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Passos-Castilho AM, Murphy DG, Blouin K, Benedetti A, Panagiotoglou D, Bruneau J, Klein MB, Kwong JC, Sander B, Janjua NZ, Greenaway C. Ongoing Gaps in the Hepatitis C Care Cascade during the Direct-Acting Antiviral Era in a Large Retrospective Cohort in Canada: A Population-Based Study. Viruses 2024; 16:389. [PMID: 38543755 PMCID: PMC10975766 DOI: 10.3390/v16030389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 02/26/2024] [Accepted: 02/28/2024] [Indexed: 05/23/2024] Open
Abstract
To achieve hepatitis C virus (HCV) elimination, high uptake along the care cascade steps for all will be necessary. We mapped engagement with the care cascade overall and among priority groups in the post-direct-acting antivirals (DAAs) period and assessed if this changed relative to pre-DAAs. We created a population-based cohort of all reported HCV diagnoses in Quebec (1990-2018) and constructed the care cascade [antibody diagnosed, RNA tested, RNA positive, genotyped, treated, sustained virologic response (SVR)] in 2013 and 2018. Characteristics associated with RNA testing and treatment initiation were investigated using marginal logistic models via generalized estimating equations. Of the 31,439 individuals HCV-diagnosed in Quebec since 1990 and alive as of 2018, there was significant progress in engagement with the care cascade post- vs. pre-DAAs; 86% vs. 77% were RNA-tested, and 64% vs. 40% initiated treatment. As of 2018, a higher risk of not being RNA-tested or treated was observed among individuals born <1945 vs. >1965 [hazard ratio (HR); 95% CI; 1.35 (1.16-1.57)], those with material and social deprivation [1.21 (1.06-1.38)], and those with alcohol use disorder [1.21 (1.08-1.360]. Overall, non-immigrants had lower rates of RNA testing [0.76 (0.67-0.85)] and treatment initiation [0.63 (0.57-0.70)] than immigrants. As of 2018, PWID had a lower risk of not being RNA tested [0.67 (0.61-0.85)] but a similar risk of not being treated, compared to non-PWID. Engagement in the HCV care cascade have improved in the post-DAA era, but inequities remain. Vulnerable subgroups, including certain older immigrants, were less likely to have received RNA testing or treatment as of 2018 and would benefit from focused interventions to strengthen these steps.
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Affiliation(s)
- Ana Maria Passos-Castilho
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, QC H3T 1E2, Canada
- Department of Medicine, McGill University, Montreal, QC H3G 2M1, Canada
| | - Donald G. Murphy
- Laboratoire de Santé Publique du Québec, Institut National de Santé Publique du Québec, Sainte-Anne-de-Bellevue, QC H9X 3R5, Canada;
| | - Karine Blouin
- Unité sur les Infections Transmissibles Sexuellement et par le Sang, Institut National de Santé Publique du Québec, Québec, QC H9X 3R5, Canada;
| | - Andrea Benedetti
- Department of Epidemiology, Biostatistics and Occupational Health, School of Population and Global Health, McGill University, Montreal, QC H3A 1G1, Canada; (A.B.); (D.P.)
| | - Dimitra Panagiotoglou
- Department of Epidemiology, Biostatistics and Occupational Health, School of Population and Global Health, McGill University, Montreal, QC H3A 1G1, Canada; (A.B.); (D.P.)
| | - Julie Bruneau
- CHUM Research Centre, Centre Hospitalier de l’Université de Montréal, Montreal, QC H2X 0A9, Canada;
| | - Marina B. Klein
- Research Institute of the McGill University Health Centre, Montreal, QC H3H 2R9, Canada;
| | - Jeffrey C. Kwong
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON M5T 3M7, Canada;
- ICES, Toronto, ON M4N 3M5, Canada;
- Public Health Ontario, Toronto, ON M5G 1M1, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON M5G 1V7, Canada
| | - Beate Sander
- ICES, Toronto, ON M4N 3M5, Canada;
- Public Health Ontario, Toronto, ON M5G 1M1, Canada
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON M5G 2C4, Canada
- Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, ON M5T 3M6, Canada
| | - Naveed Z. Janjua
- School of Population and Public Health, University of British Columbia, Vancouver, BC V6T 1Z3, Canada;
| | - Christina Greenaway
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, QC H3T 1E2, Canada
- Department of Medicine, McGill University, Montreal, QC H3G 2M1, Canada
- Division of Infectious Diseases, Jewish General Hospital, Montreal, QC H3T 1E2, Canada
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Erman A, Sahakyan Y, Everett K, Greenaway C, Janjua N, Kwong JC, Wong WWL, Lu H, Sander B. Hepatitis C Attributable Healthcare Costs and Mortality among Immigrants: A Population-Based Matched Cohort Study. Can J Gastroenterol Hepatol 2024; 2024:5573068. [PMID: 38434933 PMCID: PMC10908570 DOI: 10.1155/2024/5573068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 02/09/2024] [Accepted: 02/12/2024] [Indexed: 03/05/2024] Open
Abstract
Background Data on the economic burden of chronic hepatitis C (CHC) among immigrants are limited. Our objective was to estimate the CHC-attributable mortality and healthcare costs among immigrants in Ontario, Canada. Methods We conducted a population-based matched cohort study among immigrants diagnosed with CHC between May 31, 2003, and December 31, 2018, using linked health administrative data. Immigrants with CHC (exposed) were matched 1 : 1 to immigrants without CHC (unexposed) using a combination of hard (index date, sex, and age) and propensity-score matching. Net costs (2020 Canadian dollars) collected from the healthcare payer perspective were calculated using a phase-of-care approach and used to estimate long-term costs adjusted for survival. Results We matched 5,575 exposed individuals with unexposed controls, achieving a balanced match. The mean age was 47 years, and 52% was male. On average, 10.5% of exposed and 3.5% of unexposed individuals died 15 years postindex (relative risk = 2.9; 95% confidence interval (CI): 2.6-3.5). The net 30-day costs per person were $88 (95% CI: 55 to 122) for the prediagnosis, $324 (95% CI: 291 to 356) for the initial phase, $1,016 (95% CI: 900 to 1,132) for the late phase, and $975 (95% CI: -25 to 1,974) for the terminal phase. The mean net healthcare cost adjusted for survival at 15 years was $90,448. Conclusions Compared to unexposed immigrants, immigrants infected with CHC have higher mortality rates and greater healthcare costs. These findings will support the planning of HCV elimination efforts among key risk groups in the province.
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Affiliation(s)
- Aysegul Erman
- Toronto Health Economics and Technology Assessment Collaborative (THETA), University Health Network, Toronto, ON, Canada
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Yeva Sahakyan
- Toronto Health Economics and Technology Assessment Collaborative (THETA), University Health Network, Toronto, ON, Canada
| | - Karl Everett
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Christina Greenaway
- Division of Infectious Diseases, Jewish General Hospital, McGill University, Montreal, QC, Canada
| | - Naveed Janjua
- BC Centre for Disease Control, Vancouver, BC, Canada
| | - Jeffrey C. Kwong
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
- Public Health Ontario, Toronto, ON, Canada
| | | | - Hong Lu
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Beate Sander
- Toronto Health Economics and Technology Assessment Collaborative (THETA), University Health Network, Toronto, ON, Canada
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
- Public Health Ontario, Toronto, ON, Canada
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Petrosyan Y, Simmons JG, Kelly E, Cooper CL. Uptake and factors associated with direct-acting antiviral therapy for hepatitis C and treatment outcomes among Canadian immigrants: A retrospective cohort analysis. CANADIAN LIVER JOURNAL 2022; 5:388-401. [DOI: 10.3138/canlivj-2021-0037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 01/15/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND: We sought to compare rates and factors associated with Direct Acting Antiviral (DAA) treatment uptake and sustained virological response (SVR) between Canadian-born and foreign-born patients. METHODS: The study was conducted utilizing a retrospective cohort of hepatitis C virus (HCV)-infected patients assessed at The Ottawa Hospital Viral Hepatitis Clinic between January 2015 and October 2021. Risk factors, income, and clinical characteristics of HCV infection associated with DAA therapy uptake and SVR were compared by immigration status using logistic regression. RESULTS: Of 1,459 HCV-infected patients, 264 (18.1%) were born outside of the country. A median 17 years passed from immigration to first assessment at the clinic. The proportion of patients initiating DAA therapy was similar between groups (65.2% versus 69.5%, p = 0.17). Characteristics associated with DAA therapy uptake included age at first assessment (OR = 1.02; 95% CI 1.01 to 1.03) and being cirrhotic (OR = 3.19; 95% CI 1.99 to 2.13). Crude SVR rate was higher in immigrants than in Canadian-born patients (91.5% versus 83.7%, p = 0.01). After controlling for other variables, only advancing age was associated with the likelihood of achieving crude SVR (OR = 1.04, 95% CI 1.02 to 1.05). CONCLUSIONS: We found that DAA therapy uptake and HCV cure rates were high in both groups suggesting equity of opportunity in those referred to our program. The older age at presentation suggests missed opportunities to diagnose and engage immigrants in HCV care. These findings emphasize the importance of early large-scale screening and engagement in care for HCV infection of immigrant populations to prevent future complications.
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Affiliation(s)
- Yelena Petrosyan
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | | | - Erin Kelly
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Curtis L Cooper
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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Cooper CL, Read D, Vachon ML, Conway B, Wong A, Ramji A, Borgia S, Tam E, Barrett L, Smyth D, Feld JJ, Lee S. Hepatitis C virus infection characteristics and treatment outcomes in Canadian immigrants. BMC Public Health 2020; 20:1345. [PMID: 32883249 PMCID: PMC7469277 DOI: 10.1186/s12889-020-09464-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 08/27/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND There are multiple obstacles encountered by immigrants attempting to engage hepatitis C virus (HCV) care and treatment. We evaluated the diversity and treatment outcomes of HCV-infected immigrants evaluated for Direct Acting Antiviral (DAA) therapy in Canada. METHODS The Canadian Network Undertaking against Hepatitis C (CANUHC) Cohort contains demographic information and DAA treatment information prospectively collected at 10 Canadian sites. Information on country of origin and race are collected. Characteristics and outcomes (sustained virological response; SVR) were compared by immigration status and race. RESULTS Between January 2016 and May 2018, 725 HCV-infected patients assessed for DAA therapy were enrolled in CANUHC (mean age: 52.66 ± 12.68 years); 65.66% male; 82.08% White, 5.28% Indigenous, 4.64% South East Asian, 4.64% East Indian, 3.36% Black). 18.48% were born outside of Canada. Mean age was similar [immigrants: 54.36 ± 13.95 years), Canadian-born: 52.27 ± 12.35 years); (p = 0.085)]. The overall baseline fibrosis score (in kPa measured by transient elastography) was similar among Canadian and foreign-born patients. Fibrosis score was not predicted by race or genotype. The proportion initiating DAA therapy was similar by immigrant status (56.72% vs 49.92%). SVR rates by intent-to-treat analysis were similar (immigrants-89.47%, Canadian-born-92.52%; p = 0.575). CONCLUSION A diverse immigrant population is engaging care in Canada, initiating HCV antiviral therapy in an equitable fashion and achieving SVR proportions similar to Canada-born patients. Our Canadian experience may be of value in informing HCV elimination efforts in economically developed regions.
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Affiliation(s)
- Curtis L Cooper
- University of Ottawa, Roger Guindon Hall, 451 Smyth Rd #2044, Ottawa, ON, K1H 8M5, Canada.
- University of Ottawa, The Ottawa Hospital-General Campus, G12-501 Smyth Rd, Ottawa, ON, K1H 8L6, Canada.
| | - Daniel Read
- University of Ottawa, Roger Guindon Hall, 451 Smyth Rd #2044, Ottawa, ON, K1H 8M5, Canada
| | - Marie-Louise Vachon
- Laval University, Ferdinand Vandry Pavillon, 1050 Avenue de la Médecine, Quebec City, Quebec, G1V 0A6, Canada
| | - Brian Conway
- Vancouver Infectious Diseases Centre, 1200 Burrard St, Vancouver, BC, V6Z 2C7, Canada
| | - Alexander Wong
- University of Saskatchewan, 107 Wiggins Rd, Saskatoon, SK, S7N 5E5, Canada
| | - Alnoor Ramji
- University of British Columbia, 317 - 2194 Health Sciences Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Sergio Borgia
- McMaster University, Michael DeGroote Centre for Learning and Discovery (MDCL) - 3104, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada
| | - Ed Tam
- Liver Health Centre, 750 W Broadway, Vancouver, BC, V5Z 1H2, Canada
| | - Lisa Barrett
- Dalhousie University, 5849 University Ave, Halifax, NS, B3H 4R2, Canada
| | - Dan Smyth
- Dalhousie University, 5849 University Ave, Halifax, NS, B3H 4R2, Canada
| | - Jordan J Feld
- Toronto General Hospital Research Institute, 200 Elizabeth St, Toronto, ON, M5G 2C4, Canada
| | - Sam Lee
- Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada
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Coppola N, Alessio L, Onorato L, Sagnelli C, Macera M, Sagnelli E, Pisaturo M. Epidemiology and management of hepatitis C virus infections in immigrant populations. Infect Dis Poverty 2019; 8:17. [PMID: 30871599 PMCID: PMC6419370 DOI: 10.1186/s40249-019-0528-6] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 02/26/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND At present, there is a continuous flow of immigrants from the south of the world to north-western countries. Often immigrants originate from areas of high-prevalence of viral hepatitis and pose a challenge to the healthcare systems of the host nations. Aims of this study is to evaluate the prevalence and virological and clinical characteristics of hepatitis C virus (HCV) infection in immigrants and the strategies to identify and take care of the immigrants infected with HCV. MAIN BODY We conducted an electronic literature search in several biomedical databases, including PubMed, Google Scholar, Scopus, Web of Science, using different combinations of key words: "HCV infection; chronic hepatitis C, immigrants; low-income countries". We included studies written in English indicating the epidemiological data of HCV infection in the immigrant population, studies that assessed the clinical presentation, clinical management and treatment with directly acting antiviral agent in immigrants, HCV infection is unevenly distributed in different countries, with worldwide prevalence in the general population ranging from 0.5 to 6.5%. In Western countries and Australia this rate ranges from 0.5 to 1.5%, and reaches 2.3% in countries of south-east Asia and eastern Mediterranean regions, 3.2% in China, 0.9% in India, 2.2% in Indonesia and 6.5% in Pakistan; in sub-Saharan Africa the prevalence of HCV infection varies from 4 to 9%. Immigrants and refugees from intermediate/high HCV endemic countries to less- or non-endemic areas are more likely to have an increased risk of HCV infection due to HCV exposure in their countries of origin. Because of the high HCV endemicity in immigrant populations and of the high efficacy of directly acting antiviral agent therapy, a campaign could be undertaken to eradicate the infection in this setting. CONCLUSIONS The healthcare authorities should support screening programs for immigrants, performed with the help of cultural mediators and including educational aspects to break down the barriers limiting access to treatments, which obtain the HCV clearance in 95% of cases and frequently prevent the development of liver cirrhosis and hepatocellular carcinoma.
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Affiliation(s)
- Nicola Coppola
- Department of Mental Health and Public Medicine, Section of Infectious Diseases, University of Campania, Via: L. Armanni 5, 80131, Naples, Italy. .,Infectious Diseases Unit, AORN Sant'Anna e San Sebastiano di Caserta, 81100, Caserta, Italy.
| | - Loredana Alessio
- Infectious Diseases Unit, AORN Sant'Anna e San Sebastiano di Caserta, 81100, Caserta, Italy
| | - Lorenzo Onorato
- Department of Mental Health and Public Medicine, Section of Infectious Diseases, University of Campania, Via: L. Armanni 5, 80131, Naples, Italy
| | - Caterina Sagnelli
- Department of Mental Health and Public Medicine, Section of Infectious Diseases, University of Campania, Via: L. Armanni 5, 80131, Naples, Italy
| | - Margherita Macera
- Department of Mental Health and Public Medicine, Section of Infectious Diseases, University of Campania, Via: L. Armanni 5, 80131, Naples, Italy
| | - Evangelista Sagnelli
- Department of Mental Health and Public Medicine, Section of Infectious Diseases, University of Campania, Via: L. Armanni 5, 80131, Naples, Italy
| | - Mariantonietta Pisaturo
- Department of Mental Health and Public Medicine, Section of Infectious Diseases, University of Campania, Via: L. Armanni 5, 80131, Naples, Italy.,Infectious Diseases Unit, AORN Sant'Anna e San Sebastiano di Caserta, 81100, Caserta, Italy
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Greenaway C, Makarenko I, Chakra CNA, Alabdulkarim B, Christensen R, Palayew A, Tran A, Staub L, Pareek M, Meerpohl JJ, Noori T, Veldhuijzen I, Pottie K, Castelli F, Morton RL. The Effectiveness and Cost-Effectiveness of Hepatitis C Screening for Migrants in the EU/EEA: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:E2013. [PMID: 30223539 PMCID: PMC6164358 DOI: 10.3390/ijerph15092013] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 08/24/2018] [Accepted: 09/10/2018] [Indexed: 12/16/2022]
Abstract
Chronic hepatitis C (HCV) is a public health priority in the European Union/European Economic Area (EU/EEA) and is a leading cause of chronic liver disease and liver cancer. Migrants account for a disproportionate number of HCV cases in the EU/EEA (mean 14% of cases and >50% of cases in some countries). We conducted two systematic reviews (SR) to estimate the effectiveness and cost-effectiveness of HCV screening for migrants living in the EU/EEA. We found that screening tests for HCV are highly sensitive and specific. Clinical trials report direct acting antiviral (DAA) therapies are well-tolerated in a wide range of populations and cure almost all cases (>95%) and lead to an 85% lower risk of developing hepatocellular carcinoma and an 80% lower risk of all-cause mortality. At 2015 costs, DAA based regimens were only moderately cost-effective and as a result less than 30% of people with HCV had been screened and less 5% of all HCV cases had been treated in the EU/EEA in 2015. Migrants face additional barriers in linkage to care and treatment due to several patient, practitioner, and health system barriers. Although decreasing HCV costs have made treatment more accessible in the EU/EEA, HCV elimination will only be possible in the region if health systems include and treat migrants for HCV.
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Affiliation(s)
- Christina Greenaway
- Division of Infectious Diseases, Jewish General Hospital, McGill University, Montreal, QC H3T 1E2 Canada.
- Centre for Clinical Epidemiology of the Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, QC H3T 1E2.
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC H3A 1A2, Canada.
| | - Iuliia Makarenko
- Centre for Clinical Epidemiology of the Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, QC H3T 1E2.
| | - Claire Nour Abou Chakra
- Department of Microbiology and Infectious Diseases, Université de Sherbrooke, Sherbrooke, QC J1H 5NG, Canada.
| | - Balqis Alabdulkarim
- Centre for Clinical Epidemiology of the Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, QC H3T 1E2.
| | - Robin Christensen
- Musculoskeletal Statistics Unit, The Parker Institute, Bispebjerg and Frederiksberg Hospital & Department of Rheumatology, Odense University Hospital, DK2000 Odense, Denmark.
| | - Adam Palayew
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC H3A 1A2, Canada.
| | - Anh Tran
- NHMRC Clinical Trials Centre, The University of Sydney, Sydney 1450, Australia.
| | - Lukas Staub
- NHMRC Clinical Trials Centre, The University of Sydney, Sydney 1450, Australia.
| | - Manish Pareek
- Department of Infection, Immunity and Inflammation, University of Leicester, Leicester LE1 7RH, UK.
| | - Joerg J Meerpohl
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center, University of Freiburg, 79110 Freiburg, Germany.
| | - Teymur Noori
- European Centre for Disease Prevention and Control, 169 73 Solna, Sweden.
| | - Irene Veldhuijzen
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), 3720 BA Bilthoven, The Netherlands.
| | - Kevin Pottie
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON K1N 5C8, Canada.
- Centre for Global Health, University of Ottawa, Ottawa, ON K1N 5C8, Canada.
| | - Francesco Castelli
- Division of Infectious Diseases, University of Brescia, 255123 Brescia, Italy.
| | - Rachael L Morton
- NHMRC Clinical Trials Centre, The University of Sydney, Sydney 1450, Australia.
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Greenaway C, Makarenko I, Tanveer F, Janjua NZ. Addressing hepatitis C in the foreign-born population: A key to hepatitis C virus elimination in Canada. CANADIAN LIVER JOURNAL 2018; 1:34-50. [PMID: 35990716 PMCID: PMC9202799 DOI: 10.3138/canlivj.1.2.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 03/12/2018] [Indexed: 10/26/2023]
Abstract
Hepatitis C virus (HCV) is the leading cause of death from infectious disease in Canada. Immigrants are an important group who are at increased risk for HCV; they account for a disproportionate number of all HCV cases in Canada (~30%) and have approximately a twofold higher prevalence of HCV (~2%) than those born in Canada. HCV-infected immigrants are more likely to develop cirrhosis and hepatocellular carcinoma and are more likely to have a liver-related death during a hospitalization than HCV-infected non-immigrants. Several factors, including lack of routine HCV screening programs in Canada for immigrants before or after arrival, lack of awareness on the part of health practitioners that immigrants are at increased risk of HCV and could benefit from screening, and several patient- and health system-level barriers that affect access to health care and treatment likely contribute to delayed diagnosis and treatment uptake. HCV screening and engagement in care among immigrants can be improved through reminders in electronic medical records that prompt practitioners to screen for HCV during clinical visits and implementation of decentralized community-based screening strategies that address cultural and language barriers. In conclusion, early screening and linkage to care for immigrants from countries with an intermediate or high prevalence of HCV would not only improve the health of this population but will be key to achieving HCV elimination in Canada. This article describes the unique barriers encountered by the foreign-born population in accessing HCV care and approaches to overcoming these barriers.
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Affiliation(s)
- Christina Greenaway
- Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, Montréal, Québec, Canada
- Division of Infectious Diseases, Jewish General Hospital, McGill University, Montréal, Québec, Canada
| | - Iuliia Makarenko
- Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, Montréal, Québec, Canada
| | - Fozia Tanveer
- CATIE (Canada’s source for HIV and hepatitis C information), Toronto, Ontario, Canada
| | - Naveed Z Janjua
- Clinical Preventative Services, British Columbia Centers for Disease Control, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
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Sanna A, Le Strat Y, Roudot-Thoraval F, Deuffic Burban S, Carrieri P, Delarocque-Astagneau E, Larsen C. Severe liver disease related to chronic hepatitis C virus infection in treatment-naive patients: epidemiological characteristics and associated factors at first expert centre visit, France, 2000 to 2007 and 2010 to 2014. ACTA ACUST UNITED AC 2018; 22:30582. [PMID: 28797326 PMCID: PMC5553056 DOI: 10.2807/1560-7917.es.2017.22.30.30582] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 05/14/2017] [Indexed: 12/15/2022]
Abstract
Given recent profound improvements in the effectiveness of antiviral treatment for chronic Hepatitis C virus (HCV) infection, we aimed to describe the characteristics of patients referred to hepatology expert centres in France from 2000 to 2007 and from 2010 to 2014, and to identify factors associated with severe liver disease at their first visit for evaluation. We analysed data from two sources covering all of France: the former hepatitis C surveillance network, which included patients between 2000 and 2007, and the ANRS CO22 HEPATHER multi-centre cohort, which included patients between 2012 and 2014. Severe liver disease (SLD) was defined as the presence of either cirrhosis (histological, biochemical or clinical) or hepatocellular carcinoma. Multivariable Poisson regression models were used to identify the factors associated with SLD in complete-case analysis and after multiple imputation. Overall, 16,851 patients were included in the analysis and SLD was diagnosed in 11.6%. SLD at first visit was significantly associated with known risk factors (male sex, history of excessive alcohol intake, HCV genotype 3), late referral to hepatologists after diagnosis and HCV diagnosis at an older age. Providing earlier specialised care and treatment may be an important target for public health action.
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Affiliation(s)
- Alice Sanna
- Santé publique France, French National Public Health Agency, Saint-Maurice, France
| | - Yann Le Strat
- Santé publique France, French National Public Health Agency, Saint-Maurice, France
| | - Françoise Roudot-Thoraval
- Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Université Paris-Est Créteil, Paris, France
| | - Sylvie Deuffic Burban
- IAME (Infection Antimicrobials Modelling Evolution), UMR1137 INSERM, Université Paris Diderot - Sorbonne Paris Cité, Paris, France.,LIRIC (Lille Inflammation Research International Center), UMR995 INSERM, Université de Lille, CHRU de Lille, Lille, France
| | - Patrizia Carrieri
- SESSTIM (Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale), UMR912 INSERM, Aix-Marseille Université, IRD, Marseille, France.,ORS PACA (Observatoire Régional de la Santé Provence Alpes Côte d'Azur), Marseille, France
| | - Elisabeth Delarocque-Astagneau
- B2PHI (Biostatistics, Biomathematics, Pharmacoepidemiology, and Infectious Diseases), UMR 1181 INSERM, Université de Versailles Saint-Quentin-en-Yvelines, Institut Pasteur, Paris, France
| | - Christine Larsen
- Santé publique France, French National Public Health Agency, Saint-Maurice, France
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9
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Greenaway C, Azoulay L, Allard R, Cox J, Tran VA, Abou Chakra CN, Steele R, Klein M. A population-based study of chronic hepatitis C in immigrants and non-immigrants in Quebec, Canada. BMC Infect Dis 2017; 17:140. [PMID: 28193199 PMCID: PMC5307836 DOI: 10.1186/s12879-017-2242-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Accepted: 02/02/2017] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Immigrants originating from intermediate and high HCV prevalence countries may be at increased risk of exposure to hepatitis C infection (HCV) in their countries of origin, however they are not routinely screened after arrival in most low HCV prevalence host countries. We aimed to describe the epidemiology of HCV in immigrants compared to the Canadian born population. METHODS Using the reportable infectious disease database linked to the landed immigration database and several provincial administrative databases, we assembled a cohort of all reported cases of HCV in Quebec, Canada (1998-2008). Underlying co-morbidities were identified in the health services databases. Stratum specific rates of reported cases/100,000, rate ratios (RRs) and trends over the study period were estimated. RESULTS A total of 20,862 patients with HCV were identified, among whom 1922 (9.2%) were immigrants. Immigrants were older and diagnosed a mean of 9.8 ± 7 years after arrival. The Canadian born population was more likely to have behavior co-morbidities (problematic alcohol or drug use) and HIV co-infection. Immigrants from Sub-Saharan Africa, Asia and Eastern Europe had the highest HCV reported rates with RRs compared to non-immigrants ranging from 1.5 to 1.7. The age and sex adjusted rates decreased by 4.9% per year in non-immigrants but remained unchanged in immigrants. The proportion of HCV occurring in immigrants doubled over the study period from 5 to 11%. CONCLUSIONS Immigrants from intermediate and high HCV prevalence countries are at increased risk for HCV and had a mean delay in diagnosis of almost 10 years after arrival suggesting that they may benefit from targeted HCV screening and earlier linkage to care.
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Affiliation(s)
- Christina Greenaway
- Division of Infectious Diseases, Jewish General Hospital, McGill University, 3755 Côte St. Catherine Road, Room E-0057, Montreal, PQ H3T 1E2 Canada
- Centre for Clinical Epidemiology, Lady Davis Research Institute for Medical Research, Jewish General Hospital, McGill University, Montreal, Canada
| | - Laurent Azoulay
- Centre for Clinical Epidemiology, Lady Davis Research Institute for Medical Research, Jewish General Hospital, McGill University, Montreal, Canada
- Department of Oncology, McGill University, Montreal, Canada
| | - Robert Allard
- Department of Oncology, McGill University, Montreal, Canada
- Montreal Public Health Department, Montreal, Canada
| | - Joseph Cox
- Sexually Transmitted Infections Division, Montreal Public Health Department, Montreal, Canada
| | - Viet Anh Tran
- Centre for Clinical Epidemiology, Lady Davis Research Institute for Medical Research, Jewish General Hospital, McGill University, Montreal, Canada
| | - Claire Nour Abou Chakra
- Centre for Clinical Epidemiology, Lady Davis Research Institute for Medical Research, Jewish General Hospital, McGill University, Montreal, Canada
| | - Russ Steele
- Centre for Clinical Epidemiology, Lady Davis Research Institute for Medical Research, Jewish General Hospital, McGill University, Montreal, Canada
- Department of Mathematics and Statistics, McGill University, Montreal, Canada
| | - Marina Klein
- Division of Infectious Diseases, McGill University Health Center, McGill University, Montreal, Canada
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10
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Kamstra R, Azoulay L, Steele R, Klein MB, Greenaway C. Hospitalizations in Immigrants and Nonimmigrants Diagnosed With Chronic Hepatitis C Infection in Québec. Clin Infect Dis 2016; 63:1439-1448. [PMID: 27501843 DOI: 10.1093/cid/ciw540] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Accepted: 08/02/2016] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Rates of hospitalization due to chronic hepatitis C virus (HCV) are increasing in Canada and the United States. A large proportion of immigrants originate from countries with intermediate to high HCV prevalence but are not screened for HCV post-arrival and may therefore have increased risks of liver-related complications and hospitalization. METHODS We conducted a retrospective cohort study of reported HCV cases in Québec, Canada, from 1998 to 2007 that were linked to administrative health databases. Outcomes included all-cause and liver-related hospitalizations and in-hospital days in immigrants compared with nonimmigrants adjusted for age, sex, and comorbidities. RESULTS We identified 20 139 HCV cases; 9% (N = 1821) were immigrants. At diagnosis, immigrants were older (47.6 vs 43.2 years) and more likely to have hepatocellular carcinoma (HCC; 0.93% vs 0.31%), while nonimmigrants were 2- to 10-fold more likely to have substance use-related comorbidities. Mean time to HCV diagnosis after arrival was 9.8 years. Nonimmigrants had higher rates of all-cause hospitalization (adjusted rate ratio [95% confidence interval], 1.42 [1.35-1.47]), driven by mental illness and injury and/or poisoning. Unadjusted liver-related hospitalization rates were similar between cohorts. After adjustment, immigrant status was associated with lower rates of liver-related hospitalization (0.68 [.53-.88]). CONCLUSIONS Higher burden of all-cause hospitalization in nonimmigrants likely reflects more prevalent behavioral comorbidities. Similar liver-related hospitalization rates appear to be driven by older age in immigrants who were more likely to have HCC at diagnosis possibly reflecting delayed HCV diagnosis. These findings suggest that earlier screening and treatment in immigrants could play an important role in preventing HCV complications in this population.
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Affiliation(s)
- Rhiannon Kamstra
- Centre for Clinical Epidemiology, Lady Davis Research Institute for Medical Research, Jewish General Hospital.,Department of Epidemiology, Biostatistics and Occupational Health
| | - Laurent Azoulay
- Centre for Clinical Epidemiology, Lady Davis Research Institute for Medical Research, Jewish General Hospital.,Department of Epidemiology, Biostatistics and Occupational Health
| | - Russell Steele
- Department of Epidemiology, Biostatistics and Occupational Health.,Department of Mathematics, McGill University
| | - Marina B Klein
- Department of Epidemiology, Biostatistics and Occupational Health.,Division of Infectious Diseases, Chronic Viral Illness Service, McGill University Health Center
| | - Christina Greenaway
- Centre for Clinical Epidemiology, Lady Davis Research Institute for Medical Research, Jewish General Hospital.,Department of Epidemiology, Biostatistics and Occupational Health.,Division of Infectious Diseases, Jewish General Hospital, McGill University, Montreal, Canada
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11
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Chen W, Krahn M. Disease burden of chronic hepatitis C among immigrants in Canada. J Viral Hepat 2015; 22:1043-54. [PMID: 26110922 DOI: 10.1111/jvh.12432] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Accepted: 04/30/2015] [Indexed: 01/16/2023]
Abstract
Immigrants with chronic hepatitis C (CHC) in Canada have doubled risk of hepatocellular carcinoma. To measure the burden of CHC among immigrants in Canada. A decision analytic model was developed to compare immigrants with CHC and age-matched immigrants without CHC for survival years, quality-adjusted life-years (QALYs) and medical costs per life year. Hepatitis C epidemiology among immigrants was based on hepatitis C prevalence in their home countries. A cohort of immigrant patients was retrospectively followed up to estimate fibrosis stage distribution, treatment patterns and prognosis of compensated cirrhosis. Other model variables were based on published sources. Base case analysis, one-way sensitivity analysis and probabilistic sensitivity analysis were performed to measure the burden of CHC and assess the impact of uncertainty associated with model variables on the burden of CHC. CHC could reduce survival by 9.6 years [95% credible interval (CI): 8.0-10.9 years], reduce QALYs by 9.5 years (95% CI: 6.0-13.8 years) and increase medical costs per life year by $1950 (95% CI: $1518 to $2486, 2006 Canadian dollars). Because nearly half of immigrants with CHC were not diagnosed until the development of cirrhosis, the burden of CHC was highly sensitive to the risks of liver-related complications and mortality but insensitive to pegylated interferon plus ribavirin. The burden of CHC among immigrants in Canada is substantial mainly due to liver-related complications and mortality. The delay in diagnosis was another important contributor to the burden of CHC among immigrants.
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Affiliation(s)
- W Chen
- Toronto Health Economics and Technology Assessment Collaborative, University of Toronto, Toronto, ON, Canada.,Division of Social and Administrative Pharmacy, Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - M Krahn
- Toronto Health Economics and Technology Assessment Collaborative, University of Toronto, Toronto, ON, Canada.,Division of Social and Administrative Pharmacy, Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada.,Department of Medicine, University Health Network, University of Toronto, Toronto, ON, Canada
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12
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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: 87] [Impact Index Per Article: 9.7] [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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