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Moonen CPB, den Heijer CDJ, Dukers-Muijrers NHTM, van Dreumel R, Steins SCJ, Hoebe CJPA. A systematic review of barriers and facilitators for hepatitis B and C screening among migrants in the EU/EEA region. Front Public Health 2023; 11:1118227. [PMID: 36875381 PMCID: PMC9975596 DOI: 10.3389/fpubh.2023.1118227] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 01/31/2023] [Indexed: 02/17/2023] Open
Abstract
Introduction Hepatitis B and C are a threat to public health. Screening of high-risk groups, such as migrants from high-endemic areas, enables early identification and treatment initiation. This systematic review identified barriers and facilitators for hepatitis B and C screening among migrants in the European Union/European Economic Area (EU/EEA). Methods Following PRISMA guidelines, databases PubMed, Embase via Ovid, and Cochrane were searched for English articles published between 1 July 2015 and 24 February 2022. Articles were included, not restricted to a specific study design, if they elaborated on HBV or HCV screening in migrant populations from countries outside Western Europe, North America, and Oceania, and residing in EU/EEA countries. Excluded were studies with solely an epidemiological or microbiological focus, including only general populations or non-migrant subgroups, or conducted outside the EU/EEA, without qualitative, quantitative, or mixed methods. Data appraisal, extraction, and quality assessment were conducted and assessed by two reviewers. Barriers and facilitators were categorized into seven levels based on multiple theoretical frameworks and included factors related to guidelines, the individual health professional, the migrant and community, interaction, the organization and economics, the political and legal level, and innovations. Results The search strategy yielded 2,115 unique articles of which 68 were included. Major identified barriers and facilitators to the success of screening related to the migrant (knowledge and awareness) and community level (culture, religion, support) and the organizational and economic level (capacity, resources, coordinated structures). Given possible language barriers, language support and migrant sensitivity are indispensable for facilitating interaction. Rapid point-of-care-testing is a promising strategy to lower screening barriers. Discussion The inclusion of multiple study designs provided extensive insight into barriers, strategies to lower these barriers, and facilitators to maximize the success of screening. A great variety of factors were revealed on multiple levels, therefore there is no one-size-fits-all approach for screening, and initiatives should be adopted for the targeted group(s), including tailoring to cultural and religious beliefs. We provide a checklist of facilitators and barriers to inform adapted interventions to allow for optimal screening impact.
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Affiliation(s)
- Chrissy P B Moonen
- Living Lab Public Health, Department of Sexual Health, Infectious Diseases and Environmental Health, South Limburg Public Health Service, Heerlen, Netherlands.,Department of Social Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, Netherlands
| | - Casper D J den Heijer
- Living Lab Public Health, Department of Sexual Health, Infectious Diseases and Environmental Health, South Limburg Public Health Service, Heerlen, Netherlands.,Department of Social Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, Netherlands
| | - Nicole H T M Dukers-Muijrers
- Living Lab Public Health, Department of Sexual Health, Infectious Diseases and Environmental Health, South Limburg Public Health Service, Heerlen, Netherlands.,Department of Health Promotion, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, Netherlands
| | - Ragni van Dreumel
- Living Lab Public Health, Department of Sexual Health, Infectious Diseases and Environmental Health, South Limburg Public Health Service, Heerlen, Netherlands
| | - Sabine C J Steins
- Living Lab Public Health, Department of Sexual Health, Infectious Diseases and Environmental Health, South Limburg Public Health Service, Heerlen, Netherlands
| | - Christian J P A Hoebe
- Living Lab Public Health, Department of Sexual Health, Infectious Diseases and Environmental Health, South Limburg Public Health Service, Heerlen, Netherlands.,Department of Social Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, Netherlands.,Department of Medical Microbiology, Care and Public Health Research Institute (CAPHRI), Maastricht University Medical Centre (MUMC+), Maastricht, Netherlands
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2
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Taye BW, Valery PC, Clark PJ. Targeted antiviral treatment of hepatitis B virus in culturally and linguistically diverse populations to achieve elimination targets in Australia. J Viral Hepat 2022; 29:868-878. [PMID: 35748684 PMCID: PMC9544141 DOI: 10.1111/jvh.13727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 06/03/2022] [Accepted: 06/09/2022] [Indexed: 12/09/2022]
Abstract
The majority of Australia's hepatitis B virus (HBV) burden is borne by culturally and linguistically diverse (CALD) populations, and antiviral treatment is the mainstay of intervention. Using modelling, we estimated the impact of targeted antiviral treatment scale-up and changes in migration on HBV-related mortality and HBV elimination in CALD populations in Australia. We fitted a deterministic mathematical model based on the natural history of HBV and the Australian migration effect in four CALD population groups according to country of birth. We used three antiviral treatment scale-up scenarios: baseline (9.3% coverage); intermediate (coverage of 80% of patients eligible for antiviral therapy by 2030); and optimistic (coverage of 20% of all patients living with HBV by 2022). Our model predicted that if the baseline treatment is followed between 2015 and 2030, the number of chronic HBV cases and HBV-related mortality will increase. Following the optimistic scale-up, the number of new HBV cases could be reduced by 78%, 73%, 74% and 83% in people born in Asia-Pacific, Europe, Africa and the Middle East, and Americas, respectively, between 2015 and 2030. An optimistic treatment scale-up could result in a 19.2%-24.5% reduction in HBV-related mortality and a 15%-25% reduction in HCC-related mortality in CALD populations between 2015 and 2030. In conclusion, our findings highlight that targeted antiviral treatment for CALD populations provides significant health system benefits by reducing HBV-related complications from cirrhosis and HCC. Expanded antiviral treatment programmes focusing on high-prevalence CALD populations may be an effective strategy to reduce HBV-related morbidity and mortality.
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Affiliation(s)
- Belaynew W. Taye
- Faculty of MedicineThe University of QueenslandBrisbaneQueenslandAustralia,Mater Research Institute‐University of QueenslandBrisbaneQueenslandAustralia,Population HealthQIMR Berghofer Medical Research InstituteBrisbaneQueenslandAustralia,Department of EpidemiologyBahir Dar UniversityBahir DarEthiopia
| | - Patricia C. Valery
- Faculty of MedicineThe University of QueenslandBrisbaneQueenslandAustralia,Population HealthQIMR Berghofer Medical Research InstituteBrisbaneQueenslandAustralia
| | - Paul J. Clark
- Faculty of MedicineThe University of QueenslandBrisbaneQueenslandAustralia,Mater Research Institute‐University of QueenslandBrisbaneQueenslandAustralia,Population HealthQIMR Berghofer Medical Research InstituteBrisbaneQueenslandAustralia,Department of Gastroenterology and HepatologyMater HospitalsBrisbaneQueenslandAustralia,Department of Gastroenterology and HepatologyPrincess Alexandra HospitalBrisbaneQueenslandAustralia
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3
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Le D, Ciceron AC, Pan J, Juon HS, Berg CJ, Nguyen TA, Le HC, Yang YT. Linkage-to-Care Following Community-Based HBV and HCV Screening Among Immigrants from the Washington–Baltimore Metropolitan Area, 2016–2019. J Immigr Minor Health 2022; 24:1137-1144. [PMID: 35064900 PMCID: PMC8783186 DOI: 10.1007/s10903-022-01327-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2021] [Indexed: 12/14/2022]
Abstract
Understanding characteristics that impact linkage-to-care (LTC) among individuals living with HBV and/or HCV can enhance public health efforts to provide tailored care services to prevent and treat viral hepatitis among immigrants. Using HBV/HCV screening and LTC data from immigrants (2016–2019), descriptive and logistic regression analyses were conducted to assess (1) the relationship between LTC and sociodemographic factors and (2) factors associated with HBV/HCV LTC. About 87% of those positive HBsAg had LTC and 52% had LTC among those with HCVAB and confirmed PCR. Access to care was an important LTC predictor for HBV–LTC: those who had neither health insurance nor primary care provider (PCP) were more likely to have HBV–LTC than those who had either health insurance or PCP (aOR = 2.95, 95% CI = 1.32–6.59). It is essential to equally provide HBV/HCV LTC support to all immigrants from countries with high prevalence regardless of access to care.
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Affiliation(s)
- Daisy Le
- School of Nursing, The George Washington University, 1919 Pennsylvania NW, Suite 500, Washington, DC, 20006, USA.
- Milken Institute School of Public Health, The George Washington University, Washington, DC, USA.
| | - Annie Coriolan Ciceron
- School of Nursing, The George Washington University, 1919 Pennsylvania NW, Suite 500, Washington, DC, 20006, USA
| | - Jane Pan
- Hepatitis B Initiative of Washington DC (HBI-DC), Washington, DC, USA
| | - Hee-Soon Juon
- Department of Medical Oncology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Carla J Berg
- Milken Institute School of Public Health, The George Washington University, Washington, DC, USA
| | - T Angeline Nguyen
- Hepatitis B Initiative of Washington DC (HBI-DC), Washington, DC, USA
| | - Hai Chi Le
- Hepatitis B Initiative of Washington DC (HBI-DC), Washington, DC, USA
| | - Y Tony Yang
- School of Nursing, The George Washington University, 1919 Pennsylvania NW, Suite 500, Washington, DC, 20006, USA
- Milken Institute School of Public Health, The George Washington University, Washington, DC, USA
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4
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Cornberg M, Sandmann L, Protzer U, Niederau C, Tacke F, Berg T, Glebe D, Jilg W, Wedemeyer H, Wirth S, Höner Zu Siederdissen C, Lynen-Jansen P, van Leeuwen P, Petersen J. S3-Leitlinie der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) zur Prophylaxe, Diagnostik und Therapie der Hepatitis-B-Virusinfektion – (AWMF-Register-Nr. 021-11). ZEITSCHRIFT FUR GASTROENTEROLOGIE 2021; 59:691-776. [PMID: 34255317 DOI: 10.1055/a-1498-2512] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Markus Cornberg
- Deutsches Zentrum für Infektionsforschung (DZIF), Klinik für Gastroenterologie, Hepatologie und Endokrinologie, Medizinische Hochschule Hannover, Hannover; Centre for individualised infection Medicine (CiiM), Hannover.,Klinik für Gastroenterologie, Hepatologie und Endokrinologie, Medizinische Hochschule Hannover, Hannover
| | - Lisa Sandmann
- Klinik für Gastroenterologie, Hepatologie und Endokrinologie, Medizinische Hochschule Hannover, Hannover
| | - Ulrike Protzer
- Institut für Virologie, Technische Universität München/Helmholtz Zentrum München, München
| | | | - Frank Tacke
- Medizinische Klinik m. S. Hepatologie und Gastroenterologie, Charité Universitätsmedizin Berlin, Berlin
| | - Thomas Berg
- Klinik und Poliklinik für Gastroenterologie und Rheumatologie, Universitätsklinikum Leipzig, Leipzig
| | - Dieter Glebe
- Institut für Medizinische Virologie, Nationales Referenzzentrum für Hepatitis-B-Viren und Hepatitis-D-Viren, Justus-Liebig-Universität Gießen, Gießen
| | - Wolfgang Jilg
- Institut für Medizinische Mikrobiologie und Hygiene, Universität Regensberg, Regensburg
| | - Heiner Wedemeyer
- Klinik für Gastroenterologie, Hepatologie und Endokrinologie, Medizinische Hochschule Hannover, Hannover
| | - Stefan Wirth
- Zentrum für Kinder- und Jugendmedizin, Helios Universitätsklinikum Wuppertal, Wuppertal
| | | | - Petra Lynen-Jansen
- Deutsche Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS), Berlin
| | - Pia van Leeuwen
- Deutsche Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS), Berlin
| | - Jörg Petersen
- IFI Institut für Interdisziplinäre Medizin an der Asklepios Klinik St. Georg, Hamburg
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5
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Hvass AMF, Norredam M, Sodemann M, Wejse C. Is there a need of health assessments for resettling refugees? A cross-sectional study of 1431 refugees who arrived in Denmark between 2014 and 2018. J Migr Health 2021; 3:100044. [PMID: 34405189 PMCID: PMC8352093 DOI: 10.1016/j.jmh.2021.100044] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 12/03/2020] [Accepted: 04/10/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Refugees have increased health risks due to factors related to their country of origin, the migration itself and the receiving country. Based on systematic general health assessments of newly arrived refugees, we aimed to study the characteristics with regard to background, migration and health needs. METHODS All refugees (children/adolescents and adults) arriving in Aarhus, Denmark from 1 January 2014 to 1 November 2018 were offered a general health assessment by a doctor including: medical history, a physical examination and blood samples. RESULTS A cohort of 1431 (of 1618 invited, (88.4%) participants accepted the health assessment. The most commonly found health conditions in children were vitamin D deficiency (28.3%), elevated serum-IgE (34%) and lack of immunity against vaccine-preventable diseases (measles 20.1%, polio 3.9%). In adults, vitamin D deficiency (34.6%), IgE elevation (30%), latent tuberculosis (20.3%) and symptoms of PTSD (15.9%) were most prevalent. We found participants from Southern Asia (Iran, Afghanistan and Pakistan) to be overrepresented with regard to vitamin D deficiency, vitamin B12 deficiency and symptoms of PTSD. Furthermore, we found that origin in Africa was associated with latent tuberculosis. In total, 63.8% of examined refugees had one or more health problems requiring further testing, treatment or follow-up. CONCLUSIONS A comprehensive health assessment among recently arrived refugees showed multiple health issues to address, and demonstrates the need of systematic health assessments for resettling refugees.
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Affiliation(s)
- Anne Mette F. Hvass
- Department of Infectious Diseases, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Aarhus, Denmark
- Department of Social Medicine, Aarhus Municipality, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Denmark
| | - Marie Norredam
- Danish Research Centre for Migration, Ethnicity and Health, Institute of Public Health, University of Copenhagen, Øster Farimagsgade 5, 1353, Copenhagen K, Denmark
- Section for Immigrant Medicine, Department of Infectious Diseases, Hvidovre University Hospital, Denmark
| | - Morten Sodemann
- Migrant Health Clinic, Department of Infectious Diseases, Odense University Hospital
| | - Christian Wejse
- Department of Infectious Diseases, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Denmark
- Department of Public Health, Center for Global Health, Aarhus University, Bartolins Alle 4, 8000 Aarhus C, Denmark
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6
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Hargreaves S, Nellums LB, Johnson C, Goldberg J, Pantelidis P, Rahman A, Friedland FMedSci JS. Delivering multi-disease screening to migrants for latent TB and blood-borne viruses in an emergency department setting: A feasibility study. Travel Med Infect Dis 2020; 36:101611. [PMID: 32126293 PMCID: PMC7493708 DOI: 10.1016/j.tmaid.2020.101611] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 11/06/2019] [Accepted: 02/26/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Screening for latent tuberculosis infection (LTBI) in migrants is important for elimination of tuberculosis in low-incidence countries, alongside the need to detect blood-borne infections to align with new guidelines on migrant screening for multiple infections in European countries. However, feasibility needs to be better understood. METHODS We did a feasibility study to test an innovative screening model offering combined testing for LTBI (QuantiFERON), HIV, hepatitis B/C in a UK emergency department, with two year follow-up. RESULTS 96 economic migrants, asylum seekers and refugees from 43 countries were screened (46 [47.9%] women; mean age 35.2 years [SD 11.7; range 18-73]; mean time in the UK 4.8 years [SD 3.2; range 0-10]). 14 migrants (14.6%) tested positive for LTBI alongside HIV [1], hepatitis B [2], and hepatitis C [1] Of migrants with LTBI, 5 (35.7%) were successfully engaged in treatment. 74 (77.1%) migrants reported no previous screening since migrating to the UK. CONCLUSION Multi-disease screening in this setting is feasible and merits being further tested in larger-scale studies. However, greater emphasis must be placed on ensuring successful treatment outcomes. We identified major gaps in current screening provision; most migrants had been offered no prior screening despite several years since migration, which holds relevance to policy and practice in the UK and other European countries.
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Affiliation(s)
- Sally Hargreaves
- Institute for Infection & Immunity, St. George's, University of London, United Kingdom.
| | - Laura B Nellums
- Institute for Infection & Immunity, St. George's, University of London, United Kingdom; Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Catherine Johnson
- Section of Infectious Diseases & Immunity, Imperial College London, United Kingdom
| | - Jacob Goldberg
- Section of Infectious Diseases & Immunity, Imperial College London, United Kingdom
| | | | - Asif Rahman
- Imperial College Healthcare NHS Trust, London, United Kingdom
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7
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Thijssen M, Lemey P, Amini-Bavil-Olyaee S, Dellicour S, Alavian SM, Tacke F, Verslype C, Nevens F, Pourkarim MR. Mass migration to Europe: an opportunity for elimination of hepatitis B virus? Lancet Gastroenterol Hepatol 2020; 4:315-323. [PMID: 30860067 DOI: 10.1016/s2468-1253(19)30014-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 01/08/2019] [Accepted: 01/10/2019] [Indexed: 02/07/2023]
Abstract
People from low-to-middle income countries have been migrating to western Europe on a large scale in recent years. Data indicate that the number of first-time asylum applications by non-EU members increased from 290 000 in 2011 to more than 1·3 million in 2015. During the peak period of migration, The Global Health Sector Strategy on Viral Hepatitis was adopted by WHO. Viral hepatitis, and particularly hepatitis B virus (HBV), is an important disease because of its high prevalence and associated mortality. In some cases, HBV can be carried by refugees arriving from regions of high and intermediate prevalence. Refugees with HBV might not show clinical symptoms and not be diagnosed in destination countries with a low prevalence, where screening is not regularly done. Although transmission to the host population is low, dedicated surveillance and tailored public health policies are required. It is important to note that some of the countries that receive many migrants do not have a universal HBV vaccination programme. In this Viewpoint, we argue that the current large-scale movement from regions with high or intermediate HBV prevalence should be taken as an opportunity to achieve viral hepatitis elimination targets, by establishing a well prepared infrastructure for HBV screening, vaccination, and treatment.
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Affiliation(s)
- Marijn Thijssen
- Department of Microbiology and Immunology, Rega Institute, Laboratory of Clinical and Epidemiological Virology, KU Leuven, Leuven, Belgium
| | - Philippe Lemey
- Laboratory of Evolutionary and Computational Virology, KU Leuven, Leuven, Belgium
| | | | - Simon Dellicour
- Laboratory of Evolutionary and Computational Virology, KU Leuven, Leuven, Belgium; Spatial Epidemiology Lab, Université Libre de Bruxelles, Brussels, Belgium
| | - Seyed Moayed Alavian
- Baqiyatallah Research Center for Gastroenterology and Liver Diseases, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Frank Tacke
- Department of Medicine III, Rheinisch-Westfälische Technische Hochschule-University Hospital Aachen, Aachen, Germany
| | - Chris Verslype
- Department of Gastroenterology and Hepatology, University Hospitals KU Leuven, Leuven Belgium
| | - Frederik Nevens
- Department of Gastroenterology and Hepatology, University Hospitals KU Leuven, Leuven Belgium
| | - Mahmoud Reza Pourkarim
- Department of Microbiology and Immunology, Rega Institute, Laboratory of Clinical and Epidemiological Virology, KU Leuven, Leuven, Belgium; Health Policy Research Center, Institute of Health, Shiraz University of Medical Sciences, Shiraz, Iran.
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8
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Mohamed EA, Giama NH, Shaleh HM, Kerandi L, Oseini AM, Ahmed Mohammed H, Kerandi H, Allotey LK, Waaeys IA, Ali HA, Ali HM, Mohamed SA, Yang JD, Gaga WO, Tamire LL, Windissa A, Patten CA, Balls-Berry JE, Roberts LR. Knowledge, Attitudes, and Behaviors of Viral Hepatitis Among Recent African Immigrants in the United States: A Community Based Participatory Research Qualitative Study. Front Public Health 2020; 8:25. [PMID: 32211358 PMCID: PMC7067746 DOI: 10.3389/fpubh.2020.00025] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 01/27/2020] [Indexed: 12/13/2022] Open
Abstract
Background: In the United States, hepatocellular carcinoma is the ninth leading cause of cancer mortality. Hepatocellular carcinoma disproportionately affects individuals of African ancestry with the rates being higher amongst individuals of foreign-born African ancestry. This study explored knowledge, attitudes, and behaviors toward viral hepatitis transmission, screening, and vaccination among recent African immigrants in Minnesota and identify ways to improve early detection and screening methods. Methods: A community based participatory research (CBPR) team with minority researchers and community members sought to gain insight on persons of African Ancestry knowledge, attitudes, and behaviors related to viral hepatitis by conducting a qualitative research study. The CBPR team developed a focus group moderator's guide with semi-structured questions related to transmission, screening, and vaccination of viral hepatitis. We conducted seven focus groups using bilingual, bicultural moderators with participants from local Ethiopian, Liberian and Kenyan communities from August 10th, 2014 to October 11th, 2014. Focus groups were audio recorded and transcribed. The CBPR team categorized the data into themes and subthemes with consensus using traditional content analysis. Results: Community partners recruited 63 participants with a majority identifying as male (51%). Participants lacked knowledge of viral hepatitis screening, vaccination, and treatment. Participants were aware of some behaviors that increased risk of acquisition of hepatitis. Participants endorsed a strategy of developing and delivering educational materials for African immigrants. Moreover, access to care and cultural awareness were mentioned as pivotal for prevention and treatment of viral hepatitis. Conclusions: Findings from this pilot study provide insight on areas of research focus. Having a research team consisting of members from the community helped to increase trust and foster an understanding of shared community values. Information from this study provides evidence to support the development culturally appropriate strategies to address disparities in viral hepatitis in these communities.
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Affiliation(s)
- Essa A Mohamed
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, United States
| | - Nasra H Giama
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, United States
| | - Hassan M Shaleh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, United States
| | - Linda Kerandi
- Urgent Care and Clinic, Midpoint Medical Clinic, Brooklyn Park, MN, United States
| | - Abdul M Oseini
- Division of Gastroenterology, Virginia Commonwealth University, Richmond, VA, United States
| | - Hager Ahmed Mohammed
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, United States
| | - Henry Kerandi
- Urgent Care and Clinic, Midpoint Medical Clinic, Brooklyn Park, MN, United States
| | - Loretta K Allotey
- Medical School, University of Minnesota, Rochester, MN, United States
| | | | - Hamdi A Ali
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, United States
| | - Hawa M Ali
- Medical School, University of Minnesota, Rochester, MN, United States
| | | | - Ju Dong Yang
- Transplant Hepatology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Wudneh O Gaga
- St. George Ethiopian Tewahido Orthodox Church, Rochester, MN, United States
| | - Lily L Tamire
- St. George Ethiopian Tewahido Orthodox Church, Rochester, MN, United States
| | - Awol Windissa
- Pillsbury United Communities, Minneapolis, MN, United States
| | - Christi A Patten
- Behavioral Health Research Program, Mayo Clinic, Rochester, MN, United States
| | | | - Lewis R Roberts
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, United States
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9
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Bil JP, Schrooders PA, Prins M, Kouw PM, Klomp JH, Scholing M, Huijbregts LP, Sonder GJ, Waegemaekers TC, de Vries HJ, Meijer W, Zuure FR, Tostmann A. Integrating hepatitis B, hepatitis C and HIV screening into tuberculosis entry screening for migrants in the Netherlands, 2013 to 2015. ACTA ACUST UNITED AC 2019; 23. [PMID: 29560855 PMCID: PMC5861593 DOI: 10.2807/1560-7917.es.2018.23.11.17-00491] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
We evaluated uptake and diagnostic outcomes of voluntary hepatitis B (HBV) and C virus (HCV) screening offered during routine tuberculosis entry screening to migrants in Gelderland and Amsterdam, the Netherlands, between 2013 and 2015. In Amsterdam, HIV screening was also offered. Overall, 54% (461/859) accepted screening. Prevalence of chronic HBV infection (HBsAg-positive) and HCV exposure (anti-HCV-positive) in Gelderland was 4.48% (9/201; 95% confidence interval (CI): 2.37–8.29) and 0.99% (2/203; 95% CI: 0.27–3.52), respectively, all infections were newly diagnosed. Prevalence of chronic HBV infection, HCV exposure and chronic HCV infection (HCV RNA-positive) in Amsterdam was 0.39% (1/256; 95% CI: 0.07–2.18), 1.17% (3/256; 95% CI: 0.40–3.39) and 0.39% (1/256; 95% CI: 0.07–2.18), respectively, with all chronic HBV/HCV infections previously diagnosed. No HIV infections were found. In univariate analyses, newly diagnosed chronic HBV infection was more likely in participants migrating for reasons other than work or study (4.35% vs 0.83%; odds ratio (OR) = 5.45; 95% CI: 1.12–26.60) and was less likely in participants in Amsterdam than Gelderland (0.00% vs 4.48%; OR = 0.04; 95% CI: 0.00–0.69). Regional differences in HBV prevalence might be explained by differences in the populations entering compulsory tuberculosis screening. Prescreening selection of migrants based on risk factors merits further exploration.
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Affiliation(s)
- Janneke P Bil
- Department of Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, the Netherlands
| | - Peter Ag Schrooders
- Department of Infectious Diseases, Public Health Service of Noord- en Oost-Gelderland, Warnsveld, the Netherlands
| | - Maria Prins
- Department of Internal Medicine, Amsterdam Infection and Immunity Institute (AI&II), Academic Medical Center (University of Amsterdam), Amsterdam, The Netherlands.,Department of Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, the Netherlands
| | - Peter M Kouw
- Department of Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, the Netherlands
| | - Judith He Klomp
- Department of Infectious Diseases, Public Health Service of Gelderland Zuid, Nijmegen, the Netherlands
| | - Maarten Scholing
- Department of Medical Microbiology, Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, the Netherlands.,Department of Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, the Netherlands
| | - Lutje Phm Huijbregts
- Department of Infectious Diseases, Public Health Service of Noord- en Oost-Gelderland, Warnsveld, the Netherlands
| | - Gerard Jb Sonder
- Department of Internal Medicine, Amsterdam Infection and Immunity Institute (AI&II), Academic Medical Center (University of Amsterdam), Amsterdam, The Netherlands.,Department of Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, the Netherlands
| | - Toos Chfm Waegemaekers
- National Coordination Centre for Communicable Disease Control, National Institute for Public Health and the Environment, Bilthoven, the Netherlands
| | - Henry Jc de Vries
- Department of Internal Medicine, Amsterdam Infection and Immunity Institute (AI&II), Academic Medical Center (University of Amsterdam), Amsterdam, The Netherlands.,Department of Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, the Netherlands
| | - Wieneke Meijer
- Department of Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, the Netherlands
| | - Freke R Zuure
- These authors share joint last authorship.,Department of Internal Medicine, Amsterdam Infection and Immunity Institute (AI&II), Academic Medical Center (University of Amsterdam), Amsterdam, The Netherlands.,Department of Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, the Netherlands
| | - Alma Tostmann
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, the Netherlands.,These authors share joint last authorship
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Baauw A, Kist-van Holthe J, Slattery B, Heymans M, Chinapaw M, van Goudoever H. Health needs of refugee children identified on arrival in reception countries: a systematic review and meta-analysis. BMJ Paediatr Open 2019; 3:e000516. [PMID: 31646192 PMCID: PMC6782036 DOI: 10.1136/bmjpo-2019-000516] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 08/14/2019] [Accepted: 08/24/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The worldwide number of refugees has considerably increased due to ongoing wars, national instability, political persecution and food insecurity. In Europe, about one-third of all refugees are children, an increasing number of which are travelling alone. There are often no systematic medical health assessments for these refugee children on entry in reception countries despite the fact that they are recognised as an at-risk population due to increased burden of physical and mental health conditions. We aimed to perform a systematic review of the literature to describe the health status of refugee children on entering reception countries. METHODS A systematic search of published literature was conducted using the terms refugee, immigrant or migrant, medical or health, and screening. RESULTS Of the 3487 potentially relevant papers, 53 population-based studies were included in this review. This systematic review showed that refugee children exhibit high estimated prevalence rates for anaemia (14%), haemoglobinopathies (4%), chronic hepatitis B (3%), latent tuberculosis infection (11%) and vitamin D deficiency (45%) on entry in reception countries. Approximately one-third of refugee children had intestinal infection. Nutritional problems ranged from wasting and stunting to obesity. CONCLUSIONS Refugee children entering reception countries should receive comprehensive health assessments based on the outcomes of this systematic review, national budgets, cost-effectiveness and personal factors of the refugees. The health assessment should be tailored to individual child health needs depending on preflight, flight and postarrival conditions.A paradigm shift that places focus on child health and development will help this vulnerable group of children integrate into their new environments. PROSPERO REGISTRATION NUMBER 122561.
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Affiliation(s)
- Albertine Baauw
- Emma Children's Hospital, University of Amsterdam, Amsterdam, The Netherlands
- Pediatrics, Wilhelmina Children's Hospital University Medical Centre, Utrecht, The Netherlands
- Public and Occupational Health, Amsterdam Public Health Research Institute, VU Medical Center, Amsterdam, The Netherlands
| | - Joana Kist-van Holthe
- Public and Occupational Health, Amsterdam Public Health Research Institute, VU Medical Center, Amsterdam, The Netherlands
| | - Bridget Slattery
- Emma Children's Hospital, University of Amsterdam, Amsterdam, The Netherlands
| | - Martijn Heymans
- Department of Epidemiology and Biostatistics, University of Amsterdam, Amsterdam, The Netherlands
| | - Mai Chinapaw
- Public and Occupational Health, Amsterdam Public Health Research Institute, VU Medical Center, Amsterdam, The Netherlands
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Martin NK, Vickerman P, Khakoo S, Ghosh A, Ramsay M, Hickman M, Williams J, Miners A. Chronic hepatitis B virus case-finding in UK populations born abroad in intermediate or high endemicity countries: an economic evaluation. BMJ Open 2019; 9:e030183. [PMID: 31256040 PMCID: PMC6609059 DOI: 10.1136/bmjopen-2019-030183] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 05/03/2019] [Accepted: 05/28/2019] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES The majority (>90%) of new or undiagnosed cases of hepatitis B virus (HBV) in the UK are among individuals born in countries with intermediate or high prevalence levels (≥2%). We evaluate the cost-effectiveness of increased HBV case-finding among UK migrant populations, based on a one-time opt out case-finding approach in a primary care setting. DESIGN Cost-effectiveness evaluation. A decision model based on a Markov approach was built to assess the progression of HBV infection with and without treatment as a result of case-finding. The model parameters, including the cost and effects of case-finding and treatment, were estimated from the literature. All costs were expressed in 2017/2018 British Pounds (GBPs) and health outcomes as quality-adjusted life-years (QALYs). INTERVENTION Hepatitis B virus case-finding among UK migrant populations born in countries with intermediate or high prevalence levels (≥2%) in a primary care setting compared with no intervention (background testing). RESULTS At a 2% hepatitis B surface antigen (HBsAg) prevalence, the case-finding intervention led to a mean incremental cost-effectiveness ratio of £13 625 per QALY gained which was 87% and 98% likely of being cost-effective at willingness to pay (WTP) thresholds of £20 000 and £30 000 per additional QALY, respectively. Sensitivity analyses indicated that the intervention would remain cost-effective under a £20 000 WTP threshold as long as HBsAg prevalence among the migrant population is at least 1%. However, the results were sensitive to a number of parameters, especially the time horizon and probability of treatment uptake. CONCLUSIONS HBV case-finding using a one-time opt out approach in primary care settings is very likely to be cost-effective among UK migrant populations with HBsAg prevalence ≥1% if the WTP for an additional QALY is around £20 000.
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Affiliation(s)
- Natasha K Martin
- Department of Medicine, University of California San Diego, La Jolla, California, USA
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Peter Vickerman
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Salim Khakoo
- Clinical and Experimental Sciences, University of Southampton, Southampton, UK
| | | | - Mary Ramsay
- Immunisation, Public Health England, London, UK
- Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - M Hickman
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Jack Williams
- Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Alec Miners
- Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
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12
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Flanagan S, Kunkel J, Appleby V, Eldridge SE, Ismail S, Moreea S, Griffiths C, Walton R, Pitt M, Salmon A, Madurasinghe V, Barnes E, Simms E, Agarwal K, Foster GR. Case finding and therapy for chronic viral hepatitis in primary care (HepFREE): a cluster-randomised controlled trial. Lancet Gastroenterol Hepatol 2018; 4:32-44. [PMID: 30477810 DOI: 10.1016/s2468-1253(18)30318-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 09/24/2018] [Accepted: 09/24/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND The prevalence of viral hepatitis (hepatitis B virus and hepatitis C virus) in migrants is higher than among the general population in many high-income countries. We aimed to determine whether incentivising and supporting primary-care physicians in areas with a high density of migrants increases the numbers of adult migrants screened for viral hepatitis. METHODS HepFREE was a multicentre, open, cluster-randomised controlled trial in general practices in areas of the UK with a high density of migrants (Bradford, Yorkshire, and northeast and southeast London). Participants were adult patients (aged 18 years or older) in primary care, who had been identified as a first or second generation migrant from a high-risk country. General practices were randomly assigned (1:2:2:2:2) to an opportunistic screening (control) group or to one of four targeted screening (interventional) groups: standard (ie, hospital-based) care and a standard invitation letter; standard care and an enhanced invitation letter; community care and a standard invitation letter; or community care and an enhanced invitation letter. In control screening, general practitioners (GPs) were given a teaching session on viral hepatitis and were asked to test all registered migrants. In the intervention, GPs were paid a nominal sum for setting up searches of records, reimbursed for signed consent forms, and supported by a dedicated clinician. Patients who were eligible for testing and tested positive for viral hepatitis in the intervention groups were eligible to enrol in a second embedded trial of community versus hospital based care. The primary outcomes were the proportion of patients eligible for screening, the proportion of those eligible who were sent an invitation letter in the intervention groups, the uptake of viral hepatitis screening (in the intention-to-treat population), the proportion of patients who tested positive for viral hepatitis, the proportion who complied with treatment, and the cost-effectiveness of the intervention. This trial is registered with ISRCTN, number ISRCTN54828633. FINDINGS Recruitment and testing ran from Oct 31, 2013, to Feb 4, 2017, and each practice recruited for 18 consecutive calendar months. We approached 70 general practices in three areas with a high density of migrants, of which 63 general practices agreed to participate. Five practices withdrew and 58 practices were randomly assigned: eight to control and 50 to an intervention. In control practices, 26 046 (38·4%) of 67 820 patients who were initially registered were eligible for testing, as were 152 321 (43·3%) of 351 710 patients in the interventional groups in London and Bradford. Of 51 773 randomly selected eligible patients in the intervention groups in London and Bradford, letters were sent to 43 585 (84·2%) patients. In the eight control general practices, screening was taken up by 543 (1·7%) of 31 738 eligible participants, which included 5692 newly registered patients. However, in the 50 general practices that used the intervention, screening was taken up by 11 386 (19·5%) of 58 512 eligible participants (including 6739 newly registered patients; incidence rate ratio 3·70, 95% CI 1·30-10·51; p=0·014) and this intervention was cost-effective. 720 (4·5%) of 15 844 patients who received a standard letter versus 1032 (3·7%) of 28 095 patients who received the enhanced letter were tested (0·70, 0·38-1·31; p=0·26). In the control group, 17 patients tested positive for viral hepatitis, as did 220 patients (one with a co-infection) in the intervention groups. In the embedded study, 220 patients were randomly assigned to either hospital-based care or community care; 80 (87·9%) of 91 patients in the hospital setting complied with treatment versus 105 (81·4%) of 129 patients in the community setting. The intervention was cost-effective at willingness to pay thresholds in excess of £8540. One serious adverse event (thyroiditis) was noted. INTERPRETATION Screening migrants for viral hepatitis in primary care is effective if doctors are incentivised and supported. Community care is expensive and there is no evidence that this offers benefits in this setting or that bespoke invitation letters add value. We suggest that bespoke invitation letters should not be used, and we suggest that outreach, community-based services for migrants should not be developed. FUNDING National Institute for Health Research.
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Affiliation(s)
- Stuart Flanagan
- Barts Liver Centre, Queen Mary University of London, London, UK
| | - Jan Kunkel
- Barts Liver Centre, Queen Mary University of London, London, UK
| | - Victoria Appleby
- Department of Gastroenterology, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | | | - Sharif Ismail
- Barts Liver Centre, Queen Mary University of London, London, UK
| | - Sulleman Moreea
- Department of Gastroenterology, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | | | - Robert Walton
- Blizard Institute, Queen Mary University of London, London, UK
| | - Martin Pitt
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - Andrew Salmon
- College of Medicine and Health, University of Exeter, Exeter, UK
| | | | - Eleanor Barnes
- Nuffield Department of Medicine and Oxford University Hospitals NHS Trust, University of Oxford, Oxford, UK
| | - Elizabeth Simms
- Nuffield Department of Medicine and Oxford University Hospitals NHS Trust, University of Oxford, Oxford, UK
| | | | - Graham R Foster
- Barts Liver Centre, Queen Mary University of London, London, UK.
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Suijkerbuijk AWM, van Hoek AJ, Koopsen J, de Man RA, Mangen MJJ, de Melker HE, Polder JJ, de Wit GA, Veldhuijzen IK. Cost-effectiveness of screening for chronic hepatitis B and C among migrant populations in a low endemic country. PLoS One 2018; 13:e0207037. [PMID: 30408079 PMCID: PMC6224111 DOI: 10.1371/journal.pone.0207037] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 10/23/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Chronic infection with hepatitis B or C virus (HBV/HCV) can progress to cirrhosis, liver cancer, and even death. In a low endemic country as the Netherlands, migrants are a key risk group and could benefit from early diagnosis and antiviral treatment. We assessed the cost-effectiveness of screening foreign-born migrants for chronic HBV and/or HCV using a societal perspective. METHODS The cost-effectiveness was evaluated using a Markov model. Estimates on prevalence, screening programme costs, participation and treatment uptake, transition probabilities, healthcare costs, productivity losses and utilities were derived from the literature. The cost per Quality Adjusted Life Year (QALY) gained was estimated and sensitivity analyses were performed. RESULTS For most migrant groups with an expected high number of chronically infected cases in the Netherlands combined screening is cost-effective, with incremental cost-effectiveness ratios (ICERs) ranging from €4,962/QALY gained for migrants originating from the Former Soviet Union and Vietnam to €9,375/QALY gained for Polish migrants. HBV and HCV screening proved to be cost-effective for migrants from countries with chronic HBV or HCV prevalence of ≥0.41% and ≥0.22%, with ICERs below the Dutch cost-effectiveness reference value of €20,000/QALY gained. Sensitivity analysis showed that treatment costs influenced the ICER for both infections. CONCLUSIONS For most migrant populations in a low-endemic country offering combined HBV and HCV screening is cost-effective. Implementation of targeted HBV and HCV screening programmes to increase early diagnosis and treatment is important to reduce the burden of chronic hepatitis B and C among migrants.
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Affiliation(s)
- Anita W. M. Suijkerbuijk
- Centre for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - Albert Jan van Hoek
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jelle Koopsen
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - Robert A. de Man
- Department of Gastroenterology and Hepatology, Erasmus MC, Rotterdam, the Netherlands
| | - Marie-Josee J. Mangen
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - Hester E. de Melker
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - Johan J. Polder
- Centre for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
- Tranzo Scientific Center for Care and Welfare, Tilburg School of Social and Behavioral Sciences, Tilburg University, Tilburg, The Netherlands
| | - G. Ardine de Wit
- Centre for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
- Julius Centre for Health Sciences and Primary Health Care, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Irene K. Veldhuijzen
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
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14
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Myran DT, Morton R, Biggs BA, Veldhuijzen I, Castelli F, Tran A, Staub LP, Agbata E, Rahman P, Pareek M, Noori T, Pottie K. The Effectiveness and Cost-Effectiveness of Screening for and Vaccination Against Hepatitis B Virus among Migrants in the EU/EEA: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:ijerph15091898. [PMID: 30200406 PMCID: PMC6164421 DOI: 10.3390/ijerph15091898] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 08/17/2018] [Accepted: 08/27/2018] [Indexed: 02/07/2023]
Abstract
Migrants from hepatitis B virus (HBV) endemic countries to the European Union/European Economic Area (EU/EEA) comprise 5.1% of the total EU/EEA population but account for 25% of total chronic Hepatitis B (CHB) infection. Migrants from high HBV prevalence regions are at the highest risk for CHB morbidity. These migrants are at risk of late detection of CHB complications; mortality and onwards transmission. The aim of this systematic review is to evaluate the effectiveness and cost-effectiveness of CHB screening and vaccination programs among migrants to the EU/EEA. We found no RCTs or direct evidence evaluating the effectiveness of CHB screening on morbidity and mortality of migrants. We therefore used a systematic evidence chain approach to identify studies relevant to screening and prevention programs; testing, treatment, and vaccination. We identified four systematic reviews and five additional studies and guidelines that reported on screening and vaccination effectiveness. Studies reported that vaccination programs were highly effective at reducing the prevalence of CHB in children (RR 0.07 95% CI 0.04 to 0.13) following vaccination. Two meta-analyses of therapy for chronic HBV infection found improvement in clinical outcomes and intermediate markers of disease. We identified nine studies examining the cost-effectiveness of screening for CHB: a strategy of screening and treating CHB compared to no screening. The median acceptance of HB screening was 87.4% (range 32.3–100%). Multiple studies highlighted barriers to and the absence of effective strategies to ensure linkage of treatment and care for migrants with CHB. In conclusion, screening of high-risk children and adults and vaccination of susceptible children, combined with treatment of CHB infection in migrants, are promising and cost-effective interventions, but linkage to treatment requires more attention.
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Affiliation(s)
- Daniel T Myran
- University of Ottawa School of Epidemiology and Public Health, Ottawa, ON K1G 5Z3, Canada.
| | - Rachael Morton
- NHMRC Clinical Trials Centre, The University of Sydney, Sydney 2006, Australia.
| | - Beverly-Ann Biggs
- Department of Medicine at the Doherty Institute, University of Melbourne, and Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne 3000, Australia.
| | - Irene Veldhuijzen
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), Bilthoven 3720, The Netherlands.
| | - Francesco Castelli
- University Department of Infectious and Tropical Diseases University of Brescia and ASST Spedali Civili, Brescia 25123, Italy.
| | - Anh Tran
- NHMRC Clinical Trials Centre, The University of Sydney, Sydney 2006, Australia.
| | - Lukas P Staub
- NHMRC Clinical Trials Centre, The University of Sydney, Sydney 2006, Australia.
| | - Eric Agbata
- Department of Paediatrics, Obstetrics, Gynaecology and Preventive Medicine, Universität Autònoma de Barcelona, Barcelona 08193, Spain.
| | - Prinon Rahman
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON K1R 7G5, Canada.
| | - Manish Pareek
- Department of Infection, Immunity and Inflammation, University of Leicester, Leicester LE1 7RH, UK.
| | - Teymur Noori
- European Centre for Disease Prevention and Control, Stockholm 169 73, Sweden.
| | - Kevin Pottie
- Bruyere Research Institute, School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON K1R 7G5, Canada.
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Abstract
OBJECTIVE To describe liver disease related mortality in the United States during 1999-2016 by age group, sex, race, cause of liver disease, and geographic region. DESIGN Observational cohort study. SETTING Death certificate data from the Vital Statistics Cooperative, and population data from the US Census Bureau compiled by the Center for Disease Control and Prevention's Wide-ranging Online Data for Epidemiologic Research (1999-2016). PARTICIPANTS US residents. MAIN OUTCOME MEASURE Deaths from cirrhosis and hepatocellular carcinoma, with trends evaluated using joinpoint regression. RESULTS From 1999 to 2016 in the US annual deaths from cirrhosis increased by 65%, to 34 174, while annual deaths from hepatocellular carcinoma doubled to 11 073. Only one subgroup-Asians and Pacific Islanders-experienced an improvement in mortality from hepatocellular carcinoma: the death rate decreased by 2.7% (95% confidence interval 2.2% to 3.3%, P<0.001) per year. Annual increases in cirrhosis related mortality were most pronounced for Native Americans (designated as "American Indians" in the census database) (4.0%, 2.2% to 5.7%, P=0.002). The age adjusted death rate due to hepatocellular carcinoma increased annually by 2.1% (1.9% to 2.3%, P<0.001); deaths due to cirrhosis began increasing in 2009 through 2016 by 3.4% (3.1% to 3.8%, P<0.001). During 2009-16 people aged 25-34 years experienced the highest average annual increase in cirrhosis related mortality (10.5%, 8.9% to 12.2%, P<0.001), driven entirely by alcohol related liver disease. During this period, mortality due to peritonitis and sepsis in the setting of cirrhosis increased substantially, with respective annual increases of 6.1% (3.9% to 8.2%) and 7.1% (6.1% to 8.4%). Only one state, Maryland, showed improvements in mortality (-1.2%, -1.7% to -0.7% per year), while many, concentrated in the south and west, observed disproportionate annual increases: Kentucky 6.8% (5.1% to 8.5%), New Mexico 6.0% (4.1% to 7.9%), Arkansas 5.7% (3.9% to 7.6%), Indiana 5.0% (3.8% to 6.1%), and Alabama 5.0% (3.2% to 6.8%). No state showed improvements in hepatocellular carcinoma related mortality, while Arizona (5.1%, 3.7% to 6.5%) and Kansas (4.3%, 2.8% to 5.8%) experienced the most severe annual increases. CONCLUSIONS Mortality due to cirrhosis has been increasing in the US since 2009. Driven by deaths due to alcoholic cirrhosis, people aged 25-34 have experienced the greatest relative increase in mortality. White Americans, Native Americans, and Hispanic Americans experienced the greatest increase in deaths from cirrhosis. Mortality due to cirrhosis is improving in Maryland but worst in Kentucky, New Mexico, and Arkansas. The rapid increase in death rates among young people due to alcohol highlight new challenges for optimal care of patients with preventable liver disease.
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Affiliation(s)
- Elliot B Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, MI, USA
- Gastroenterology Section, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Neehar D Parikh
- Division of Gastroenterology and Hepatology, University of Michigan, MI, USA
- Gastroenterology Section, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
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16
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How effective are approaches to migrant screening for infectious diseases in Europe? A systematic review. THE LANCET. INFECTIOUS DISEASES 2018; 18:e259-e271. [PMID: 29778396 DOI: 10.1016/s1473-3099(18)30117-8] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 01/26/2018] [Accepted: 02/06/2018] [Indexed: 12/20/2022]
Abstract
Rates of migration to Europe, and within Europe, have increased in recent years, with considerable implications for health systems. Migrants in Europe face a disproportionate burden of tuberculosis, HIV, and hepatitis B and C, yet experience a large number of barriers to accessing statutory health care on arrival. A better understanding of how to deliver effective and cost-effective screening, vaccination, and health services to this group is now crucial. We did a systematic review to document and assess the effectiveness and cost-effectiveness of approaches used for infectious diseases screening, and to explore facilitators and barriers experienced by migrants to accessing screening programmes. Following PRISMA guidelines, we searched Embase, PubMed, PsychINFO, the Cochrane Library, and Web of Science (1989 to July 1, 2015, updated on Jan 1, 2018), with no language restrictions, and systematically approached experts across the European Union (EU) for grey literature. Inclusion criteria were primary research studies assessing screening interventions for any infectious disease in the migrant (foreign-born) population residing in EU or European Economic Area (EEA) countries. Primary outcomes were the following effectiveness indicators: uptake of screening, coverage, infections detected, and treatment outcomes. Of 4112 unique records, 47 studies met our inclusion criteria, from ten European countries (Belgium, Denmark, France, Italy, the Netherlands, Norway, Spain, Sweden, Switzerland, and the UK) encompassing 248 402 migrants. We found that most European countries screening migrants focus on single diseases only-predominantly active or latent tuberculosis infection-and specifically target asylum seekers and refugees, with 22 studies reporting on other infections (including HIV and hepatitis B and C). An infection was detected in 3·74% (range 0·00-95·16) of migrants. Latent tuberculosis had the highest prevalence across all infections (median 15·02% [0·35-31·81]). Uptake of screening by migrants was high (median 79·50% [18·62-100·00]), particularly in primary health-care settings (uptake 96·77% [76·00-100·00]). However, in 24·62% (0·12-78·99) of migrants screening was not completed and a final diagnosis was not made. Pooled data highlight high treatment completion in migrants (83·79%, range 0·00-100·00), yet data were highly heterogeneous for this outcome, masking important disparities between studies and infections, with only 54·45% (35·71-72·27) of migrants with latent tuberculosis ultimately completing treatment after screening. Coverage of the migrant population in Europe is low (39·29% [14·53-92·50]). Data on cost-effectiveness were scarce, but suggest moderate to high cost-effectiveness of migrant screening programmes depending on migrant group and disease targeted. European countries have adopted a variety of approaches to screening migrants for infections; however, these are limited in scope to single diseases and a narrow subset of migrants, with low coverage. More emphasis must be placed on developing innovative and sustainable strategies to facilitate screening and treatment completion and improve health outcomes, encompassing multiple key infections with consideration given to a wider group of high-risk migrants. Policy makers and researchers involved with global migration need to ensure a longer-term view on improving health outcomes in migrant populations as they integrate into health systems in host countries.
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High rates of chronic HBV genotype E infection in a group of migrants in Italy from West Africa: Virological characteristics associated with poor immune clearance. PLoS One 2018; 13:e0195045. [PMID: 29596494 PMCID: PMC5875859 DOI: 10.1371/journal.pone.0195045] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2017] [Accepted: 03/13/2018] [Indexed: 12/14/2022] Open
Abstract
Hepatitis B virus (HBV) genotype E almost exclusively occurs in African people, and its presence is more commonly associated with the development of chronic HBV (CHB) infection. Moreover, an epidemiological link has been found between the distribution of HBV genotype E infection and African countries with high incidences of hepatocellular carcinoma. As part of a programme for the health assessment of migrants, we evaluated 358 young African subjects for HBV infection; 58.1% (208/358) were positive for an HBV marker, and 54 (25.5%) had CHB. Eighty-one percent of the CHB subjects were infected with HBV genotype E, with a median serum HBV-DNA of 3.2 (IQR: 2.7-3.6) logIU/ml. All patients had high serum HBsAg titres (10,899 [range 5,359-20,272] IU/ml), and no correlation was found between HBsAg titres and HBV-DNA plasma levels. RT sequence analysis showed the presence of a number of immune escape mutations: strains from all of the patients had a serine at HBsAg position 140; 3 also had T116N, Y100C, and P142L+S143L substitutions; and 1 had a G112R substitution. Six (18%) patients had stop-codons at position 216. In 5 of the 9 (26.5%) CHB patients, ultrasound liver biopsy, quantification of total intrahepatic HBV-DNA and cccDNA, and RT/HBsAg sequencing were performed. The median (IQR) total intrahepatic HBV-DNA was 766 (753-1139) copies/1000 cells, and the median (IQR) cccDNA was 17 (10-27) copies/1000 cells. Correlations were observed for both total intrahepatic HBV-DNA and cccDNA with serum HBV-DNA, while no correlation was found for the HBsAg titres. A difference of 2.5/1,000 nucleotides was found in the HBsAg sequences obtained from plasma and from liver tissue, with 3 cases of possible viral anatomical compartmentalization. In conclusion, a high rate of CHB infection due to the E genotype was demonstrated in a group of immigrants from Western Africa. An analysis of the viral strains obtained showed the virological characteristics of immune escape, which may be the cause of viral replication persistence. Moreover, a fair percentage of stop codon mutations were found. The lack of correlation between HBsAg titres and plasma or intrahepatic HBV-DNA found in these subjects suggests a pathway of virus production that is not linked to HBsAg secretion. Studies with a larger number of patients with CHB due to the E genotype are advisable to corroborate these observations.
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18
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Tiittala P, Ristola M, Liitsola K, Ollgren J, Koponen P, Surcel HM, Hiltunen-Back E, Davidkin I, Kivelä P. Missed hepatitis b/c or syphilis diagnosis among Kurdish, Russian, and Somali origin migrants in Finland: linking a population-based survey to the national infectious disease register. BMC Infect Dis 2018; 18:137. [PMID: 29558910 PMCID: PMC5859750 DOI: 10.1186/s12879-018-3041-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 03/11/2018] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Migrants are considered a key population at risk for sexually transmitted and blood-borne diseases in Europe. Prevalence data to support the design of infectious diseases screening protocols are scarce. We aimed to estimate the prevalence of hepatitis B and C, human immunodefiency virus (HIV) infection and syphilis in specific migrant groups in Finland and to assess risk factors for missed diagnosis. METHODS A random sample of 3000 Kurdish, Russian, or Somali origin migrants in Finland was invited to a migrant population-based health interview and examination survey during 2010-2012. Participants in the health examination were offered screening for hepatitis B and C, HIV and syphilis. Notification prevalence in the National Infectious Diseases Register (NIDR) was compared between participants and non-participants to assess non-participation. Missed diagnosis was defined as test-positive case in the survey without previous notification in NIDR. Inverse probability weighting was used to correct for non-participation. RESULTS Altogether 1000 migrants were screened for infectious diseases. No difference in the notification prevalence among participants and non-participants was observed. Seroprevalence of hepatitis B surface antigen (HBsAg) was 2.3%, hepatitis C antibodies 1.7%, and Treponema pallidum antibodies 1.3%. No cases of HIV were identified. Of all test-positive cases, 61% (34/56) had no previous notification in NIDR. 48% of HBsAg, 62.5% of anti-HCV and 84.6% of anti-Trpa positive cases had been missed. Among the Somali population (n = 261), prevalence of missed hepatitis B diagnosis was 3.0%. Of the 324 Russian migrants, 3.0% had not been previously diagnosed with hepatitis C and 2.4% had a missed syphilis diagnosis. In multivariable regression model missed diagnosis was associated with migrant origin, living alone, poor self-perceived health, daily smoking, and previous diagnosis of another blood-borne infection. CONCLUSIONS More than half of chronic hepatitis and syphilis diagnoses had been missed among migrants in Finland. Undiagnosed hepatitis B among Somali migrants implies post-migration transmission that could be prevented by enhanced screening and vaccinations. Rate of missed diagnoses among Russian migrants supports implementation of targeted hepatitis and syphilis screening upon arrival and also in later health care contacts. Coverage and up-take of current screening among migrants should be evaluated.
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Affiliation(s)
- Paula Tiittala
- Doctoral Programme in Population Health, University of Helsinki, Helsinki, Finland. .,Department of Health Security, National Institute for Health and Welfare, Mannerheimintie 166, 00271, Helsinki, Finland.
| | - Matti Ristola
- Inflammation Center, Helsinki University Hospital, Meilahdentie 2, 00250, Helsinki, Finland
| | - Kirsi Liitsola
- Department of Health Security, National Institute for Health and Welfare, Mannerheimintie 166, 00271, Helsinki, Finland
| | - Jukka Ollgren
- Department of Health Security, National Institute for Health and Welfare, Mannerheimintie 166, 00271, Helsinki, Finland
| | - Päivikki Koponen
- Department of Public Health Solutions, National Institute for Health and Welfare, Mannerheimintie 166, 00271, Helsinki, Finland
| | - Heljä-Marja Surcel
- Department of Health Security, National Institute for Health and Welfare, Mannerheimintie 166, 00271, Helsinki, Finland.,Oulu University Hospital, Biobank Borealis of Northern Finland, Aapistie 5B, 90220, Oulu, Finland
| | - Eija Hiltunen-Back
- Inflammation Center, Helsinki University Hospital, Meilahdentie 2, 00250, Helsinki, Finland
| | - Irja Davidkin
- Department of Health Security, National Institute for Health and Welfare, Mannerheimintie 166, 00271, Helsinki, Finland
| | - Pia Kivelä
- Inflammation Center, Helsinki University Hospital, Meilahdentie 2, 00250, Helsinki, Finland
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19
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Heil J, Hoebe CJPA, Cals JWL, Ter Waarbeek HLG, van Loo IHM, Dukers-Muijrers NHTM. Detecting Hepatitis B and C by Combined Public Health and Primary Care Birth Cohort Testing. Ann Fam Med 2018; 16:21-27. [PMID: 29311171 PMCID: PMC5758316 DOI: 10.1370/afm.2166] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 06/23/2017] [Accepted: 07/12/2017] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Both chronic hepatitis C (HCV) and B virus (HBV) infections are generally asymptomatic, and many remain undetected or are diagnosed at a late stage. Studies that evaluate best practice hepatitis testing strategies are needed to better detect this hidden population. METHODS In this prospective cohort study, we aimed to determine the diagnostic yield (test uptake and rate of positive test results) of a combined public health and primary care birth cohort testing strategy in detecting hidden cases of HCV and HBV infections. We invited all patients aged between 40 and 70 years (n = 6,743) registered with 11 family practices serving 2 higher prevalence areas, or hotspots (ie, estimated HCV prevalence of 1%; national estimated prevalence is 0.1-0.4%), in the south of the Netherlands. RESULTS Test uptake was 50.9% (n = 3,434 patients). No active or chronic HCV infection was detected: 0.00% (95% CI, 0.00%-0.11%). Positive test rates were 0.20% (95% CI, 0.08%-0.42%) for anti-HCV (n = 7), 0.26% (95% CI, 0.12%-0.50%) for hepatitis B surface antigen (n = 9), and 4.14% (95% CI, 3.49%-4.86%) for antihepatitis B core (n = 142). CONCLUSIONS This best practice testing strategy was effective in achieving a high test uptake. It completely failed, however, to detect hidden chronic HCV infections and is not recommended for countries with a low prevalence of the disease.
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Affiliation(s)
- Jeanne Heil
- Department of Sexual Health, Infectious Diseases and Environmental Health, Public Health Service (GGD) South Limburg, Heerlen, The Netherlands
- Department of Medical Microbiology, Care and Public Health Research Institute (CAPHRI), Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Christian J P A Hoebe
- Department of Sexual Health, Infectious Diseases and Environmental Health, Public Health Service (GGD) South Limburg, Heerlen, The Netherlands
- Department of Medical Microbiology, Care and Public Health Research Institute (CAPHRI), Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Jochen W L Cals
- Department of Family Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Henriëtte L G Ter Waarbeek
- Department of Sexual Health, Infectious Diseases and Environmental Health, Public Health Service (GGD) South Limburg, Heerlen, The Netherlands
- Department of Medical Microbiology, Care and Public Health Research Institute (CAPHRI), Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Inge H M van Loo
- Department of Medical Microbiology, Care and Public Health Research Institute (CAPHRI), Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Nicole H T M Dukers-Muijrers
- Department of Sexual Health, Infectious Diseases and Environmental Health, Public Health Service (GGD) South Limburg, Heerlen, The Netherlands
- Department of Medical Microbiology, Care and Public Health Research Institute (CAPHRI), Maastricht University Medical Centre, Maastricht, The Netherlands
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20
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Nayagam S, Sicuri E, Lemoine M, Easterbrook P, Conteh L, Hallett TB, Thursz M. Economic evaluations of HBV testing and treatment strategies and applicability to low and middle-income countries. BMC Infect Dis 2017; 17:692. [PMID: 29143675 PMCID: PMC5688395 DOI: 10.1186/s12879-017-2778-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Background Many people living with chronic HBV infection remain undiagnosed until later stages of disease. Increasing testing and treatment rates form part of the strategy to respond to the WHO goal of eliminating viral hepatitis as a public health threat by 2030. However, achieving these ambitious targets is dependent on finding effective and cost-effective methods of scale up strategies. The aim of this study was to undertake a narrative review of the literature on economic evaluations of testing and treatment for HBV infection, to help inform the development of the 2017 WHO Hepatitis Testing Guidelines. Methods We undertook a focussed literature review for economic evaluations on testing for HBV accompanied by antiviral treatment. The search was carried out in Pubmed and included only articles published after 2000 and written in English. We narratively synthesise the results and discuss the key drivers of cost-effectiveness and their applicability to low and middle-income countries (LMICs). Results Nine published studies were included in this review, only one of which was performed in a low or middle-income setting in West Africa. Eight studies were performed in high-income settings, seven among high risk groups and one among the general population. The studies were heterogeneous in many respects including the population and testing strategy under consideration, model structure and baselines parameters, willingness to pay thresholds and outcome measures used. However, most studies found HBV testing and treatment to be cost-effective, even at low HBsAg prevalence levels. Conclusions Currently economic evaluations of HBV testing and treatment strategies in LMICs is lacking, therefore limiting the ability to provide formal recommendations on the basis of cost-effectiveness alone. Further implementation research is needed in order to help guide national policy planning.
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Affiliation(s)
- Shevanthi Nayagam
- Division of Digestive Diseases, Imperial College, London, UK. .,Department of Infectious Disease Epidemiology, School of Public Health, Imperial College, London, UK.
| | - Elisa Sicuri
- Health Economics Group, Department of Infectious Disease Epidemiology, School of Public Health, Imperial College, London, UK.,ISGlobal, Barcelona Centre for International Health Research (CRESIB), Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
| | - Maud Lemoine
- Division of Digestive Diseases, Imperial College, London, UK
| | - Philippa Easterbrook
- Global Hepatitis Programme, HIV Department, World Health Organization, Geneva, Switzerland
| | - Lesong Conteh
- Health Economics Group, Department of Infectious Disease Epidemiology, School of Public Health, Imperial College, London, UK
| | - Timothy B Hallett
- Department of Infectious Disease Epidemiology, School of Public Health, Imperial College, London, UK
| | - Mark Thursz
- Division of Digestive Diseases, Imperial College, London, UK
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21
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Chernet A, Utzinger J, Sydow V, Probst-Hensch N, Paris DH, Labhardt ND, Neumayr A. Prevalence rates of six selected infectious diseases among African migrants and refugees: a systematic review and meta-analysis. Eur J Clin Microbiol Infect Dis 2017; 37:605-619. [PMID: 29080108 DOI: 10.1007/s10096-017-3126-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 10/16/2017] [Indexed: 12/27/2022]
Abstract
The objective of this paper was to systematically review the literature on the prevalence of selected infectious diseases among migrants/refugees of African origin and to provide policy makers and health care professionals with evidence-based information. We pursued a systematic review and meta-analysis to determine the prevalence of six selected infectious diseases (i.e., syphilis, helminthiasis, schistosomiasis, intestinal protozoa infections, hepatitis B, and hepatitis C) among migrants/refugees of African origin. Three electronic databases (i.e., PubMed, EMBASE, and ISI Web of Science) were searched without language restrictions. Relevant data were extracted and random-effects meta-analyses conducted. Only adjusted estimates were analyzed to help account for heterogeneity and potential confounding. We assessed the quality of evidence using the GRADE approach. The results were stratified by geographical region. Ninety-six studies were included. The evidence was of low quality due to the small numbers of countries, infectious diseases, and participants included. African migrants/refugees had median (with 95% confidence interval [95% CI]) prevalence for syphilis, helminthiasis, schistosomiasis, intestinal protozoa infection, hepatitis B, and hepatitis C of 6.0% [95% CI: 2.0-7.0%], 13.0% [95% CI: 9.5-14.5%], 14.0% [95% CI: 13.0-17.0%], 15.0% [95% CI: 10.5-21.0%], 10.0% [95% CI: 6.0-14.0%], and 3.0% [95% CI: 1.0-4.0%], respectively. We found high heterogeneity regardless of the disease (I 2; minimum 97.5%, maximum 99.7%). The relatively high prevalence of some infectious diseases among African migrants/refugees warrants for systematic screening. The large heterogeneity of the available published data does not allow for stratifying such screening programs according to the geographical origin of African migrants/refugees.
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Affiliation(s)
- A Chernet
- Swiss Tropical and Public Health Institute, P.O. Box CH-4002, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - J Utzinger
- Swiss Tropical and Public Health Institute, P.O. Box CH-4002, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - V Sydow
- Swiss Tropical and Public Health Institute, P.O. Box CH-4002, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - N Probst-Hensch
- Swiss Tropical and Public Health Institute, P.O. Box CH-4002, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - D H Paris
- Swiss Tropical and Public Health Institute, P.O. Box CH-4002, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - N D Labhardt
- Swiss Tropical and Public Health Institute, P.O. Box CH-4002, Basel, Switzerland
- University of Basel, Basel, Switzerland
- Division of Infectious Disease and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - A Neumayr
- Swiss Tropical and Public Health Institute, P.O. Box CH-4002, Basel, Switzerland.
- University of Basel, Basel, Switzerland.
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22
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Ruggeri M, Basile M, Coretti S, Drago C, Cicchetti A. Economic Analysis and Budget Impact of Tenofovir and Entecavir in the First-Line Treatment of Hepatitis B Virus in Italy. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2017; 15:479-490. [PMID: 28197805 DOI: 10.1007/s40258-017-0311-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
BACKGROUND Chronic hepatitis B is a common, progressive disease, particularly when viral replication is detected. Oral antivirals can suppress viral replication and prevent or delay the development of cirrhosis and liver-related complications. The treatments of chronic hepatitis B cannot totally cure the disease but can prevent its progression to hepatocellular carcinoma, decreasing the levels of both morbidity and mortality. To date, there are several therapies indicated by the international guidelines as first-line treatments for the management of hepatitis B; two of the most effective are those based on either tenofovir or entecavir. OBJECTIVE The aim of this study is to evaluate the cost-effectiveness of tenofovir and entecavir in the treatment of naïve patients with chronic hepatitis B. The two treatments are compared with the "no treatment" and to one another. METHODS The cost-effectiveness analysis was conducted using a Markov model; patients entered one of the following health states: chronic hepatitis, cirrhosis (compensated or decompensated), hepatocellular carcinoma, liver transplantation or death. The analysis was carried out from the perspective of the Italian National Health Service by considering a life-time horizon with cycles lasting 1 year and with costs and QALYs (quality-adjusted life years) discounted at a rate of 3.5%. The results of the model were analysed in terms of incremental cost-effectiveness ratio (ICER). RESULTS ICERs for tenofovir and entecavir emerging from the comparison versus "no treatment" were equal to €10,274.73 and €16,300.44 per QALY gained, respectively, on the life-time horizon. Tenofovir was dominant in the direct comparison with entecavir, indicating more QALYs and a lower consumption of resources. The Monte Carlo simulation demonstrated that in 97% (tenofovir) and in 85% (entecavir) of the scenarios performed, the cost per QALY fell below the threshold of €30,000/QALY. The budget impact analysis showed savings for tenofovir amounting to 33% compared to entecavir in the first year on treatment and to 31% in following years. CONCLUSIONS Entecavir and tenofovir are recommended for the treatment of patients with chronic Hepatitis B in the Italian Health System. In particular, tenofovir appeared to be the more cost-effective drug for the management of chronic hepatitis B virus (HBV) infections. These results could help decision makers and clinicians to address their decision when choosing a first-line treatment for the management of people affected by chronic HBV.
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Affiliation(s)
- M Ruggeri
- Catholic University of Sacred Heart, Rome, Italy
| | - M Basile
- Catholic University of Sacred Heart, Rome, Italy.
| | - S Coretti
- Catholic University of Sacred Heart, Rome, Italy
| | - C Drago
- "Nicolò Cusano" University, Rome, Italy
| | - A Cicchetti
- Catholic University of Sacred Heart, Rome, Italy
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23
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Schilling T, Rauscher S, Menzel C, Reichenauer S, Müller-Schilling M, Schmid S, Selgrad M. Migrants and Refugees in Europe: Challenges, Experiences and Contributions. Visc Med 2017; 33:295-300. [PMID: 29034258 DOI: 10.1159/000478763] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Due to the current geopolitical situation more refugees from crisis countries were and will be treated in Europe. In 2015 the number of displaced people reached an unprecedented level, with more than one million crossing into Europe. The migration itself can impair both mental and physical health. Therefore, the provision of medical care for refugees and migrants is a novel and major challenge for the health care systems in Europe. In this article we describe our experiences and contribution in providing medical care for refugees who have newly arrived in Stuttgart, Baden-Wuerttemberg, Germany. Furthermore, we report our experiences from a tertiary referral University center in Regensburg, Bavaria, Germany. We focus on challenges in both the outpatient and the inpatient setting, with a special focus on intensive care patients. In addition, we provide an overview about the spectrum of diseases in this specific patient cohort.
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Affiliation(s)
- Tobias Schilling
- Interdisciplinary Emergency Department, Katharinenhospital Stuttgart, Stuttgart, Germany
| | - Stephan Rauscher
- Interdisciplinary Emergency Department, Katharinenhospital Stuttgart, Stuttgart, Germany
| | - Christian Menzel
- Interdisciplinary Emergency Department, Katharinenhospital Stuttgart, Stuttgart, Germany
| | - Simon Reichenauer
- Interdisciplinary Emergency Department, Katharinenhospital Stuttgart, Stuttgart, Germany
| | | | - Stephan Schmid
- Department of Internal Medicine I, University Hospital Regensburg, Regensburg, Germany
| | - Michael Selgrad
- Department of Internal Medicine I, University Hospital Regensburg, Regensburg, Germany
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24
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Walters J, Sullivan A. Early Identification and Linkage to Care of Foreign-Born People with Chronic Hepatitis B Virus Infection, Multnomah County, Oregon, 2012-2014. Public Health Rep 2017; 131 Suppl 2:105-11. [PMID: 27168669 DOI: 10.1177/00333549161310s216] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE Hepatitis B virus (HBV) infection is a global health concern, with a large proportion of high-risk individuals unaware of their infection status. People born in countries with medium to high endemicity of HBV should be tested and linked to care. We describe a program that improved identification and linkage to care for refugees and immigrants at the Multnomah County Health Department in Oregon. METHODS We instituted outreach clinics and community referrals and expanded refugee screening to identify foreign-born people at risk for HBV. We obtained data from electronic health records and electronic laboratory reporting, including patient demographics, hepatitis B testing variables, vaccination history, and-for positive cases-risk-factor and linkage-to-care data. All results were entered into an Internet-based data collection tool. For this analysis, we only used results for testing performed from October 2012 through June 2014. RESULTS We screened 2,087 foreign-born people for HBV infection and identified 77 (4%) people with positive results. HBV infection prevalence varied by site, with 7% of HBV-positive people identified through the outreach and voucher program and 3% identified through refugee screening. Of the 77 people testing positive for HBV, 72 (94%) were successfully linked to care, of whom 68 (94%) attended their first follow-up visit. CONCLUSION Implementation of a culturally competent screening program among immigrants and refugees in Multnomah County improved case finding and subsequent linkage to care.
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Affiliation(s)
- Jaime Walters
- Multnomah County Health Department, Community Epidemiology Services, Portland, OR
| | - Amy Sullivan
- Multnomah County Health Department, Communicable Disease Services, Portland, OR
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25
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Vedio A, Liu EZH, Lee ACK, Salway S. Improving access to health care for chronic hepatitis B among migrant Chinese populations: A systematic mixed methods review of barriers and enablers. J Viral Hepat 2017; 24:526-540. [PMID: 28092419 PMCID: PMC5516707 DOI: 10.1111/jvh.12673] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 12/22/2016] [Indexed: 12/26/2022]
Abstract
Migrant Chinese populations in Western countries have a high prevalence of chronic hepatitis B but often experience poor access to health care and late diagnosis. This systematic review aimed to identify obstacles and supports to timely and appropriate health service use among these populations. Systematic searches resulted in 48 relevant studies published between 1996 and 2015. Data extraction and synthesis were informed by models of healthcare access that highlight the interplay of patient, provider and health system factors. There was strong consistent evidence of low levels of knowledge among patients and community members; but interventions that were primarily focused on increasing knowledge had only modest positive effects on testing and/or vaccination. There was strong consistent evidence that Chinese migrants tend to misunderstand the need for health care for hepatitis B and have low satisfaction with services. Stigma was consistently associated with hepatitis B, and there was weak but consistent evidence of stigma acting as a barrier to care. However, available evidence on the effects of providing culturally appropriate services for hepatitis B on increasing uptake is limited. There was strong consistent evidence that health professionals miss opportunities for testing and vaccination. Practitioner education interventions may be important, but evidence of effectiveness is limited. A simple prompt in patient records for primary care physicians improved the uptake of testing, and a dedicated service increased targeted vaccination coverage for newborns. Further development and more rigorous evaluation of more holistic approaches that address patient, provider and system obstacles are needed.
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Affiliation(s)
- A. Vedio
- Department of Infection and Tropical MedicineSheffield Teaching Hospitals NHS Foundation TrustSheffieldUK
- Public HealthSchool of Health and Related ResearchUniversity of SheffieldSheffieldUK
| | - E. Z. H. Liu
- Public HealthSchool of Health and Related ResearchUniversity of SheffieldSheffieldUK
| | - A. C. K. Lee
- Public HealthSchool of Health and Related ResearchUniversity of SheffieldSheffieldUK
| | - S. Salway
- Public HealthSchool of Health and Related ResearchUniversity of SheffieldSheffieldUK
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26
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Sehr MA, Joshi KD, Fontanesi JM, Wong RJ, Bitmead RR, Gish RG. Markov modeling in hepatitis B screening and linkage to care. Theor Biol Med Model 2017; 14:11. [PMID: 28521828 PMCID: PMC5437626 DOI: 10.1186/s12976-017-0057-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 05/09/2017] [Indexed: 12/23/2022] Open
Abstract
Background With up to 240 million people chronically infected with hepatitis B worldwide, including an estimated 2 million in the United States, widespread screening is needed to link the infected to care and decrease the possible consequences of untreated infection, including liver cancer, cirrhosis and death. Screening is currently fraught with challenges in both the developed and developing world. New point-of-care tests may have advantages over standard-of-care tests in terms of cost-effectiveness and linkage to care. Stochastic modeling is applied here for relative utility assessment of point-of-care tests and standard-of-care tests for screening. Methods We analyzed effects of point-of-care versus standard-of-care testing using Markov models for disease progression in individual patients. Simulations of large cohorts with distinctly quantified models permitted the assessment of particular screening schemes. The validity of the trends observed is supported by sensitivity analyses for the simulation parameters. Results Increased utilization of point-of-care screening was shown to decrease hepatitis B-related mortalities and increase life expectancy at low projected expense. Conclusions The results suggest that standard-of-care screening should be substituted by point-of-care tests resulting in improved linkage to care and decrease in long-term complications.
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Affiliation(s)
- Martin A Sehr
- Department of Mechanical and Aerospace Engineering, University of California, San Diego, 9500 Gilman Drive, MS 0411, La Jolla, CA, 92093-0411, USA
| | - Kartik D Joshi
- Midwestern University, Arizona College of Osteopathic Medicine, 19555 North 59th Avenue, Glendale, AZ, 85308, USA
| | - John M Fontanesi
- Department of Medicine, Division of General Internal Medicine, University of California, San Diego, 200 W. Arbor Drive #8415, San Diego, CA, 92103, USA
| | - Robert J Wong
- Division of Gastroenterology and Hepatology, Alameda Health System - Highland Hospital, 1411 East 31st Street, Highland Care Pavilion - 5th Floor Endoscopy Unit, Oakland, CA, 94602, USA
| | - Robert R Bitmead
- Department of Mechanical and Aerospace Engineering, University of California, San Diego, 9500 Gilman Drive, MS 0411, La Jolla, CA, 92093-0411, USA
| | - Robert G Gish
- Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University, Alway Building, Room M211, 300 Pasteur Drive, MC: 5187, Stanford, CA, 94305-5187, USA. .,National Viral Hepatitis Roundtable, 1612 K Street NW, Suite 1202, Washington, DC, 20006, USA. .,Hepatitis B Foundation, 3805 Old Easton Road, Doylestown, PA, USA.
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27
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Coenen S, van Meer S, Vrolijk JM, Richter C, van Erpecum KJ, Mostert MC, Veldhuijzen IK, Reijnders JGP, van Soest H, Dirksen K, Drenth JPH, Koene RPM, Bosschart M, Friederich P, Ter Borg MJ, Daemen RHPJ, Arends JE, Verhagen MAMT, Schout C, Spanier BWM. Clinical impact of five large-scale screening projects for chronic hepatitis B in Chinese migrants in the Netherlands. Liver Int 2016; 36:1425-32. [PMID: 27001619 DOI: 10.1111/liv.13125] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 03/09/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS In low-endemic countries it is debated whether first-generation migrants should be screened for chronic hepatitis B infection. We describe the clinical impact of five large-scale Dutch screening projects for hepatitis B in first-generation Chinese migrants. METHODS Between 2009 and 2013 five independent outreach screening projects for hepatitis B targeting first-generation Chinese migrants were conducted in five main Dutch regions. To explore the relevance of our screening we defined clinical impact as the presence of an indication for: (i) antiviral therapy, (ii) strict follow-up because of high hepatitis B DNA levels and/or (iii) surveillance for hepatocellular carcinoma. RESULTS In total, 4423 persons participated in the projects of whom 6.0% (n = 264) were HBsAg positive. One hundred and twenty-nine newly diagnosed HBsAg-positive patients were analysed in specialist care. Among these patients prevalence of cirrhosis was 6.9% and antiviral therapy for hepatitis B was started in 32 patients (25%). In patients without a treatment indication, strict follow-up because of high hepatitis B DNA levels and/or surveillance for hepatocellular carcinoma was considered indicated in 64 patients (50%). CONCLUSIONS In our screening project in first-generation Chinese migrants, antiviral treatment, strict follow-up because of high hepatitis B DNA levels and/or surveillance for hepatocellular carcinoma were considered indicated in three of four analysed HBsAg-positive patients. These data show that detection of hepatitis B in Chinese migrants can have considerable impact on patient care.
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Affiliation(s)
- Sandra Coenen
- Department of Gastroenterology and Hepatology, Rijnstate Hospital Arnhem, Arnhem, the Netherlands.
| | - Suzanne van Meer
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Jan M Vrolijk
- Department of Gastroenterology and Hepatology, Rijnstate Hospital Arnhem, Arnhem, the Netherlands
| | - Clemens Richter
- Department of Internal Medicine and Infectious diseases, Rijnstate Hospital Arnhem, Arnhem, the Netherlands
| | - Karel J van Erpecum
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Marijke C Mostert
- Department of Infectious Disease Control, Municipal Health Services, Rotterdam, the Netherlands
| | - Irene K Veldhuijzen
- Department of Infectious Disease Control, Municipal Health Services, Rotterdam, the Netherlands
| | - Jurriën G P Reijnders
- Department of Gastroenterology and Hepatology, Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Hanneke van Soest
- Department of Gastroenterology and Hepatology, Medical Center Haaglanden The Hague, The Hague, the Netherlands
| | - Kees Dirksen
- Department of Infectious Disease Control, Municipal Health Services, The Hague, the Netherlands
| | - Joost P H Drenth
- Department of Gastroenterology and Hepatology, Radboudumc Nijmegen, Nijmegen, the Netherlands
| | - René P M Koene
- Department of Infectious Disease Control, Municipal Health Services, Gelderland Zuid, the Netherlands
| | - Maaike Bosschart
- Department of Infectious Disease Control, Municipal Health Services, Gelderland Midden, the Netherlands
| | - Pieter Friederich
- Department of Gastroenterology and Hepatology, Catharina Hospital Eindhoven, Eindhoven, the Netherlands
| | - Martijn J Ter Borg
- Department of Gastroenterology and Hepatology, Maxima Medical Center Eindhoven, Eindhoven, the Netherlands
| | - Rick H P J Daemen
- Departments of Infectious Disease Control, Municipal Health Services, Eindhoven, the Netherlands
| | - Joop E Arends
- Department of Internal Medicine and Infectious diseases, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Marc A M T Verhagen
- Department of Gastroenterology and Hepatology, Diakonessen Hospital Utrecht, Utrecht, the Netherlands
| | - Christine Schout
- Departments of Infectious Disease Control, Municipal Health Services, Utrecht, the Netherlands
| | - B W Marcel Spanier
- Department of Gastroenterology and Hepatology, Rijnstate Hospital Arnhem, Arnhem, the Netherlands
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Infectious Diseases in Refugee Children: To Screen or Not to Screen. CURRENT PEDIATRICS REPORTS 2016. [DOI: 10.1007/s40124-016-0103-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Aktuelle Seroprävalenz, Impfstatus und prädiktiver Wert der Leberenzyme für Hepatitis B bei Flüchtlingen in Deutschland. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2016; 59:578-83. [DOI: 10.1007/s00103-016-2333-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Herdman M, Cole A, Hoyle CK, Coles V, Carroll S, Devlin N. Sources and Characteristics of Utility Weights for Economic Evaluation of Pediatric Vaccines: A Systematic Review. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2016; 19:255-266. [PMID: 27021761 DOI: 10.1016/j.jval.2015.11.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Revised: 07/31/2015] [Accepted: 11/04/2015] [Indexed: 06/05/2023]
Abstract
BACKGROUND Cost-effectiveness analysis of pediatric vaccines for infectious diseases often requires quality-of-life (utility) weights. OBJECTIVE To investigate how utility weights have been elicited and used in this context. METHODS A systematic review was conducted of studies published between January 1990 and July 2013 that elicited or used utility weights in cost-effectiveness analyses of vaccines for pediatric populations. The review focused on vaccines for 17 infectious diseases and is presented following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology. RESULTS A total of 6410 titles and abstracts and 225 full-text articles were reviewed. Of those selected for inclusion (n = 101), 15 articles described the elicitation of utility weights and 86 described economic modeling studies using utilities. Various methods were used to generate utilities, including time trade-off, contingent valuation, and willingness to pay, as well as a preference-based measure with associated value sets, such as the EuroQol five-dimensional questionnaire or the Health Utilities Index. In modeling studies, the source of utilities used was often unclear, poorly reported, or based on weak underlying evidence. We found no articles that reported on the elicitation or use of utilities in diphtheria, polio, or tetanus. CONCLUSIONS The scarcity of appropriate utility weights for vaccine-preventable infectious diseases in children and a lack of standardization in their use in economic assessments limit the ability to accurately assess the benefits associated with interventions to prevent infectious diseases. This is an issue that should be of concern to those making decisions regarding the prevention and treatment of infectious childhood illnesses.
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Abstract
BACKGROUND Little is known about the prognosis and complications of chronic hepatitis B in countries with low disease prevalence including Germany. MATERIALS AND METHODS This retrospective/prospective study analyzes the course of 608 HBsAg-positive patients between 2002 and 2012 in Germany. The follow-up duration was 5.2±2.9 years (mean±SD) and the age of the patients was 40.4±13.8 years. Of the total cohort, 59.9% were men; 34.9% had been born in Germany, 30.4% in Turkey, and 34.7% in other countries. RESULTS In 78.3% of women, diagnosis was made during pregnancy screening, which is the only reinforced screening procedure in Germany. During follow-up, 21 patients died, five had a LTX, and 20 developed a hepatocellular carcinoma. Of the total cohort, 15% developed at least one severe liver-associated complication. By multivariate analysis, prognosis was associated with high age and cirrhosis, but not with sex, HBV-DNA, alanine aminotransferase, and ethnic origin. Of the 608 patients, 211 (34.7%) had at least one antiviral therapy. Of the 178 patients who were treated with nucleot(s)ides at the last visit 88.8% had an HBV-DNA less than 20 IU/ml. CONCLUSION Today, in Germany, hepatitis B is a disease of migrants. The present data show that mandatory screening is effective and needs to include more high-risk groups. Mortality and complications including hepatocellular carcinoma are associated primarily with cirrhosis and age, but not with HBeAg status or viral load probably because modern therapies considerably reduce viral replication in almost all patients. The prognosis is exclusively determined by the risk for hepatocellular carcinoma.
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Geue C, Wu O, Xin Y, Heggie R, Hutchinson S, Martin NK, Fenwick E, Goldberg D. Cost-Effectiveness of HBV and HCV Screening Strategies--A Systematic Review of Existing Modelling Techniques. PLoS One 2015; 10:e0145022. [PMID: 26689908 PMCID: PMC4686364 DOI: 10.1371/journal.pone.0145022] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 11/28/2015] [Indexed: 12/15/2022] Open
Abstract
Introduction Studies evaluating the cost-effectiveness of screening for Hepatitis B Virus (HBV) and Hepatitis C Virus (HCV) are generally heterogeneous in terms of risk groups, settings, screening intervention, outcomes and the economic modelling framework. It is therefore difficult to compare cost-effectiveness results between studies. This systematic review aims to summarise and critically assess existing economic models for HBV and HCV in order to identify the main methodological differences in modelling approaches. Methods A structured search strategy was developed and a systematic review carried out. A critical assessment of the decision-analytic models was carried out according to the guidelines and framework developed for assessment of decision-analytic models in Health Technology Assessment of health care interventions. Results The overall approach to analysing the cost-effectiveness of screening strategies was found to be broadly consistent for HBV and HCV. However, modelling parameters and related structure differed between models, producing different results. More recent publications performed better against a performance matrix, evaluating model components and methodology. Conclusion When assessing screening strategies for HBV and HCV infection, the focus should be on more recent studies, which applied the latest treatment regimes, test methods and had better and more complete data on which to base their models. In addition to parameter selection and associated assumptions, careful consideration of dynamic versus static modelling is recommended. Future research may want to focus on these methodological issues. In addition, the ability to evaluate screening strategies for multiple infectious diseases, (HCV and HIV at the same time) might prove important for decision makers.
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Affiliation(s)
- Claudia Geue
- Health Economics and Health Technology Assessment, Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
- * E-mail:
| | - Olivia Wu
- Health Economics and Health Technology Assessment, Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Yiqiao Xin
- Health Economics and Health Technology Assessment, Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Robert Heggie
- Health Economics and Health Technology Assessment, Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Sharon Hutchinson
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, United Kingdom
| | - Natasha K. Martin
- Division of Global Public Health, University of California San Diego, San Diego, California, United States of America
- School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
| | | | - David Goldberg
- Health Protection Scotland, NHS Health Scotland, Glasgow, United Kingdom
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Sharma S, Carballo M, Feld JJ, Janssen HLA. Immigration and viral hepatitis. J Hepatol 2015; 63:515-22. [PMID: 25962882 DOI: 10.1016/j.jhep.2015.04.026] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 04/29/2015] [Accepted: 04/30/2015] [Indexed: 01/09/2023]
Abstract
WHO estimates reveal that the global prevalence of viral hepatitis may be as high as 500 million, with an annual mortality rate of up to 1.3 million individuals. The majority of this global burden of disease is borne by nations of the developing world with high rates of vertical and iatrogenic transmission of HBV and HCV, as well as poor access to healthcare. In 2013, 3.2% of the global population (231 million individuals) migrated into a new host nation. Migrants predominantly originate from the developing countries of the south, into the developed economies of North America and Western Europe. This mass migration of individuals from areas of high-prevalence of viral hepatitis poses a unique challenge to the healthcare systems of the host nations. Due to a lack of universal standards for screening, vaccination and treatment of viral hepatitis, the burden of chronic liver disease and hepatocellular carcinoma continues to increase among migrant populations globally. Efforts to increase case identification and treatment among migrants have largely been limited to small outreach programs in urban centers, such that the majority of migrants with viral hepatitis continue to remain unaware of their infection. This review summarizes the data on prevalence of viral hepatitis and burden of chronic liver disease among migrants, current standards for screening and treatment of immigrants and refugees, and efforts to improve the identification and treatment of viral hepatitis among migrants.
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Affiliation(s)
- Suraj Sharma
- Toronto Centre for Liver Disease, University Health Network, University of Toronto, Toronto, Canada
| | - Manuel Carballo
- International Centre for Migration, Health and Development, Geneva, Switzerland
| | - Jordan J Feld
- Toronto Centre for Liver Disease, University Health Network, University of Toronto, Toronto, Canada
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, University Health Network, University of Toronto, Toronto, Canada; Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
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Sangmala P, Chaikledkaew U, Tanwandee T, Pongchareonsuk P. Economic evaluation and budget impact analysis of the surveillance program for hepatocellular carcinoma in Thai chronic hepatitis B patients. Asian Pac J Cancer Prev 2015; 15:8993-9004. [PMID: 25374242 DOI: 10.7314/apjcp.2014.15.20.8993] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The incidence rate and the treatment costs of hepatocellular carcinoma (HCC) are high, especially in Thailand. Previous studies indicated that early detection by a surveillance program could help by down-staging. This study aimed to compare the costs and health outcomes associated with the introduction of a HCC surveillance program with no program and to estimate the budget impact if the HCC surveillance program were implemented. MATERIALS AND METHODS A cost utility analysis using a decision tree and Markov models was used to compare costs and outcomes during the lifetime period based on a societal perspective between alternative HCC surveillance strategies with no program. Costs included direct medical, direct non-medical, and indirect costs. Health outcomes were measured as life years (LYs), and quality adjusted life years (QALYs). The results were presented in terms of the incremental cost-effectiveness ratio (ICER) in Thai THB per QALY gained. One- way and probabilistic sensitivity analyses were applied to investigate parameter uncertainties. Budget impact analysis (BIA) was performed based on the governmental perspective. RESULTS Semi-annual ultrasonography (US) and semi-annual ultrasonography plus alpha-fetoprotein (US plus AFP) as the first screening for HCC surveillance would be cost-effective options at the willingness to pay (WTP) threshold of 160,000 THB per QALY gained compared with no surveillance program (ICER=118,796 and ICER=123,451 THB/QALY), respectively. The semi-annual US plus AFP yielded more net monetary benefit, but caused a substantially higher budget (237 to 502 million THB) than semi-annual US (81 to 201 million THB) during the next ten fiscal years. CONCLUSIONS Our results suggested that a semi-annual US program should be used as the first screening for HCC surveillance and included in the benefit package of Thai health insurance schemes for both chronic hepatitis B males and females aged between 40-50 years. In addition, policy makers considered the program could be feasible, but additional evidence is needed to support the whole prevention system before the implementation of a strategic plan.
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Affiliation(s)
- Pannapa Sangmala
- Social and Administrative Pharmacy Excellence Research (SAPER) Unit, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand E-mail :
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Let It "B"? The role of Hepatitis B universal vaccination among italian problematic drug users. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2015; 12:3979-92. [PMID: 25872013 PMCID: PMC4410228 DOI: 10.3390/ijerph120403979] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Revised: 03/31/2015] [Accepted: 04/01/2015] [Indexed: 02/07/2023]
Abstract
Hepatitis B virus (HBV) hepatitis is extremely common among problematic drug users (DUs). As of 2012, 47 of the 53 European countries had implemented a universal hepatitis B vaccination programme, a scenario that could radically change its spread. Even so, drug users are still one of the main groups at risk of being infected by HBV, exposing the fact that universal vaccination still has not managed to reach an optimal level of contagion protection. In order to evaluate the role of universal HBV vaccination in protecting against risk behaviour related to the use of illicit drugs, a group of 748 DUs, 511 male and 237 female, was tested for HBV markers, at their first access to public addiction clinics in the metropolitan area of Bologna, Italy. 487 were born after 1981, so they were eligible to have received HBV vaccination in adolescence or at birth; in these subjects antibodies against HBV core antigen had the significant prevalence of 6.2%. Universal HBV vaccination has shown evidence of protecting against infection in the general population. These results, amongst the first to evaluate actual protection in DUs vaccinated at birth or during adolescence, show that compulsory universal vaccination does not solve the problem of HBV transmission in the most at risk groups and that additional strategies must be studied and implemented to address this issue.
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Blanas DA, Nichols K, Bekele M, Shankar H, Bekele S, Jandorf L, Izzeldin S, Ndiaye D, Traore A, Bassam M, Perumalswami PV. Adapting the Andersen model to a francophone West African immigrant population: hepatitis B screening and linkage to care in New York City. J Community Health 2015; 40:175-84. [PMID: 25000917 DOI: 10.1007/s10900-014-9916-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Hepatitis B virus (HBV) is highly endemic in West Africa and immigration from this region to the United States has greatly increased over the past quarter century. Using the Andersen Model as a conceptual framework, this study qualitatively examines francophone West African immigrants' perceptions of factors affecting access to HBV screening and linkage-to-care in New York City. Four focus groups were conducted with 39 purposefully selected participants. The focus groups were conducted in French, audio-recorded, translated into English, transcribed, analyzed, and coded for major themes. Participants identified increasing knowledge of HBV and opportunities to access care in a culturally-sensitive manner that decreases fatalism and avoids generating stigma as priorities. They also emphasized the importance of engaging religious establishments and social networks and employing the Internet to disseminate HBV-relevant information. Cost and health insurance are identified as future challenges that will need to be addressed in a health care environment in which undocumented immigrants are ineligible for health insurance. The qualitative analysis in this study highlights the recursive and interdependent nature of the Andersen Model, and a modification of the model is proposed that is intended to inform examinations of other minority communities' access to health care.
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Affiliation(s)
- Demetri A Blanas
- Institute for Family Health, Harlem Residency in Family Medicine, 1824 Madison Ave, New York, NY, 10035, USA,
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Jazwa A, Coleman MS, Gazmararian J, Wingate LT, Maskery B, Mitchell T, Weinberg M. Cost-benefit comparison of two proposed overseas programs for reducing chronic Hepatitis B infection among refugees: is screening essential? Vaccine 2015; 33:1393-9. [PMID: 25595868 DOI: 10.1016/j.vaccine.2015.01.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Revised: 12/23/2014] [Accepted: 01/07/2015] [Indexed: 12/17/2022]
Abstract
BACKGROUND Refugees are at an increased risk of chronic Hepatitis B virus (HBV) infection because many of their countries of origin, as well as host countries, have intermediate-to-high prevalence rates. Refugees arriving to the US are also at risk of serious sequelae from chronic HBV infection because they are not routinely screened for the virus overseas or in domestic post-arrival exams, and may live in the US for years without awareness of their infection status. METHODS A cohort of 26,548 refugees who arrived in Minnesota and Georgia during 2005-2010 was evaluated to determine the prevalence of chronic HBV infection. This prevalence information was then used in a cost-benefit analysis comparing two variations of a proposed overseas program to prevent or ameliorate the effects of HBV infection, titled 'Screen, then vaccinate or initiate management' (SVIM) and 'Vaccinate only' (VO). The analyses were performed in 2013. All values were converted to US 2012 dollars. RESULTS The estimated six year period-prevalence of chronic HBV infection was 6.8% in the overall refugee population arriving to Minnesota and Georgia and 7.1% in those ≥6 years of age. The SVIM program variation was more cost beneficial than VO. While the up-front costs of SVIM were higher than VO ($154,084 vs. $73,758; n=58,538 refugees), the SVIM proposal displayed a positive net benefit, ranging from $24 million to $130 million after only 5 years since program initiation, depending on domestic post-arrival screening rates in the VO proposal. CONCLUSIONS Chronic HBV infection remains an important health problem in refugees resettling to the United States. An overseas screening policy for chronic HBV infection is more cost-beneficial than a 'Vaccination only' policy. The major benefit drivers for the screening policy are earlier medical management of chronic HBV infection and averted lost societal contributions from premature death.
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Affiliation(s)
- Amelia Jazwa
- U.S. Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases, Division of Global Migration and Quarantine, United States
| | - Margaret S Coleman
- U.S. Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases, Division of Global Migration and Quarantine, United States
| | | | - La'Marcus T Wingate
- U.S. Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases, Division of Global Migration and Quarantine, United States
| | - Brian Maskery
- U.S. Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases, Division of Global Migration and Quarantine, United States.
| | - Tarissa Mitchell
- U.S. Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases, Division of Global Migration and Quarantine, United States
| | - Michelle Weinberg
- U.S. Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases, Division of Global Migration and Quarantine, United States
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Mukhtar NA, Toy BC, Burman BE, Yu A, Chen AH, Berman P, Nguyen T, Chan D, Hammer H, McCulloch CE, Khalili M. Assessment of HBV preventive services in a medically underserved Asian and Pacific Islander population using provider and patient data. J Gen Intern Med 2015; 30:68-74. [PMID: 25324148 PMCID: PMC4284271 DOI: 10.1007/s11606-014-3057-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Revised: 05/22/2014] [Accepted: 09/24/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Hepatitis B (HBV) represents a significant health disparity among medically underserved Asian and Hawaiian/Pacific Islander (API) populations. Studies evaluating adherence to HBV screening and vaccination guidelines in this population are limited. OBJECTIVE The purpose of this study was to evaluate HBV screening and vaccination practices using both provider self-report and patient records. DESIGN Medical records for 20,574 API adults were reviewed retrospectively and primary care providers were surveyed to evaluate rates and adherence to HBV screening and vaccination guidelines. PARTICIPANTS The study included primary care providers and their adult API patients in the San Francisco safety-net healthcare system. MAIN MEASURES Patient, practice, and provider factors, as well as HBV screening and vaccination practices, were assessed using provider survey constructs and patient laboratory and clinical data. Generalized linear mixed models and multivariate logistic regression analyses were used to identify factors associated with recommended HBV screening and vaccination. KEY RESULTS The mean age of patients was 52 years, and 63.4 % of patients were female. Only 61.5 % underwent HBV testing, and 47.4 % of HBV-susceptible patients were vaccinated. Of 148 (44.8 %) responding providers, most were knowledgeable and had a favorable attitude towards screening, but 43.2 % were unfamiliar with HBV guidelines. HBV screening was positively associated with favorable provider attitude score (OR per unit 1.80, 95 % CI 1.18-2.74) and negatively associated with female patient sex (OR 0.82, 95 % CI 0.73-0.92), a higher number of clinic patients per week (OR per 20 patients 0.46, 95 % CI 0.28-0.76), and provider barrier score (OR per unit 0.45, 95 % CI 0.24-0.87). HBV vaccination was negatively associated with provider barrier score (OR per unit 0.48, 95 % CI 0.25-0.91). CONCLUSIONS Rates of HBV screening and vaccination of API patients in this safety-net system are suboptimal, and provider factors play a significant role. Efforts to cultivate positive attitudes among providers and expand healthcare system resources to reduce provider barriers to HBV care are warranted.
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Affiliation(s)
- Nizar A. Mukhtar
- />Department of Medicine, University of California, San Francisco, San Francisco, CA USA
| | - Brian C. Toy
- />Department of Medicine, University of California, San Francisco, San Francisco, CA USA
| | - Blaire E. Burman
- />Department of Medicine, University of California, San Francisco, San Francisco, CA USA
| | - Albert Yu
- />Department of Family and Community Medicine, University of California, San Francisco, San Francisco, CA USA
| | - Alice Hm Chen
- />Department of Medicine, University of California, San Francisco, San Francisco, CA USA
| | - Peter Berman
- />Department of Family and Community Medicine, University of California, San Francisco, San Francisco, CA USA
| | - Tung Nguyen
- />Department of Medicine, University of California, San Francisco, San Francisco, CA USA
| | - Daniel Chan
- />North East Medical Services, San Francisco, CA USA
| | - Hali Hammer
- />Department of Family and Community Medicine, University of California, San Francisco, San Francisco, CA USA
| | - Charles E. McCulloch
- />Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA USA
| | - Mandana Khalili
- />Department of Medicine, University of California, San Francisco, San Francisco, CA USA
- />Liver Center, University of California, San Francisco, San Francisco, CA USA
- />San Francisco General Hospital, University of California, San Francisco, 1001 Potrero Avenue, NH-3D, San Francisco, CA 94110 USA
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Hargreaves S, Seedat F, Car J, Escombe R, Hasan S, Eliahoo J, Friedland JS. Screening for latent TB, HIV, and hepatitis B/C in new migrants in a high prevalence area of London, UK: a cross-sectional study. BMC Infect Dis 2014; 14:657. [PMID: 25466442 PMCID: PMC4261901 DOI: 10.1186/s12879-014-0657-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Accepted: 11/24/2014] [Indexed: 01/03/2023] Open
Abstract
Background Rising rates of infectious diseases in international migrants has reignited the debate around screening. There have been calls to strengthen primary-care-based programmes, focusing on latent TB. We did a cross-sectional study of new migrants to test an innovative one-stop blood test approach to detect multiple infections at one appointment (HIV, latent tuberculosis, and hepatitis B/C) on registration with a General Practitioner (GP) in primary care. Methods The study was done across two GP practices attached to hospital Accident and Emergency Departments (A&E) in a high migrant area of London for 6 months. Inclusion criteria were foreign-born individuals from a high TB prevalence country (>40 cases per 100,000) who have lived in the UK ≤ 10 years, and were over 18 years of age. All new migrants who attended a New Patient Health Check were screened for eligibility and offered the blood test. We followed routine care pathways for follow-up. Results There were 1235 new registrations in 6 months. 453 attended their New Patient Health Check, of which 47 (10.4%) were identified as new migrants (age 32.11 years [range 18–72]; 22 different nationalities; time in UK 2.28 years [0–10]). 36 (76.6%) participated in the study. The intervention only increased the prevalence of diagnosed latent TB (18.18% [95% CI 6.98-35.46]; 181.8 cases per 1000). Ultimately 0 (0%) of 6 patients with latent TB went on to complete treatment (3 did not attend referral). No cases of HIV or hepatitis B/C were found. Foreign-born patients were under-represented at these practices in relation to 2011 Census data (Chi-square test −0.111 [95% CI −0.125 to −0.097]; p < 0.001). Conclusion The one-stop approach was feasible in this context and acceptability was high. However, the number of presenting migrants was surprisingly low, reflecting the barriers to care that this group face on arrival, and none ultimately received treatment. The ongoing UK debate around immigration checks and charging in primary care for new migrants can only have negative implications for the promotion of screening in this group. Until GP registration is more actively promoted in new migrants, a better place to test this one-stop approach could be in A&E departments where migrants may present in larger numbers. Electronic supplementary material The online version of this article (doi:10.1186/s12879-014-0657-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sally Hargreaves
- Imperial College London, Department of Medicine, Section of Infectious Diseases and Immunity, Hammersmith Hospital Campus, 8th Floor Commonwealth Building, DuCane Road, London, W12 ONN, UK.
| | - Farah Seedat
- Imperial College London, Department of Medicine, Section of Infectious Diseases and Immunity, Hammersmith Hospital Campus, 8th Floor Commonwealth Building, DuCane Road, London, W12 ONN, UK.
| | - Josip Car
- Hammersmith and Fulham Centres for Health, Hammersmith Hospital, Hammersmith, London.
| | - Rod Escombe
- Hammersmith and Fulham Centres for Health, Hammersmith Hospital, Hammersmith, London.
| | - Samia Hasan
- Hammersmith and Fulham Centres for Health, Hammersmith Hospital, Hammersmith, London.
| | - Joseph Eliahoo
- Imperial College London, Department of Medicine, Section of Infectious Diseases and Immunity, Hammersmith Hospital Campus, 8th Floor Commonwealth Building, DuCane Road, London, W12 ONN, UK.
| | - Jon S Friedland
- Imperial College London, Department of Medicine, Section of Infectious Diseases and Immunity, Hammersmith Hospital Campus, 8th Floor Commonwealth Building, DuCane Road, London, W12 ONN, UK.
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Sewell J, Capocci S, Johnson J, Solamalai A, Hopkins S, Cropley I, Webster DP, Lipman M. Expanded blood borne virus testing in a tuberculosis clinic. A cost and yield analysis. J Infect 2014; 70:317-23. [PMID: 25452045 DOI: 10.1016/j.jinf.2014.10.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Revised: 08/11/2014] [Accepted: 10/07/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Testing for HIV is a standard of care for people with active tuberculosis (TB). People investigated for TB in the UK often originate from areas with a high prevalence of HIV and other blood borne viruses (BBV). However, assessment for these infections is patchy. We determined the yield and costs of different testing strategies for BBV in a UK TB clinic. METHODS Since 2009, it has been routine to test all TB clinic attendees. Demographic, clinical and virological data were retrospectively extracted from patient notes and hospital databases. RESULTS Over 3 years, 1036 people were assessed in the TB service. 410 had a final diagnosis of active TB. HIV testing of the latter population diagnosed 27 new HIV cases at a cost of £3017. When BBV testing was offered to all clinic attendees, a further 6 (total 33) new HIV, 5 Hepatitis B (HBV) and 2 Hepatitis C (HCV) diagnoses were made at a total cost of £22,170. CONCLUSIONS We have identified previously undiagnosed HIV, HBV and HCV in a TB clinic population. Our data suggest that despite increasing upfront expense, the associated yield argues strongly for BBV testing to be offered to all patients being investigated for possible TB, irrespective of their final diagnosis.
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Affiliation(s)
- J Sewell
- Department of Health and Population Sciences, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, United Kingdom.
| | - S Capocci
- Department of Respiratory Medicine, Royal Free London NHS Foundation Trust, Pond Street, London NW3 2QG, United Kingdom.
| | - J Johnson
- Department of Respiratory Medicine, Royal Free London NHS Foundation Trust, Pond Street, London NW3 2QG, United Kingdom.
| | - A Solamalai
- North Central London TB Service, Royal Free London NHS Foundation Trust, Pond Street, London NW3 2QG, United Kingdom.
| | - S Hopkins
- Department of Infectious Diseases, Royal Free London NHS Foundation Trust, Pond Street, London NW3 2QG, United Kingdom.
| | - I Cropley
- Department of Infectious Diseases, Royal Free London NHS Foundation Trust, Pond Street, London NW3 2QG, United Kingdom.
| | - D P Webster
- Department of Virology, Royal Free London NHS Foundation Trust, Pond Street, London NW3 2QG, United Kingdom.
| | - M Lipman
- Department of Respiratory Medicine, Royal Free London NHS Foundation Trust, Pond Street, London NW3 2QG, United Kingdom; University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, United Kingdom.
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41
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Bocanegra C, Salvador F, Sulleiro E, Sánchez-Montalvá A, Pahissa A, Molina I. Screening for imported diseases in an immigrant population: experience from a teaching hospital in Barcelona, Spain. Am J Trop Med Hyg 2014; 91:1277-81. [PMID: 25331805 DOI: 10.4269/ajtmh.14-0206] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
The objective of this study was to describe the screening for imported diseases among an immigrant population. This retrospective observational study was of all adult immigrants attended at the Tropical Medicine Unit of the Vall d'Hebron Teaching Hospital from September of 2007 to March of 2010. The screening strategy was adjusted by symptoms, country of origin, and length of residence in Europe. Overall, 927 patients were included. The median age was 34.5 years, and 42.1% of patients were male. A diagnosis was made in 419 (45.2%) patients. The most frequent diagnoses were Chagas disease, anemia, latent tuberculosis infection, intestinal parasitosis, hepatitis B virus (HBV) infection, and human immunodeficiency virus (HIV) infection. After screening, more diseases were identified in immigrants from sub-Saharan Africa (new diagnoses in 56.6% of patients) than patients from other geographic areas. The geographic origin and length of residence in a developed country determine the prevalence of diseases; hence, screening protocols must be based on this information.
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Affiliation(s)
- Cristina Bocanegra
- Departments of Infectious Diseases and Microbiology, Vall d'Hebron Teaching Hospital, Barcelona, Spain
| | - Fernando Salvador
- Departments of Infectious Diseases and Microbiology, Vall d'Hebron Teaching Hospital, Barcelona, Spain
| | - Elena Sulleiro
- Departments of Infectious Diseases and Microbiology, Vall d'Hebron Teaching Hospital, Barcelona, Spain
| | - Adrián Sánchez-Montalvá
- Departments of Infectious Diseases and Microbiology, Vall d'Hebron Teaching Hospital, Barcelona, Spain
| | - Albert Pahissa
- Departments of Infectious Diseases and Microbiology, Vall d'Hebron Teaching Hospital, Barcelona, Spain
| | - Israel Molina
- Departments of Infectious Diseases and Microbiology, Vall d'Hebron Teaching Hospital, Barcelona, Spain
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Abstract
INTRODUCTION Chronic hepatitis B (CHB) affects over 350 million people worldwide and can lead to life-threatening complications, including liver failure and hepatocellular cancer (HCC). Modern antiviral therapies could stem the rising tide of hepatitis B-related HCC, provided that individuals and populations at risk can be reliably identified through hepatitis B screening and appropriately linked to care. Opportunistic disease screening cannot deliver population-level outcomes, given the large number of undiagnosed people, but they may be achievable through well-organized and targeted community-based screening interventions. MATERIAL AND METHODS This review summarizes the experience with community-based CHB screening programs published in the English-language literature over the last 30 years. RESULTS They include experiences from Taiwan, the USA, The Netherlands, New Zealand, and Australia. Despite great variability in program setting and design, successful programs shared common features, including effective community engagement incorporating the target population's cultural values and the ability to provide low-cost or free access to care, including antiviral treatment. CONCLUSION While many questions still remain about the best funding mechanisms to ensure program sustainability and what the most effective strategies are to ensure program reach, linkage to care, and access to treatment, the evidence suggests scope for cautious optimism. A number of successful, large-scale initiatives in the USA, Asia-Pacific, and Europe demonstrated the feasibility of community-based interventions in effectively screening large numbers of people with CHB. By providing an effective mechanism for community outreach, scaling up these interventions could deliver population-level outcomes in liver cancer prevention relevant for many countries with a large burden of disease.
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Affiliation(s)
| | - Jacob George
- Storr Liver Unit, Westmead Millennium Institute and Westmead Hospital, University of Sydney, Westmead, Sydney, NSW Australia
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Niederau C. Chronic hepatitis B in 2014: great therapeutic progress, large diagnostic deficit. World J Gastroenterol 2014; 20:11595-617. [PMID: 25206267 PMCID: PMC4155353 DOI: 10.3748/wjg.v20.i33.11595] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Revised: 01/03/2014] [Accepted: 04/27/2014] [Indexed: 02/06/2023] Open
Abstract
This review analyzes progress and limitations of diagnosis, screening, and therapy of patients with chronic hepatitis B infection. A literature review was carried out by framing the study questions. Vaccination in early childhood has been introduced in most countries and reduces the infection rate. Treatment of chronic hepatitis B can control viral replication in most patients today. It reduces risks for progression and may reverse liver fibrosis. The treatment effect on development of hepatocellular carcinoma is less pronounced when cirrhosis is already present. Despite the success of vaccination and therapy chronic hepatitis B remains a problem since many infected patients do not know of their disease. Although all guidelines recommend screening in high risk groups such as migrants, these suggestions have not been implemented. In addition, the performance of hepatocellular cancer surveillance under real-life conditions is poor. The majority of people with chronic hepatitis B live in resource-constrained settings where effective drugs are not available. Despite the success of vaccination and therapy chronic hepatitis B infection remains a major problem since many patients do not know of their disease. The problems in diagnosis and screening may be overcome by raising awareness, promoting partnerships, and mobilizing resources.
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Komatsu H. Hepatitis B virus: Where do we stand and what is the next step for eradication? World J Gastroenterol 2014; 20:8998-9016. [PMID: 25083074 PMCID: PMC4112872 DOI: 10.3748/wjg.v20.i27.8998] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Revised: 12/09/2013] [Accepted: 04/16/2014] [Indexed: 02/06/2023] Open
Abstract
Hepatitis B (HB) virus (HBV) infection, which causes liver cirrhosis and hepatocellular carcinoma, is endemic worldwide. Hepatitis B vaccines became commercially available in the 1980s. The World Health Organization recommended the integration of the HB vaccine into the national immunisation programs in all countries. HBV prevention strategies are classified into three groups: (1) universal vaccination alone; (2) universal vaccination with screening of pregnant women plus HB immune globulin (HBIG) at birth; and (3) selective vaccination with screening of pregnant women plus HBIG at birth. Most low-income countries have adopted universal vaccine programs without screening of pregnant women. However, HB vaccines are not widely used in low-income countries. The Global Alliance for Vaccine and Immunization was launched in 2000, and by 2012, the global coverage of a three-dose HB vaccine had increased to 79%. The next challenges are to further increase the coverage rate, close the gap between recommendations and routine practices, approach high-risk individuals, screen and treat chronically infected individuals, and prevent breakthrough infections. To eradicate HBV infections, strenuous efforts are required to overcome socioeconomic barriers to the HB vaccine; this task is expected to take several decades to complete.
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Poor adherence to AASLD guidelines for chronic hepatitis B Management and treatment in a large academic medical center. Am J Gastroenterol 2014; 109:867-75. [PMID: 24732869 PMCID: PMC4624277 DOI: 10.1038/ajg.2014.72] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Accepted: 02/04/2014] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Adherence to the American Association for the Study of Liver Disease (AASLD) guidelines for the management of chronic hepatitis B (CHB) has not been systematically assessed. We sought to comprehensively evaluate adherence to five key areas of these guidelines. We also evaluated physician and patient factors underlying nonadherence, and predictors of nonadherence such as physician type, patient demographic factors, and phase of CHB infection. METHODS Nine hundred and sixty-two adult patients were retrospectively identified. Each patient chart was reviewed in detail. The primary outcome was adherence to five areas of the AASLD guidelines: (i) timely alanine aminotransferase (ALT)/hepatitis B virus DNA level checks needed to monitor inactive carrier and immune-tolerant phases; (ii) liver biopsy to guide decisions on initiating treatment; (iii) treatment initiation when indicated; (iv) hepatocellular carcinoma (HCC) screening; (v) testing for hepatitis A virus (HAV) immunity, HIV, and hepatitis C virus (HCV) co-infections. RESULTS Sixty percent did not undergo clinically indicated liver biopsies, largely owing to physician nonadherence. Eighty-nine percent of these missed biopsies were needed to further assess possible e-antigen-negative CHB. A high treatment initiation rate was found for the treatment eligible, but 121 patients had unclear treatment eligibility as they warranted, but did not undergo, liver biopsy. Forty-five percent did not have timely HCC screening, although gastroenterology physicians had the highest odds of adherence, and 29% did not have timely CHB lab assessment; patients seen by gastroenterologists had twice the odds compared with primary care physicians of undergoing timely lab monitoring. Thirty-five, 24, and 54% were not tested for HAV, HCV, and HIV co-infections. CONCLUSIONS Our findings show remarkably poor adherence to AASLD guidelines, particularly in the areas of liver biopsy, timely HCC and ALT monitoring, and testing for co-infection. These findings call for greater efforts to meet physician knowledge gaps, incorporation of decision support tools, and improved communication among providers.
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Screening for chronic hepatitis B and C in migrants from Afghanistan, Iran, Iraq, the former Soviet Republics, and Vietnam in the Arnhem region, The Netherlands. Epidemiol Infect 2014; 142:2140-6. [PMID: 24398373 DOI: 10.1017/s0950268813003415] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Migrants born in hepatitis B virus (HBV) and hepatitis C virus (HCV) endemic countries are at increased risk of being infected with these viruses. The first symptoms may arise when liver damage has already occurred. The challenge is to identify these infections early, since effective treatment has become available. In 2011 we conducted a screening project in first-generation migrants (FGMs) born in Afghanistan, Iran, Iraq, the former Soviet Republics, and Vietnam and living in Arnhem and Rheden. All participants were offered free blood screening for HBV and HCV. In total 959 participants were tested, with the country of origin known for 927, equating to 28·7% of all registered FGMs from the chosen countries. Nineteen percent (n = 176) had serological signs of past or chronic HBV infection and 2·2% (n = 21) had chronic HBV infection. The highest prevalence of chronic HBV infection was found in the Vietnamese population (9·5%, n = 12). Chronic HCV was found in two persons from the former Soviet Republics and one from Vietnam. Twenty-four percent (n = 5) of the newly identified patients with chronic HBV and one of the three patients with chronic HCV received treatment. Three of the patients, two with HCV and one with HBV, already had liver cirrhosis. The highest (9·5%) HBV prevalence was found in FGMs from Vietnam, indicating a high need for focusing on that particular immigrant population in order to identify more people with silent HBV infection. The fact that three patients already had liver cirrhosis underlines the necessity of early identification of HBV and HCV infection in risk groups.
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Use of laboratory-based surveillance data to estimate the number of people chronically infected with hepatitis B living in Scotland. Epidemiol Infect 2013; 142:2121-30. [PMID: 24480044 DOI: 10.1017/s0950268813003105] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
It is paramount to understand the epidemiology of chronic hepatitis B to inform national policies on vaccination and screening/testing as well as cost-effectiveness studies. However, information on the national (Scottish) prevalence of chronic hepatitis B by ethnic group is lacking. To estimate the number of people with chronic hepatitis B in Scotland in 2009 by ethnicity, gender and age, the test data from virology laboratories in the four largest cities in Scotland were combined with estimates of the ethnic distribution of the Scottish population. Ethnicity in both the test data and the Scottish population was derived using a name-based ethnicity classification software (OnoMAP; Publicprofiler Ltd, UK). For 2009, we estimated 8720 [95% confidence interval (CI) 7490-10 230] people aged ⩾15 years were living with chronic hepatitis B infection in Scotland. This corresponds to 0·2% (95% CI 0·17-0·24) of the Scottish population aged ⩾15 years. Although East and South Asians make up a small proportion of the Scottish population, they make up 44% of the infected population. In addition, 75% of those infected were aged 15-44 years with almost 60% male. This study quantifies for the first time on a national level the burden of chronic hepatitis B infection by ethnicity, gender and age. It confirms the importance of promoting and targeting ethnic minority groups for hepatitis B testing.
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48
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Toy M. Cost-effectiveness of viral hepatitis B & C treatment. Best Pract Res Clin Gastroenterol 2013; 27:973-85. [PMID: 24182615 DOI: 10.1016/j.bpg.2013.08.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Revised: 07/16/2013] [Accepted: 08/26/2013] [Indexed: 01/31/2023]
Abstract
With the availability of effective antiviral therapies for chronic viral hepatitis B and C, cost-effectiveness studies have been performed to assess the outcomes and costs of these therapies to support health policy. It is now accepted that treatment of active CHB is cost-effective versus no treatment, although there are a variety of options. And with the new developments around CHC treatment and diagnostic tools it is of interest to both the clinician and policy makers to know both the costs and effects of these choices. The purpose of this article is to provide the reader with an insight into the recent treatment developments and cost-effectiveness issues related to chronic hepatitis B and C treatment, and an overview of recent cost-effectiveness studies evolving around HBV and HCV therapy.
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Affiliation(s)
- Mehlika Toy
- Department of Global Health and Population, Harvard School of Public Health, Harvard University, Boston, USA.
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MacLachlan JH, Wang YJ, Cowie BC. A validation of the use of names to screen for risk of chronic hepatitis B in Victoria, Australia, 2001 to 2010. ACTA ACUST UNITED AC 2013; 18. [PMID: 24300885 DOI: 10.2807/1560-7917.es2013.18.47.20638] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The burden of chronic hepatitis B (CHB) is increasing in Australia, particularly in those born in the Asia-Pacific region, and nearly half are undiagnosed. Primary care clinicians have a key role in diagnosing CHB, however identification of patients at risk is hindered by lack of awareness and limited information on country of birth in patient records. This study evaluates the potential of a validated list of names associated with Asian country of birth as a screening tool to predict risk of CHB, by comparing it with surveillance records for all people diagnosed with CHB or salmonellosis in Victoria from 2001 to 2010, and analysed using standard screening tools. Name list match was associated with CHB notification, with over 60% of cases having one name matching the list (sensitivity), and nearly one third matching both given name and surname; less than 15% and 2% of salmonellosis notifications matched for one name and both names, respectively (false positives). These results show that more than half of notified cases of CHB would have been identified by this name list, and that it could be used in support of initiatives to improve diagnosis of patients with diseases associated with country of birth when limited information is available.
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Affiliation(s)
- J H MacLachlan
- World Health Organisation Regional Reference Laboratory for Hepatitis B, Victorian Infectious Diseases Reference Laboratory, Victoria, Australia
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50
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Miners AH, Martin NK, Ghosh A, Hickman M, Vickerman P. Assessing the cost-effectiveness of finding cases of hepatitis C infection in UK migrant populations and the value of further research. J Viral Hepat 2013; 21:616-23. [PMID: 24215210 DOI: 10.1111/jvh.12190] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2013] [Accepted: 09/25/2013] [Indexed: 02/01/2023]
Abstract
Hepatitis C (HCV) infection can cause cirrhosis, liver cancer and death in the absence of treatment. Many people living in the UK but born overseas are believed to be infected with HCV although many are unlikely to know they are infected. The aim of this study is to assess the potential for a case-finding approach to be cost-effective and to estimate the value of further research. An economic evaluation and value of information analysis was undertaken by developing a model of HCV disease progression and by populating it with evidence from the published literature. They were performed from a UK National Health Services cost perspective, and outcomes were expressed in terms of quality-adjusted life-years (QALYs). The comparator intervention was defined as the background rate of testing (i.e. no intervention). The base case results generated an incremental cost-effectiveness ratio (ICER) of about £23,200 per additional QALY. However, the ICER was shown to be particularly sensitive to HCV seroprevalence, the intervention effect / cost and the probability of treatment uptake. The value of information analysis suggested that approximately £4 million should be spent on further research. This evaluation demonstrates that testing UK migrants for HCV could be cost-effective. However, further research, particularly to refine estimates of the probability of treatment uptake once identified, the utility associated with sustained virological response and the cost of the intervention, would help to increase the robustness of this conclusion.
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Affiliation(s)
- A H Miners
- Department Health Services Research & Policy, London School of Hygiene and Tropical Medicine (LSHTM), London, UK
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