Retrieval of lost patients in the system for hepatitis C microelimination: a single-center retrospective study

ReLink strategy in diagnosed-but-untreated hepatitis C-positive patients in Germany: report from a single center

OBJECTIVE

The ReLink project aims to reintegrate diagnosed-but-untreated hepatitis-C-positive patients into medical care and initiate a therapy.

MATERIAL/METHODS

A retrospective search within the practice management system of a single center in Germany identified among 1965 hepatitis-C-positive patients 100 untreated patients with available contact details and meeting all inclusion criteria. Patients were contacted by 2 contact rounds.

RESULTS

Out of 100 patients, 64% were male. Most patients (81%) were aged between 30 and 59 years. The patients belonged to high-risk groups for hepatitis C virus infections or had other comorbidities. The majority of patients injected drugs (21%) and/or were currently or had been on substitution therapy (44%); alcohol addiction was also frequent (21%). Out of 25 patients who agreed to an appointment, 10 patients (40%) started therapy and 5 additional patients (20%) agreed to therapy but were not yet able to start or had not yet made a decision. One‑third of patients who agreed to an appointment did not show up.

CONCLUSIONS

Diagnosed-but-untreated patients are an important subgroup of hepatitis-C-positive patients; their recall to the clinic for direct-acting antiviral therapy is possible. However, inaccurate contact information, unresponsiveness to outreach, and further reluctance to attend doctor appointments limited the overall impact of this program. Regular review of the patients' contact details may facilitate both follow-up and recall.

Micro-elimination of chronic hepatitis C virus in mental health settings: A prospective multicentre pragmatic trial

INTRODUCTION

Hepatitis C virus (HCV) prevalence is high in the mental health population. We sought to evaluate testing and treatment uptake for HCV following the implementation of a universal nurse led study in inpatient and outpatient mental health populations.

METHODS

From January 2018 to December 2020, we screened mental health inpatients (n = 322) and community mental health patients (n = 615) for HCV with either specialist hepatology nurses or mental health nurses (mental health nurse).

RESULTS

75.5% (464/615) of community patients and 100% (322/322) of inpatients consented to screening, with an HCV antibody-positive prevalence of 12.7% (59/464) in community patients and 19.6% (63/322) in inpatients. RNA detectable prevalence was 4.0% (22/464) and 7.5% (24/322), respectively. Community patients who were screened by specialist hepatology nurses were more likely to consent to screening (94.4% vs. 45.7%, p < 0.001) but had lower proportion of HCV antibody (10.5% vs. 20.3%, p < 0.001) and RNA detectable (4.0% vs. 7.5%, p = 0.018) when compared to mental health nurse screening. Engagement with treatment was 27.0% of community mental health patients and 45.8% of mental health inpatients undergoing treatment. All patients undergoing treatment and underwent sustained viral response (SVR) testing achieved SVR.

DISCUSSION AND CONCLUSIONS

Universal screening of HCV using a nurse-led model has high rates of success in mental health patients with high proportions undergoing screening, with no reduction in the rates of SVR achieved with DAA therapy compared to the general population. Further work is needed to bridge the gap between identification of HCV and treatment among mental health patients.

Retrieval of HCV patients lost to follow-up as a strategy for Hepatitis C Microelimination: results of a Brazilian multicentre study

BACKGROUND

Several HCV patients in Brazil were lost to follow-up (LTFU) in the last two decades before achievement of sustained virological response (SVR). Strategies to recall those diagnosed but untreated patients have been used elsewhere with different success rates.

AIM

To identify and retrieve LTFU patients in order to offer them the treatment with the current highly effective direct acting antiviral agents (DAAs).

METHODS

Registries ofall HCV patients from three large reference centers in Brazil were retrospectively reviewed to identify those with no registry of SVR. Reasons for non-achievement of SVR were elicited in HCV-RNA + patients. All patients who were not treated or cured were contacted to offer the therapy with DAAs.

RESULTS

10,289 HCV patients (50% males, mean age 52 ± 11 years) were identified. Only 4,293 (41.7%) had been successfully treated previously. From the remaining 5,996 most were LTFU (59%), were not treated for other reasons (14.7%) or were non-responders (26.3%). After revision of the charts 3,559 were considered eligible to be retrieved. The callback success of phone calls was 18%, 13% to cellphone messages (SMS or WhatsApp) and 7% to regular mail. Five-hundred sixty patients had been already treatedor were on treatment and 234 were reported to be dead or transplanted. Finally, 201 had made an appointment and initiated antiviral treatment.

CONCLUSION

Even considering the low callback rate, retrieval of LTFU patients was shown to be an important strategy forhepatitis C micro-elimination in Brazil.

Outcomes of an automated alert system from Microbiology to link diagnosis to treatment in patients with hepatitis C virus

INTRODUCTION

simplification strategies for the care circuit of patients with hepatitis C virus (HCV) are key to achieve eradication. An electronic identification system was set up for HCV serology to link diagnosis to specialist management, aimed to reduce patient loss.

MATERIAL AND METHODS

a retrospective, single-center study was performed in patients with HCV identified from 15/3/2020 to 15/12/2021, using an alert system from Microbiology that notified specialists of positive cases. The patient was contacted and appointed a Fibroscan® and viral load measurement, with antiviral therapy prescribed on the same day. Origin, public health data, patient location rate and antiviral therapy prescription were recorded.

RESULTS

of 174 patients identified, 171 had positive viremia, with a mean age of 59.6 ± 15.9 years, 61.5 % were males and 81.2 % were Spanish nationals. Origin in the outpatient setting predominated (57.9 %, 99/171), particularly Primary Care (51/171), penitentiaries (21/171) and addiction units (14/171). Overall, 43.3 % (74/171) were aware of their diagnosis; 19.4 % (20/103) of patients had F3 fibrosis and 25.2 % (26/103) had F4 fibrosis. Also, 78.4 % (134/171) were deemed candidates for treatment. Of these, 74.6 % (100/134) were located and treatment was initiated, and all those who completed their treatment achieved a sustained viral response (96/96). This system managed 58.5 % (100/171) of the patients identified. The only association found between antiviral therapy and patient variables was comorbidities with being untreated (OR, 7.14; p ˂ 0.001).

CONCLUSIONS

this alert system allows to minimize patient loss in the care circuit and provides high rates of treated patients.

Retrieval of patients with hepatitis C who were lost to follow-up in Southern Denmark

BACKGROUND

The goal of the C-Free-South project is to eliminate hepatitis C (HCV) in the Region of Southern Denmark (1.2 million inhabitants). One target group consists of people with HCV who had received care but were lost to follow-up. The study aim was to evaluate program efficacy in locating these patients and getting them into care.

METHODS

Patients were contacted if they were HCV-RNA positive and age 18+ years, registered in the clinical hepatitis database as of November 1, 2019, and had no scheduled HCV-related appointment. They were contacted at 2-month intervals by phone or letter. For patients who did not respond, we asked their general practitioner to refer them, if possible.

RESULTS

We identified 69 (7%) patients in the database who were listed as untreated and not being followed up. We successfully contacted 54 (78%), and the remaining 15 (22%) did not respond to our contacts. To date, 45 (65%) had initiated treatment, one (1%) had rejected treatment, and eight (12%) did not show up to their appointments. Among those receiving treatment, 20 (44%) responded after the first contact, 18 (40%) after the second contact, and 7 (16%) after informing the general practitioner.

CONCLUSION

An intensified and persistent effort made it possible to reach most HCV patients lost to follow-up. All new contact attempts increased the possibility that patients would receive treatment. Nevertheless, 22% of HCV patients lost to follow-up did not respond to repeated contact attempts.

Hepatitis C micro-elimination through the retrieval strategy of patients lost to follow-up

BACKGROUND AND AIM

World Health Organization sets up an ambitious and attainable goal to eliminate hepatitis C (HCV) by 2030. The previous diagnosed HCV patients lost to follow-up were considered as an important target group for HCV elimination. We conducted a call back program to retrieve the lost to follow-up HCV patients and link them to care in our hospital. By analyzing and comparing our result with that from other studies, we wish to improve our retrieval strategy and provide our experience to the general communities.

METHODS

A list of the patients with a medical record showing seropositive for antibody to HCV (anti-HCV Ab) from 2004 to 2017 was retrieved by the department of intelligent technology of our hospital. Three dedicated staff members reviewed the patients' electronic medical records (EMRs) and recruited the patient lost follow-up to the call back program. The staff members contacted the qualified patients by telephone and inquired about their opinions for treating their chronic HCV infection. We also informed the patients about the retrieval strategy and why we contact them. As our National Health Insurance request, we gave all patient one informed consent for hepatitis C treatment. Informed consents have been obtained from all patients. Referrals to our gastroenterology unit (GU) were arranged for the patients who would like to continue their chronic HCV care in our hospital.

RESULTS

There were 31,275 anti-HCV positive patients. We included 11,934 patients (38.2%) into the call back system and contacted them by telephone. Based on the response to our call, we ascertained 1277 eligible cases (10.7%) for retrieval. The patients who were younger (< 55), lived in Taoyaun City or had tested positive for anti-HCV Ab at the department of internal medicine department had an increased rate of successful call back. There were 563 patients (44.1%) returning to our GU. Of them, 354 patients (62.9%) were positive for HCV viremia. 323 patients (91.2%) received the DAAs treatment. The SVR12 with Grazoprevir + elbasvir, Glecaprevir + pibrentasvir, Sofosbuvir + ledipasvir and Sofosbuvir + velpatasvir were 97.9%, 98.8%, 100% and 97.5%, respectively.

CONCLUSIONS

Call back system can expand our reach to those unaware or ignoring chronic HCV infection patients and link them to treatment.

Implementation of a re-linkage to care strategy in patients with chronic hepatitis C who were lost to follow-up in Latin America

To achieve WHO's goal of eliminating hepatitis C virus (HCV), innovative strategies must be designed to diagnose and treat more patients. Therefore, we aimed to describe an implementation strategy to identify patients with HCV who were lost to follow-up (LTFU) and offer them re-linkage to HCV care. We conducted an implementation study utilizing a strategy to contact patients with HCV who were not under regular follow-up in 13 countries from Latin America. Patients with HCV were identified by the international classification of diseases (ICD-9/10) or equivalent. Medical records were then reviewed to confirm the diagnosis of chronic HCV infection defined by anti-HCV+ and detectable HCV-RNA. Identified patients who were not under follow-up by a liver specialist were contacted by telephone or email, and offered a medical reevaluation. A total of 10,364 patients were classified to have HCV. After reviewing their medical charts, 1349 (13%) had undetectable HCV-RNA or were wrongly coded. Overall, 9015 (86.9%) individuals were identified with chronic HCV infection. A total of 5096 (56.5%) patients were under routine HCV care and 3919 (43.5%) had been LTFU. We were able to contact 1617 (41.3%) of the 3919 patients who were LTFU at the primary medical institution, of which 427 (26.4%) were cured at a different institutions or were dead. Of the remaining patients, 906 (76.1%) were candidates for retrieval. In our cohort, about one out of four patients with chronic HCV who were LTFU were candidates to receive treatment. This strategy has the potential to be effective, accessible and significantly impacts on the HCV care cascade.

Machine-Learning Algorithm for Predicting Fatty Liver Disease in a Taiwanese Population

The rising incidence of fatty liver disease (FLD) poses a health challenge, and is expected to be the leading global cause of liver-related morbidity and mortality in the near future. Early case identification is crucial for disease intervention. A retrospective cross-sectional study was performed on 31,930 Taiwanese subjects (25,544 training and 6386 testing sets) who had received health check-ups and abdominal ultrasounds in Changhua Christian Hospital from January 2009 to January 2019. Clinical and laboratory factors were included for analysis by different machine-learning algorithms. In addition, the performance of the machine-learning algorithms was compared with that of the fatty liver index (FLI). Totally, 6658/25,544 (26.1%) and 1647/6386 (25.8%) subjects had moderate-to-severe liver disease in the training and testing sets, respectively. Five machine-learning models were examined and demonstrated exemplary performance in predicting FLD. Among these models, the xgBoost model revealed the highest area under the receiver operating characteristic (AUROC) (0.882), accuracy (0.833), F1 score (0.829), sensitivity (0.833), and specificity (0.683) compared with those of neural network, logistic regression, random forest, and support vector machine-learning models. The xgBoost, neural network, and logistic regression models had a significantly higher AUROC than that of FLI. Body mass index was the most important feature to predict FLD according to the feature ranking scores. The xgBoost model had the best overall prediction ability for diagnosing FLD in our study. Machine-learning algorithms provide considerable benefits for screening candidates with FLD.

Pan-Genotypic Direct-Acting Antiviral Agents for Undetermined or Mixed-Genotype Hepatitis C Infection: A Real-World Multi-Center Effectiveness Analysis

Although the pan-genotypic direct-acting antiviral regimen was approved for treating chronic hepatitis C infection regardless of the hepatitis C virus (HCV) genotype, real-world data on its effectiveness against mixed-genotype or genotype-undetermined HCV infection are scarce. We evaluated the real-world safety and efficacy of two pan-genotypic regimens (Glecaprevir/Pibrentasvir and Sofosbuvir/Velpatasvir) for HCV-infected patients with mixed or undetermined HCV genotypes from the five hospitals in the Changhua Christian Care System that commenced treatment between August 2018 and December 2020. This retrospective study evaluated the efficacy and safety of pan-genotypic direct-acting antiviral (DAA) treatment in adults with HCV infection. The primary endpoint was the sustained virological response (SVR) observed 12 weeks after completing the treatment. Altogether, 2446 HCV-infected patients received the pan-genotypic DAA regimen, 37 (1.5%) patients had mixed-genotype HCV infections and 110 (4.5%) patients had undetermined HCV genotypes. The mean age was 63 years and 55.8% of our participants were males. Nine (6.1%) patients had end-stage renal disease and three (2%) had co-existing hepatomas. We lost one patient to follow-up during treatment and one more patient after treatment. A total of four patients died. However, none of these losses were due to treatment-related side effects. The rates of SVR12 for mixed-genotype and genotype-undetermined infections were 97.1% and 96.2%, respectively, by per-protocol analyses, and 91.9% and 92.7% respectively, by intention-to-treat population analyses. Laboratory adverse events with grades ≥3 included anemia (2.5%), thrombocytopenia (2.5%), and jaundice (0.7%). Pan-genotypic DAAs are effective and well-tolerated for mixed-genotype or genotype-undetermined HCV infection real-world settings.

Real-World Experience of Chronic Hepatitis C-Related Compensated Liver Cirrhosis Treated with Glecaprevir/Pibrentasvir: A Multicenter Retrospective Study

Background: Glecaprevir/pibrentasvir is a protease inhibitor-containing pangenotypic direct-acting antiviral regimen that has been approved for the treatment of chronic hepatitis C. The present study aimed to evaluate the safety and efficacy of glecaprevir/pibrentasvir in patients with compensated cirrhosis in a real-world setting. Methods: We evaluated the real-world safety and efficacy of glecaprevir/pibrentasvir in patients with compensated cirrhosis from five hospitals in the Changhua Christian Care System, who underwent treatment between August 2018 and October 2020. The primary endpoint was a sustained virological response observed 12 weeks after completion of the treatment. Results: Ninety patients, including 70 patients who received the 12-week therapy and 20 patients who received the 8-week therapy, were enrolled. The mean age of the patients was 65 years, and 57.8% of the patients were males. Sixteen (17.8%) patients had end-stage renal disease, and 15 (16.7%) had co-existing hepatoma. The hepatitis C virus genotypes 1 (40%) and 2 (35.6%) were most common. The common side effects included anorexia (12.2%), pruritus (7.8%), abdominal discomfort (7.8%), and malaise (7.8%). Laboratory adverse grade ≥3 events included anemia (6.3%), thrombocytopenia (5.1%), and jaundice (2.2%). The overall sustained virological response rates were 94.4% and 97.7% in the intention-to-treat and per-protocol analyses, respectively. Conclusions: the glecaprevir/pibrentasvir treatment regimen was highly effective and well tolerated among patients with compensated cirrhosis in the real-world setting.

Strategy for the Micro-Elimination of Hepatitis C among Patients with Diabetes Mellitus-A Hospital-Based Experience

Hepatitis C virus (HCV) infection can induce insulin resistance, and patients with diabetes mellitus (DM) have a higher prevalence of HCV infection. Patient outcomes improve after HCV eradication in DM patients. However, HCV micro-elimination targeting this population has not been approached. Little is known about using electronic alert systems for HCV screening among patients with DM in a hospital-based setting. We implemented an electronic reminder system for HCV antibody screening and RNA testing in outpatient departments among patients with DM. The screening rates and treatment rates at different departments before and after system implementation were compared. The results indicated that the total HCV screening rate increased from 49.3% (9505/19,272) to 78.2% (15,073/19,272), and the HCV-RNA testing rate increased from 73.4% to 94.2%. The anti-HCV antibody seropositive rate was 5.7%, and the HCV viremia rate was 62.7% in our patient population. The rate of positive anti-HCV antibodies and HCV viremia increased with patient age. This study demonstrates the feasibility and usefulness of an electronic alert system for HCV screening and treatment among DM patients in a hospital-based setting.

Evaluation of non-alcoholic fatty liver disease in patients with inflammatory bowel disease using controlled attenuation parameter technology: A Taiwanese retrospective cohort study

Background/purpose

An increased prevalence of non-alcoholic fatty liver disease (NAFLD) is observed in patients with inflammatory bowel disease (IBD) in Western countries. Both intestinal inflammation and metabolic factors contribute to the pathogenesis of IBD-associated NAFLD. The burden of NAFLD is not clear in the Asian population. This study aimed to evaluate the prevalence of NAFLD and liver fibrosis in a cohort of Taiwanese patients with IBD.

Methods

From January to December 2019, patients with IBD who underwent ultrasound examination were enrolled. Hepatic steatosis and fibrosis were measured with liver stiffness measurement (LSM) and controlled attenuation parameter (CAP) using FibroScan. Patients with a history of excessive alcohol or recent steroid use were excluded. Univariate and multivariate analysis were performed.

Results

A total of 81 consecutive patients were enrolled and included in the analysis (45 with ulcerative colitis, 36 with Crohn’s disease). The median age was 42 years old. The patients were classified in terms of body mass index as normal weight (54.3%), underweight (11.1%), overweight (28.4%), and obese (6.2%). The mean CAP increased to 162.22 dB/m in the underweight group, 210.86 dB/m in the normal weight group, 260.7 dB/m in the overweight group, and 274.0 dB/m in the obese group. NAFLD was observed in 29.6% of the patients, 1.2% of which had significant fibrosis. Increased body mass index (odds ratio [OR] 1.33, 95% confidence interval [CI] 1.1–1.62) and older age at IBD diagnosis (OR: 1.05, 95% CI 1–1.11) was found to be associated with the presence of NAFLD.

Conclusion

In this study, the prevalence of NAFLD was lower (29.6%) in IBD patients than in the Western population. Higher BMI and older age were associated with NAFLD in our study.