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Goodman SH, Zahn M, Boden-Albala B, Lakon CM. Insurance Status, Comorbidity Diagnosis, and Hepatitis C Diagnosis Among Antibody-Positive Patients: A Retrospective Cohort Study. Health Serv Res Manag Epidemiol 2023; 10:23333928231175795. [PMID: 37197291 PMCID: PMC10184194 DOI: 10.1177/23333928231175795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/19/2023] Open
Abstract
Background In California, laboratories report all hepatitis C (HCV)-positive antibody tests to the state; however, that does not accurately reflect active infection among those patients without a viral load test confirming a patient's HCV diagnosis. These public health surveillance disease incident records do not include patient details such as comorbidities or insurance status found in electronic medical records (EMRs). Objective This research seeks to understand how insurance type, insurance status, patient comorbidities, and other sociodemographic factors related to HCV diagnosis as defined by a positive viral load test among HCV antibody-positive persons from January 1, 2010 to March 1, 2020. Methods HCV antibody-positive individuals reported to the California Reportable Disease Information Exchange (CalREDIE), with a medical record number associated with the University of California, Irvine Medical Center, and an unrestricted EMR (n = 521) were extracted using manual chart review. Main Outcomes and measures HCV diagnosis as indicated in a patient's EMR in the problem list or disease registry. Results Less than a quarter of patients in this sample were diagnosed as having HCV in their EMR, with 0.4% of those diagnosed (5/116) patients with indicated HCV treatment in the medication field of their charts. After adjusting for multiple comorbidities, a multinomial logistic regression found that the relative risk ratios (RRRs) of HCV diagnosis found that patients with insurance were more likely to be diagnosed compared to those without insurance. When comparing uninsured patients to those with government insurance at the P < .05 level (RRR = 10.61 (95% confidence interval (CI): 4.14-27.22)) and those uninsured to private insurance (RRR = 6.79 (95% CI: 2.31-19.92). Conclusions These low frequencies of HCV diagnosis among the study population, particularly among the uninsured, indicate a need for increased viral load testing and linkage to care. Reflex testing on existing samples and improving HCV screening and diagnosis can help increase linkage to care and work towards eliminating this disease.
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Affiliation(s)
- Sara H. Goodman
- Department of Pediatrics – Infectious Diseases, Stanford University School of Medicine, Palo Alto, CA, USA
- Department of Health, Society, and Behavior, Program in Public Health Susan and Henry Samueli College of Health Sciences, University of California, Irvine, CA, USA
| | - Matthew Zahn
- Communicable Disease Control, Orange County Health Care Agency, Santa Ana, CA, USA
| | - Bernadette Boden-Albala
- Department of Health, Society, and Behavior, Program in Public Health Susan and Henry Samueli College of Health Sciences, University of California, Irvine, CA, USA
| | - Cynthia M. Lakon
- Department of Health, Society, and Behavior, Program in Public Health Susan and Henry Samueli College of Health Sciences, University of California, Irvine, CA, USA
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2
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Impact of Hepatitis B Virus Infection, Non-alcoholic Fatty Liver Disease, and Hepatitis C Virus Co-infection on Liver-Related Death among People Tested for Hepatitis B Virus in British Columbia: Results from a Large Longitudinal Population-Based Cohort Study. Viruses 2022; 14:v14112579. [PMID: 36423186 PMCID: PMC9694514 DOI: 10.3390/v14112579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 11/17/2022] [Accepted: 11/18/2022] [Indexed: 11/23/2022] Open
Abstract
Data on the contribution of hepatitis B virus (HBV) infection and related comorbidities to liver-related mortality in Canada are limited. We assessed the concurrent impact of HBV infection, non-alcoholic fatty liver disease (NAFLD), and hepatitis C virus (HCV) coinfection on liver-related deaths in British Columbia (BC), Canada. We used data from the BC Hepatitis Testers Cohort (BC-HTC). We used Fine-Gray multivariable sub-distributional hazards models to assess the effect of HBV, NAFLD, and HCV coinfection on liver-related mortality, while adjusting for confounders and competing mortality risks. The liver-related mortality rate was higher among people with HBV infection than those without (2.57 per 1000 PYs (95%CI: 2.46, 2.69) vs. 0.62 per 1000 PYs (95%CI: 0.61, 0.64), respectively). Compared with the HBV negative groups, HBV infection was associated with increased liver-related mortality risk in almost all of the subgroups: HBV mono-infection (adjusted subdistribution hazards ratio (asHR) of 3.35, 95% CI 3.16, 3.55), NAFLD with HBV infection, (asHR 12.5, 95% CI 7.08, 22.07), and HBV/HCV coinfection (asHR 8.4, 95% CI 7.62, 9.26). HBV infection is associated with a higher risk of liver-related mortality, and has a greater relative impact on people with NAFLD and those with HCV coinfection. The diagnosis and treatment of viral and fatty liver disease are required to mitigate liver-related morbidity and mortality.
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3
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McDonald SA, Barclay ST, Innes HA, Fraser A, Hayes PC, Bathgate A, Dillon JF, Went A, Goldberg DJ, Hutchinson SJ. Uptake of interferon-free DAA therapy among HCV-infected decompensated cirrhosis patients and evidence for decreased mortality. J Viral Hepat 2021; 28:1246-1255. [PMID: 34002914 DOI: 10.1111/jvh.13543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 04/24/2021] [Indexed: 12/09/2022]
Abstract
Interferon-free DAA therapies have recently been licensed for patients infected with hepatitis C virus (HCV) who have decompensated cirrhosis (DC). Our aim was to describe factors associated with uptake of IFN-free DAAs in DC patients and to compare mortality risk and hospital admission rates between pre-DAA and DAA eras. This observational study used record-linkage between Scotland's HCV Clinical Database and national inpatient hospitalization and mortality registers. For the DAA uptake analysis, the study population (n = 297) was restricted to patients alive on 1 November 2014, and Cox regression was used to estimate uptake associated with various covariates. For the Cox regression of mortality comparing pre-DAA and DAA eras, the study population (n = 624) comprised those diagnosed with DC in 2005-2018; follow-up was censored at two years. DAA uptake was 63% overall and was significantly higher for treatment-experienced patients (adjusted hazard ratio (aHR) = 1.64, 95% CI:1.14-2.34), genotype 1 vs. other genotypes (aHR = 1.55. 95% CI:1.15-2.10) and lower for persons diagnosed with DC pre-2014 (0.47, 95% CI:0.33-0.68) and in Greater Glasgow (0.64, 95% CI:0.47-0.88). The intention-to-treat SVR rate was 89% (95% CI:83-93%). All-cause and liver-related mortality risk were significantly reduced among patients diagnosed with DC in the DAA era (November 2014-December 2018) compared with the pre-DAA era (2005-October 2014) (aHRs of 0.68, 95% CI:0.49-0.93; 0.69, 95% CI:0.50-0.95, respectively); in contrast, hospital admission rates were higher in the DAA era (aRR = 1.14, 95% CI:1.04-1.26). The majority of HCV-infected DC patients engaged with specialist services can be treated with IFN-free DAAs. Improved survival among patients diagnosed with DC in the DAA era supports the beneficial impact of IFN-free therapies among those with advanced liver disease.
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Affiliation(s)
- Scott A McDonald
- School of Health and Life Sciences, Glasgow Caledonian University and Health Protection Scotland, Glasgow, UK
| | | | - Hamish A Innes
- School of Health and Life Sciences, Glasgow Caledonian University and Health Protection Scotland, Glasgow, UK
| | - Andrew Fraser
- Aberdeen Royal Infirmary, Aberdeen, UK.,Queen Elizabeth University Hospital, Glasgow, UK
| | | | | | - John F Dillon
- School of Medicine, University of Dundee, Dundee, UK
| | | | - David J Goldberg
- School of Health and Life Sciences, Glasgow Caledonian University and Health Protection Scotland, Glasgow, UK
| | - Sharon J Hutchinson
- School of Health and Life Sciences, Glasgow Caledonian University and Health Protection Scotland, Glasgow, UK
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4
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Han R, Liang S, François C, Aballea S, Clay E, Toumi M. Allocating treatment resources for hepatitis C in the UK: a constrained optimization modelling approach. JOURNAL OF MARKET ACCESS & HEALTH POLICY 2021; 9:1887664. [PMID: 33828822 PMCID: PMC8008927 DOI: 10.1080/20016689.2021.1887664] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Background and objective: Although the treatment of chronic hepatitis C (CHC) has significantly evolved with the introduction of direct-acting antivirals, the treatment uptake rates have been low especially among marginalized groups in the UK, such as people who inject drug (PWID) and men who have sex with men (MSM). Cutting health inequality is a major focus of healthcare agencies. This study aims to identify the optimal allocation of treatment budget for chronic hepatitis CHC among populations and treatments in the UK so that liver-related mortality in patients with CHC is minimized, given the constraint of treatment budget and equity issue. Methods: A constrained optimization modelling of resource allocation for the treatment of CHC was developed in Excel from the perspective of the UK National Health System over a lifetime horizon. The model was designated with the objective function of minimizing liver-related deaths by varying the decision variables, representing the number of patients receiving each treatment (elbasvir-grazoprevir, ombitasvir-paritaprevir-ritonavir-dasabuvir, sofosbuvir-ledipasvir, and pegylated interferon-ribavirin) in each population (the general population, PWID, and MSM). Two main constraints were formulated including treatment budget and the issue of equity. The model was populated with UK local data applying linear programming and underwent internal and external validation. Scenario analyses were performed to assess the robustness of model results. Results: Within the constraints of no additional funding over original spending in status quo and the consideration of the issue of equity among populations, the optimal allocation from the constrained optimization modelling (treating 13,122 PWID, 160 MSM, and 904 general patients with ombitasvir-paritaprevir-ritonavir-dasabuvir) was found to treat 2,430 more patients (relative change: 20.7%) and avert 78 liver-related deaths (relative change: 0.3%) compared with the current allocation. The number of patients receiving treatment increased 4,928 (relative change: 60.1%) among PWID and 42 (relative change: 35.8%) among MSM. Conclusion: The current allocation of treatment budget for CHC is not optimal in the UK. More patients would be treated, and more liver-related deaths would be avoided using a new allocation from a constrained optimization modelling without incurring additional spending and considering the issue of equity.
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Affiliation(s)
- Ru Han
- Public Health Department - Research Unit, University of Aix-Marseille, Marseille, France
- HEOR, Creativ-Ceutical, Paris, France
- CONTACT Ru Han HEOR, University of Aix-Marseille, 215, Rue De Faubourg St-Honoré, 75008, Paris
| | - Shuyao Liang
- Public Health Department - Research Unit, University of Aix-Marseille, Marseille, France
- HEOR, Creativ-Ceutical, Paris, France
| | - Clément François
- Public Health Department - Research Unit, University of Aix-Marseille, Marseille, France
- HEOR, Creativ-Ceutical, Paris, France
| | - Samuel Aballea
- Public Health Department - Research Unit, University of Aix-Marseille, Marseille, France
- Creativ-Ceutical, HEOR, Rotterdam, Netherland
| | - Emilie Clay
- Public Health Department - Research Unit, University of Aix-Marseille, Marseille, France
- HEOR, Creativ-Ceutical, Paris, France
| | - Mondher Toumi
- Public Health Department - Research Unit, University of Aix-Marseille, Marseille, France
- HEOR, Creativ-Ceutical, Paris, France
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5
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Goodman S, Zahn M, Bruckner T, Boden-Albala B, Lakon CM. Measuring Hazards of Undetectable Viral Load among Hepatitis C Antibody Positive Residents of a Large Southern California County. Health Serv Res Manag Epidemiol 2021; 8:23333928211066181. [PMID: 34926722 PMCID: PMC8671667 DOI: 10.1177/23333928211066181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 11/16/2021] [Accepted: 11/22/2021] [Indexed: 12/09/2022] Open
Abstract
Background Hepatitis C virus (HCV) infection is the most common bloodborne infection in the U.S. However, only a small proportion of persons are treated and cured. Previous research has not characterized sociodemographic characteristics of who receives treatment. We examined predictors of undetectable for HCV in Orange County, the sixth largest county in the United States, where HCV is the most commonly reported infection. METHODS From 2014 to 2020, we acquired public health surveillance data from 91,165 HCV antibody-positive care encounters from the California Reportable Disease Information Exchange (CalREDIE). We used a time-to-event proportional hazards framework to estimate individual and area-level correlates of time-to-HCV undetectable viral load among HCV + individuals. RESULTS Older adults (>65 years) showed an increased hazard of undetectable viral load relative to younger adults (HR = 2.00). In addition, residents of census tracts with greater enrollment in health insurance showed a greater likelihood of undetectable viral load (HR = 1.36). The moderating effect of higher tract median household income and higher tract levels of health insurance were more likely to have undetectable viral load and was statistically significant. CONCLUSION In a large urban county, HCV antibody-positive older adults appear much more likely to show undetectable viral load compared to younger adults. Residents in areas with higher quartiles of health insurance enrollment have an increased likelihood of undetectable viral load. The extent to which constraints impede HCV care requires further investigation, including follow-up studies on health insurance type to test the relationship of health insurance type to undetectable viral load.
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Affiliation(s)
- Sara Goodman
- Program in Public Health, Department of Health, Society, and Behavior, Susan and Henry Samueli College of Health Sciences, University of California, Irvine, Irvine, USA
| | - Matthew Zahn
- Communicable Disease Control, Orange County Health Care Agency, Santa Ana, California, USA
| | - Tim Bruckner
- Program in Public Health, Department of Health, Society, and Behavior, Susan and Henry Samueli College of Health Sciences, University of California, Irvine, Irvine, USA
- Center for Population, Inequality, and Policy, University of California, Irvine, Irvine, USA
| | - Bernadette Boden-Albala
- Program in Public Health, Department of Health, Society, and Behavior, Susan and Henry Samueli College of Health Sciences, University of California, Irvine, Irvine, USA
- School of Medicine, Department of Neurology, Susan and Henry Samueli College of Health Sciences, University of California, Irvine, Irvine, USA
- Program in Public Health, Department of Epidemiology and Biostatistics, University of California, Irvine, Irvine, USA
| | - Cynthia M. Lakon
- Program in Public Health, Department of Health, Society, and Behavior, Susan and Henry Samueli College of Health Sciences, University of California, Irvine, Irvine, USA
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6
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Hutchinson SJ, Valerio H, McDonald SA, Yeung A, Pollock K, Smith S, Barclay S, Dillon JF, Fox R, Bramley P, Fraser A, Kennedy N, Gunson RN, Templeton K, Innes H, McLeod A, Weir A, Hayes PC, Goldberg D. Population impact of direct-acting antiviral treatment on new presentations of hepatitis C-related decompensated cirrhosis: a national record-linkage study. Gut 2020; 69:2223-2231. [PMID: 32217640 DOI: 10.1136/gutjnl-2019-320007] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 02/19/2020] [Accepted: 02/24/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Population-based studies demonstrating the clinical impact of interferon-free direct-acting antiviral (DAA) therapies are lacking. We examined the impact of the introduction of DAAs on HCV-related decompensated cirrhosis (DC) through analysis of population-based data from Scotland. DESIGN Through analysis of national surveillance data (involving linkage of HCV diagnosis and clinical databases to hospital and deaths registers), we determined i) the scale-up in the number of patients treated and achieving a sustained viral response (SVR), and ii) the change in the trend of new presentations with HCV-related DC, with the introduction of DAAs. RESULTS Approximately 11 000 patients had been treated in Scotland over the 8-year period 2010/11 to 2017/18. The scale-up in the number of patients achieving SVR between the pre-DAA and DAA eras was 2.3-fold overall and 5.9-fold among those with compensated cirrhosis (the group at immediate risk of developing DC). In the pre-DAA era, the annual number of HCV-related DC presentations increased 4.6-fold between 2000 (30) and 2014 (142). In the DAA era, presentations decreased by 51% to 69 in 2018 (and by 67% among those with chronic infection at presentation), representing a significant change in trend (rate ratio 0.88, 95% CI 0.85 to 0.90). With the introduction of DAAs, an estimated 330 DC cases had been averted during 2015-18. CONCLUSIONS National scale-up in interferon-free DAA treatment is associated with the rapid downturn in presentations of HCV-related DC at the population-level. Major progress in averting HCV-related DC in the short-term is feasible, and thus other countries should strive to achieve the same.
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Affiliation(s)
- Sharon J Hutchinson
- Centre for Living, School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK .,Blood Borne Virus & Sexually Transmitted Infections Team, Health Protection Scotland, Glasgow, UK
| | - Heather Valerio
- Centre for Living, School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK.,Blood Borne Virus & Sexually Transmitted Infections Team, Health Protection Scotland, Glasgow, UK
| | - Scott A McDonald
- Centre for Living, School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK.,Blood Borne Virus & Sexually Transmitted Infections Team, Health Protection Scotland, Glasgow, UK
| | - Alan Yeung
- Centre for Living, School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK.,Blood Borne Virus & Sexually Transmitted Infections Team, Health Protection Scotland, Glasgow, UK
| | - Kevin Pollock
- Centre for Living, School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK.,Blood Borne Virus & Sexually Transmitted Infections Team, Health Protection Scotland, Glasgow, UK
| | - Shanley Smith
- Centre for Living, School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK.,Blood Borne Virus & Sexually Transmitted Infections Team, Health Protection Scotland, Glasgow, UK
| | - Stephen Barclay
- Centre for Living, School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK.,Glasgow Royal Infirmary, Glasgow, UK
| | | | | | | | - Andrew Fraser
- Aberdeen Royal Infirmary, Aberdeen, UK.,Queen Elizabeth University Hospital, Glasgow, UK
| | | | - Rory N Gunson
- West of Scotland Specialist Virology Centre, Glasgow Royal Infirmary, Glasgow, UK
| | - Kate Templeton
- East of Scotland Specialist Virology Centre, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Hamish Innes
- Centre for Living, School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK.,Blood Borne Virus & Sexually Transmitted Infections Team, Health Protection Scotland, Glasgow, UK
| | - Allan McLeod
- Blood Borne Virus & Sexually Transmitted Infections Team, Health Protection Scotland, Glasgow, UK
| | - Amanda Weir
- Blood Borne Virus & Sexually Transmitted Infections Team, Health Protection Scotland, Glasgow, UK
| | | | - David Goldberg
- Centre for Living, School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK.,Blood Borne Virus & Sexually Transmitted Infections Team, Health Protection Scotland, Glasgow, UK
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7
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Ireland G, Mandal S, Hickman M, Ramsay M, Harris R, Simmons R. Mortality rates among individuals diagnosed with hepatitis C virus (HCV); an observational cohort study, England, 2008 to 2016. ACTA ACUST UNITED AC 2020; 24. [PMID: 31362807 PMCID: PMC6668288 DOI: 10.2807/1560-7917.es.2019.24.30.1800695] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Monitoring trends in mortality for individuals diagnosed with hepatitis C virus (HCV) infection are important as we expand treatment and move towards World Health Organization elimination targets. Aim To estimate mortality rates for individuals aged ≥ 15 years diagnosed with HCV infection in England 2008–16. Methods An observational cohort study whereby death certificate information was linked to the Sentinel Surveillance of Blood Borne Virus Testing in England. Age-sex standardised mortality rates (ASMR) for individuals diagnosed with HCV infection (2008–16) were calculated and compared to the general population. Results Of 43,895 individuals with HCV infection, 2,656 (6.3%) died. All-cause ASMRs were 2,834.2 per 100,000 person years (PY), 2.3 times higher than in the general population. In individuals aged 30–69 years, all-cause mortality rates were 1,768.9 per 100,000 PY among individuals with HCV, 4.7 times higher than in the general population. ASMRs had not decreased between 2010 (2,992) and 2016 (2,340; p=0.10), with no change from 2014 (p = 0.058). ASMRs were 441.0 times higher for hepatitis, 34.4 times higher for liver cancer, 8.1 times higher for end stage liver disease and 6.4 times higher for external causes than in the general population. Conclusions Mortality was higher in individuals with diagnosed HCV infection compared to the general population, highlighting health inequalities. There is a need to improve HCV diagnosis, engagement in care and treatment rates. The high mortality from external causes highlights the importance of integrated health and social care strategies and addressing the needs of this vulnerable population.
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Affiliation(s)
- Georgina Ireland
- The National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Blood Borne and Sexually Transmitted Infections at University College London, United Kingdom.,National Infection Service, Public Health England, London, United Kingdom
| | - Sema Mandal
- The National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Blood Borne and Sexually Transmitted Infections at University College London, United Kingdom.,National Infection Service, Public Health England, London, United Kingdom
| | - Matthew Hickman
- Population Health Sciences, Bristol Medical School, Bristol, United Kingdom.,The National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Evaluation of Interventions at University of Bristol, Bristol, United Kingdom
| | - Mary Ramsay
- National Infection Service, Public Health England, London, United Kingdom
| | - Ross Harris
- National Infection Service, Public Health England, London, United Kingdom
| | - Ruth Simmons
- The National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Blood Borne and Sexually Transmitted Infections at University College London, United Kingdom.,National Infection Service, Public Health England, London, United Kingdom
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8
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Jung J, Du P, Feldman R, Kong L, Riley T. Racial/Ethnic and Socioeconomic Disparities in Use of Direct-Acting Antivirals Among Medicare Beneficiaries with Chronic Hepatitis C, 2014-2016. J Manag Care Spec Pharm 2020; 25:1236-1242. [PMID: 31663464 DOI: 10.18553/jmcp.2019.25.11.1236] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND New hepatitis C virus (HCV) drugs-direct-acting antivirals (DAAs)-are highly effective but costly, which raises a concern about limited access to DAAs by vulnerable populations. Previous studies of disparities in DAA use across patient groups showed mixed results, but their generalizability was limited due to using data from commercial insurers or from 2014 only-the first year DAAs were available. Disparities in DAA use in a national cohort in the years when more DAAs were available is unknown. OBJECTIVE To examine whether disparities in DAA use by patient race/ethnicity and socioeconomic status in Medicare changed between 2014 and 2016. METHODS The study population was made up of chronic hepatitis C patients in fee-for-service Medicare with Part D between 2014 and 2016. We used multinomial logistic regression to estimate adjusted odds ratios (aOR) of using DAAs by patient race/ethnicity and socioeconomic status. We estimated the model separately for 2014 and 2014-2016. RESULTS Of 281,810 Medicare patients who were followed to the end of 2016, a total of 90,419 (32.1%) filled prescriptions for DAAs. In the 2014 analysis, blacks were less likely to use DAAs than whites (aOR = 0.95; 95% CI = 0.91-0.99). However, in the 2014-2016 analysis, blacks had higher odds of using DAAs than whites (aOR = 1.24; 95% CI = 1.22-1.27). No significant Hispanic-white gap existed during the study period. Income was positively associated with DAA use in both periods. Between 2014 and 2016, patients who received a Part D low-income subsidy had lower odds of using DAAs than patients who did not (aOR = 0.90; 95% CI = 0.88-0.92), and patients in areas with the higher income tertiles were more likely to initiate DAAs than those in areas with the lowest income tertile. CONCLUSIONS DAA use among Medicare patients remained far below the level needed to eradicate HCV. The black-white gap in HCV treatment was closed by 2016, but disparities by patient socioeconomic status remained. DAA use also varied by patient age and health risk, as well as across geographic regions. Continued efforts to improve DAA uptake in all HCV patients are needed to eradicate HCV. DISCLOSURES This study was supported by the National Institute on Aging (1 R01 AG055636-01A1) and National Institute of Child Health & Human Development (R24 HD04025). The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Feldman owns stock in Gilead Sciences and Abbvie. No other potential competing interest exists.
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Affiliation(s)
- Jeah Jung
- Department of Health Policy and Administration, The Pennsylvania State University, University Park
| | - Ping Du
- Department of Public Health Sciences, College of Medicine
| | - Roger Feldman
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis
| | - Lan Kong
- Department of Public Health Sciences, College of Medicine
| | - Thomas Riley
- Department of Medicine, College of Medicine, The Pennsylvania State University, Hershey
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9
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Bartlett SR, Yu A, Chapinal N, Rossi C, Butt Z, Wong S, Darvishian M, Gilbert M, Wong J, Binka M, Alvarez M, Tyndall M, Krajden M, Janjua NZ. The population level care cascade for hepatitis C in British Columbia, Canada as of 2018: Impact of direct acting antivirals. Liver Int 2019; 39:2261-2272. [PMID: 31444846 DOI: 10.1111/liv.14227] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 08/14/2019] [Accepted: 08/19/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Population-level monitoring of hepatitis C virus (HCV) infected people across cascades of care identifies gaps in access and engagement in care and treatment. We characterized the population-level care cascade for HCV in British Columbia (BC), Canada before and after introduction of Direct Acting Antiviral (DAA) treatment. METHODS BC Hepatitis Testers Cohort (BC-HTC) includes 1.7 million individuals tested for HCV, HIV, reported cases of hepatitis B, and active tuberculosis in BC from 1990 to 2018 linked to medical visits, hospitalizations, cancers, prescription drugs and mortality data. We defined six HCV care cascade stages: (a) antibody diagnosed; (b) RNA tested; (c) RNA positive; (d) genotyped; (e) initiated treatment; and (f) achieved sustained virologic response (SVR). RESULTS We estimated 61 127 people were HCV antibody positive in BC in 2018 (undiagnosed: 7686, 13%; diagnosed: 53 441, 87%). Of those diagnosed, 83% (44 507) had HCV RNA testing, and of those RNA positive, 90% (28 716) were genotyped. Of those genotyped, 61% (17 441) received therapy, with 90% (15 672) reaching SVR. Individuals from older birth cohorts had lower progression to HCV RNA testing. While people who currently inject drugs had the highest proportional progression to RNA testing, this group had the lowest proportional treatment uptake. CONCLUSIONS Although gaps in HCV RNA and genotype testing after antibody diagnosis exist, the largest gap in the care cascade is treatment initiation, despite introduction of DAA treatment and removal of treatment eligibility restrictions. Further interventions are required to ensure testing and treatment is equitably accessible in BC.
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Affiliation(s)
- Sofia R Bartlett
- British Columbia Centre for Disease Control (BCCDC), Vancouver, BC, Canada.,Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada.,Kirby Institute, University of New South Wales Australia, Sydney, NSW, Australia
| | - Amanda Yu
- British Columbia Centre for Disease Control (BCCDC), Vancouver, BC, Canada
| | - Nuria Chapinal
- British Columbia Centre for Disease Control (BCCDC), Vancouver, BC, Canada
| | - Carmine Rossi
- British Columbia Centre for Disease Control (BCCDC), Vancouver, BC, Canada.,Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Zahid Butt
- British Columbia Centre for Disease Control (BCCDC), Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Stanley Wong
- British Columbia Centre for Disease Control (BCCDC), Vancouver, BC, Canada
| | - Maryam Darvishian
- British Columbia Centre for Disease Control (BCCDC), Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Mark Gilbert
- British Columbia Centre for Disease Control (BCCDC), Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Jason Wong
- British Columbia Centre for Disease Control (BCCDC), Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Mawuena Binka
- British Columbia Centre for Disease Control (BCCDC), Vancouver, BC, Canada.,Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Maria Alvarez
- British Columbia Centre for Disease Control (BCCDC), Vancouver, BC, Canada
| | - Mark Tyndall
- British Columbia Centre for Disease Control (BCCDC), Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Mel Krajden
- British Columbia Centre for Disease Control (BCCDC), Vancouver, BC, Canada.,Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Naveed Z Janjua
- British Columbia Centre for Disease Control (BCCDC), Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
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10
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Lee KK, Stelzle D, Bing R, Anwar M, Strachan F, Bashir S, Newby DE, Shah JS, Chung MH, Bloomfield GS, Longenecker CT, Bagchi S, Kottilil S, Blach S, Razavi H, Mills PR, Mills NL, McAllister DA, Shah ASV. Global burden of atherosclerotic cardiovascular disease in people with hepatitis C virus infection: a systematic review, meta-analysis, and modelling study. Lancet Gastroenterol Hepatol 2019; 4:794-804. [PMID: 31377134 PMCID: PMC6734111 DOI: 10.1016/s2468-1253(19)30227-4] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 06/26/2019] [Accepted: 06/28/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND More than 70 million people worldwide are estimated to have hepatitis C virus (HCV) infection. Emerging evidence indicates an association between HCV and atherosclerotic cardiovascular disease. We aimed to determine the association between HCV and cardiovascular disease, and estimate the national, regional, and global burden of cardiovascular disease attributable to HCV. METHODS For this systematic review and meta-analysis, we searched MEDLINE, Embase, Ovid Global Health, and Web of Science databases from inception to May 9, 2018, without language restrictions, for longitudinal studies that evaluated the risk ratio (RR) of cardiovascular disease in people with HCV compared with those without HCV. Two investigators independently reviewed and extracted data from published reports. The main outcome was cardiovascular disease, defined as hospital admission with, or mortality from, acute myocardial infarction or stroke. We calculated the pooled RR of cardiovascular disease associated with HCV using a random-effects model. Additionally, we calculated the population attributable fraction and disability-adjusted life-years (DALYs) from HCV-associated cardiovascular disease at the national, regional, and global level. We also used age-stratified and sex-stratified HCV prevalence estimates and cardiovascular DALYs for 100 countries to estimate country-level burden associated with HCV. This study is registered with PROSPERO, number CRD42018091857. FINDINGS Our search identified 16 639 records, of which 36 studies were included for analysis, including 341 739 people with HCV. The pooled RR for cardiovascular disease was 1·28 (95% CI 1·18-1·39). Globally, 1·5 million (95% CI 0·9-2·1) DALYs per year were lost due to HCV-associated cardiovascular disease. Low-income and middle-income countries had the highest disease burden with south Asian, eastern European, north African, and Middle Eastern regions accounting for two-thirds of all HCV-associated cardiovascular DALYs. INTERPRETATION HCV infection is associated with an increased risk of cardiovascular disease. The global burden of cardiovascular disease associated with HCV infection was responsible for 1·5 million DALYs, with the highest burden in low-income and middle-income countries. FUNDING British Heart Foundation and Wellcome Trust.
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Affiliation(s)
- Kuan Ken Lee
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Dominik Stelzle
- Department of Neurology, Center for Global Health, Technical University of Munich, Munich, Germany
| | - Rong Bing
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Mohamed Anwar
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Fiona Strachan
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Sophia Bashir
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - David E Newby
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Jasmit S Shah
- Department of Medicine, Aga Khan University, Nairobi, Kenya
| | | | - Gerald S Bloomfield
- Department of Medicine, Duke Clinical Research Institute and Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Chris T Longenecker
- Division of Cardiology, University Hospitals Harrington Heart and Vascular Institute, School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Shashwatee Bagchi
- Division of Infectious Diseases and Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Shyamasundaran Kottilil
- Division of Infectious Diseases and Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Sarah Blach
- Center for Disease Analysis Foundation, Lafayette, CO, USA
| | - Homie Razavi
- Center for Disease Analysis Foundation, Lafayette, CO, USA
| | - Peter R Mills
- Department of Gastroenterology, Gartnavel General Hospital, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Nicholas L Mills
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK; Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | | | - Anoop S V Shah
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK; Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK.
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11
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Ryu H, Ahn SJ, Yoon JH, Lee JM. Inter-platform reproducibility of liver stiffness measured with two different point shear wave elastography techniques and 2-dimensional shear wave elastography using the comb-push technique. Ultrasonography 2019; 38:345-354. [PMID: 31500403 PMCID: PMC6769187 DOI: 10.14366/usg.19001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 03/13/2019] [Accepted: 03/23/2019] [Indexed: 12/12/2022] Open
Abstract
PURPOSE The purpose of this study was to compare the technical success rate and reliability of measurements made using three shear wave elastography (SWE) techniques and to assess the inter-platform reproducibility of the resultant liver stiffness measurements. METHODS This prospective study included 54 patients with liver disease. Liver stiffness (LS) measurements were obtained using 2-point SWE techniques (Virtual Touch Quantification and S-Shearwave) and 2-dimensional (2D) SWE, with transient elastography (TE) serving as the reference standard. The technical success rates and measurement reliability of the three techniques were compared. LS values measured using the three SWE techniques and TE were compared using Spearman correlation coefficients and 95% Bland-Altman limits of agreement. Intra-class correlation coefficients (ICC) were used to analyze the inter-platform reproducibility of LS measurements. RESULTS The three SWE techniques and TE showed similar technical success rates (P=0.682) but demonstrated significant differences in the reliability of LS measurements (P=0.006) and mean LS measurements (P<0.001). Despite strong correlations (r=0.73-0.94) between SWE systems, various degrees of inter-platform reproducibility (ICC, 0.58-0.92) were observed for the three SWE techniques. The best agreement was observed between S-Shearwave and TE (ICC, 0.92), and the worst agreement was observed between 2D-SWE and TE (ICC, 0.58). In the BlandAltman analysis, a tendency toward lower LS values with the three SWE techniques than with TE in patients with F3 and F4 disease was observed. CONCLUSION Significant inter-system variability was observed in LS measurements made using the three SWE techniques. Therefore, LS values measured using different SWE techniques should not be used interchangeably for longitudinal follow-up.
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Affiliation(s)
- Hwaseong Ryu
- Department of Radiology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Su Joa Ahn
- Department of Radiology, Gachon University Gil Medical Center, Incheon, Korea
| | - Jeong Hee Yoon
- Department of Radiology, Seoul National University Hospital, Seoul, Korea
| | - Jeong Min Lee
- Department of Radiology, Seoul National University Hospital, Seoul, Korea
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
- Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Korea
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12
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Hickman M, Dillon JF, Elliott L, De Angelis D, Vickerman P, Foster G, Donnan P, Eriksen A, Flowers P, Goldberg D, Hollingworth W, Ijaz S, Liddell D, Mandal S, Martin N, Beer LJZ, Drysdale K, Fraser H, Glass R, Graham L, Gunson RN, Hamilton E, Harris H, Harris M, Harris R, Heinsbroek E, Hope V, Horwood J, Inglis SK, Innes H, Lane A, Meadows J, McAuley A, Metcalfe C, Migchelsen S, Murray A, Myring G, Palmateer NE, Presanis A, Radley A, Ramsay M, Samartsidis P, Simmons R, Sinka K, Vojt G, Ward Z, Whiteley D, Yeung A, Hutchinson SJ. Evaluating the population impact of hepatitis C direct acting antiviral treatment as prevention for people who inject drugs (EPIToPe) - a natural experiment (protocol). BMJ Open 2019; 9:e029538. [PMID: 31551376 PMCID: PMC6773339 DOI: 10.1136/bmjopen-2019-029538] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 07/25/2019] [Accepted: 07/29/2019] [Indexed: 01/15/2023] Open
Abstract
INTRODUCTION Hepatitis C virus (HCV) is the second largest contributor to liver disease in the UK, with injecting drug use as the main risk factor among the estimated 200 000 people currently infected. Despite effective prevention interventions, chronic HCV prevalence remains around 40% among people who inject drugs (PWID). New direct-acting antiviral (DAA) HCV therapies combine high cure rates (>90%) and short treatment duration (8 to 12 weeks). Theoretical mathematical modelling evidence suggests HCV treatment scale-up can prevent transmission and substantially reduce HCV prevalence/incidence among PWID. Our primary aim is to generate empirical evidence on the effectiveness of HCV 'Treatment as Prevention' (TasP) in PWID. METHODS AND ANALYSIS We plan to establish a natural experiment with Tayside, Scotland, as a single intervention site where HCV care pathways are being expanded (including specialist drug treatment clinics, needle and syringe programmes (NSPs), pharmacies and prison) and HCV treatment for PWID is being rapidly scaled-up. Other sites in Scotland and England will act as potential controls. Over 2 years from 2017/2018, at least 500 PWID will be treated in Tayside, which simulation studies project will reduce chronic HCV prevalence among PWID by 62% (from 26% to 10%) and HCV incidence will fall by approximately 2/3 (from 4.2 per 100 person-years (p100py) to 1.4 p100py). Treatment response and re-infection rates will be monitored. We will conduct focus groups and interviews with service providers and patients that accept and decline treatment to identify barriers and facilitators in implementing TasP. We will conduct longitudinal interviews with up to 40 PWID to assess whether successful HCV treatment alters their perspectives on and engagement with drug treatment and recovery. Trained peer researchers will be involved in data collection and dissemination. The primary outcome - chronic HCV prevalence in PWID - is measured using information from the Needle Exchange Surveillance Initiative survey in Scotland and the Unlinked Anonymous Monitoring Programme in England, conducted at least four times before and three times during and after the intervention. We will adapt Bayesian synthetic control methods (specifically the Causal Impact Method) to generate the cumulative impact of the intervention on chronic HCV prevalence and incidence. We will use a dynamic HCV transmission and economic model to evaluate the cost-effectiveness of the HCV TasP intervention, and to estimate the contribution of the scale-up in HCV treatment to observe changes in HCV prevalence. Through the qualitative data we will systematically explore key mechanisms of TasP real world implementation from provider and patient perspectives to develop a manual for scaling up HCV treatment in other settings. We will compare qualitative accounts of drug treatment and recovery with a 'virtual cohort' of PWID linking information on HCV treatment with Scottish Drug treatment databases to test whether DAA treatment improves drug treatment outcomes. ETHICS AND DISSEMINATION Extending HCV community care pathways is covered by ethics (ERADICATE C, ISRCTN27564683, Super DOT C Trial clinicaltrials.gov: NCT02706223). Ethical approval for extra data collection from patients including health utilities and qualitative interviews has been granted (REC ref: 18/ES/0128) and ISCRCTN registration has been completed (ISRCTN72038467). Our findings will have direct National Health Service and patient relevance; informing prioritisation given to early HCV treatment for PWID. We will present findings to practitioners and policymakers, and support design of an evaluation of HCV TasP in England.
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Affiliation(s)
- Matthew Hickman
- Population Health Sciences, Bristol Medical School, Bristol, Bristol, UK
| | - John F Dillon
- Hepatology & Gastroenterology, Clinical & Molecular Medicine, School of Medicine, University of Dundee, Dundee, UK
| | | | - Daniela De Angelis
- MRC Biostatistics Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Peter Vickerman
- Population Health Sciences, Bristol Medical School, Bristol, Bristol, UK
| | - Graham Foster
- Blizard Institute, Queen Mary University of London, London, UK
- Barts Health NHS Trust, London, UK
| | - Peter Donnan
- Dundee Epidemiology and Biostatistics Unit, University of Dundee, Dundee, UK
| | | | | | - David Goldberg
- Glasgow Caledonian University, Glasgow, UK
- Health Protection Scotland, Glasgow, UK
| | | | - Samreen Ijaz
- National Infection Service, Public Health England, London, UK
| | | | - Sema Mandal
- National Infection Service, Public Health England, London, UK
| | - Natasha Martin
- Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, UK
| | - Lewis J Z Beer
- Tayside Clinical Trials Unit, Tayside Medical Science Centre, University of Dundee, Dundee, UK
| | - Kate Drysdale
- Blizard Institute, Queen Mary University of London, London, UK
- Barts Health NHS Trust, London, UK
| | - Hannah Fraser
- Population Health Sciences, Bristol Medical School, Bristol, Bristol, UK
| | - Rachel Glass
- National Infection Service, Public Health England, London, UK
| | | | - Rory N Gunson
- West Of Scotland Specialist Virology Centre, NHS Greater Glasgow & Clyde Board, Glasgow, UK
| | | | - Helen Harris
- National Infection Service, Public Health England, London, UK
| | | | - Ross Harris
- National Infection Service, Public Health England, London, UK
| | | | - Vivian Hope
- Liverpool John Moores University, Liverpool, UK
| | - Jeremy Horwood
- Population Health Sciences, Bristol Medical School, Bristol, Bristol, UK
| | - Sarah Karen Inglis
- Tayside Clinical Trials Unit, Tayside Medical Science Centre, University of Dundee, Dundee, UK
| | - Hamish Innes
- Glasgow Caledonian University, Glasgow, UK
- Health Protection Scotland, Glasgow, UK
| | - Athene Lane
- Population Health Sciences, Bristol Medical School, Bristol, Bristol, UK
| | - Jade Meadows
- Population Health Sciences, Bristol Medical School, Bristol, Bristol, UK
| | - Andrew McAuley
- Glasgow Caledonian University, Glasgow, UK
- Health Protection Scotland, Glasgow, UK
| | - Chris Metcalfe
- Population Health Sciences, Bristol Medical School, Bristol, Bristol, UK
| | | | | | - Gareth Myring
- Population Health Sciences, Bristol Medical School, Bristol, Bristol, UK
| | - Norah E Palmateer
- Glasgow Caledonian University, Glasgow, UK
- Health Protection Scotland, Glasgow, UK
| | - Anne Presanis
- MRC Biostatistics Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Andrew Radley
- Hepatology & Gastroenterology, Clinical & Molecular Medicine, School of Medicine, University of Dundee, Dundee, UK
- Directorate of Public Health, NHS Tayside, Dundee, UK
| | - Mary Ramsay
- National Infection Service, Public Health England, London, UK
| | - Pantelis Samartsidis
- MRC Biostatistics Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Ruth Simmons
- National Infection Service, Public Health England, London, UK
| | - Katy Sinka
- National Infection Service, Public Health England, London, UK
| | | | - Zoe Ward
- Population Health Sciences, Bristol Medical School, Bristol, Bristol, UK
| | | | - Alan Yeung
- Glasgow Caledonian University, Glasgow, UK
- Health Protection Scotland, Glasgow, UK
| | - Sharon J Hutchinson
- Glasgow Caledonian University, Glasgow, UK
- Health Protection Scotland, Glasgow, UK
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13
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Simmons R, Ireland G, Ijaz S, Ramsay M, Mandal S. Causes of death among persons diagnosed with hepatitis C infection in the pre- and post-DAA era in England: A record linkage study. J Viral Hepat 2019; 26:873-880. [PMID: 30896055 DOI: 10.1111/jvh.13096] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Revised: 02/13/2019] [Accepted: 02/20/2019] [Indexed: 12/12/2022]
Abstract
Through record linkage, we describe the causes of death among persons with diagnosis of hepatitis C virus (HCV) in England. Persons ≥1 year with anti-HCV/HCV-PCR tests reported to PHE sentinel surveillance during 2002-2016 were linked to death registrations from the Office for National Statistics during 2008-2016. We found that 8.6% of the 204 265 with evidence of HCV during the study period died. Among them, external causes (accidental poisoning from drugs) and liver disease (end-stage liver disease, liver cancer, hepatitis, alcohol- and non-alcohol-related) were the leading underlying causes of death (18% and 34.5%, respectively); the latter increased to 49.2% if reported anywhere on the death certificate. Median age of death was lower in persons with evidence of HCV than the general population (53 years vs 81 years). A higher proportion of persons with HCV died of external causes, liver disease and HIV compared to the general population (P < 0.001). Potential impact of new HCV treatments was observed as a relative reduction in liver-related deaths in 2016 compared with 2015. Recording of HCV as a contributory cause of death was 28.4% for all underlying causes, but 58.8% among the subgroup who died of liver disease. Data linkage between laboratory diagnosis and deaths data is an important tool for monitoring all-cause mortality among those with HCV and quantifying under-reporting of HCV in death registrations. Changes in mortality trends (causes and prematurity) in people with HCV can help evaluate the impact in the UK of HCV treatment scale-up and other interventions to achieve HCV elimination.
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Affiliation(s)
- Ruth Simmons
- Immunisation, Hepatitis, and Blood Safety Department, National Infection Service, Public Health England, London, UK.,The National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Blood Borne and Sexually Transmitted Infections at University College London, London, UK
| | - Georgina Ireland
- Immunisation, Hepatitis, and Blood Safety Department, National Infection Service, Public Health England, London, UK.,The National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Blood Borne and Sexually Transmitted Infections at University College London, London, UK
| | - Samreen Ijaz
- The National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Blood Borne and Sexually Transmitted Infections at University College London, London, UK.,Blood-borne Virus Unit, Virus Reference Department, National Infection Service, Public Health England, London, UK
| | - Mary Ramsay
- Immunisation, Hepatitis, and Blood Safety Department, National Infection Service, Public Health England, London, UK
| | - Sema Mandal
- Immunisation, Hepatitis, and Blood Safety Department, National Infection Service, Public Health England, London, UK.,The National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Blood Borne and Sexually Transmitted Infections at University College London, London, UK
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14
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Selfridge M, Cunningham EB, Milne R, Drost A, Barnett T, Lundgren K, Guarasci K, Grebely J, Fraser C. Direct-acting antiviral treatment for hepatitis C, reinfection and mortality among people attending an inner-city community health centre in Victoria, Canada. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2019; 72:106-113. [PMID: 31178254 DOI: 10.1016/j.drugpo.2019.03.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 03/08/2019] [Accepted: 03/13/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Direct-acting antiviral (DAA) treatment for hepatitis C virus (HCV) has been shown to be effective among PWID, but more real-world data on treatment outcomes is needed. The aim of this analysis was to assess the efficacy of DAA therapy, and the rate of reinfection and mortality among people attending an inner-city community health centre in Victoria, Canada. METHODS In this retrospective study, patients treated with DAA therapy between November 2014 and Dec 31, 2017 were included. Retrospective chart review was performed to assess recent injecting drug use (IDU, previous six months) or receipt of opioid agonist treatment (OAT). The primary endpoint was Sustained Virologic Response (SVR12). Secondary endpoints included HCV reinfection and mortality. RESULTS Of 270 patients who initiated DAA treatment (31% female), 20% (n=54) had HIV/HCV coinfection, 32% (n=84) had cirrhosis, 67% (n=181) had genotype 1, 6% (n=15) had genotype 2, 26% (n=69) had genotype 3. 46% (n=125) of patients were receiving OAT and 49% (n=132) reported recent IDU. 98% (n=265) completed treatment; two people stopped due to mental health, two people died, and one was non-adherent. 92% (249 of 270) achieved SVR12. 16 patients with End of Treatment (EOT) response did not have a SVR12; 7 were lost to follow-up; 2 people refused bloodwork; 2 people died; 1 had reinfection; and 4 had viral relapse. There was no difference in SVR12 by OAT (OAT, 93% vs. no OAT, 91%, P=0.435), recent injecting drug use (yes, 92% vs. no, 92%, P=0.904), or HIV status (HIV, 92% vs. no HIV, 94%, P=0.498). Eight cases of HCV reinfection were observed over 253 person-years of follow up (3.2 cases per 100 person-years; 95% CI 1.6-6.3). Twenty people died (6.3 per 100 person-years; 95% CI 3.9-10.3), including two during therapy (drug overdose, n=2) and 18 following therapy completion (drug overdose, n=7). CONCLUSION This study demonstrates that DAA treatment is effective among a marginalized population receiving care in an inner-city community health centre. The high mortality in this study highlights the importance of integrating HCV care within a framework addressing drug-related harms, preventing overdose mortality, addressing social inequalities, and improving the health of PWID.
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Affiliation(s)
| | | | | | - Anne Drost
- Cool Aid Community Health Centre, Victoria, Canada
| | | | | | | | | | - Chris Fraser
- Cool Aid Community Health Centre, Victoria, Canada
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15
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Krajden M, Cook D, Janjua NZ. Contextualizing Canada's hepatitis C virus epidemic. CANADIAN LIVER JOURNAL 2018; 1:218-230. [PMID: 35992621 PMCID: PMC9202764 DOI: 10.3138/canlivj.2018-0011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 04/18/2018] [Indexed: 07/29/2023]
Abstract
In 2016, Canada signed on to the World Health Organization (WHO) 2030 hepatitis C virus (HCV) disease elimination targets. Most of Canada's HCV disease burden is among five disproportionately affected population groups: 1) Baby boomers, who are at increased risk of dying from decompensated cirrhosis and hepatocellular carcinoma and for whom one-time screening should be recommended to identify those undiagnosed; 2) People who inject drugs (PWID), whose mortality risks include HCV infection, HCV acquisition risks and co-morbid conditions. While HCV infection in PWID can be effectively cured with direct-acting antivirals, premature deaths from acquisition risks, now exacerbated by Canada's opioid crisis, will need to be addressed to achieve the full benefits of curative treatment. PWID require syndemic-based solutions (harm reduction, addictions and mental health support, and management of co-infections, including HIV); 3) Indigenous populations who will require wellness-based health promotion, prevention, care and treatment designed by Indigenous people to address their underlying health disparities; 4) Immigrants who will require culturally designed and linguistically appropriate services to enhance screening and engagement into care; and (5) For those incarcerated because of drug-related crimes, decriminalization and better access to harm reduction could help reduce the impact of HCV infections and premature mortality. A comprehensive prevention, care and treatment framework is needed for Canada's vulnerable populations, including those co-infected with HIV, if we are to achieve the WHO HCV elimination targets by 2030. The aim of this review is to describe the HCV epidemic in the Canadian context.
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Affiliation(s)
- Mel Krajden
- Clinical Prevention Services, BC Centre for Disease Control, Vancouver, British Columbia
- Dept. of Pathology & Laboratory Medicine, University of British Columbia, Vancouver, British Columbia
| | - Darrel Cook
- Clinical Prevention Services, BC Centre for Disease Control, Vancouver, British Columbia
| | - Naveed Z Janjua
- Clinical Prevention Services, BC Centre for Disease Control, Vancouver, British Columbia
- School of Population and Public Health, University of British Columbia, Vancouver British Columbia
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16
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Salomone F, Catania M, Montineri A, Bertino G, Godos J, Rizzo L, Magrì G, Li Volti G. Hepatitis C virus eradication by direct antiviral agents improves glucose tolerance and reduces post-load insulin resistance in nondiabetic patients with genotype 1. Liver Int 2018; 38:1206-1211. [PMID: 29265719 DOI: 10.1111/liv.13669] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 12/11/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIMS Genotype 1 chronic hepatitis C is associated with an impairment of glucose homoeostasis, especially in the advanced stages of the disease. Glucose tolerance is an independent predictor of liver-related mortality in patients with cirrhosis because of chronic hepatitis C. However, no study has demonstrated so far weather hepatitis C virus clearance affects glucose tolerance. METHODS To this aim, we performed a prospective study assessing the effects of direct antiviral agents treatment in nondiabetic cirrhotic patients with genotypes 1a/1b and impaired glucose tolerance based on a 75-g oral glucose tolerance test. Impaired glucose tolerance was diagnosed by a 2-hour plasma glucose between 140 and 199 mg/dL. Insulin resistance was estimated by the oral glucose insulin sensitivity index, an oral glucose tolerance test-derived measure. RESULTS After meeting the inclusion criteria, the study population included 32 outpatients (26/6 genotypes 1b/1a; age 62 ± 7.4 years; 18 males) with compensated Child-A cirrhosis. All patients achieved a sustained virological response following direct antiviral agents treatment. After viral eradication, we did not observe change in fasting plasma glucose (103.5 ± 7.1 vs 102.8 ± 7.2 mg/dL, P = .15) but 2-hour plasma glucose was reduced (165.2 ± 22.7 vs 138.5 ± 21.3 mg/dL, P < .001). Hepatitis C virus eradication led also to a significant reduction in HbA1c (6.1 ± 0.2% vs 5.7 ± 0.3%, P < .001) and post-load insulin resistance as assessed by the oral glucose insulin sensitivity index (6.92 ± 1.56 vs 9.52 ± 1.39 mg/kg/min, P < .001). These effects were observed despite no change in body mass index from baseline to follow-up (25.6 ± 4.3 vs 25.8 ± 4.4, P > .5). CONCLUSIONS Our results indicate that hepatitis C virus eradication may early improve glucose tolerance in patients with hepatitis C virus-related cirrhosis.
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Affiliation(s)
- Federico Salomone
- Division of Gastroenterology, Ospedale di Acireale, Azienda Sanitaria Provinciale di Catania, Catania, Italy
| | - Maurizio Catania
- Division of Laboratory Medicine, Ospedale di Acireale, Azienda Sanitaria Provinciale di Catania, Catania, Italy
| | - Arturo Montineri
- Division of Infectious Diseases, Ospedale "Ferrarotto", Catania, Italy
| | - Gaetano Bertino
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Justyna Godos
- Department of Biomedical and Biotechnological Sciences, University of Catania, Catania, Italy
| | | | - Giovanni Magrì
- Division of Gastroenterology, Ospedale di Acireale, Azienda Sanitaria Provinciale di Catania, Catania, Italy
| | - Giovanni Li Volti
- Department of Biomedical and Biotechnological Sciences, University of Catania, Catania, Italy
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17
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18
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The contribution of alcohol use disorder to decompensated cirrhosis among people with hepatitis C: An international study. J Hepatol 2018; 68:393-401. [PMID: 29107152 DOI: 10.1016/j.jhep.2017.10.019] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 08/21/2017] [Accepted: 10/07/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS The advent of direct-acting antivirals (DAAs) has led to ambitious targets for hepatitis C virus (HCV) elimination. However, in the context of alcohol use disorder the ability of DAAs to achieve these targets may be compromised. The aim of this study was to evaluate the contribution of alcohol use disorder to HCV-related decompensated cirrhosis in three settings. METHODS HCV notifications from British Columbia, Canada; New South Wales, Australia, and Scotland (1995-2011/2012/2013, respectively) were linked to hospital admissions (2001-2012/2013/2014, respectively). Alcohol use disorder was defined as non-liver-related hospitalisation due to alcohol use. Age-standardised decompensated cirrhosis incidence rates were plotted, associated factors were assessed using Cox regression, and alcohol use disorder-associated population attributable fractions (PAFs) were computed. RESULTS Among 58,487, 84,529, and 31,924 people with HCV in British Columbia, New South Wales, and Scotland, 2,689 (4.6%), 3,169 (3.7%), and 1,375 (4.3%) had a decompensated cirrhosis diagnosis, and 28%, 32%, and 50% of those with decompensated cirrhosis had an alcohol use disorder, respectively. Age-standardised decompensated cirrhosis incidence rates were considerably higher in people with alcohol use disorder in New South Wales and Scotland. Decompensated cirrhosis was independently associated with alcohol use disorder in British Columbia (aHR 1.92; 95% CI 1.76-2.10), New South Wales (aHR 3.68; 95% CI 3.38-4.00) and Scotland (aHR 3.88; 95% CI 3.42-4.40). The PAFs of decompensated cirrhosis-related to alcohol use disorder were 13%, 25%, and 40% in British Columbia, New South Wales and Scotland, respectively. CONCLUSIONS Alcohol use disorder was a major contributor to HCV liver disease burden in all settings, more distinctly in Scotland. The extent to which alcohol use would compromise the individual and population-level benefits of DAA therapy needs to be closely monitored. Countries, where appropriate, must develop strategies combining promotion of DAA treatment uptake with management of alcohol use disorders, if World Health Organization 2030 HCV mortality reduction targets are going to be achieved. LAY SUMMARY The burden of liver disease has been rising among people with hepatitis C globally. The recent introduction of highly effective medicines against hepatitis C (called direct-acting antivirals or DAAs) has brought renewed optimism to the sector. DAA scale-up could eliminate hepatitis C as a public health threat in the coming decades. However, our findings show heavy alcohol use is a major risk factor for liver disease among people with hepatitis C. If continued, heavy alcohol use could compromise the benefits of new antiviral treatments at the individual- and population-level. To tackle hepatitis C as a public health threat, where needed, DAA therapy should be combined with management of heavy alcohol use.
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Saeed S, Strumpf EC, Moodie EE, Young J, Nitulescu R, Cox J, Wong A, Walmsely S, Cooper C, Vachon ML, Martel-Laferriere V, Hull M, Conway B, Klein MB. Disparities in direct acting antivirals uptake in HIV-hepatitis C co-infected populations in Canada. J Int AIDS Soc 2018; 20. [PMID: 29116684 PMCID: PMC5810331 DOI: 10.1002/jia2.25013] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 09/25/2017] [Indexed: 12/27/2022] Open
Abstract
Background Direct acting antivirals (DAAs) have revolutionized hepatitis C (HCV) treatment with >90% cure rates even in real‐world studies, giving hope that HCV can be eliminated. However, for DAAs to have a population‐level impact on the burden of HCV disease, treatment uptake needs to be expanded. We investigated temporal trends in HCV treatment uptake and evaluated factors associated with second‐generation DAA initiation and efficacy among key HIV‐HCV co‐infected populations in Canada. Methods The Canadian HIV‐HCV Co‐Infection Cohort Study prospectively follows 1699 participants from 18 centres. Among HCV RNA+ participants, we determined the incidence of HCV treatment initiation per year overall and by key populations between 2007 and 2015. Key populations were based on World Health Organization (WHO) guidelines including: people who actively inject drugs (PWID) (reporting injection drug use, last 6 months); Indigenous people; women and men who have sex with men (MSM). Multivariate Cox models were used to estimate adjusted hazard ratios (aHR) and 2‐year probability of initiating second‐generation DAAs for each of the key populations. Results Overall, HCV treatment initiation rates increased from 8 (95% CI, 6–11) /100 person‐years in 2013 to 28 (95% CI, 23–33) /100 person‐years in 2015. Among 911 HCV RNA + participants, there were 202 second‐generation DAA initiations (93% with interferon‐free regimens). After adjustment (aHR, 95% CI), active PWID (0.60, 0.38–0.94 compared to people not injecting drugs) and more generally, people with lower income (<$18 000 CAD/year) (0.50, 0.35, 0.71) were less likely to initiate treatment. Conversely, MSM were more likely to initiate 1.95 (1.33, 2.86) compared to heterosexual men. In our cohort, the population profile with the lowest 2‐year probability of initiating DAAs was Indigenous, women who inject drugs (5%, 95% CI 3–8%). Not having any of these risk factors resulted in a 35% (95% CI 32–38%) probability of initiating DAA treatment. Sustained virologic response (SVR) rates were >82% in all key populations. Conclusion While treatment uptake has increased with the availability of second‐generation DAAs, marginalized populations, already engaged in care, are still failing to access treatment. Targeted strategies to address barriers are needed to avoid further health inequities and to maximize the public health impact of DAAs.
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Affiliation(s)
- Sahar Saeed
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada.,Division of Infectious Diseases/Chronic Viral Illness Service, Department of Medicine, Glen site, McGill University Health Centre, Montreal, QC, Canada
| | - Erin C Strumpf
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada.,Department of Economics, McGill University, Montreal, QC, Canada
| | - Erica Em Moodie
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada
| | - Jim Young
- Division of Infectious Diseases/Chronic Viral Illness Service, Department of Medicine, Glen site, McGill University Health Centre, Montreal, QC, Canada
| | - Roy Nitulescu
- Division of Infectious Diseases/Chronic Viral Illness Service, Department of Medicine, Glen site, McGill University Health Centre, Montreal, QC, Canada
| | - Joseph Cox
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada.,Division of Infectious Diseases/Chronic Viral Illness Service, Department of Medicine, Glen site, McGill University Health Centre, Montreal, QC, Canada
| | | | - Sharon Walmsely
- University Health Network, Toronto, ON, Canada.,CIHR Canadian HIV Trials Network, Vancouver, BC, Canada
| | - Curtis Cooper
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | | | | | - Mark Hull
- Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, BC, Canada
| | - Brian Conway
- Vancouver Infectious Diseases Centre, Vancouver, BC, Canada
| | - Marina B Klein
- Division of Infectious Diseases/Chronic Viral Illness Service, Department of Medicine, Glen site, McGill University Health Centre, Montreal, QC, Canada.,CIHR Canadian HIV Trials Network, Vancouver, BC, Canada
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20
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Innes H, McAuley A, Alavi M, Valerio H, Goldberg D, Hutchinson SJ. The contribution of health risk behaviors to excess mortality in American adults with chronic hepatitis C: A population cohort-study. Hepatology 2018; 67:97-107. [PMID: 28777874 DOI: 10.1002/hep.29419] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 07/06/2017] [Accepted: 08/01/2017] [Indexed: 01/01/2023]
Abstract
UNLABELLED In resource-rich countries, chronic hepatitis C (CHC) infection is associated with a sizeable excess mortality risk. The extent to which this is due to (1) the biological sequelae of CHC infection versus (2) a high concomitant burden of health risk behaviors (HRBs) is unclear. We used data from the 1999-2010 U.S. National Health and Nutritional Examination Surveys (NHANES), which include detailed information on HRBs and CHC infection status. We calculated the prevalence of the five major HRBs-alcohol use; cigarette smoking, physical inactivity, unhealthy diet, and illicit drug use-according to CHC after adjusting for sociodemographic differences. Mortality status after survey interview was ascertained by linkage to the U.S. National Death Index. To assess the contribution of HRBs to the excess mortality risk, we determined the all-cause mortality rate ratio (MRR) for individuals with CHC relative to individuals without, and then calculated the attenuation in this MRR following adjustment for HRBs. This analysis included 27,468 adult participants of NHANES of which 363 tested positive for CHC. All HRBs were markedly more prevalent among individuals with CHC versus individuals without. CHC was associated with a 2.4-fold higher mortality rate after adjustment for sociodemographic factors (MRR, 2.36; 95% CI, 1.60-3.49). Subsequent adjustment for all five HRBs attenuated this ratio by 50.7% to MRR 1.67 (95% CI, 1.14-2.44). Higher levels of attenuation (69.1%) were observed among individuals aged 45-70 years, who form the target demographic for U.S. birth cohort screening. CONCLUSION At least half the excess mortality risk for individuals with CHC in the United States may be attributed to HRBs rather than CHC. The remedial response to hepatitis C must not neglect action on HRBs if it is to fully resolve the high mortality problem in this population. (Hepatology 2018;67:97-107).
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Affiliation(s)
- Hamish Innes
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, United Kingdom.,Health Protection Scotland, Glasgow Caledonian University, Glasgow, United Kingdom
| | - Andrew McAuley
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, United Kingdom.,Health Protection Scotland, Glasgow Caledonian University, Glasgow, United Kingdom
| | - Maryam Alavi
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, United Kingdom.,The Kirby Institute for Infection and Immunity in Society, University of New South Wales, Sydney, Australia
| | - Heather Valerio
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, United Kingdom.,Health Protection Scotland, Glasgow Caledonian University, Glasgow, United Kingdom
| | - David Goldberg
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, United Kingdom.,Health Protection Scotland, Glasgow Caledonian University, Glasgow, United Kingdom
| | - Sharon J Hutchinson
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, United Kingdom.,Health Protection Scotland, Glasgow Caledonian University, Glasgow, United Kingdom
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21
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El Sherif O, Afhdal N, Curry M. No one size fits all-Shortening duration of therapy with direct-acting antivirals for hepatitis C genotype 1 infection. J Viral Hepat 2017; 24:808-813. [PMID: 28581634 DOI: 10.1111/jvh.12734] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 04/10/2017] [Indexed: 12/24/2022]
Abstract
The advent of shorter duration, highly effective and well-tolerated interferon-free therapy now provides an opportunity for virtually all HCV-infected individuals to be cured. However, there continues to be a need to simplify and shorten treatment duration. Shortening therapy to 8 weeks with sofosbuvir and ledipasvir can be considered in treatment patients with HCV genotype 1 infection and low baseline viral load. A number of other 8-week dual and triple therapy direct-acting antiviral (DAA) regimens are in advanced clinical development. Several small studies have further demonstrated the feasibility of 6 weeks of sofosbuvir therapy in combination with an NS5A inhibitor and a protease inhibitor for HCV genotype 1. Four weeks of therapy with various combinations of the currently available DAAs appears to be suboptimal with poor response rates observed in phase 2 trials. Response-guided therapy is another promising tool that may allow for shorter therapy but require further research. Shortening therapy and retreating relapsers may be a viable cost-saving measure, but requires further cost-benefit analysis and more data on the impact of resistance on retreatment options.
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Affiliation(s)
- O El Sherif
- Hepatology Centre, St. James's Hospital, Dublin 8, Ireland.,Beth Israel Deaconess Medical Centre, Boston, MA, USA
| | - N Afhdal
- Beth Israel Deaconess Medical Centre, Boston, MA, USA
| | - M Curry
- Beth Israel Deaconess Medical Centre, Boston, MA, USA
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22
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McDonald SA, Innes HA, Aspinall E, Hayes PC, Alavi M, Valerio H, Goldberg DJ, Hutchinson SJ. Prognosis of 1169 hepatitis C chronically infected patients with decompensated cirrhosis in the predirect-acting antiviral era. J Viral Hepat 2017; 24:295-303. [PMID: 27885753 DOI: 10.1111/jvh.12646] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Accepted: 10/05/2016] [Indexed: 12/19/2022]
Abstract
At a population level, little is known regarding the risk of liver- and nonliver-related mortality and hospitalization and the development of hepatocellular carcinoma (HCC) in hepatitis C virus (HCV)-infected patients with decompensated cirrhosis (DC). This large-scale national record-linkage study estimates these outcomes following first hospital admission for DC. Record-linkages between national HCV diagnosis and clinical databases and the national inpatient hospital episode database and mortality register were conducted to follow-up the disease course of all identified HCV-diagnosed and chronically infected persons. The study population consisted of 1169 HCV chronically infected persons who had a first hospital admission for DC within the period 1994-2013. We observed an overall average annual percentage change of 12.6% in new DC patients (from 63 in 1994-1999 to 541 in 2009-2013), with no evidence for any improvement in the relative risks of liver-related or all-cause death over time. Between 1 January 1994 and 31 May 2014, 722 and 95 DC patients had died of a liver- and a nonliver-related cause, respectively, and 106 patients had a subsequent first admission for HCC. The 5-year cumulative incidence of liver-related mortality, nonliver-related mortality and first subsequent HCC admission was 61.3%, 8.2% and 8.8%, respectively. The health burden in HCV-infected patients associated with development of decompensated cirrhosis has increased dramatically over the last 20 years. Our findings establish the baseline mortality and HCC progression rates in DC patients against which the impact of new antiviral therapies can be measured.
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Affiliation(s)
- S A McDonald
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK.,Health Protection Scotland, Glasgow, UK
| | - H A Innes
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK.,Health Protection Scotland, Glasgow, UK
| | - E Aspinall
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK.,Health Protection Scotland, Glasgow, UK
| | - P C Hayes
- Royal Infirmary of Edinburgh, Edinburgh, UK
| | - M Alavi
- Health Protection Scotland, Glasgow, UK
| | - H Valerio
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK.,Health Protection Scotland, Glasgow, UK
| | - D J Goldberg
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK.,Health Protection Scotland, Glasgow, UK
| | - S J Hutchinson
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK.,Health Protection Scotland, Glasgow, UK
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23
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Innes H, McDonald S, Hayes P, Dillon JF, Allen S, Goldberg D, Mills PR, Barclay ST, Wilks D, Valerio H, Fox R, Bhattacharyya D, Kennedy N, Morris J, Fraser A, Stanley A, Bramley P, Hutchinson SJ. Mortality in hepatitis C patients who achieve a sustained viral response compared to the general population. J Hepatol 2017; 66:19-27. [PMID: 27545496 DOI: 10.1016/j.jhep.2016.08.004] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 08/03/2016] [Accepted: 08/05/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS The number of people living with previous hepatitis C infection that have attained a sustained viral response (SVR) is expected to grow rapidly. So far, the prognosis of this group relative to the general population is unclear. METHODS Individuals attaining SVR in Scotland in 1996-2011 were identified using a national database. Through record-linkage, we obtained cause-specific mortality data complete to Dec 2013. We calculated standardised mortality ratios (SMRs) to compare the frequency of mortality in SVR patients to the general population. In a parallel analysis, we used Cox regression to identify modifiable patient characteristics associated with post-SVR mortality. RESULTS We identified 1824 patients, followed on average for 5.2years after SVR. In total, 78 deaths were observed. Overall, all-cause mortality was 1.9 times more frequent for SVR patients than the general population (SMR: 1.86; 95% confidence interval (CI): 1.49-2.32). Significant cause-specific elevations were seen for death due to primary liver cancer (SMR: 23.50; 95% CI: 12.23-45.16), and death due to drug-related causes (SMR: 6.58, 95% CI: 4.15-10.45). Together these two causes accounted for 66% of the total excess death observed. All of the modifiable characteristics associated with increased mortality were markers either of heavy alcohol use or injecting drug use. Individuals without these behavioural markers (32.8% of cohort) experienced equivalent survival to the general population (SMR: 0.70; 95% CI: 0.41-1.18) CONCLUSIONS: Mortality in Scottish SVR patients is higher overall than the general population. The excess was driven by death from drug-related causes and liver cancer. Health risk behaviours emerged as important modifiable determinants of mortality in this population. LAY SUMMARY Patients cured of hepatitis C through treatment had a higher mortality rate overall than the general population. Most of the surplus mortality was due to drug-related causes and death from liver cancer. A history of heavy alcohol and injecting drug use were associated with a higher mortality risk.
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Affiliation(s)
- Hamish Innes
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK; Health Protection Scotland, Glasgow, UK.
| | - Scott McDonald
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK; Health Protection Scotland, Glasgow, UK
| | | | | | | | - David Goldberg
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK; Health Protection Scotland, Glasgow, UK
| | | | | | | | - Heather Valerio
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK; Health Protection Scotland, Glasgow, UK
| | - Ray Fox
- The Brownlee Centre, Glasgow, UK
| | | | | | | | | | | | | | - Sharon J Hutchinson
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK; Health Protection Scotland, Glasgow, UK
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Staugaard B, Christensen PB, Mössner B, Hansen JF, Madsen BS, Søholm J, Krag A, Thiele M. Feasibility of transient elastography versus real-time two-dimensional shear wave elastography in difficult-to-scan patients. Scand J Gastroenterol 2016; 51:1354-9. [PMID: 27310486 DOI: 10.1080/00365521.2016.1193217] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Transient elastography (TE) is hampered in some patients by failures and unreliable results. We hypothesized that real time two-dimensional shear wave elastography (2D-SWE), the FibroScan XL probe, and repeated TE exams, could be used to obtain reliable liver stiffness measurements in patients with an invalid TE examination. METHODS We reviewed 1975 patients with 5764 TE exams performed between 2007 and 2014, to identify failures and unreliable exams. Fifty-four patients with an invalid TE at their latest appointment entered a comparative feasibility study of TE vs. 2D-SWE. RESULTS The initial TE exam was successful in 93% (1835/1975) of patients. Success rate increased from 89% to 96% when the XL probe became available (OR: 1.07, 95% CI 1.06-1.09). Likewise, re-examining those with a failed or unreliable TE led to a reliable TE in 96% of patients. Combining availability of the XL probe with TE re-examination resulted in a 99.5% success rate on a per-patient level. When comparing the feasibility of TE vs. 2D-SWE, 96% (52/54) of patients obtained a reliable TE, while 2D-SWE was reliable in 63% (34/54, p < 0.001). The odds of a successful 2D-SWE exam decreased with higher skin-capsule distance (OR = 0.77, 95% CI 0.67-0.98). CONCLUSIONS Transient elastography can be accomplished in nearly all patients by use of the FibroScan XL probe and repeated examinations. In difficult-to-scan patients, the feasibility of TE is superior to 2D-SWE.
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Affiliation(s)
- Benjamin Staugaard
- a Department of Infectious Diseases , Odense University Hospital , Odense , Denmark ;,b Institute of Clinical Research, University of Southern Denmark , Odense , Denmark
| | - Peer Brehm Christensen
- a Department of Infectious Diseases , Odense University Hospital , Odense , Denmark ;,b Institute of Clinical Research, University of Southern Denmark , Odense , Denmark
| | - Belinda Mössner
- a Department of Infectious Diseases , Odense University Hospital , Odense , Denmark
| | - Janne Fuglsang Hansen
- a Department of Infectious Diseases , Odense University Hospital , Odense , Denmark ;,b Institute of Clinical Research, University of Southern Denmark , Odense , Denmark
| | - Bjørn Stæhr Madsen
- b Institute of Clinical Research, University of Southern Denmark , Odense , Denmark ;,c Department of Gastroenterology and Hepatology , Odense University Hospital , Odense , Denmark
| | - Jacob Søholm
- d Department of Medicine , Lillebaelt Hospital , Kolding , Denmark
| | - Aleksander Krag
- b Institute of Clinical Research, University of Southern Denmark , Odense , Denmark ;,c Department of Gastroenterology and Hepatology , Odense University Hospital , Odense , Denmark
| | - Maja Thiele
- b Institute of Clinical Research, University of Southern Denmark , Odense , Denmark ;,c Department of Gastroenterology and Hepatology , Odense University Hospital , Odense , Denmark ;,e OPEN, Odense Patient Data Exploratory Network , Odense University Hospital , Odense , Denmark
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Meijide H, Mena Á, Rodríguez-Osorio I, Pértega S, Castro-Iglesias Á, Rodríguez-Martínez G, Pedreira J, Poveda E. Trends in hospital admissions, re-admissions, and in-hospital mortality among HIV-infected patients between 1993 and 2013: Impact of hepatitis C co-infection. Enferm Infecc Microbiol Clin 2016; 35:20-26. [PMID: 27609631 DOI: 10.1016/j.eimc.2016.07.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 07/22/2016] [Accepted: 07/26/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND New patterns in epidemiological characteristics of people living with HIV infection (PLWH) and the introduction of Highly Active Antiretroviral Therapy (HAART) have changed the profile of hospital admissions in this population. The aim of this study was to evaluate trends in hospital admissions, re-admissions, and mortality rates in HIV patients and to analyze the role of HCV co-infection. METHODS A retrospective cohort study conducted on all hospital admissions of HIV patients between 1993 and 2013. The study time was divided in two periods (1993-2002 and 2003-2013) to be compared by conducting a comparative cross-sectional analysis. RESULTS A total of 22,901 patient-years were included in the analysis, with 6917 hospital admissions, corresponding to 1937 subjects (75% male, mean age 36±11 years, 37% HIV/HCV co-infected patients). The median length of hospital stay was 8 days (5-16), and the 30-day hospital re-admission rate was 20.1%. A significant decrease in hospital admissions related with infectious and psychiatric diseases was observed in the last period (2003-2013), but there was an increase in those related with malignancies, cardiovascular, gastrointestinal, and chronic respiratory diseases. In-hospital mortality remained high (6.8% in the first period vs. 6.3% in the second one), with a progressive increase of non-AIDS-defining illness deaths (37.9% vs. 68.3%, P<.001). The admission rate significantly dropped after 1996 (4.9% yearly), but it was less pronounced in HCV co-infected patients (1.7% yearly). CONCLUSIONS Hospital admissions due to infectious and psychiatric disorders have decreased, with a significant increase in non-AIDS-defining malignancies, cardiovascular, and chronic respiratory diseases. In-hospital mortality is currently still high, but mainly because of non-AIDS-defining illnesses. HCV co-infection increased the hospital stay and re-admissions during the study period.
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Affiliation(s)
- Héctor Meijide
- Grupo de Virología Clínica, Instituto de Investigación Biomédica de A Coruña (INIBIC)-Complexo Hospitalario Universitario de A Coruña (CHUAC), Sergas, Universidade da Coruña (UDC), Spain; Servicio de Medicina Interna, Hospital Quiron, A Coruña, Spain
| | - Álvaro Mena
- Grupo de Virología Clínica, Instituto de Investigación Biomédica de A Coruña (INIBIC)-Complexo Hospitalario Universitario de A Coruña (CHUAC), Sergas, Universidade da Coruña (UDC), Spain.
| | - Iria Rodríguez-Osorio
- Grupo de Virología Clínica, Instituto de Investigación Biomédica de A Coruña (INIBIC)-Complexo Hospitalario Universitario de A Coruña (CHUAC), Sergas, Universidade da Coruña (UDC), Spain
| | - Sonia Pértega
- Unidad de Epidemiología Clínica y Bioestadística, Instituto de Investigación Biomédica de A Coruña (INIBIC)-Complexo Hospitalario Universitario de A Coruña (CHUAC), Sergas, Universidade da Coruña (UDC), Spain
| | - Ángeles Castro-Iglesias
- Grupo de Virología Clínica, Instituto de Investigación Biomédica de A Coruña (INIBIC)-Complexo Hospitalario Universitario de A Coruña (CHUAC), Sergas, Universidade da Coruña (UDC), Spain
| | - Guillermo Rodríguez-Martínez
- Unidad de Admisión y Documentación Clínica, Complexo Hospitalario Universitario de A Coruña (CHUAC), Sergas, A Coruña, Spain
| | - José Pedreira
- Grupo de Virología Clínica, Instituto de Investigación Biomédica de A Coruña (INIBIC)-Complexo Hospitalario Universitario de A Coruña (CHUAC), Sergas, Universidade da Coruña (UDC), Spain
| | - Eva Poveda
- Grupo de Virología Clínica, Instituto de Investigación Biomédica de A Coruña (INIBIC)-Complexo Hospitalario Universitario de A Coruña (CHUAC), Sergas, Universidade da Coruña (UDC), Spain
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Janjua NZ, Kuo M, Yu A, Alvarez M, Wong S, Cook D, Wong J, Grebely J, Butt ZA, Samji H, Ramji A, Tyndall M, Krajden M. The Population Level Cascade of Care for Hepatitis C in British Columbia, Canada: The BC Hepatitis Testers Cohort (BC-HTC). EBioMedicine 2016; 12:189-195. [PMID: 27596150 PMCID: PMC5078584 DOI: 10.1016/j.ebiom.2016.08.035] [Citation(s) in RCA: 86] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 08/19/2016] [Accepted: 08/23/2016] [Indexed: 01/29/2023] Open
Abstract
Background Population-level monitoring of hepatitis C virus (HCV) infected people across the cascade of care identifies gaps in access and engagement in care and treatment. We characterized a population-level cascade of care for HCV in British Columbia (BC), Canada and identified factors associated with leakage at each stage. Methods The BC Hepatitis Testers Cohort (BC-HTC) includes 1.5 million individuals tested for HCV, HIV, reported cases of hepatitis B, and active tuberculosis in BC from 1990 to 2013 linked to medical visits, hospitalizations, cancers, prescription drugs and mortality data. We defined six HCV cascade of care stages: 1) estimated population prevalence; 2) HCV diagnosed; 3) HCV RNA tested; 4) genotyped; 5) initiated treatment; and 6) achieved sustained virologic response (SVR). Results We estimated that 73,203 people were HCV antibody positive in BC in 2012 (undiagnosed: 18,301, 25%; diagnosed: 54,902, 75%). Of these, 56%(40,656) had HCV RNA testing; 34%(26,300) were genotyped; 12%( 8532 ) had received interferon-based therapy and 7%(5197) had SVR. Males, older birth cohorts, and HBV coinfected were less likely to undergo HCV RNA testing. Among those with chronic HCV infection, 32% had received liver-related care. Retention in liver care was more likely in those with HIV, cirrhosis, and drug/alcohol use and less likely in males and HBV coinfected. Conclusions Although there are gaps in HCV RNA testing and genotyping after HCV diagnosis, the major gap in the cascade of care was low treatment initiation. People with comorbidities progressed through the cascade of testing and care but few received treatment. Integration of various data sources enables HCV monitoring across the care cascade to assess program effectiveness. The majority of anti-HCV positive individuals were tested for RNA and genotyping. Very small proportion of HCV infected individuals received treatment. People with HIV coinfection and drug use despite being in liver care were less likely to receive treatment.
We have assembled data on all individuals testing for hepatitis C in British Columbia to establish a system to monitor infection and care. The majority of the individuals testing positive for anti- HCV antibodies were tested for hepatitis C RNA and subsequently genotyping, both needed for treatment. However, very small percentage received interferon-based hepatitis C treatment and it was successful in about half of them. People with HIV co-infection and drug use were more likely to receive liver care but they were less likely to receive treatment. Changes at laboratory level could overcome remaining gaps in testing while highly tolerable and effective new drugs could reduce treatment gaps.
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Affiliation(s)
- Naveed Z Janjua
- British Columbia Centre for Disease Control (BCCDC), 655 West 12th Avenue, Vancouver, BC V5Z 4R4, Canada; School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC V6T 1Z3, Canada.
| | - Margot Kuo
- British Columbia Centre for Disease Control (BCCDC), 655 West 12th Avenue, Vancouver, BC V5Z 4R4, Canada
| | - Amanda Yu
- British Columbia Centre for Disease Control (BCCDC), 655 West 12th Avenue, Vancouver, BC V5Z 4R4, Canada
| | - Maria Alvarez
- British Columbia Centre for Disease Control (BCCDC), 655 West 12th Avenue, Vancouver, BC V5Z 4R4, Canada
| | - Stanley Wong
- British Columbia Centre for Disease Control (BCCDC), 655 West 12th Avenue, Vancouver, BC V5Z 4R4, Canada
| | - Darrel Cook
- British Columbia Centre for Disease Control (BCCDC), 655 West 12th Avenue, Vancouver, BC V5Z 4R4, Canada
| | - Jason Wong
- British Columbia Centre for Disease Control (BCCDC), 655 West 12th Avenue, Vancouver, BC V5Z 4R4, Canada; School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC V6T 1Z3, Canada
| | - Jason Grebely
- Kirby Institute, University of New South Wales Australia, Sydney, NSW 2052, Australia
| | - Zahid A Butt
- British Columbia Centre for Disease Control (BCCDC), 655 West 12th Avenue, Vancouver, BC V5Z 4R4, Canada; School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC V6T 1Z3, Canada
| | - Hasina Samji
- British Columbia Centre for Disease Control (BCCDC), 655 West 12th Avenue, Vancouver, BC V5Z 4R4, Canada; School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC V6T 1Z3, Canada
| | - Alnoor Ramji
- Division of Gastroenterology, Department of Medicine, University of British Columbia, Vancouver, BC V5Z 1M9, Canada
| | - Mark Tyndall
- British Columbia Centre for Disease Control (BCCDC), 655 West 12th Avenue, Vancouver, BC V5Z 4R4, Canada; School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC V6T 1Z3, Canada
| | - Mel Krajden
- British Columbia Centre for Disease Control (BCCDC), 655 West 12th Avenue, Vancouver, BC V5Z 4R4, Canada; Department of Pathology and Laboratory Medicine, University of British Columbia, 2211 Wesbrook Mall, Vancouver, BC V6Z 1Y6, Canada
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Lazarus JV, Mozalevskis A, Safreed-Harmon K, Eramova I. Strengthening hepatitis B and C surveillance in Europe: results from the two global hepatitis policy surveys (2013 and 2014). HEPATOLOGY, MEDICINE AND POLICY 2016; 1:3. [PMID: 30288307 PMCID: PMC5918699 DOI: 10.1186/s41124-016-0009-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 05/30/2016] [Indexed: 01/16/2023]
Abstract
Background Hepatitis B and C are major public health threats in the World Health Organization (WHO) European Region. Viral hepatitis surveillance shortcomings have resulted in many WHO Member States having insufficient data available to guide decision-making. This study describes surveillance in the region based on a quantitative sub-analysis of findings from the 2013 WHO viral hepatitis policy report and a qualitative analysis of civil society survey responses associated with these findings. Methods Descriptive statistics were created from information that national government focal points for viral hepatitis in 44 countries had previously reported in response to the WHO survey. Bivariate analysis was performed to compare data from within and outside of the European Union/European Economic Area (EU/EEA). Survey responses from civil society organizations in the countries of the WHO European Region were collated, and a descriptive analysis of the comments on surveillance-related questions was performed to identify key themes. Results The response rate for the survey of governments was 83 % among both EU/EEA countries (25/30) and non-EU/EEA countries (19/23). More than 90 % of governments reported having national surveillance systems for the acute forms of hepatitis B and hepatitis C, but less than two-thirds reported surveillance for the chronic forms of both diseases. High proportions of governments reported having central registries for the reporting of deaths (96 %) and liver cancer cases (80 %), while less than half reported regularly conducting viral hepatitis sero-surveys. All responding Member States reported having adequate laboratory capacity nationally to support hepatitis outbreak investigations and other surveillance activities. Target populations for sero-surveys most commonly included people who inject drugs (27 %), the general population (25 %), men who have sex with men (20 %) and pregnant women (20 %). Few statistically significant differences were found between EU/EEA and non-EU/EEA countries. Conclusions Study findings indicated a capacity for robust viral hepatitis surveillance across the WHO European Region, with most countries having important surveillance components in place, but notable weaknesses were also identified. There is an urgent need for countries throughout the region to strengthen their surveillance programs in order to maximize the population-level impact of advances in HBV and HCV prevention and treatment. Electronic supplementary material The online version of this article (doi:10.1186/s41124-016-0009-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jeffrey V Lazarus
- 1CHIP, Centre for Health and Infectious Disease Research and WHO Collaborating Centre on HIV and Viral Hepatitis, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Antons Mozalevskis
- 2World Health Organization (WHO) Regional Office for Europe, Copenhagen, Denmark
| | - Kelly Safreed-Harmon
- 1CHIP, Centre for Health and Infectious Disease Research and WHO Collaborating Centre on HIV and Viral Hepatitis, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Irina Eramova
- 2World Health Organization (WHO) Regional Office for Europe, Copenhagen, Denmark
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Innes H, Hutchinson SJ, Obel N, Christensen PB, Aspinall EJ, Goldberg D, Krarup H, McDonald SA, McLeod A, Weir A, Omland LH. Liver mortality attributable to chronic hepatitis C virus infection in Denmark and Scotland--using spontaneous resolvers as the benchmark comparator. Hepatology 2016; 63:1506-16. [PMID: 26773546 DOI: 10.1002/hep.28458] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Revised: 12/07/2015] [Accepted: 01/10/2016] [Indexed: 01/10/2023]
Abstract
UNLABELLED Liver mortality among individuals with chronic hepatitis C (CHC) infection is common, but the relative contribution of CHC per se versus adverse health behaviors is uncertain. We explored data on spontaneous resolvers of hepatitis C virus (HCV) as a benchmark group to uncover the independent contribution of CHC on liver mortality. Using national HCV diagnosis and mortality registers from Denmark and Scotland, we calculated the liver mortality rate (LMR) for persons diagnosed with CHC infection (LMRchronic ) and spontaneously resolved infection (LMRresolved ), according to subgroups defined by age, sex, and drug use. Through these mortality rates, we determined subgroup-specific attributable fractions (AFs), defined as (LMRchronic - LMRresolved )/LMRchronic , and then calculated the total attributable fraction (TAF) as a weighted average of these AFs. Thus, the TAF represents the overall fraction (where 0.00 = not attributable at all; and 1.00 = entirely attributable) of liver mortality attributable to CHC in the diagnosed population. Our cohort comprised 7,005 and 21,729 persons diagnosed with HCV antibodies in Denmark and Scotland, respectively. Mean follow-up duration was 6.3-6.9 years. The TAF increased stepwise with age. It was lowest for death occurring at <45 years of age (0.21 in Denmark; 0.26 in Scotland), higher for death occurring at 45-59 years (0.69 in Denmark; 0.69 in Scotland), and highest for death at 60+years (0.92 in Denmark; 0.75 in Scotland). Overall, the TAF was 0.66 (95% confidence interval [CI]: 0.55-0.78) in Denmark and 0.55 (95% CI: 0.44-0.66) in Scotland. CONCLUSIONS In Denmark and Scotland, the majority of liver death in the CHC-diagnosed population can be attributed to CHC-nevertheless, an appreciable fraction cannot, cautioning that liver mortality in this population is a compound problem that can be reduced, but not solved, through antiviral therapy alone.
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Affiliation(s)
- Hamish Innes
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK.,Health Protection Scotland, Blood borne viruses and STIs, Glasgow, UK
| | - Sharon J Hutchinson
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK.,Health Protection Scotland, Blood borne viruses and STIs, Glasgow, UK
| | - Niels Obel
- Department of Infectious Diseases, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Peer B Christensen
- Department of Infectious Diseases, Odense University Hospital, Odense, Denmark
| | - Esther J Aspinall
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK.,Health Protection Scotland, Blood borne viruses and STIs, Glasgow, UK
| | - David Goldberg
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK.,Health Protection Scotland, Blood borne viruses and STIs, Glasgow, UK
| | - Henrik Krarup
- Section of Molecular Diagnostics, Clinical Biochemistry, Aalborg University Hospital, Aalborg Hospital, Aalborg, Denmark
| | - Scott A McDonald
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK.,Health Protection Scotland, Blood borne viruses and STIs, Glasgow, UK
| | - Allan McLeod
- Health Protection Scotland, Blood borne viruses and STIs, Glasgow, UK
| | - Amanda Weir
- NHS, National Services Scotland, Edinburgh, UK
| | - Lars H Omland
- Department of Infectious Diseases, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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Accurso AJ, Rastegar DA, Ghazarian SR, Fingerhood MI. Impact of hepatitis C status on 20-year mortality of patients with substance use disorders. Addict Sci Clin Pract 2015; 10:20. [PMID: 26463043 PMCID: PMC4672505 DOI: 10.1186/s13722-015-0041-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2015] [Accepted: 10/01/2015] [Indexed: 12/24/2022] Open
Abstract
Background The magnitude of the effect of hepatitis C viral infection on survival is still not fully understood. The objective of this study was to determine whether the presence of hepatitis C viral antibodies in 1991 was associated with increased mortality 20 years later within a cohort of patients with substance use disorders. Secondary objectives were to determine other factors that were associated with increased mortality in the cohort. Methods A subset of a 1991 study cohort of patients who had presented for detoxification was reexamined 20 years later. The Social Security Death Index was queried to identify which of the original patients had died. Attributes of survivors and non-survivors were compared, with special attention to their hepatitis C status in 1991. The original study and this analysis were conducted in the chemical detoxification unit at Johns Hopkins Bayview (previously Francis Scott Key Hospital), an academic urban hospital. All participants met the criteria for alcohol or opioid dependence at the time of admission in 1991. The primary study outcome was 20-year mortality after initial admission in 1991, with a planned analysis of hepatitis C status. Results Twenty years after admission, 362 patients survived and 82 had died. Of the 284 patients who were hepatitis C positive, 228 survived (80 %). Of the 160 patients who were hepatitis C negative, 134 survived (84 %). This absolute risk increase of 4 % was not statistically significant (p = 0.37). Factors associated with increased mortality included male sex, white race, older age, and reported use of alcohol, cocaine, and illicit methadone. Binary logistic regression including hepatitis C status and these other variables yielded an adjusted odds ratio of 0.87 (95 % CI 0.49–1.55); (p = 0.64) for hepatitis C positive 20-year survival. Conclusions Hepatitis C positivity was not associated with a statistically significant difference in 20-year survival. The effect of the virus on mortality, if present, is small, relative to the effect of substance use disorders alone.
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Affiliation(s)
- Anthony J Accurso
- Johns Hopkins Bayview Medical Center, 5200 Eastern Ave, Mason F. Lord Bldg, West Tower 5th floor, Baltimore, MD, 21224, USA.
| | - Darius A Rastegar
- Johns Hopkins Bayview Medical Center, 5200 Eastern Ave, Mason F. Lord Bldg, West Tower 5th floor, Baltimore, MD, 21224, USA.
| | - Sharon R Ghazarian
- Johns Hopkins Bayview Medical Center, 5200 Eastern Ave, Mason F. Lord Bldg, West Tower 5th floor, Baltimore, MD, 21224, USA.
| | - Michael I Fingerhood
- Johns Hopkins Bayview Medical Center, 5200 Eastern Ave, Mason F. Lord Bldg, West Tower 5th floor, Baltimore, MD, 21224, USA.
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Expansion of HCV treatment access to people who have injected drugs through effective translation of research into public health policy: Scotland's experience. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2015; 26:1041-9. [PMID: 26123893 DOI: 10.1016/j.drugpo.2015.05.019] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 05/11/2015] [Accepted: 05/31/2015] [Indexed: 01/15/2023]
Abstract
Seven years have elapsed since the Scottish Government launched its Hepatitis C Action Plan - a Plan to improve services to prevent transmission of infection, particularly among people who inject drugs (PWID), identify those infected and ensure those infected receive optimal treatment. The Plan was underpinned by industrial scale funding (around £100 million, in addition to the general NHS funding, will have been invested by 2015), and a web of accountable national and local multi-disciplinary multi-agency networks responsible for the planning, development and delivery of services. Initiatives ranged from the introduction of testing in specialist drug services through finger-prick blood sampling by non-clinical staff, to the setting of government targets to ensure rapid scale-up of antiviral therapy. The Plan was informed by comprehensive national monitoring systems, indicating the extent of the problem not just in terms of numbers infected, diagnosed and treated but also the more penetrative data on the number advancing to end-stage liver disease and death, and also through compelling modelling work demonstrating the potential beneficial impact of scaling-up therapy and the mounting cost of not acting. Achievements include around 50% increase in the proportion of the infected population diagnosed (38% to 55%); a sustained near two-and-a-half fold increase in the annual number of people initiated onto therapy (470 to 1050) with more pronounced increases among PWID (300 to 840) and prisoners (20 to 140); and reversing of an upward trend in the overall number of people living with chronic infection. The Action Plan has demonstrated that a Government-backed, coordinated and invested approach can transform services and rapidly improve the lives of thousands. Cited as "an impressive example of a national strategy" by the Global Commission on Drug Policy, the Scottish Plan has also provided fundamental insights of international relevance into the management of HCV among PWID.
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