59;49&#40;4&#41;&#58;1335&#8211;1374&#46;</p>"
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                  \t\t\t\t  " align="center" valign="middle" scope="col">Method&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="middle" scope="col">IU&#47;mL Conversion factor&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="middle" scope="col">Dynamic range &#40;IU&#47;mL&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="middle">&#8226; Amplicor HCV Monitor &#40;Roche Molecular Systems&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="middle">Manual RT-PCR&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="middle">0&#46;9 copies&#47;mL&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="middle">600-500&#44;000&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="middle">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="middle">&#8226; Cobas Amplicor HCV Monitor V2&#46;0 &#40;Roche Molecular Systems&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">Semiautomated RT-PCR&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="middle">2&#46;7 copies&#47;mL&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="middle">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle">&#8226; Versant HCV RNA 3&#46;0 Assay &#40;bDNA&#41; &#40;Siemens Diagnostics&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">Semiautomated bDNA&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="middle">5&#46;2 copies&#47;mL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="center" valign="middle">615-7&#44;700&#44;000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="middle">&#8226; LCx HCV RNA-Quantitative Assay &#40;Abbott Diagnostics&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">Semiautomated RT-PCR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">3&#46;8 copies&#47;mL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="center" valign="middle">25-2&#44;630&#44;000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">Semiautomated RT-PCR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">3&#46;4 copies&#47;mL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">30-1&#44;470&#44;000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="middle">&#8226; Cobas Taqman HCV Test &#40;Roche Molecular Systems&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">Semiautomated real-time PCR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">43-69&#44;000&#44;000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle">&#8226; Abbott RealTime &#40;Abbott Diagnostics&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">Semiautomated RT-PCR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">12-100&#44;000&#44;000&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">No&nbsp;\t\t\t\t\t\t\n
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        "etiqueta" => "<span class="elsevierStyleBold">Table 4&#46;</span>"
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          "leyenda" => "<p id="npara0020" class="elsevierStyleSimplePara elsevierViewall">Ghany MG&#44; Strader DB&#44; Thomas DL&#44; Seeff LB&#46; Diagnosis&#44; Management and treatment of Hepatitis C&#58; an update&#46; Hepatology 2009&#59;49&#40;4&#41;&#58;1335&#8211;1374&#46;</p>"
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                  \t\t\t\t  " align="left" valign="middle">Positive-Positive&#58; acute or chronic HCV depending on the clinical context&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="middle">Negative-Positive&#58; early acute HCV infection&#59; chronic HCV in immunosuppressed patients&#59; false positive HCV RNA test&#46;&nbsp;\t\t\t\t\t\t\n
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      "titulo" => "References"
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        0 => array:2 [
          "identificador" => "bs0005"
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              "identificador" => "bib0005"
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                    0 => array:2 [
                      "titulo" => "Hepatitis C&#58; fact <span class="elsevierStyleItalic">vs&#46;</span> fiction&#46;"
                      "autores" => array:1 [
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                          "etal" => false
                          "autores" => array:1 [
                            0 => "Alter MJ"
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                    0 => array:1 [
                      "LibroEditado" => array:5 [
                        "editores" => "MargolisHS, AlterMJ, LiangTJ, DienstagJL"
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                        "serieFecha" => "2002"
                      ]
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                ]
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              "etiqueta" => "2&#46;"
              "referencia" => array:1 [
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevalence of hepatitis C virus infection in the United States&#46;"
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                        0 => array:2 [
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                            0 => "Alter MJ"
                            1 => "Kruszon MD"
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                  "host" => array:1 [
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                      "Revista" => array:6 [
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            2 => array:3 [
              "identificador" => "bib0015"
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              "referencia" => array:1 [
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Testing for hepatitis C virus infection should be routine for persons at increased risk for infection&#46;"
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                        0 => array:2 [
                          "etal" => false
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                            0 => "Alter MJ"
                            1 => "Seeff LB"
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                    0 => array:2 [
                      "doi" => "10.7326/0003-4819-141-9-200411020-00013"
                      "Revista" => array:6 [
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              "etiqueta" => "4&#46;"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Recommendations for prevention and control of hepatitis C virus &#40;HCV&#41; infection and HCV related chronic disease&#46;"
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                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "MMWR Recomm Rep"
                        "fecha" => "1998"
                        "volumen" => "47"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9809743"
                            "web" => "Medline"
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                ]
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            4 => array:3 [
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Sensitivity and specificity of third-generation hepatitis C virus antibody detection assays&#58; an analysis of the literature&#46;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "Colin C"
                            1 => "Lanoir D"
                            2 => "Touzet S"
                            3 => "Meyaud KL"
                            4 => "Bailly F"
                            5 => "Trepo C"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Viral Hepat"
                        "fecha" => "2001"
                        "volumen" => "8"
                        "paginaInicial" => "87"
                        "paginaFinal" => "95"
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                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11264728"
                            "web" => "Medline"
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            5 => array:3 [
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              "etiqueta" => "6&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Screening for hepatitis C virus in human immunodeficiency virus-infected individuals&#46;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "Thio CL"
                            1 => "Nolt KR"
                            2 => "Astemborski J"
                            3 => "Vlahov D"
                            4 => "Nelson KE"
                            5 => "Thomas DL"
                          ]
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Article information

ISSN: 16652681
Original language: English

DOI:10.1016/S1665-2681(19)31721-1

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Year/Month	Html	Pdf	Total

2024 November	3	1	4
2024 October	22	3	25
2024 September	29	6	35
2024 August	25	7	32
2024 July	36	3	39
2024 June	28	4	32
2024 May	47	7	54
2024 April	49	4	53
2024 March	25	8	33
2024 February	54	15	69
2024 January	103	4	107
2023 December	60	10	70
2023 November	52	4	56
2023 October	64	4	68
2023 September	33	8	41
2023 August	28	5	33
2023 July	4	7	11
2023 June	10	4	14
2023 May	11	7	18
2023 April	6	0	6
2023 March	5	2	7
2023 February	4	4	8
2023 January	5	5	10
2022 December	3	1	4
2022 November	5	9	14
2022 October	7	8	15
2022 September	7	7	14
2022 August	6	10	16
2022 July	4	14	18
2022 June	8	12	20
2022 May	7	9	16
2022 April	8	9	17
2022 March	3	8	11
2022 February	4	7	11
2022 January	4	9	13
2021 December	6	12	18
2021 November	11	14	25
2021 October	8	13	21
2021 September	3	9	12
2021 August	5	6	11
2021 July	7	15	22
2021 June	5	6	11
2021 May	7	7	14
2021 April	21	5	26
2021 March	8	6	14
2021 February	4	3	7
2021 January	5	13	18
2020 December	4	2	6
2020 November	2	3	5
2020 October	3	2	5
2020 September	5	4	9
2020 August	2	2	4
2020 July	2	2	4
2020 June	4	3	7
2020 May	3	5	8
2020 April	5	2	7
2020 March	11	4	15
2020 February	3	1	4
2020 January	1	1	2
2019 December	5	8	13
2019 November	3	3	6
2019 October	1	1	2
2019 September	4	0	4
2019 August	3	1	4
2019 July	2	4	6
2019 June	1	5	6

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