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Roberts K, Macleod J, Metcalfe C, Hollingworth W, Williams J, Muir P, Vickerman P, Clement C, Gordon F, Irving W, Waldron CA, North P, Moore P, Simmons R, Miners A, Horwood J, Hickman M. Cost effectiveness of an intervention to increase uptake of hepatitis C virus testing and treatment (HepCATT): cluster randomised controlled trial in primary care. BMJ 2020; 368:m322. [PMID: 32102782 PMCID: PMC7190058 DOI: 10.1136/bmj.m322] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To evaluate the effectiveness and cost effectiveness of a complex intervention in primary care that aims to increase uptake of hepatitis C virus (HCV) case finding and treatment. DESIGN Pragmatic, two armed, practice level, cluster randomised controlled trial and economic evaluation. SETTING AND PARTICIPANTS 45 general practices in South West England (22 randomised to intervention and 23 to control arm). Outcome data were collected from all intervention practices and 21/23 control practices. Total number of flagged patients was 24 473 (about 5% of practice list). INTERVENTION Electronic algorithm and flag on practice systems identifying patients with HCV risk markers (such as history of opioid dependence or HCV tests with no evidence of referral to hepatology), staff educational training in HCV, and practice posters/leaflets to increase patients' awareness. Flagged patients were invited by letter for an HCV test (with one follow-up) and had on-screen pop-ups to encourage opportunistic testing. The intervention lasted one year, with practices recruited April to December 2016. MAIN OUTCOME MEASURES Primary outcome: uptake of HCV testing. SECONDARY OUTCOMES number of positive HCV tests and yield (proportion HCV positive); HCV treatment assessment at hepatology; cost effectiveness. RESULTS Baseline HCV testing of flagged patients (six months before study start) was 608/13 097 (4.6%) in intervention practices and 380/11 376 (3.3%) in control practices. During the study 2071 (16%) of flagged patients in the intervention practices and 1163 (10%) in control practices were tested for HCV: overall intervention effect as an adjusted rate ratio of 1.59 (95% confidence interval 1.21 to 2.08; P<0.001). HCV antibodies were detected in 129 patients from intervention practices and 51 patients from control practices (adjusted rate ratio 2.24, 1.47 to 3.42) with weak evidence of an increase in yield (6.2% v 4.4%; adjusted risk ratio 1.40, 0.99 to 1.95). Referral and assessment increased in intervention practices compared with control practices (adjusted rate ratio 5.78, 1.6 to 21.6) with a risk difference of 1.3 per 1000 and a "number needed to help" of one extra HCV diagnosis, referral, and assessment per 792 (95% confidence interval 558 to 1883) patients flagged. The average cost of HCV case finding was £4.03 (95% confidence interval £2.27 to £5.80) per at risk patient and £3165 per additional patient assessed at hepatology. The incremental cost effectiveness ratio was £6212 per quality adjusted life year (QALY), with 92.5% probability of being below £20 000 per QALY. CONCLUSION HepCATT had a modest impact but is a low cost intervention that merits optimisation and implementation as part of an NHS strategy to increase HCV testing and treatment. TRIAL REGISTRATION ISRCTN61788850.
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Affiliation(s)
- Kirsty Roberts
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - John Macleod
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- NIHR Health Protection Research Unit (HPRU) in Evaluation of Interventions, University of Bristol, Bristol, UK
| | - Chris Metcalfe
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Bristol Randomised Trials Collaboration (BRTC), Population Health Sciences, Bristol Medical School, Bristol, UK
| | - Will Hollingworth
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Jack Williams
- Department of Health Service Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
- NIHR HPRU in Blood Borne Viruses and STI, University College London, London, UK
| | - Peter Muir
- Public Health Laboratory Bristol, National Infection Service, Public Health England, Pathology Sciences Building, Southmead Hospital, Bristol, UK
| | - Peter Vickerman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- NIHR Health Protection Research Unit (HPRU) in Evaluation of Interventions, University of Bristol, Bristol, UK
| | - Clare Clement
- NIHR Health Protection Research Unit (HPRU) in Evaluation of Interventions, University of Bristol, Bristol, UK
| | - Fiona Gordon
- University Hospitals Bristol, Bristol Royal Infirmary, Bristol, UK
| | - Will Irving
- NIHR Nottingham Digestive Diseases Biomedical Research Unit, University Hospital Nottingham, Nottingham, UK
| | | | - Paul North
- Public Health Laboratory Bristol, National Infection Service, Public Health England, Pathology Sciences Building, Southmead Hospital, Bristol, UK
| | - Philippa Moore
- Public Health Laboratory Bristol, National Infection Service, Public Health England, Pathology Sciences Building, Southmead Hospital, Bristol, UK
| | - Ruth Simmons
- NIHR HPRU in Blood Borne Viruses and STI, University College London, London, UK
- National Infection Service, Public Health England, London, UK
| | - Alec Miners
- Department of Health Service Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
- NIHR HPRU in Blood Borne Viruses and STI, University College London, London, UK
| | - Jeremy Horwood
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- NIHR Health Protection Research Unit (HPRU) in Evaluation of Interventions, University of Bristol, Bristol, UK
| | - Matthew Hickman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- NIHR Health Protection Research Unit (HPRU) in Evaluation of Interventions, University of Bristol, Bristol, UK
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Williams J, Miners A, Harris R, Mandal S, Simmons R, Ireland G, Hickman M, Gore C, Vickerman P. Cost-Effectiveness of One-Time Birth Cohort Screening for Hepatitis C as Part of the National Health Service Health Check Program in England. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2019; 22:1248-1256. [PMID: 31708061 DOI: 10.1016/j.jval.2019.06.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 05/14/2019] [Accepted: 06/28/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND AND OBJECTIVES Birth cohort screening for the hepatitis C virus (HCV) has been implemented in the US, but there is little evidence of its cost-effectiveness in England. We aim to evaluate the cost-effectiveness of one-time HCV screening for individuals born between 1950 and 1979 as part of the National Health Service health check in England, a health check for adults aged 40 to 74 years in primary care. METHODS A Markov model was developed to analyze add-on HCV testing to the National Health Service health check for individuals in birth cohorts between 1950 and 1979, versus current background HCV testing only, over a lifetime horizon. The model used data from a back-calculation model of the burden of HCV in England, sentinel surveillance of HCV testing, and published literature. Results are presented from a health service perspective in pounds in 2017, as incremental cost-effectiveness ratios per quality-adjusted life years gained. RESULTS The base-case incremental cost-effectiveness ratios ranged from £7648 to £24 434, and £18 681 to £46 024, across birth cohorts when considering 2 sources of HCV transition probabilities. The intervention is most likely to be cost-effective for those born in the 1970s, and potentially cost-effective for those born from 1955 to 1969. The model results were most sensitive to the source of HCV transition probabilities, the probability of referral and receiving treatment, and the HCV prevalence among testers. The maximum value of future research across all birth cohorts was £11.3 million at £20 000 per quality-adjusted life years gained. CONCLUSION Birth cohort screening is likely to be cost-effective for younger birth cohorts, although considerable uncertainty exists for other birth cohorts. Further studies are warranted to reduce uncertainty in cost-effectiveness and consider the acceptability of the intervention.
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Affiliation(s)
- Jack Williams
- Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, England, UK; The National Institute for Health Research Health Protection Research Unit in Blood Borne and Sexually Transmitted Infections at University College London, England, UK.
| | - Alec Miners
- Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, England, UK; The National Institute for Health Research Health Protection Research Unit in Blood Borne and Sexually Transmitted Infections at University College London, England, UK
| | - Ross Harris
- National Infection Service, Public Health England, Colindale, England, UK
| | - Sema Mandal
- The National Institute for Health Research Health Protection Research Unit in Blood Borne and Sexually Transmitted Infections at University College London, England, UK; National Infection Service, Public Health England, Colindale, England, UK
| | - Ruth Simmons
- The National Institute for Health Research Health Protection Research Unit in Blood Borne and Sexually Transmitted Infections at University College London, England, UK; National Infection Service, Public Health England, Colindale, England, UK
| | - Georgina Ireland
- The National Institute for Health Research Health Protection Research Unit in Blood Borne and Sexually Transmitted Infections at University College London, England, UK; National Infection Service, Public Health England, Colindale, England, UK
| | - Matthew Hickman
- Population Health Sciences, Bristol Medical School, University of Bristol, England, UK; The National Institute for Health Research Health Protection Research Unit in Evaluation of Interventions, England, UK
| | | | - Peter Vickerman
- The National Institute for Health Research Health Protection Research Unit in Blood Borne and Sexually Transmitted Infections at University College London, England, UK; Population Health Sciences, Bristol Medical School, University of Bristol, England, UK; The National Institute for Health Research Health Protection Research Unit in Evaluation of Interventions, England, UK
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Hepatitis case finding among migrants in primary care. Lancet Gastroenterol Hepatol 2018; 4:3-4. [PMID: 30477809 DOI: 10.1016/s2468-1253(18)30385-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 11/02/2018] [Accepted: 11/08/2018] [Indexed: 11/22/2022]
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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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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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Falla AM, Ahmad AA, Duffell E, Noori T, Veldhuijzen IK. Estimating the scale of chronic hepatitis C virus infection in the EU/EEA: a focus on migrants from anti-HCV endemic countries. BMC Infect Dis 2018; 18:42. [PMID: 29338702 PMCID: PMC5771208 DOI: 10.1186/s12879-017-2908-5] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 12/11/2017] [Indexed: 12/22/2022] Open
Abstract
Background Increasing the proportion diagnosed with and on treatment for chronic hepatitis C (CHC) is key to the elimination of hepatitis C in Europe. This study contributes to secondary prevention planning in the European Union/European Economic Area (EU/EEA) by estimating the number of CHC (anti-HCV positive and viraemic) cases among migrants living in the EU/EEA and born in endemic countries, defining the most affected migrant populations, and assessing whether country of birth prevalence is a reliable proxy for migrant prevalence. Methods Migrant country of birth and population size extracted from statistical databases and anti-HCV prevalence in countries of birth and in EU/EEA countries derived from a systematic literature search were used to estimate caseload among and most affected migrants. Reliability of country of birth prevalence as a proxy for migrant prevalence was assessed via a systematic literature search. Results Approximately 11% of the EU/EEA adult population is foreign-born, 79% of whom were born in endemic (anti-HCV prevalence ≥1%) countries. Anti-HCV/CHC prevalence in migrants from endemic countries residing in the EU/EEA is estimated at 2.3%/1.6%, corresponding to ~580,000 CHC infections or 14% of the CHC disease burden in the EU/EEA. The highest number of cases is found among migrants from Romania and Russia (50–60,000 cases each) and migrants from Italy, Morocco, Pakistan, Poland and Ukraine (25–35,000 cases each). Ten studies reporting prevalence in migrants in Europe were identified; in seven of these estimates, prevalence was comparable with the country of birth prevalence and in three estimates it was lower. Discussion Migrants are disproportionately affected by CHC, account for a considerable number of CHC infections in EU/EEA countries, and are an important population for targeted case finding and treatment. Limited data suggest that country of birth prevalence can be used as a proxy for the prevalence in migrants. Electronic supplementary material The online version of this article (doi: 10.1186/s12879-017-2908-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- A M Falla
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands. .,Division of Infectious Disease Control, Municipal Public Health Service Rotterdam-Rijnmond, PO Box 70032, 3000, LP, Rotterdam, The Netherlands.
| | - A A Ahmad
- Department of Health Sciences, Hamburg University of Applied Sciences, Faculty Life Sciences / Public Health Research, Ulmenliet 20, 21033, Hamburg, Germany.,Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Martinistr 52, 20246, Hamburg, Germany
| | - E Duffell
- European Centre for Disease Prevention and Control, Granits väg 8, 171 65, Solna, Sweden
| | - T Noori
- European Centre for Disease Prevention and Control, Granits väg 8, 171 65, Solna, Sweden
| | - I K Veldhuijzen
- Division of Infectious Disease Control, Municipal Public Health Service Rotterdam-Rijnmond, PO Box 70032, 3000, LP, Rotterdam, The Netherlands.,Center for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, the Netherlands
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Morgan JR, Servidone M, Easterbrook P, Linas BP. Economic evaluation of HCV testing approaches in low and middle income countries. BMC Infect Dis 2017; 17:697. [PMID: 29143681 PMCID: PMC5688403 DOI: 10.1186/s12879-017-2779-9] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/13/2023] Open
Abstract
BACKGROUND Hepatitis C virus (HCV) infection represents a major public health burden with diverse epidemics worldwide, but at present, only a minority of infected persons have been tested and are aware of their diagnosis. The advent of highly effective direct acting antiviral (DAA) therapy, which is becoming available at increasingly lower costs in low and middle income countries (LMICs), represents a major opportunity to expand access to testing and treatment. However, there is uncertainty as to the optimal testing approaches and who to prioritize for testing. We undertook a narrative review of the cost-effectiveness literature on different testing approaches for chronic hepatitis C infection to inform decision-making and formulation of recommendations in the 2017 World Health Organization (WHO) viral hepatitis testing guidelines. METHODS We undertook a focused search and narrative review of the literature for cost effectiveness studies of testing approaches in three main groups:- 1) focused testing of specific high-risk groups (defined as those who are part of a population with higher seroprevalence or who have a history of exposure or high-risk behaviours); 2) "birth cohort" testing among easily identified age groups (i.e. specific birth cohorts) known to have a high prevalence of HCV infection; and 3) routine testing in the general population. Articles included were those published in PubMed, written in English and published after 2000. RESULTS We identified 26 eligible studies. Twenty-four of them were from Europe (n = 14) or the United States (n = 10). There was only one study from a LMIC (Egypt) and this evaluated general population testing. Thirteen studies evaluated focused testing among specific groups at high risk for HCV infection, including nine in persons who inject drugs (PWID); five among people in prison, and one among HIV-infected men who have sex with men (MSM). Eight studies evaluated birth cohort testing, and five evaluated testing in the general population. Most studies were based on a one-time testing intervention, but in one study testing was undertaken every 5 years and in another among HIV-infected MSM there was more frequent testing. Comparators were generally either: 1) no testing, 2) the status quo, or 3) multiple different strategies. Overall, we found broad agreement that focused testing of high risk groups such as persons who inject drugs and men who have sex with men was cost-effective, as was birth cohort testing. Key drivers of cost-effectiveness were the prevalence of HCV infection in these groups, efficacy and cost of treatment, stage of disease and linkage to care. The evidence for routine population testing was mixed, and the cost-effectiveness depends largely on the prevalence of HCV. CONCLUSIONS The evidence base for different HCV testing approaches in LMICs is limited, minimizing the contribution of cost-effectiveness data alone to decision-making and recommendations on testing approaches in the 2017 WHO viral hepatitis testing guidelines. Overall, the guidelines recommended focused testing in high risk-groups, particularly PWID, prisoners, and men who have sex with men; with consideration of two other approaches:- birth cohort testing in those countries with epidemiological evidence of a significant birth cohort effect; and routine access to testing across the general population in those countries with a high HCV seroprevalence above 2% - 5% in the general population. Further implementation research on different testing approaches is needed in order to help guide national policy planning.
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Affiliation(s)
- Jake R. Morgan
- Department of Medicine, Section of Infectious Diseases, Boston Medical Center, 801 Massachusetts Avenue, Boston, MA 02118 USA
| | - Maria Servidone
- Department of Medicine, Section of Infectious Diseases, Boston Medical Center, 801 Massachusetts Avenue, Boston, MA 02118 USA
- Department of Epidemiology, Boston University School of Public Health, 725 Albany St., Boston, MA 02118 USA
| | | | - Benjamin P. Linas
- Department of Medicine, Section of Infectious Diseases, Boston Medical Center, 801 Massachusetts Avenue, Boston, MA 02118 USA
- Department of Epidemiology, Boston University School of Public Health, 725 Albany St., Boston, MA 02118 USA
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Easterbrook PJ. Who to test and how to test for chronic hepatitis C infection - 2016 WHO testing guidance for low- and middle-income countries. J Hepatol 2016; 65:S46-S66. [PMID: 27641988 DOI: 10.1016/j.jhep.2016.08.002] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 08/09/2016] [Indexed: 12/11/2022]
Abstract
Testing and diagnosis of hepatitis C virus (HCV) infection is the gateway for access to both treatment and prevention services, and crucial for an effective hepatitis epidemic response. In contrast to HIV, a systematic approach to hepatitis C testing has been fragmented and limited to a few countries, and there remains a large burden of undiagnosed cases globally. Key challenges in the current hepatitis testing response, include lack of simple, reliable, and low cost diagnostic tests, laboratory capacity, and testing facilities; inadequate data to guide country-specific hepatitis testing approaches and who to test; stigmatization and social marginalization of some groups with or at risk of viral hepatitis; and lack of international or national guidelines on hepatitis testing for resource-limited settings. New tools to support the hepatitis global response include the 2016 Global Hepatitis Health Sector Strategy which include targets for testing and diagnosis, and World Health Organization (WHO) 2016 hepatitis testing guidelines for adults, adolescents, and children in low- and middle-income countries. The testing guidance complements recent published WHO guidance on the prevention, care and treatment of chronic hepatitis C and hepatitis B infection. These testing guidelines outline the public health approach to strengthening and expanding current testing practices for HCV and HBV and address what serological and virological assays to use, and who to test, as well as interventions to promote linkage to prevention and care after testing. They are intended for use across all age groups and populations. See boxes for key recommendations. Future directions and innovations in viral hepatitis testing include use of point-of-care assays for nucleic acid testing (NAT) and core antigen; validation of dried blood spots specimens with different commercial serological and NAT assays; multiplex and polyvalent platforms for integrated testing of HIV, HBV and HCV; and potential for self-testing.
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Affiliation(s)
- Philippa J Easterbrook
- Global Hepatitis Programme, HIV Department, World Health Organization, Geneva, Switzerland.
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- Global Hepatitis Programme, HIV Department, World Health Organization, Geneva, Switzerland
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Coward S, Leggett L, Kaplan GG, Clement F. Cost-effectiveness of screening for hepatitis C virus: a systematic review of economic evaluations. BMJ Open 2016; 6:e011821. [PMID: 27601496 PMCID: PMC5020747 DOI: 10.1136/bmjopen-2016-011821] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVES With the developments of near-cures for hepatitis C virus (HCV), who to screen has become a high-priority policy issue in many western countries. Cost-effectiveness of screening programmes should be one consideration when developing policy. The objective of this work is to synthesise the cost-effectiveness of HCV screening programmes. SETTING A systematic review was completed. 5 databases were searched until May 2016 (NHSEED, MEDLINE, the HTA Health Technology Assessment Database, EMBASE, EconLit). PARTICIPANTS Any study reporting an economic evaluation (any type) of screening compared with opportunistic or no screening for HCV was included. Exclusion criteria were: (1) abstracts or commentaries, (2) economic evaluations of other interventions for HCV, including blood donors screening, diagnosis tests for HCV, screening for concurrent disease or medications for treatment. PRIMARY AND SECONDARY OUTCOME MEASURES Data extraction included type of model, target population, perspective, comparators, time horizon, discount rate, clinical inputs, cost inputs and outcome. Quality was evaluated using the Consolidated Health Economic Evaluation Reporting Standards checklist. Data are summarised using narrative synthesis by population. RESULTS 2305 abstracts were identified with 52 undergoing full-text review. 30 papers met inclusion criteria addressing 7 populations: drug users (n=6), high risk (n=5), pregnant (n=4), prison (n=3), birth cohort (n=8), general population (n=5) and other (n=6). The majority (77%) of the studies were high quality. Drug users, birth cohort and high-risk populations were associated with cost-effectiveness ratios of under £30 000 per quality-adjusted-life-year (QALY). The remaining populations were associated with cost-effectiveness ratios that exceeded £30 000 per QALY. CONCLUSIONS Economic evidence for screening populations is robust. If a cost per QALY of £30 000 is considered reasonable value for money, then screening birth cohorts, drug users and high-risk populations are policy options that should be considered.
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Affiliation(s)
- Stephanie Coward
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Laura Leggett
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Gilaad G Kaplan
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Fiona Clement
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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Bertisch B, Giudici F, Negro F, Moradpour D, Müllhaupt B, Moriggia A, Estill J, Keiser O. Characteristics of Foreign-Born Persons in the Swiss Hepatitis C Cohort Study: Implications for Screening Recommendations. PLoS One 2016; 11:e0155464. [PMID: 27227332 PMCID: PMC4882055 DOI: 10.1371/journal.pone.0155464] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 04/29/2016] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Switzerland recommends individuals who originate from high-prevalence countries to be screened for hepatitis C virus (HCV) infection. However, not all these persons are equally at risk. We thus aimed to describe the number and characteristics of persons with HCV infection born outside of Switzerland. METHODS We compared characteristics of anti-HCV-positive individuals in the Swiss Hepatitis C Cohort Study (SCCS) and of HCV cases reported to the Federal Office of Public Health (FOPH), with those of the general population in Switzerland. Persons who inject drugs (PWID) and persons who do not inject drugs (non-PWID) were compared by age groups for different countries of origin (represented by ≥1% of participants in the SCCS or FOPH). RESULTS We included 4,199 persons from the SCCS and 26,610 cases from the FOPH. Both groups had similar characteristics. In both data sources non-PWID were more frequent in foreign-born than in Swiss-born persons (63% versus 34% in the SCCS). The only subgroup with a clearly higher proportion both in the SCCS and FOPH than in the general population were persons over 60 years from Italy and Spain, with a 3.7- and 2.8-fold increase in the SCCS. These persons were non-PWID (99%), less frequently HIV- and anti-HBc positive and more often female than PWID from Italy and Spain; cirrhosis at enrolment was frequent (31%). Their HCV genotypes were consistent with those observed in elderly non-PWID of their birth countries. In the FOPH a higher proportion than in the general population was also seen for cases from Georgia and Russia. CONCLUSION The identification of subgroups in which HCV infection is particularly frequent might allow for better targeting HCV screening among foreign-born persons in Switzerland and elsewhere.
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Affiliation(s)
- Barbara Bertisch
- Institute of Social and Preventive Medicine, Bern, Switzerland
- Checkpoint Zürich, Zürich, Switzerland
| | - Fabio Giudici
- Institute of Social and Preventive Medicine, Bern, Switzerland
| | - Francesco Negro
- Divisions of Gastroenterology and Hepatology and of Clinical Pathology, University Hospitals, Geneva, Switzerland
| | - Darius Moradpour
- Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Lausanne, Switzerland
| | - Beat Müllhaupt
- Swiss Hepato-Pancreato-Biliary Center and Department of Gastroenterology and Hepatology, University Hospital, Zürich, Switzerland
| | | | - Janne Estill
- Institute of Social and Preventive Medicine, Bern, Switzerland
| | - Olivia Keiser
- Institute of Social and Preventive Medicine, Bern, Switzerland
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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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Abstract
BACKGROUND Hepatitis C is often asymptomatic, presenting with liver failure and cancer decades after infection. People who inject drugs (PWID) and immigrant populations from countries with a moderate-to-high prevalence of hepatitis C virus (HCV) are the main risk groups. Deaths and hospital admissions due to HCV cirrhosis tripled between 1998 and 2010, but the majority of people with chronic HCV are unaware of it. AIM To identify patients at risk of developing hepatitis C using routine GP data, to determine the proportion not tested, and to explore GPs' views regarding testing. DESIGN AND SETTING Mixed-methods service evaluation (density-based selection of PWID) in six NHS practices in Bristol. METHOD Patients at risk of HCV were identified. The Health Protection Agency laboratory (now part of Public Health England) provided test results. Semi-structured interviews with 17 GPs were audiorecorded and thematic analyses conducted on anonymised transcripts. RESULTS Of 3765 patients identified as being at risk of developing hepatitis C, 3051 (81%) had no test result, including 53% of PWID and 93% of the 'ethnicity' group. All GPs said they usually test PWID. Most GPs test for HIV and hepatitis B in immigrants more often than they test for HCV. Barriers to testing included not questioning patients about risk factors, competing priorities, the chaotic lifestyle of PWID, difficulty extracting information from computerised records, and forgetting to address HCV. CONCLUSION Computer prompts and GP education on whom to test are warranted. Ensuring that country of origin and drug use is included on the new-patient questionnaire might also aid case-finding for HCV.
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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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