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Vo-Quang E, Lemoine M. Global elimination of HBV: Is it really achievable? J Viral Hepat 2024. [PMID: 38797984 DOI: 10.1111/jvh.13955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2024] [Accepted: 05/09/2024] [Indexed: 05/29/2024]
Abstract
Hepatitis B virus (HBV) infection is a major cause of premature death worldwide. In 2016, the World Health Organization (WHO) called for HBV elimination and set up very ambitious elimination targets. The development of effective vaccines, accurate diagnostic tools and safe antiviral drugs make HBV elimination a realistic goal. However, the most constrained-resource regions, which bear the highest burden of HBV, are facing major challenges in implementing strategies to reduce HBV incidence and mortality. Developing simplified approaches adapted to resource-limited settings and scaling up interventions for the prevention and control of HBV globally are urgently needed. Whether HBV elimination will be achieved in an equitable manner and in a reasonable timeframe remains highly uncertain.
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Affiliation(s)
- Erwan Vo-Quang
- Disease Control & Elimination Theme, Medical Research Council Unit The Gambia at London School of Hygiene & Tropical Medicine, Banjul, The Gambia
- Team "Viruses, Hepatology, Cancer", Institut Mondor de Recherche Biomédicale, INSERM U955, Université Paris-Est, Créteil, France
| | - Maud Lemoine
- Team "Viruses, Hepatology, Cancer", Institut Mondor de Recherche Biomédicale, INSERM U955, Université Paris-Est, Créteil, France
- Department of Metabolism, Digestion and Reproduction, Division of Digestive Diseases, St Mary's Hospital, Imperial College London, London, UK
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Minier N, Guingané AN, Okeke E, Sinkala E, Johannessen A, Andersson MI, Davwar P, Desalegn H, Duguru M, Fall F, Mboup S, Maponga T, Matthews PC, Ramírez Mena A, Ndow G, Orlien SMS, Riches N, Seydi M, Sonderup M, Spearman CW, Stockdale AJ, Taljaard J, Vinikoor M, Wandeler G, Lemoine M, Shimakawa Y, Sombié R. Development and evaluation of a simple treatment eligibility score (HEPSANET) to decentralise hepatitis B care in Africa: a cross-sectional study. Lancet Gastroenterol Hepatol 2024; 9:323-332. [PMID: 38367633 PMCID: PMC7616035 DOI: 10.1016/s2468-1253(23)00449-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 12/13/2023] [Accepted: 12/14/2023] [Indexed: 02/19/2024]
Abstract
BACKGROUND Hepatitis B virus (HBV) elimination requires expanding and decentralising HBV care services. However, peripheral health facilities lack access to diagnostic tools to assess eligibility for antiviral therapy. Through the Hepatitis B in Africa Collaborative Network (HEPSANET), we aimed to develop and evaluate a score using tests generally available at lower-level facilities, to simplify the evaluation of antiviral therapy eligibility in people living with HBV. METHODS We surveyed the availability of clinical and laboratory parameters across different health-care levels in sub-Saharan Africa. We used data from the HEPSANET dataset, the largest cross-sectional dataset of treatment-naive people living with HBV in sub-Saharan Africa, to derive and validate the score. Participants from this dataset were included in the analysis if they were aged 18 years or older and had liver fibrosis stages determined by a liver stiffness measurement or liver histopathology. Participants with co-infections or metabolic disorders were excluded. We allocated participants to the derivation and validation sets by geographical site. In the derivation set, we used stepwise logistic regression to identify the best performing parameters for identifying participants that met the 2017 European Association for the Study of the Liver (EASL) criteria. Regression coefficients were converted into integer points to construct simplified algorithms for different health-care levels. In the validation set, we estimated the area under the receiver operating characteristic, sensitivity, and specificity of the simplified algorithm for identifying antiviral therapy eligibility defined by the 2017 EASL criteria. FINDINGS At 11 sites from eight countries that returned surveys, aspartate aminotransferase (AST), alanine aminotransferase (ALT), and platelet count were generally available at district hospital levels, and hepatitis B e antigen and point-of-care HBV DNA tests were available only at regional and provincial hospital levels or above. Among 2895 participants included from the HEPSANET database (1740 [60·1%] male, 1155 [39·9%] female), 409 (14·1%) met EASL antiviral therapy eligibility criteria. In the derivation set, the optimal district-level hospital score was: ALT (IU/L), less than 40 (0 points), 40-79 (+1), 80 or greater (+2); AST (IU/L), less than 40 (0), 40-79 (+1), 80 or greater (+2); and platelet counts (109/L), less than 100 (+2), 100-149 (+1), 150 or greater (0). When combined with family history and clinical data for decompensated cirrhosis that do not require any biological tests, a cut-off of 2 points or more had a sensitivity and specificity of 82% (95% CI 76-86) and 95% (93-96) to identify treatment-eligible individuals in the derivation set, and 78% (71-85) and 87% (86-89) in the validation set, respectively. INTERPRETATION Using a score incorporating platelet counts, AST, and ALT, the majority of people living with HBV requiring antiviral therapy can be identified. Our findings suggest that clinical staging can be decentralised down to district hospital level in sub-Saharan Africa. FUNDING European Association for the Study of the Liver Foundation, John C Martin Foundation. TRANSLATION For the French translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Nicolas Minier
- Insitut Pasteur, Université Paris Cité, Unité d'Épidémiologie des Maladies Émergentes, Paris, France
| | - Alice Nanelin Guingané
- Hepato-Gastroenterology Department, Bogodogo University Hospital Center, Ouagadougou, Burkina Faso
| | - Edith Okeke
- Faculty of Medical Sciences, University of Jos, Jos, Nigeria
| | - Edford Sinkala
- Department of Internal Medicine, University of Zambia, Lusaka, Zambia
| | - Asgeir Johannessen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Infectious Diseases, Vestfold Hospital, Tønsberg, Norway
| | - Monique I Andersson
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK; Division of Medical Virology, Stellenbosch University Faculty of Medicine and Health Sciences & National Health Laboratory Service, Tygerberg Business Unit, Cape Town, South Africa
| | - Pantong Davwar
- Faculty of Medical Sciences, University of Jos, Jos, Nigeria
| | - Hailemichael Desalegn
- Department of Infectious Diseases, Vestfold Hospital, Tønsberg, Norway; Medical Department, St Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Mary Duguru
- Faculty of Medical Sciences, University of Jos, Jos, Nigeria
| | - Fatou Fall
- Department of Hepatology and Gastroenterology, Hopital Principal de Dakar, Dakar, Senegal
| | - Souleyman Mboup
- L'Institut de Recherche en Santé, de Surveillance Épidémiologique et de Formations (IRESSEF), Dakar, Senegal
| | - Tongai Maponga
- Division of Medical Virology, Stellenbosch University Faculty of Medicine and Health Sciences & National Health Laboratory Service, Tygerberg Business Unit, Cape Town, South Africa
| | - Philippa C Matthews
- The Francis Crick Institute, London, UK; Division of Infection and Immunity, University College London, London, UK
| | - Adrià Ramírez Mena
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland; Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Gibril Ndow
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK; MRC Unit The Gambia, London School of Hygiene & Tropical Medicine, Banjul, The Gambia
| | - Stian M S Orlien
- Department of Infectious Diseases, Vestfold Hospital, Tønsberg, Norway; Department of Pediatrics, Oslo University Hospital, Oslo, Norway
| | - Nicholas Riches
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Moussa Seydi
- Service de Maladies Infectieuses et Tropicales, Centre Regional de Recherche et de Formation, Centre Hospitalier National Universitaire de Fann, Dakar, Senegal
| | - Mark Sonderup
- Division of Hepatology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - C Wendy Spearman
- Division of Hepatology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Alexander J Stockdale
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK; Malawi-Liverpool-Wellcome Trust Clinical Research Program, Blantyre, Malawi
| | - Jantjie Taljaard
- Division of Infectious Diseases, Department of Medicine, Tygerberg Hospital and Stellenbosch University, Cape Town, South Africa
| | - Michael Vinikoor
- Department of Internal Medicine, University of Zambia, Lusaka, Zambia; University of Alabama at Birmingham, Birmingham, AL, USA
| | - Gilles Wandeler
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Maud Lemoine
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Yusuke Shimakawa
- Insitut Pasteur, Université Paris Cité, Unité d'Épidémiologie des Maladies Émergentes, Paris, France.
| | - Roger Sombié
- Hepato-Gastroenterology Department, Yalgado Ouédraogo University Hospital Center, Ouagadougou, Burkina Faso
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Pauly MD, Ganova-Raeva L. Point-of-Care Testing for Hepatitis Viruses: A Growing Need. Life (Basel) 2023; 13:2271. [PMID: 38137872 PMCID: PMC10744957 DOI: 10.3390/life13122271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 11/23/2023] [Accepted: 11/23/2023] [Indexed: 12/24/2023] Open
Abstract
Viral hepatitis, caused by hepatitis A virus (HAV), hepatitis B virus (HBV), hepatitis C virus (HCV), hepatitis D virus (HDV), or hepatitis E virus (HEV), is a major global public health problem. These viruses cause millions of infections each year, and chronic infections with HBV, HCV, or HDV can lead to severe liver complications; however, they are underdiagnosed. Achieving the World Health Organization's viral hepatitis elimination goals by 2030 will require access to simpler, faster, and less expensive diagnostics. The development and implementation of point-of-care (POC) testing methods that can be performed outside of a laboratory for the diagnosis of viral hepatitis infections is a promising approach to facilitate and expedite WHO's elimination targets. While a few markers of viral hepatitis are already available in POC formats, tests for additional markers or using novel technologies need to be developed and validated for clinical use. Potential methods and uses for the POC testing of antibodies, antigens, and nucleic acids that relate to the diagnosis, monitoring, or surveillance of viral hepatitis infections are discussed here. Unmet needs and areas where additional research is needed are also described.
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Affiliation(s)
| | - Lilia Ganova-Raeva
- Division of Viral Hepatitis, National Center for HIV, Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, 1600 Clifton Rd., NE, Atlanta, GA 30329, USA;
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Dera A, Sanou AM, Ouattara MNG, Ilboudo AK, Lankoande DB, Ilboudo D, Napon-Zongo D, Gomgnimbou MK. Evaluation of the Diagnostic Performances of the SD-Bioline ®HBeAg Rapid Test Used Routinely for the Management of HBV-Infected Individuals in Burkina Faso. Diagnostics (Basel) 2023; 13:3144. [PMID: 37835887 PMCID: PMC10572218 DOI: 10.3390/diagnostics13193144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 08/30/2023] [Accepted: 09/12/2023] [Indexed: 10/15/2023] Open
Abstract
Hepatitis B e antigen (HBeAg) is a marker of wild-type hepatitis B virus replication. In resource-limited countries where access to enzyme-linked immunosorbent assay (ELISA) remains a challenge, rapid diagnostic tests (RDT) constitute a good alternative. The HBeAg status is employed to evaluate eligibility for antiviral therapy and to prevent the transmission of hepatitis B from mother to child (PMTCT). The objective of this study was to assess the diagnostic performance of the SD-Bioline®HBeAg RDT commonly used for detecting HBeAg in laboratories in Burkina Faso. The sample panel used was collected from HBsAg-positive patients received in the laboratory for the detection of HBeAg with the rapid test. The samples were retested for HBeAg using the VIDAS HBe/Anti-HBe enzyme-linked fluorescent assay (ELFA) (Gold standard). Then, the viral load (VL) of HBV DNA was determined using the GENERIC HBV CHARGE VIRLAE kit (GHBV-CV). The diagnostic performances of the SD-Bioline®HBeAg and its agreement with the gold standard were calculated with their 95% confidence intervals. Overall, 340 sera obtained from HBsAg-positive patients were included in this evaluation Compared to the VIDAS HBe/Anti-HBe ELFA test, the sensitivity (Se) and specificity (Sp) of the SD-Bioline®HBeAg test were 33.3% and 97.9%, respectively. The concordance between the two tests was 0.42. Depending on the viral load, the Se and Sp varied from 8.8% and 98.3% for a VL < 2000 IU/mL to 35.5% and 98.4% for a VL > 2,000,000 IU/mL. The results showed a low sensibility of the SD-Bioline®HBeAg RDT test, indicating that its use is inappropriate for the clinical management of HBV-infected patients. They also highlight the urgent need to develop HBeAg rapid tests with better sensitivities.
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Affiliation(s)
- Abdoulaye Dera
- Laboratoire de Recherche sur les Maladies Infectieuses et Parasitaire (LR-MIP), Institut de Recherche en Science de la Santé, Bobo-Dioulasso 2779, Burkina Faso; (A.D.); (M.N.G.O.)
- Département des Laboratoires, Centre “Assaut-Hépatites”, Bobo-Dioulasso 2285, Burkina Faso
| | - Armel M. Sanou
- Laboratoire de Recherche sur les Maladies Infectieuses et Parasitaire (LR-MIP), Institut de Recherche en Science de la Santé, Bobo-Dioulasso 2779, Burkina Faso; (A.D.); (M.N.G.O.)
- Département des Laboratoires, Centre “Assaut-Hépatites”, Bobo-Dioulasso 2285, Burkina Faso
| | - Mathuola N. G. Ouattara
- Laboratoire de Recherche sur les Maladies Infectieuses et Parasitaire (LR-MIP), Institut de Recherche en Science de la Santé, Bobo-Dioulasso 2779, Burkina Faso; (A.D.); (M.N.G.O.)
- Département des Laboratoires, Centre “Assaut-Hépatites”, Bobo-Dioulasso 2285, Burkina Faso
| | - Abdoul K. Ilboudo
- Laboratoire de Recherche sur les Maladies Infectieuses et Parasitaire (LR-MIP), Institut de Recherche en Science de la Santé, Ouagadougou 7192, Burkina Faso;
- Département Méthodologie et Gestion des Données, Centre “Assaut-Hépatites”, Bobo-Dioulasso 2285, Burkina Faso
| | - David B. Lankoande
- Service des Urgences Médicales, Centre Hospitalier Universitaire de Bogodogo, Ouagadougou 314, Burkina Faso;
- Département Clinique, Centre “Assaut-Hépatites”, Bobo-Dioulasso 2285, Burkina Faso; (D.I.); (D.N.-Z.)
| | - Dieudonné Ilboudo
- Département Clinique, Centre “Assaut-Hépatites”, Bobo-Dioulasso 2285, Burkina Faso; (D.I.); (D.N.-Z.)
- District Sanitaire de Banfora, Direction Régionale de la Santé des Cascades, Banfora 117, Burkina Faso
| | - Delphine Napon-Zongo
- Département Clinique, Centre “Assaut-Hépatites”, Bobo-Dioulasso 2285, Burkina Faso; (D.I.); (D.N.-Z.)
- Institut Supérieur des Sciences de la Santé (INSSA), Université Nazi Boni, Bobo-Dioulasso 1091, Burkina Faso;
| | - Michel K. Gomgnimbou
- Institut Supérieur des Sciences de la Santé (INSSA), Université Nazi Boni, Bobo-Dioulasso 1091, Burkina Faso;
- Laboratoire de Biologie Moléculaire, Centre Muraz, Bobo-Dioulasso 2054, Burkina Faso
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Isa YS, Sicsic J, Njuguna H, Ward J, Chakroun M, El-Kassas M, Ramanampamonjy R, Chalal S, Vincent JP, Andersson M, Desalegn H, Fall F, Johannessen A, Matthews PC, Ndow G, Okeke E, Riches N, Seydi M, Sinkala E, Spearman CW, Stockdale A, Vinikoor MJ, Wandeler G, Sombié R, Lemoine M, Mueller JE, Shimakawa Y. Informing a target product profile for rapid tests to identify HBV-infected pregnant women with high viral loads: a discrete choice experiment with African healthcare workers. BMC Med 2023; 21:243. [PMID: 37403107 DOI: 10.1186/s12916-023-02939-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 06/13/2023] [Indexed: 07/06/2023] Open
Abstract
BACKGROUND Elimination of mother-to-child transmission of hepatitis B virus (HBV) requires infant immunoprophylaxis and antiviral prophylaxis for pregnant women with high viral loads. Since real-time polymerase chain reaction (RT-PCR), a gold standard for assessing antiviral eligibility, is neither accessible nor affordable for women living in low-income and middle-income countries (LMICs), rapid diagnostic tests (RDTs) detecting alternative HBV markers may be needed. To inform future development of the target product profile (TPP) for RDTs to identify highly viremic women, we used a discrete choice experiment (DCE) and elicited preference and trade-off of healthcare workers (HCW) in Africa between the following four attributes of fictional RDTs: price, time-to-result, diagnostic sensitivity, and specificity. METHODS Through an online questionnaire survey, we asked participants to indicate their preferred test from a set of two RDTs in seven choice tasks with varying levels of the four attributes. We used mixed multinomial logit models to quantify the utility gain or loss generated by each attribute. We attempted to define minimal and optimal criteria for test attributes that can satisfy ≥ 70% and ≥ 90% of HCWs, respectively, as an alternative to RT-PCR. RESULTS A total of 555 HCWs from 41 African countries participated. Increases in sensitivity and specificity generated significant utility and increases in cost and time-to-result generated significant disutility. The size of the coefficients for the highest attribute levels relative to the reference levels were in the following order: sensitivity (β = 3.749), cost (β = -2.550), specificity (β = 1.134), and time-to-result (β = -0.284). Doctors cared most about test sensitivity, while public health practitioners cared about cost and midwives about time-to-result. For an RDT with 95% specificity, costing 1 US$, and yielding results in 20 min, the minimally acceptable test sensitivity would be 82.5% and the optimally acceptable sensitivity would be 87.5%. CONCLUSIONS African HCWs would prefer an RDT with the following order of priority: higher sensitivity, lower cost, higher specificity, and shorter time-to-result. The development and optimization of RDTs that can meet the criteria are urgently needed to scale up the prevention of HBV mother-to-child transmission in LMICs.
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Affiliation(s)
- Yasir Shitu Isa
- Institut Pasteur, Université Paris Cité, Unité d'Épidémiologie Des Maladies Émergentes, 25-28 Rue du Dr Roux, 75015, Paris, France
- EHESP French School of Public Health, Rennes, France
| | | | - Henry Njuguna
- Coalition for Global Hepatitis Elimination, Decatur, GA, USA
| | - John Ward
- Coalition for Global Hepatitis Elimination, Decatur, GA, USA
| | - Mohamed Chakroun
- Infectious Disease Department, Fattouma Bourguiba Hospital, Monastir, Tunisia
| | - Mohamed El-Kassas
- Endemic Medicine Department, Faculty of Medicine, Helwan University, Cairo, Egypt
| | - Rado Ramanampamonjy
- Unité de Gastro-Entérologie, Hôpital Joseph Raseta Befelatanana, Antananarivo, Madagascar
| | - Salim Chalal
- Institut Pasteur, Université Paris Cité, Unité d'Épidémiologie Des Maladies Émergentes, 25-28 Rue du Dr Roux, 75015, Paris, France
- Plateforme de Data Management, Institut Pasteur, Paris, France
| | - Jeanne Perpétue Vincent
- Institut Pasteur, Université Paris Cité, Unité d'Épidémiologie Des Maladies Émergentes, 25-28 Rue du Dr Roux, 75015, Paris, France
| | - Monique Andersson
- Division of Medical Virology, Stellenbosch University, Faculty of Medicine and Health Sciences, Cape Town, South Africa
- Nuffield Division of Clinical Laboratory Science, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Hailemichael Desalegn
- Medical Department, St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Fatou Fall
- Department of Hepatology and Gastroenterology, Hopital Principal de Dakar, Dakar, Senegal
| | - Asgeir Johannessen
- Department of Infectious Diseases, Vestfold Hospital, Tønsberg, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Philippa C Matthews
- The Francis Crick Institute, London, UK
- Division of Infection and Immunity, University College London, London, UK
- Department of Infectious Diseases, University College London Hospital, London, UK
| | - Gibril Ndow
- Medical Research Council Unit The Gambia, London School of Hygiene & Tropical Medicine, Fajara, The Gambia
- Department of Metabolism, Digestion & Reproduction, Imperial College London, London, UK
| | - Edith Okeke
- Faculty of Medical Sciences, University of Jos, Jos, Nigeria
| | - Nicholas Riches
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Moussa Seydi
- Service de Maladies Infectieuses Et Tropicales, Centre Hospitalier National Universitaire de Fann, Dakar, Senegal
| | - Edford Sinkala
- Department of Internal Medicine, University of Zambia, Lusaka, Zambia
| | - C Wendy Spearman
- Division of Hepatology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Alexander Stockdale
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection, University of Liverpool, Liverpool, UK
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Michael J Vinikoor
- Department of Internal Medicine, University of Zambia, Lusaka, Zambia
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Gilles Wandeler
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Roger Sombié
- Service d'Hépato-Gastroentérologie, Centre Hospitalier Universitaire Yalgado Ouédraogo, Ouagadougou, Burkina Faso
| | - Maud Lemoine
- Medical Research Council Unit The Gambia, London School of Hygiene & Tropical Medicine, Fajara, The Gambia
- Department of Metabolism, Digestion & Reproduction, Imperial College London, London, UK
| | - Judith E Mueller
- Institut Pasteur, Université Paris Cité, Unité d'Épidémiologie Des Maladies Émergentes, 25-28 Rue du Dr Roux, 75015, Paris, France
- EHESP French School of Public Health, Rennes, France
| | - Yusuke Shimakawa
- Institut Pasteur, Université Paris Cité, Unité d'Épidémiologie Des Maladies Émergentes, 25-28 Rue du Dr Roux, 75015, Paris, France.
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Nayagam S, de Villiers MJ, Shimakawa Y, Lemoine M, Thursz MR, Walsh N, Hallett TB. Impact and cost-effectiveness of hepatitis B virus prophylaxis in pregnancy: a dynamic simulation modelling study. Lancet Gastroenterol Hepatol 2023; 8:635-645. [PMID: 37150181 DOI: 10.1016/s2468-1253(23)00074-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 03/11/2023] [Accepted: 03/13/2023] [Indexed: 05/09/2023]
Abstract
BACKGROUND In 2020, WHO recommended the addition of peripartum antiviral prophylaxis (PAP) to hepatitis B birth dose vaccination (HepB-BD) and hepatitis B infant vaccination (HepB3) to reduce mother-to-child transmission of hepatitis B virus (HBV) infection in pregnant women who have a marker of high infectivity (ie, HBV DNA ≥200 000 international units per mL or HBeAg-positive). We aimed to evaluate the impact and cost-effectiveness of this recommendation and of a theoretical simplified strategy whereby PAP is given to all pregnant women who are HBsAg-positive without risk stratification. METHODS This modelling study used a dynamic simulation model of the HBV epidemic in 110 countries in all WHO regions, structured by age, sex, and country. We assessed three strategies of scaling up PAP for pregnant women: PAP for those with high viral load (PAP-VL); PAP for those who are HBeAg-positive (PAP-HBeAg); and PAP for all pregnant women who are HBsAg-positive (PAP-universal), in comparison with neonatal vaccination alone (HepB-BD). We investigated how different diagnostic and antiviral drug costs affected the cost-effectiveness of the strategies evaluated. Using a health-care provider perspective, we calculated incremental cost-effectiveness ratios in cost (US$) per disability-adjusted life-year (DALY) averted in each country's population and compared these with country-specific cost-effectiveness thresholds. We also calculated new neonatal infections averted for each of the strategies. FINDINGS Adding PAP-VL to HepB-BD could avert around 1·1 million (95% uncertainty interval 1·0 million-1·2 million) new neonatal infections by 2030 and around 3·2 million (95% uncertainty interval 3·0 million-3·4 million) new neonatal infections and approximately 8·8 million (7·8 million-9·7 million) DALYs by 2100 across all the countries modelled. This strategy would probably be cost-effective up to 2100 in 28 (26%) of 106 countries analysed (which included some of the countries that have the greatest HBV burden) if costs are as currently expected to be, and in 74 (70%) countries if diagnostic and monitoring costs were lowered (by about 60-75%). The relative cost-effectiveness of PAP-VL and PAP-HBeAg was finely balanced and depended on the respective diagnostic and monitoring costs. The PAP-universal strategy could be more cost-effective than either of these strategies in most countries, but the use of antiviral treatment could be five times as high than with PAP-VL. INTERPRETATION PAP can provide substantial health benefits, and, although the current approach might already be cost-effective in some high-burden settings, decreased diagnostic costs would probably be needed for PAP to be cost-effective in most countries. Therefore, careful consideration needs to be given about how such a strategy is implemented, and securing reduced costs for diagnostics should be a priority. The theoretical strategy of offering PAP to all women who are HBsAg-positive (eg, if diagnostic tests to identify mothers at risk of transmission are not available) could be a cost-effective alternative, depending on prevailing costs of diagnostics and antiviral therapy. FUNDING UK Medical Research Council, UK National Institute for Health and Care Research, and the Vaccine Impact Modelling Consortium.
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Affiliation(s)
- Shevanthi Nayagam
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK; Division of Digestive Diseases, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK.
| | - Margaret J de Villiers
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK
| | - Yusuke Shimakawa
- Unité d'Épidémiologie des Maladies Émergentes, Institut Pasteur, Paris, France
| | - Maud Lemoine
- Division of Digestive Diseases, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK; MRC Unit The Gambia at the London School of Hygiene & Tropical Medicine, Fajara, The Gambia
| | - Mark R Thursz
- Division of Digestive Diseases, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Nick Walsh
- Department of Epidemiology and Preventative Medicine, School of Public Health and Preventative Medicine, Monash University, Melbourne, VIC, Australia
| | - Timothy B Hallett
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK
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7
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Johannessen A, Stockdale AJ, Henrion MYR, Okeke E, Seydi M, Wandeler G, Sonderup M, Spearman CW, Vinikoor M, Sinkala E, Desalegn H, Fall F, Riches N, Davwar P, Duguru M, Maponga T, Taljaard J, Matthews PC, Andersson M, Mboup S, Sombie R, Shimakawa Y, Lemoine M. Systematic review and individual-patient-data meta-analysis of non-invasive fibrosis markers for chronic hepatitis B in Africa. Nat Commun 2023; 14:45. [PMID: 36596805 PMCID: PMC9810658 DOI: 10.1038/s41467-022-35729-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 12/20/2022] [Indexed: 01/05/2023] Open
Abstract
In sub-Saharan Africa, simple biomarkers of liver fibrosis are needed to scale-up hepatitis B treatment. We conducted an individual participant data meta-analysis of 3,548 chronic hepatitis B patients living in eight sub-Saharan African countries to assess the World Health Organization-recommended aspartate aminotransferase-to-platelet ratio index and two other fibrosis biomarkers using a Bayesian bivariate model. Transient elastography was used as a reference test with liver stiffness measurement thresholds at 7.9 and 12.2kPa indicating significant fibrosis and cirrhosis, respectively. At the World Health Organization-recommended cirrhosis threshold (>2.0), aspartate aminotransferase-to-platelet ratio index had sensitivity (95% credible interval) of only 16.5% (12.5-20.5). We identified an optimised aspartate aminotransferase-to-platelet ratio index rule-in threshold (>0.65) for liver stiffness measurement >12.2kPa with sensitivity and specificity of 56.2% (50.5-62.2) and 90.0% (89.0-91.0), and an optimised rule-out threshold (<0.36) with sensitivity and specificity of 80.6% (76.1-85.1) and 64.3% (62.8-65.8). Here we show that the World Health Organization-recommended aspartate aminotransferase-to-platelet ratio index threshold is inappropriately high in sub-Saharan Africa; improved rule-in and rule-out thresholds can optimise treatment recommendations in this setting.
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Affiliation(s)
- Asgeir Johannessen
- Department of Infectious Diseases, Vestfold Hospital, Tønsberg, Norway.
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Alexander J Stockdale
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Marc Y R Henrion
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Edith Okeke
- Faculty of Medical Sciences, University of Jos, Jos, Nigeria
| | - Moussa Seydi
- Service de Maladies Infectieuses et Tropicales, Centre Regional de Recherche et de Formation, Centre Hospitalier National Universitaire de Fann, Dakar, Senegal
| | - Gilles Wandeler
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Mark Sonderup
- Division of Hepatology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - C Wendy Spearman
- Division of Hepatology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Michael Vinikoor
- Department of Internal Medicine, University of Zambia, Lusaka, Zambia
- University of Alabama at Birmingham, Birmingham, AL, USA
| | - Edford Sinkala
- Department of Internal Medicine, University of Zambia, Lusaka, Zambia
| | - Hailemichael Desalegn
- Department of Infectious Diseases, Vestfold Hospital, Tønsberg, Norway
- Medical Department, St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Fatou Fall
- Department of Hepatology and Gastroenterology, Hopital Principal de Dakar, Dakar, Senegal
| | - Nicholas Riches
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Pantong Davwar
- Faculty of Medical Sciences, University of Jos, Jos, Nigeria
| | - Mary Duguru
- Faculty of Medical Sciences, University of Jos, Jos, Nigeria
| | - Tongai Maponga
- Division of Medical Virology, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, South Africa
| | - Jantjie Taljaard
- Division of Infectious Diseases, Department of Medicine, Tygerberg Hospital and Stellenbosch University, Cape Town, South Africa
| | - Philippa C Matthews
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- The Francis Crick Institute, London, UK
- University College London, London, UK
| | - Monique Andersson
- Division of Medical Virology, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, South Africa
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Souleyman Mboup
- L'Institut de Recherche en Santé, de Surveillance Épidémiologique et de Formations (IRESSEF), Dakar, Senegal
| | - Roger Sombie
- Yalgado Ouédraogo University Hospital Center, Ouagadougou, Burkina Faso
| | - Yusuke Shimakawa
- Unité d'Epidémiologie des Maladies Emergentes, Institut Pasteur, Paris, France
| | - Maud Lemoine
- Department of Metabolism, Digestion and Reproduction, Division of Digestive Diseases, Hepatology section, Imperial College London, London, UK
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Thanapirom K, Suksawatamnuay S, Thaimai P, Treeprasertsuk S, Komolmit P, Tangkijvanich P. Assessment and validation of the TREAT-B score to assess the treatment eligibility of patients with chronic hepatitis B virus infection. Front Med (Lausanne) 2022; 9:995857. [PMID: 36330056 PMCID: PMC9623013 DOI: 10.3389/fmed.2022.995857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 09/26/2022] [Indexed: 11/18/2022] Open
Abstract
Background and aims Access to Hepatitis B virus (HBV) DNA testing to determine treatment eligibility is limited in low-income countries. Therefore, this study aimed to assess and validate the TREAT-B score proposed as the treatment threshold in an Asian cohort in determining the HBV treatment eligibility. Methods A retrospective analysis was conducted on consecutive patients with treatment-naïve chronic HBV mono-infection who visited the liver clinic at Chulalongkorn University Hospital, Bangkok, Thailand, from 2016 to 2020. The 2018 American Association for the Study of Liver Diseases guideline was the reference standard. Results Overall, 825 patients with chronic HBV infection were enrolled, comprising 409 (50.4%) males, with a median age of 50 (38–58) years. Of these, 216 (26.2%), 565 (68.5%), and 377 (45.7%) were eligible for treatment based on the AASLD, TREAT-B score, and simplified WHO criteria, respectively. The area under the receiver operating characteristics curve (AUROC) of the TREAT-B ≥ 2 was better than the simplified WHO criteria (0.69 vs. 0.62, p = 0.006) for selecting patients eligible for antiviral therapy. The sensitivity and specificity of the TREAT-B ≥ 2 were 96.3% and 41.4%, respectively. Applying the TREAT-B ≥ 3 improved the specificity (89.0%) and AUROC (0.80, 95% CI 0.76–0.84, but reduced the sensitivity (70.8%) for selecting eligible patients for HBV therapy. Conclusions In resource-constrained countries where HBV DNA is unavailable, the TREAT-B score is an alternative criteria for indicating treatment eligibility. The TREAT-B score of ≥3 is highly accurate and may minimize the number of patients unnecessarily treated in Asian HBV patients.
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Affiliation(s)
- Kessarin Thanapirom
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
- Liver Fibrosis and Cirrhosis Research Unit, Chulalongkorn University, Bangkok, Thailand
- Center of Excellence in Liver Diseases, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Sirinporn Suksawatamnuay
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
- Liver Fibrosis and Cirrhosis Research Unit, Chulalongkorn University, Bangkok, Thailand
- Center of Excellence in Liver Diseases, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Panarat Thaimai
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
- Liver Fibrosis and Cirrhosis Research Unit, Chulalongkorn University, Bangkok, Thailand
- Center of Excellence in Liver Diseases, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Sombat Treeprasertsuk
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Piyawat Komolmit
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
- Liver Fibrosis and Cirrhosis Research Unit, Chulalongkorn University, Bangkok, Thailand
- Center of Excellence in Liver Diseases, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Pisit Tangkijvanich
- Center of Excellence in Hepatitis and Liver Cancer, Department of Biochemistry, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- *Correspondence: Pisit Tangkijvanich
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9
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Peliganga LB, Horta MAP, Lewis-Ximenez LL. Enduring Challenges despite Progress in Preventing Mother-to-Child Transmission of Hepatitis B Virus in Angola. Pathogens 2022; 11:pathogens11020225. [PMID: 35215168 PMCID: PMC8874832 DOI: 10.3390/pathogens11020225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 01/31/2022] [Accepted: 02/02/2022] [Indexed: 02/01/2023] Open
Abstract
Sub-Saharan Africa has one of the highest rates of hepatitis B virus (HBV) infection globally, with an incidence of 1.5 million and 0.8 million yearly deaths, which drives synergistic efforts towards its elimination. To assess the risk of mother-to-child transmission of HBV infection, a cross-sectional study was conducted on 1012 pregnant women in Angola to investigate HBV serological and molecular profiles. The prevalence of HBV was 8.7% (n = 88), with hepatitis B core IgM antibody (anti-HBc IgM) positivity identified in 12.8%, hepatitis B “e” antigen (HBeAg) positivity in 30%, and HBV DNA ≥ 200,000 IU/mL in 28.2%. Family tracking studied 44 children, of which 11 (25%) received at least two doses of the hepatitis B vaccine. HBV was detected in 10/44 (22.7%) children, with vaccination reported in one infected child. Further testing identified anti-HBc IgM positivity in 3/10 (30%), HBeAg positivity in 55%, and both seromarkers in 20%. The results revealed the importance of antenatal HBV screening, antiviral prophylaxis for mothers with high viral loads or HBeAg positivity, and timely first-dose hepatitis B vaccines in newborns. Anti-HBc IgM positivity among pregnant women and children highlights prophylactic measures worth considering, including antenatal hepatitis B vaccination and catch-up vaccination to young children.
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Affiliation(s)
- Luis Baião Peliganga
- Viral Hepatitis Laboratory, Oswaldo Cruz Institute, Oswaldo Cruz Foundation, Rio de Janeiro 21040-900, Brazil;
- Disease Control Department, National Directorate of Public Health, Ministry of Health, Luanda, Angola
- Internal Medicine Investigation Department, Faculdade de Medicina da Universidade Agostinho Neto, Luanda, Angola
| | | | - Lia Laura Lewis-Ximenez
- Viral Hepatitis Laboratory, Oswaldo Cruz Institute, Oswaldo Cruz Foundation, Rio de Janeiro 21040-900, Brazil;
- Correspondence: ; Tel.: +55-(21)-991-921-519
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