International Journal of Infectious Diseases 18 (2014) 90–93
Contents lists available at ScienceDirect
International Journal of Infectious Diseases journal homepage: www.elsevier.com/locate/ijid
Short Communication
Hepatitis C virus genotypes in Tirana, Albania§ Migena Haldeda a, Julien Baume b, Catherine Tamalet b,c, Melpomeni Bizhga a, Philippe Colson b,c,* a
Laboratory of Virology, University Hospital Center ‘‘Mother Teresa’’, Tirana, Albania Institut Hospitalo-Universitaire (IHU) Me´diterrane´e Infection, Poˆle des Maladies Infectieuses et Tropicales Clinique et Biologique, Fe´de´ration de Bacte´riologie-Hygie`ne-Virologie, Centre Hospitalo-Universitaire Timone, Assistance Publique – Hoˆpitaux de Marseille, 264 rue Saint-Pierre 13385, Marseille Cedex 05, France c URMITE UM 63 CNRS 7278 IRD 198 INSERM U1905, Aix-Marseille Univ., Faculte´s de Me´decine et de Pharmacie, Marseille, France b
A R T I C L E I N F O
S U M M A R Y
Article history: Received 22 May 2013 Received in revised form 29 August 2013 Accepted 30 August 2013
Hepatitis C virus (HCV) infection is a worldwide concern. Knowledge of the HCV genotype is clinically important because it predicts the rate of response to therapy and guides the treatment duration. Moreover, it allows molecular epidemiology to be performed. To our knowledge, the prevalence of HCV genotypes has been assessed only once in Albania, using a line probe genotyping assay. We determined HCV genotypes by population sequencing of HCV-infected patients in Tirana, Albania. HCV genotype and sequence analyses were performed for serum samples collected from January 2011 through May 2012 from 61 HCV-seropositive patients using population sequencing of the NS3 protease gene and alternatively the NS5b gene and the 50 untranslated region (UTR). HCV RNA was retrieved from the blood samples of 50 patients. The HCV NS3 protease gene was sequenced for 28 patients and NS5b and/or 50 UTR fragments were sequenced for an additional 22 patients. The predominant genotype was 1b in 25 patients (50%), followed by genotypes 2c, 4a, 3a, and 1a in 18%, 14%, 8%, and 6% of cases, respectively. Best matches for these HCV RNAs in GenBank were obtained in different countries worldwide. One NS3 protease naturally harbored an amino acid conferring minor drug resistance to newly available HCV protease inhibitors. In conclusion, HCV-1b was predominant in the present Albanian population, as in southeastern Europe. ß 2013 The Authors. Published by Elsevier Ltd on behalf of International Society for Infectious Diseases. All rights reserved.
Corresponding Editor: Eskild Petersen, Aarhus, Denmark Keywords: Hepatitis C HCV genotype HCV epidemiology Albania HCV NS3 protease
1. Introduction Hepatitis C virus (HCV) genotype identification is clinically important because it predicts the rate of sustained virological response and contributes to the determination of treatment duration.1 In addition, HCV genotyping is a powerful tool to describe HCV epidemiology.2 Very few data exist on HCV infection in Albania. The prevalence of HCV antibodies was found to be 0.07% in blood donors, 2.3% and 0.3% in Albanian emigrant populations in Greece and southern Italy, respectively, and 14% and 11% in 1995 and 2005, respectively, for patients with viral and/or alcoholic liver disease at the University Hospital of Tirana, the capital city.3–5 To our knowledge, HCV molecular epidemiology has been assessed
§ This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-No Derivative Works License, which permits non-commercial use, distribution, and reproduction in any medium, provided the original author and source are credited. * Corresponding author. Tel.: +33 491 385 519. E-mail address: [email protected] (P. Colson).
only once in Albania, using a line probe genotyping assay. We determined HCV genotype prevalence in Albanian patients by sequencing. 2. Materials and methods Serum samples collected from 61 HCV-infected patients from January 2011 through May 2012 at the University Hospital Center (UHC) of Tirana, Albania, were analyzed. The HCV-infected patients were mostly on the following wards: hepatology (n = 22), nephrology including dialysis (n = 12), infectious diseases (n = 9), pediatrics (n = 4), and hematology (n = 2). Thirty-nine patients were men (64%). HCV genotyping was performed using in-house assays targeting initially the NS3 protease gene (543 nucleotides),2 then, in the case of negative PCR amplification of this gene, a 195nucleotide-long fragment of the NS5b gene or an approximately 200-nucleotide-long region of the 50 untranslated region (UTR).2 HCV sequences were retrieved using a 3130XL Genetic Analyzer (Applied Biosystems, Branchburg, NJ, USA) then analyzed using Seqscape v2.5 (Applied Biosystems). HCV RNA sequences were
1201-9712/$36.00 – see front matter ß 2013 The Authors. Published by Elsevier Ltd on behalf of International Society for Infectious Diseases. All rights reserved. http://dx.doi.org/10.1016/j.ijid.2013.08.015
M. Haldeda et al. / International Journal of Infectious Diseases 18 (2014) 90–93
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Figure 1. Phylogenetic tree based on partial sequences of the NS3 protease gene of the HCV genome (513 nucleotides; nucleotides 3420–3932 in reference to HCV genome accession number AF011751). HCV sequences obtained in the present study are indicated with the black boxes. Sequences with the highest BLAST score recovered from the NCBI GenBank nucleotide sequence database (indicated in boldface, underlined and labeled with BBH, GenBank accession number, country, and year of collection or submission) for sequences obtained in the present study have been incorporated in the phylogeny reconstruction in addition to sequences with known genotypes and subtypes (http://www.ncbi.nlm.nih.gov/projects/genotyping/view.cgi?db=3). Nucleotide alignments were performed using ClustalX v2.0 (http://www.clustal.org/ download/current/). The tree was constructed using MEGA v5.0 software (http://www.megasoftware.net/) and the neighbor-joining method. Branches with bootstrap values 50%, obtained from 1000 resamplings of the data, are labeled on the tree. The HCV sequence EF108306 (genotype 7) was used as an outgroup. The scale bar indicates the number of nucleotide substitutions per site. (BBH, best BLAST hit; Ref, reference sequence.).
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M. Haldeda et al. / International Journal of Infectious Diseases 18 (2014) 90–93
Figure 2. Phylogenetic tree based on partial sequences of the NS5b encoding gene of the HCV genome (195 nucleotides; nucleotides 8287–8481 in reference to HCV genome accession number AF011751). HCV sequences obtained in the present study are indicated with the black boxes. Sequences with the highest BLAST score recovered from the NCBI GenBank nucleotide sequence database (indicated in boldface, underlined and labeled with BBH, GenBank accession number, country, and year of collection or submission) for sequences obtained in the present study have been incorporated in the phylogeny reconstruction in addition to sequences with known genotypes and subtypes (http://www.ncbi.nlm.nih.gov/projects/genotyping/view.cgi?db=3). Nucleotide alignments were performed using ClustalX v2.0 (http://www.clustal.org/ download/current/). The tree was constructed using MEGA v5.0 software (http://www.megasoftware.net/) and the neighbor-joining method. Branches with bootstrap values 50%, obtained from 1000 resamplings of the data, are labeled on the tree. The HCV sequence EF108306 (genotype 7) was used as an outgroup. The scale bar indicates the number of nucleotide substitutions per site. (BBH, best BLAST hit; Ref, reference sequence.).
M. Haldeda et al. / International Journal of Infectious Diseases 18 (2014) 90–93
aligned using ClustalX v2.0 (http://www.clustal.org/download/ current/) with sequences from the reference set of the NCBI genotyping tool (http://www.ncbi.nlm.nih.gov/projects/genotyping/view.cgi?db=3) and the two best matches obtained through BLAST searches against the NCBI sequence database for each sequence recovered here. Pairwise nucleotide similarities were generated using BioEdit (http://www.mbio.ncsu.edu/bioedit/ page2.html). Phylogeny reconstructions were performed using MEGA v5 (http://www.megasoftware.net/). 3. Results HCV RNA was obtained from 50 blood samples, PCR amplification being negative in 11 cases. HCV NS3 protease sequences were obtained for 28 sera (Figure 1) and the NS5b gene fragment (Figure 2) and 50 UTR were obtained for 18 and four additional sera, respectively. The predominant genotype was 1b, found in 25 patients (50%). Other genotypes, in decreasing prevalence, were genotype 2c (n = 9, 18%), 4a (n = 7, 14%), 3a (n = 4, 8%), 1a (n = 3, 6%), and 2a and 4d (n = 1, 0.2% each). Best BLAST matches for HCV-1b had been recovered in the USA, France, Switzerland, the UK, Brazil, Australia, and Japan (Figures 1 and 2). Best matches for HCV-2c had been obtained in Japan, Argentina, Italy, the UK, and France, while those for HCV-4a had been obtained in Egypt, Cyprus, and France. HCV-1b NS3 and NS5b sequences from the present study showed a mean standard deviation identity of 91.3 1.6% and 94.2 2.2%, respectively. HCV-1b NS3 RNA from two patients (numbers 860 and 639) were clustered together and showed 98.8% identity (Figure 1). These sequences had been recovered in nephrology and dialysis units. In addition, HCV-1b NS5b RNA from three patients in a pediatrics unit (numbers 623, 188 and 290) were clustered and showed 97.5–99.0% identity, and HCV-4a RNA from four patients including three dialysis patients (numbers 33p, 839, 795, and 323) were clustered and showed 97.0–99.5% identity. Overall, five of eight patients (62%) sampled in the dialysis ward were infected with HCV-4a. Of note, amino acid substitution V55A within the HCV NS3 protease was observed in one patient naive to anti-HCV therapy (number 369) and infected with HCV-1a. 4. Discussion To our knowledge, we have provided the first HCV sequences from patients in Albania. Half of these patients were infected with HCV-1b. In a previous study conducted on 18 patients with chronic liver diseases in Tirana using a line probe genotyping assay, HCV1b was identified in 11 cases (61%), then HCV-2a/2c and HCV-3a were identified in five and two patients, respectively.5 This distribution of HCV genotypes is similar to that observed here. In addition, the predominance of HCV-1b has been reported in other southeastern European countries, including Greece, Serbia, Montenegro, Slovenia, Croatia, and Bosnia and Herzegovina.6–10 (http://hcv.lanl.gov/components/sequence/HCV/geo/geo.comp). Best matches for HCV RNA obtained here were obtained in multiple
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countries on the five continents, but not in southeastern Europe, apart from Cyprus. This finding may be explained by the small number of HCV sequences available from southeastern Europe, especially when regarding the NS3 protease region. The population studied here may not be fully representative of that of HCV-infected patients in Albania. Notably, only a few patients likely acquired HCV through intravenous drug use, as this population is managed in other centers. In one HCV-1a-infected patient, amino acid 55A was observed within the NS3 protease in the absence of any prior anti-HCV therapy. The HCV NS3-V55A substitution was associated with minor drug resistance to linear HCV NS3 protease inhibitors and compromised viral fitness.11 Further studies, conducted on larger and different populations and in different regions, are needed to strengthen knowledge on HCV genotypes that circulate in Albania. Acknowledgements We are grateful to the team of the Virology Laboratory at IHU Me´diterrane´e Infection, Centre Hospitalo-Universitaire Timone, Marseille, France for technical help. Conflict of interest: No potential conflict of interest or financial disclosure for all authors.
References 1. Kamili S, Drobeniuc J, Araujo AC, Hayden TM. Laboratory diagnostics for hepatitis C virus infection. Clin Infect Dis 2012;55(Suppl 1):S43–8. 2. Colson P, Bregigeon S, Tourres C, Solas C, Poizot-Martin I, Tamalet C. Relapse of hepatitis C virus after 14 months of sustained virological response following pegylated-interferon alpha plus ribavirin therapy in a human immunodeficiency virus type 1 infected patient. J Clin Virol 2013;58:309–14. 3. Roussos A, Goritsas C, Pappas T, Spanaki M, Papadaki P, Ferti A. Prevalence of hepatitis B and C markers among refugees in Athens. World J Gastroenterol 2003;9:993–5. 4. Durro V, Koraqi A, Saliasi S. Trends in the prevalence of transfusion-transmissible infections among blood donors in Albania. Clin Lab 2010;56:591–5. 5. Kondili LA, Cuko L, Chionne P, Candido A, Madonna E, Dentico P, et al. Hepatitis B, C and delta virus infections in Albanian patients with chronic liver disease: evaluation of possible changes during the last 10 years. Eur J Gastroenterol Hepatol 2010;22:167–71. 6. Stamouli M, Panagiotou I, Kairis D, Michopoulou A, Skliris A, Totos G. Genotype distribution in chronic hepatitis C patients in Greece. Clin Lab 2012;58:173–6. 7. Katsoulidou A, Sypsa V, Tassopoulos NC, Boletis J, Karafoulidou A, Ketikoglou I, et al. Molecular epidemiology of hepatitis C virus (HCV) in Greece: temporal trends in HCV genotype-specific incidence and molecular characterization of genotype 4 isolates. J Viral Hepat 2006;13:19–27. 8. Svirtlih N, Delic D, Simonovic J, Jevtovic D, Dokic L, Gvozdenovic E, et al. Hepatitis C virus genotypes in Serbia and Montenegro: the prevalence and clinical significance. World J Gastroenterol 2007;13:355–60. 9. Seme K, Vrhovac M, Mocilnik T, Maticic M, Lesnicar G, Baklan Z, et al. Hepatitis C virus genotypes in 1,504 patients in Slovenia, 1993-2007. J Med Virol 2009;81:634–9. 10. Ahmetagic S, Salkic N, Cickusic E, Zerem E, Mott-Divkovic´ S, Tihic N, et al. Hepatitis C virus genotypes in chronic hepatitis C patients and in first time blood donors in northeastern Bosnia and Herzegovina. Bosn J Basic Med Sci 2009;9:278–82. 11. Welsch C, Schweizer S, Shimakami T, Domingues FS, Kim S, Lemon SM, et al. Ketoamide resistance and hepatitis C virus fitness in val55 variants of the NS3 serine protease. Antimicrob Agents Chemother 2012;56:1907–15.
Contents lists available at ScienceDirect
International Journal of Infectious Diseases journal homepage: www.elsevier.com/locate/ijid
Short Communication
Hepatitis C virus genotypes in Tirana, Albania§ Migena Haldeda a, Julien Baume b, Catherine Tamalet b,c, Melpomeni Bizhga a, Philippe Colson b,c,* a
Laboratory of Virology, University Hospital Center ‘‘Mother Teresa’’, Tirana, Albania Institut Hospitalo-Universitaire (IHU) Me´diterrane´e Infection, Poˆle des Maladies Infectieuses et Tropicales Clinique et Biologique, Fe´de´ration de Bacte´riologie-Hygie`ne-Virologie, Centre Hospitalo-Universitaire Timone, Assistance Publique – Hoˆpitaux de Marseille, 264 rue Saint-Pierre 13385, Marseille Cedex 05, France c URMITE UM 63 CNRS 7278 IRD 198 INSERM U1905, Aix-Marseille Univ., Faculte´s de Me´decine et de Pharmacie, Marseille, France b
A R T I C L E I N F O
S U M M A R Y
Article history: Received 22 May 2013 Received in revised form 29 August 2013 Accepted 30 August 2013
Hepatitis C virus (HCV) infection is a worldwide concern. Knowledge of the HCV genotype is clinically important because it predicts the rate of response to therapy and guides the treatment duration. Moreover, it allows molecular epidemiology to be performed. To our knowledge, the prevalence of HCV genotypes has been assessed only once in Albania, using a line probe genotyping assay. We determined HCV genotypes by population sequencing of HCV-infected patients in Tirana, Albania. HCV genotype and sequence analyses were performed for serum samples collected from January 2011 through May 2012 from 61 HCV-seropositive patients using population sequencing of the NS3 protease gene and alternatively the NS5b gene and the 50 untranslated region (UTR). HCV RNA was retrieved from the blood samples of 50 patients. The HCV NS3 protease gene was sequenced for 28 patients and NS5b and/or 50 UTR fragments were sequenced for an additional 22 patients. The predominant genotype was 1b in 25 patients (50%), followed by genotypes 2c, 4a, 3a, and 1a in 18%, 14%, 8%, and 6% of cases, respectively. Best matches for these HCV RNAs in GenBank were obtained in different countries worldwide. One NS3 protease naturally harbored an amino acid conferring minor drug resistance to newly available HCV protease inhibitors. In conclusion, HCV-1b was predominant in the present Albanian population, as in southeastern Europe. ß 2013 The Authors. Published by Elsevier Ltd on behalf of International Society for Infectious Diseases. All rights reserved.
Corresponding Editor: Eskild Petersen, Aarhus, Denmark Keywords: Hepatitis C HCV genotype HCV epidemiology Albania HCV NS3 protease
1. Introduction Hepatitis C virus (HCV) genotype identification is clinically important because it predicts the rate of sustained virological response and contributes to the determination of treatment duration.1 In addition, HCV genotyping is a powerful tool to describe HCV epidemiology.2 Very few data exist on HCV infection in Albania. The prevalence of HCV antibodies was found to be 0.07% in blood donors, 2.3% and 0.3% in Albanian emigrant populations in Greece and southern Italy, respectively, and 14% and 11% in 1995 and 2005, respectively, for patients with viral and/or alcoholic liver disease at the University Hospital of Tirana, the capital city.3–5 To our knowledge, HCV molecular epidemiology has been assessed
§ This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-No Derivative Works License, which permits non-commercial use, distribution, and reproduction in any medium, provided the original author and source are credited. * Corresponding author. Tel.: +33 491 385 519. E-mail address: [email protected] (P. Colson).
only once in Albania, using a line probe genotyping assay. We determined HCV genotype prevalence in Albanian patients by sequencing. 2. Materials and methods Serum samples collected from 61 HCV-infected patients from January 2011 through May 2012 at the University Hospital Center (UHC) of Tirana, Albania, were analyzed. The HCV-infected patients were mostly on the following wards: hepatology (n = 22), nephrology including dialysis (n = 12), infectious diseases (n = 9), pediatrics (n = 4), and hematology (n = 2). Thirty-nine patients were men (64%). HCV genotyping was performed using in-house assays targeting initially the NS3 protease gene (543 nucleotides),2 then, in the case of negative PCR amplification of this gene, a 195nucleotide-long fragment of the NS5b gene or an approximately 200-nucleotide-long region of the 50 untranslated region (UTR).2 HCV sequences were retrieved using a 3130XL Genetic Analyzer (Applied Biosystems, Branchburg, NJ, USA) then analyzed using Seqscape v2.5 (Applied Biosystems). HCV RNA sequences were
1201-9712/$36.00 – see front matter ß 2013 The Authors. Published by Elsevier Ltd on behalf of International Society for Infectious Diseases. All rights reserved. http://dx.doi.org/10.1016/j.ijid.2013.08.015
M. Haldeda et al. / International Journal of Infectious Diseases 18 (2014) 90–93
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Figure 1. Phylogenetic tree based on partial sequences of the NS3 protease gene of the HCV genome (513 nucleotides; nucleotides 3420–3932 in reference to HCV genome accession number AF011751). HCV sequences obtained in the present study are indicated with the black boxes. Sequences with the highest BLAST score recovered from the NCBI GenBank nucleotide sequence database (indicated in boldface, underlined and labeled with BBH, GenBank accession number, country, and year of collection or submission) for sequences obtained in the present study have been incorporated in the phylogeny reconstruction in addition to sequences with known genotypes and subtypes (http://www.ncbi.nlm.nih.gov/projects/genotyping/view.cgi?db=3). Nucleotide alignments were performed using ClustalX v2.0 (http://www.clustal.org/ download/current/). The tree was constructed using MEGA v5.0 software (http://www.megasoftware.net/) and the neighbor-joining method. Branches with bootstrap values 50%, obtained from 1000 resamplings of the data, are labeled on the tree. The HCV sequence EF108306 (genotype 7) was used as an outgroup. The scale bar indicates the number of nucleotide substitutions per site. (BBH, best BLAST hit; Ref, reference sequence.).
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M. Haldeda et al. / International Journal of Infectious Diseases 18 (2014) 90–93
Figure 2. Phylogenetic tree based on partial sequences of the NS5b encoding gene of the HCV genome (195 nucleotides; nucleotides 8287–8481 in reference to HCV genome accession number AF011751). HCV sequences obtained in the present study are indicated with the black boxes. Sequences with the highest BLAST score recovered from the NCBI GenBank nucleotide sequence database (indicated in boldface, underlined and labeled with BBH, GenBank accession number, country, and year of collection or submission) for sequences obtained in the present study have been incorporated in the phylogeny reconstruction in addition to sequences with known genotypes and subtypes (http://www.ncbi.nlm.nih.gov/projects/genotyping/view.cgi?db=3). Nucleotide alignments were performed using ClustalX v2.0 (http://www.clustal.org/ download/current/). The tree was constructed using MEGA v5.0 software (http://www.megasoftware.net/) and the neighbor-joining method. Branches with bootstrap values 50%, obtained from 1000 resamplings of the data, are labeled on the tree. The HCV sequence EF108306 (genotype 7) was used as an outgroup. The scale bar indicates the number of nucleotide substitutions per site. (BBH, best BLAST hit; Ref, reference sequence.).
M. Haldeda et al. / International Journal of Infectious Diseases 18 (2014) 90–93
aligned using ClustalX v2.0 (http://www.clustal.org/download/ current/) with sequences from the reference set of the NCBI genotyping tool (http://www.ncbi.nlm.nih.gov/projects/genotyping/view.cgi?db=3) and the two best matches obtained through BLAST searches against the NCBI sequence database for each sequence recovered here. Pairwise nucleotide similarities were generated using BioEdit (http://www.mbio.ncsu.edu/bioedit/ page2.html). Phylogeny reconstructions were performed using MEGA v5 (http://www.megasoftware.net/). 3. Results HCV RNA was obtained from 50 blood samples, PCR amplification being negative in 11 cases. HCV NS3 protease sequences were obtained for 28 sera (Figure 1) and the NS5b gene fragment (Figure 2) and 50 UTR were obtained for 18 and four additional sera, respectively. The predominant genotype was 1b, found in 25 patients (50%). Other genotypes, in decreasing prevalence, were genotype 2c (n = 9, 18%), 4a (n = 7, 14%), 3a (n = 4, 8%), 1a (n = 3, 6%), and 2a and 4d (n = 1, 0.2% each). Best BLAST matches for HCV-1b had been recovered in the USA, France, Switzerland, the UK, Brazil, Australia, and Japan (Figures 1 and 2). Best matches for HCV-2c had been obtained in Japan, Argentina, Italy, the UK, and France, while those for HCV-4a had been obtained in Egypt, Cyprus, and France. HCV-1b NS3 and NS5b sequences from the present study showed a mean standard deviation identity of 91.3 1.6% and 94.2 2.2%, respectively. HCV-1b NS3 RNA from two patients (numbers 860 and 639) were clustered together and showed 98.8% identity (Figure 1). These sequences had been recovered in nephrology and dialysis units. In addition, HCV-1b NS5b RNA from three patients in a pediatrics unit (numbers 623, 188 and 290) were clustered and showed 97.5–99.0% identity, and HCV-4a RNA from four patients including three dialysis patients (numbers 33p, 839, 795, and 323) were clustered and showed 97.0–99.5% identity. Overall, five of eight patients (62%) sampled in the dialysis ward were infected with HCV-4a. Of note, amino acid substitution V55A within the HCV NS3 protease was observed in one patient naive to anti-HCV therapy (number 369) and infected with HCV-1a. 4. Discussion To our knowledge, we have provided the first HCV sequences from patients in Albania. Half of these patients were infected with HCV-1b. In a previous study conducted on 18 patients with chronic liver diseases in Tirana using a line probe genotyping assay, HCV1b was identified in 11 cases (61%), then HCV-2a/2c and HCV-3a were identified in five and two patients, respectively.5 This distribution of HCV genotypes is similar to that observed here. In addition, the predominance of HCV-1b has been reported in other southeastern European countries, including Greece, Serbia, Montenegro, Slovenia, Croatia, and Bosnia and Herzegovina.6–10 (http://hcv.lanl.gov/components/sequence/HCV/geo/geo.comp). Best matches for HCV RNA obtained here were obtained in multiple
93
countries on the five continents, but not in southeastern Europe, apart from Cyprus. This finding may be explained by the small number of HCV sequences available from southeastern Europe, especially when regarding the NS3 protease region. The population studied here may not be fully representative of that of HCV-infected patients in Albania. Notably, only a few patients likely acquired HCV through intravenous drug use, as this population is managed in other centers. In one HCV-1a-infected patient, amino acid 55A was observed within the NS3 protease in the absence of any prior anti-HCV therapy. The HCV NS3-V55A substitution was associated with minor drug resistance to linear HCV NS3 protease inhibitors and compromised viral fitness.11 Further studies, conducted on larger and different populations and in different regions, are needed to strengthen knowledge on HCV genotypes that circulate in Albania. Acknowledgements We are grateful to the team of the Virology Laboratory at IHU Me´diterrane´e Infection, Centre Hospitalo-Universitaire Timone, Marseille, France for technical help. Conflict of interest: No potential conflict of interest or financial disclosure for all authors.
References 1. Kamili S, Drobeniuc J, Araujo AC, Hayden TM. Laboratory diagnostics for hepatitis C virus infection. Clin Infect Dis 2012;55(Suppl 1):S43–8. 2. Colson P, Bregigeon S, Tourres C, Solas C, Poizot-Martin I, Tamalet C. Relapse of hepatitis C virus after 14 months of sustained virological response following pegylated-interferon alpha plus ribavirin therapy in a human immunodeficiency virus type 1 infected patient. J Clin Virol 2013;58:309–14. 3. Roussos A, Goritsas C, Pappas T, Spanaki M, Papadaki P, Ferti A. Prevalence of hepatitis B and C markers among refugees in Athens. World J Gastroenterol 2003;9:993–5. 4. Durro V, Koraqi A, Saliasi S. Trends in the prevalence of transfusion-transmissible infections among blood donors in Albania. Clin Lab 2010;56:591–5. 5. Kondili LA, Cuko L, Chionne P, Candido A, Madonna E, Dentico P, et al. Hepatitis B, C and delta virus infections in Albanian patients with chronic liver disease: evaluation of possible changes during the last 10 years. Eur J Gastroenterol Hepatol 2010;22:167–71. 6. Stamouli M, Panagiotou I, Kairis D, Michopoulou A, Skliris A, Totos G. Genotype distribution in chronic hepatitis C patients in Greece. Clin Lab 2012;58:173–6. 7. Katsoulidou A, Sypsa V, Tassopoulos NC, Boletis J, Karafoulidou A, Ketikoglou I, et al. Molecular epidemiology of hepatitis C virus (HCV) in Greece: temporal trends in HCV genotype-specific incidence and molecular characterization of genotype 4 isolates. J Viral Hepat 2006;13:19–27. 8. Svirtlih N, Delic D, Simonovic J, Jevtovic D, Dokic L, Gvozdenovic E, et al. Hepatitis C virus genotypes in Serbia and Montenegro: the prevalence and clinical significance. World J Gastroenterol 2007;13:355–60. 9. Seme K, Vrhovac M, Mocilnik T, Maticic M, Lesnicar G, Baklan Z, et al. Hepatitis C virus genotypes in 1,504 patients in Slovenia, 1993-2007. J Med Virol 2009;81:634–9. 10. Ahmetagic S, Salkic N, Cickusic E, Zerem E, Mott-Divkovic´ S, Tihic N, et al. Hepatitis C virus genotypes in chronic hepatitis C patients and in first time blood donors in northeastern Bosnia and Herzegovina. Bosn J Basic Med Sci 2009;9:278–82. 11. Welsch C, Schweizer S, Shimakami T, Domingues FS, Kim S, Lemon SM, et al. Ketoamide resistance and hepatitis C virus fitness in val55 variants of the NS3 serine protease. Antimicrob Agents Chemother 2012;56:1907–15.
