A large HCV transmission network enabled a fast-growing HIV outbreak in rural Indiana, 2015Research in context
Sumathi Ramachandran,
Hong Thai,
Joseph C. Forbi,
Romeo Regi Galang,
Zoya Dimitrova,
Guo-liang Xia,
Yulin Lin,
Lili T. Punkova,
Pamela R. Pontones,
Jessica Gentry,
Sara J. Blosser,
Judith Lovchik,
William M. Switzer,
Eyasu Teshale,
Philip Peters,
John Ward,
Yury Khudyakov
Affiliations
Sumathi Ramachandran
Centers for Disease Control and Prevention, Molecular Epidemiology and Bioinformatics Laboratory, Division of Viral hepatitis, USA; Corresponding author.
Hong Thai
Centers for Disease Control and Prevention, Molecular Epidemiology and Bioinformatics Laboratory, Division of Viral hepatitis, USA
Joseph C. Forbi
Centers for Disease Control and Prevention, Molecular Epidemiology and Bioinformatics Laboratory, Division of Viral hepatitis, USA
Romeo Regi Galang
Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, GA, USA
Zoya Dimitrova
Centers for Disease Control and Prevention, Molecular Epidemiology and Bioinformatics Laboratory, Division of Viral hepatitis, USA
Guo-liang Xia
Centers for Disease Control and Prevention, Molecular Epidemiology and Bioinformatics Laboratory, Division of Viral hepatitis, USA
Yulin Lin
Centers for Disease Control and Prevention, Molecular Epidemiology and Bioinformatics Laboratory, Division of Viral hepatitis, USA
Lili T. Punkova
Centers for Disease Control and Prevention, Molecular Epidemiology and Bioinformatics Laboratory, Division of Viral hepatitis, USA
Pamela R. Pontones
Indiana State Department of Health, USA
Jessica Gentry
Indiana State Department of Health, USA
Sara J. Blosser
Indiana State Department of Health, USA
Judith Lovchik
Indiana State Department of Health, USA
William M. Switzer
Centers for Disease Control and Prevention, Division of HIV/AIDS Prevention, USA
Eyasu Teshale
Centers for Disease Control and Prevention, Molecular Epidemiology and Bioinformatics Laboratory, Division of Viral hepatitis, USA
Philip Peters
Centers for Disease Control and Prevention, Division of HIV/AIDS Prevention, USA
John Ward
Centers for Disease Control and Prevention, Molecular Epidemiology and Bioinformatics Laboratory, Division of Viral hepatitis, USA
Yury Khudyakov
Centers for Disease Control and Prevention, Molecular Epidemiology and Bioinformatics Laboratory, Division of Viral hepatitis, USA
Background: A high prevalence (92.3%) of hepatitis C virus (HCV) co-infection among HIV patients identified during a large HIV outbreak associated with injection of oxymorphone in Indiana prompted genetic analysis of HCV strains. Methods: Molecular epidemiological analysis of HCV-positive samples included genotyping, sampling intra-host HVR1 variants by next-generation sequencing (NGS) and constructing transmission networks using Global Hepatitis Outbreak and Surveillance Technology (GHOST). Findings: Results from the 492 samples indicate predominance of HCV genotypes 1a (72.2%) and 3a (20.4%), and existence of 2 major endemic NS5B clusters involving 49.8% of the sequenced strains. Among 76 HIV co-infected patients, 60.5% segregated into 2 endemic clusters. NGS analyses of 281 cases identified 826,917 unique HVR1 sequences and 51 cases of mixed subtype/genotype infections. GHOST mapped 23 transmission clusters. One large cluster (n = 130) included 50 cases infected with ≥2 subtypes/genotypes and 43 cases co-infected with HIV. Rapid strain replacement and superinfection with different strains were found among 7 of 12 cases who were followed up. Interpretation: GHOST enabled mapping of HCV transmission networks among persons who inject drugs (PWID). Findings of numerous transmission clusters, mixed-genotype infections and rapid succession of infections with different HCV strains indicate a high rate of HCV spread. Co-localization of HIV co-infected patients in the major HCV clusters suggests that HIV dissemination was enabled by existing HCV transmission networks that likely perpetuated HCV in the community for years. Identification of transmission networks is an important step to guiding efficient public health interventions for preventing and interrupting HCV and HIV transmission among PWID. Fund: US Centers for Disease Control and Prevention, and US state and local public health departments.
