Socioeconomic status in HCV infected patients - risk and prognosis

Results from a retrospective case finding and re-engagement exercise for people previously diagnosed with hepatitis C virus to increase uptake of directly acting antiviral treatment

BACKGROUND

Direct acting antivirals (DAAs) for the Hepatitis C virus (HCV) have shifted the World Health Organisation global strategic focus to the elimination of HCV by 2030. In England, the UK Health Security Agency (UKHSA) led a national 'patient re-engagement exercise', using routine surveillance data, which was delivered through the HCV Operational Delivery Networks (ODNs) with support from National Health Service England (NHSE), to help find and support people with a positive HCV PCR test result to access treatment. We report a quantitative evaluation of outcomes of this exercise.

METHODS

Individuals with a recorded positive HCV antibody or PCR result between 1996 and 2017 were identified using UKHSA's records of HCV laboratory diagnosis. Linkage with established health-care datasets helped to enhance patient identification and minimise attempts to contact deceased or previously treated individuals. From September to November 2018 each ODN was provided with a local list of diagnosed individuals. ODNs were asked to perform further data quality checks through local systems and then write to each individual's GP to inform them that the individual would be contacted by the ODN to offer confirmatory HCV PCR testing, assessment and treatment unless the GP advised otherwise. Outcomes of interest were receipt of treatment, a negative PCR result, and death. Data were collected in 2022.

RESULTS

Of 176,555 individuals with a positive HCV laboratory report, 55,329 individuals were included in the exercise following linkage to healthcare datasets and data reconciliation. Participants in the study had a median age of 51 years (IQR: 43, 59), 36,779 (66.5%) were males, 47,668 (86.2%) were diagnosed before 2016 and 11,148 (20.2%) lived in London. Of the study population, 7,442 (13.4%) had evidence of treatment after the re-engagement exercise commenced, 6,435 (11.6%) were reported as PCR negative (96% had no previous treatment records), 4,195 (7.6%) had prescription data indicating treatment before the exercise commenced or were reported to have been treated previously by their ODN, and 2,990 (5.4%) had died. The status of 32,802 (59.3%) people remains unknown.

CONCLUSIONS

A substantial number of those included had treatment recorded after the exercise commenced, however, many more remain unengaged. Evaluation of the exercise highlighted areas that could be streamlined to improve future exercises.

Occurrence of hepatitis B and C virus infection in socioeconomic population strata from Recife, Pernambuco, Northeast Brazil

OBJECTIVE

To estimate the probability of infection with hepatitis B (HBV) and C (HCV) viruses in different socioeconomic strata of the population of Recife, Northeast Brazil.

METHODS

Study carried out from samples obtained in a survey of residents of a large urban center that had a population base and stratified sampling with random selection of households using the "Brazil Sample" package in the R software. HBV (HBsAg) and anti-HCV was performed using immunochromatographic tests. In cases positive for HBsAg, anti-HBc and HBeAg were tested using chemiluminescence, as well as HBV-DNA using real-time PCR. For cases positive for anti-HCV, the search for this antibody was repeated by chemiluminescence and for HCV-RNA by real-time PCR. The occurrence of HBsAg and anti-HCV cases in the general population was estimated based on a theoretical negative binomial distribution.

RESULTS

Among 2,070 samples examined, 5 (0.24%) were HBsAg and 2 (0.1%) anti-HCV positive. The majority of cases had self-reported skin color as black/brown (6/7), education level up to high school (6/7), a steady partner (5/7) and lived in an area of low socioeconomic status (5/7).

CONCLUSION

The occurrence of HBsAg and anti-HCV was lower than those previously found in population-based studies and slightly lower than the most recent estimates. Individuals with lower socioeconomic status should be a priority target of public health policies.

Epidemiology of Hepatitis C Virus in HIV Patients from West Mexico: Implications for Controlling and Preventing Viral Hepatitis

The complex epidemiology of hepatitis C virus (HCV) infection among human immunodeficiency virus (HIV) patients in West Mexico remains poorly understood. Thus, this study aimed to investigate the HCV prevalence, HCV-associated risk factors, and HCV genotypes/subtypes and assess their impacts on liver fibrosis in 294 HIV patients (median age: 38 years; 88.1% male). HCV RNA was extracted and amplified by PCR. Hepatic fibrosis was assessed using three noninvasive methods: transient elastography (TE), the aspartate aminotransferase (AST)-to-platelets ratio index score (APRI), and the fibrosis-4 score (FIB4). Patients with liver stiffness of ≥9.3 Kpa were considered to have advanced liver fibrosis. HCV genotypes/subtypes were determined by line probe assay (LiPA) or Sanger sequencing. The prevalence of HIV/HCV infection was 36.4% and was associated with injection drug use (odds ratio (OR) = 13.2; 95% confidence interval (CI) = 5.9-33.6; p < 0.001), imprisonment (OR = 3.0; 95% CI = 1.7-5.4; p < 0.001), the onset of sexual life (OR = 2.6; 95% CI = 1.5-4.5; p < 0.001), blood transfusion (OR = 2.5; 95% CI = 1.5-4.2; p = 0.001), tattooing (OR = 2.4; 95% CI = 1.4-3.9; p = 0.001), being a sex worker (OR = 2.3; 95% CI = 1.0-5.4; p = 0.046), and surgery (OR = 1.7; 95% CI = 1.0-2.7; p = 0.042). The HCV subtype distribution was 68.2% for 1a, 15.2% for 3a, 10.6% for 1b, 3.0% for 2b, 1.5% for 2a, and 1.5% for 4a. The advanced liver fibrosis prevalence was highest in patients with HIV/HCV co-infection (47.7%), especially in those with HCV subtype 1a. CD4+ counts, albumin, direct bilirubin, and indirect bilirubin were associated with liver fibrosis. In conclusion, HCV infection had a significant impact on the liver health of Mexican HIV patients, highlighting the need for targeted preventive strategies in this population.

Hepatitis C Virus Infection and Hospital-Related Outcomes: A Systematic Review

Background

People living with hepatitis C infection (HCV) have a significant impact on the global healthcare system, with high rates of inpatient service use. Direct-acting antivirals (DAAs) have the potential to alleviate this burden; however, the evidence on the impact of HCV infection and hospital outcomes is undetermined. This systematic review aims to assess this research gap, including how DAAs may modify the relationship between HCV infection and hospital-related outcomes.

Methods

We searched five databases up to August 2022 to identify relevant studies evaluating the impact of HCV infection on hospital-related outcomes. We created an electronic database of potentially eligible articles, removed duplicates, and then independently screened titles, abstracts, and full-text articles.

Results

A total of 57 studies were included. Analysis of the included studies found an association between HCV infection and increased number of hospitalizations, length of stay, and readmissions. There was less consistent evidence of a relationship between HCV and in-hospital mortality. Only four studies examined the impact of DAAs, which showed that DAAs were associated with a reduction in hospitalizations and mortality. In the 14 studies available among people living with HIV, HCV coinfection similarly increased hospitalization, but there was less evidence for the other hospital-related outcomes.

Conclusions

There is good to high-quality evidence that HCV negatively impacts hospital-related outcomes, primarily through increased hospitalizations, length of stay, and readmissions. Given the paucity of studies on the effect of DAAs on hospital outcomes, future research is needed to understand their impact on hospital-related outcomes.

Mortality rates among patients successfully treated for hepatitis C in the era of interferon-free antivirals: population based cohort study

OBJECTIVES

To quantify mortality rates for patients successfully treated for hepatitis C in the era of interferon-free, direct acting antivirals and compare these rates with those of the general population.

DESIGN

Population based cohort study.

SETTING

British Columbia, Scotland, and England (England cohort consists of patients with cirrhosis only).

PARTICIPANTS

21 790 people who were successfully treated for hepatitis C in the era of interferon-free antivirals (2014-19). Participants were divided into three liver disease severity groups: people without cirrhosis (pre-cirrhosis), those with compensated cirrhosis, and those with end stage liver disease. Follow-up started 12 weeks after antiviral treatment completion and ended on date of death or 31 December 2019.

MAIN OUTCOME MEASURES

Crude and age-sex standardised mortality rates, and standardised mortality ratio comparing the number of deaths with that of the general population, adjusting for age, sex, and year. Poisson regression was used to identify factors associated with all cause mortality rates.

RESULTS

1572 (7%) participants died during follow-up. The leading causes of death were drug related mortality (n=383, 24%), liver failure (n=286, 18%), and liver cancer (n=250, 16%). Crude all cause mortality rates (deaths per 1000 person years) were 31.4 (95% confidence interval 29.3 to 33.7), 22.7 (20.7 to 25.0), and 39.6 (35.4 to 44.3) for cohorts from British Columbia, Scotland, and England, respectively. All cause mortality was considerably higher than the rate for the general population across all disease severity groups and settings; for example, all cause mortality was three times higher among people without cirrhosis in British Columbia (standardised mortality ratio 2.96, 95% confidence interval 2.71 to 3.23; P<0.001) and more than 10 times higher for patients with end stage liver disease in British Columbia (13.61, 11.94 to 15.49; P<0.001). In regression analyses, older age, recent substance misuse, alcohol misuse, and comorbidities were associated with higher mortality rates.

CONCLUSION

Mortality rates among people successfully treated for hepatitis C in the era of interferon-free, direct acting antivirals are high compared with the general population. Drug and liver related causes of death were the main drivers of excess mortality. These findings highlight the need for continued support and follow-up after successful treatment for hepatitis C to maximise the impact of direct acting antivirals.

Impact of Race and Neighborhood Socioeconomic Characteristics on Liver Cancer Diagnosis in Patients with Viral Hepatitis and Cirrhosis

Background

Concerning data have revealed that viral hepatitis and hepatocellular carcinoma (HCC) disproportionally impact non-White patients and those from lower socioeconomic status. A recent study found that HCC clusters were more likely to be in high poverty areas in New York City.

Aims

We aim to investigate the impacts of neighborhood characteristics on those with viral hepatitis and cirrhosis, particularly with advanced HCC diagnosis.

Methods

Patients with cirrhosis and viral hepatitis admitted to a New York City health system between 2012 and 2019 were included. Those with prior liver transplants were excluded. Neighborhood characteristics were obtained from US Census. Our primary outcome was HCC and advanced HCC diagnosis.

Results

This study included 348 patients; 209 without history of HCC, 20 with early HCC, 98 with advanced HCC, and 21 patients with HCC but no staging information. Patients with advanced HCC were more likely to be older, male, Asian, history of HBV, and increased mortality. They were more likely to live in areas with more foreign-born, limited English speakers, and less than high school education. After adjusting for age, sex, and payor type, Asian race and low income were independent risk factors for advanced HCC. Neighborhood factors were not associated with mortality or readmissions.

Conclusion

We observed that in addition to age and sex, Asian race, lower household income, lower education, and lower English proficiency were associated with increased risk of advanced HCC. These disparities likely reflect suboptimal screening programs and linkage to care among vulnerable populations. Further efforts are crucial to validate and address these concerning disparities.

Risk prediction of hepatitis B or C or HIV among newly diagnosed cancer patients

BACKGROUND

Screening for viral infection in cancer patients is inconsistent. A mechanism to readily identify cancer patients at increased risk of existing or prior viral infection could enhance screening efforts while reducing costs.

METHODS

We identified factors associated with increased risk of past or chronic hepatitis virus B, hepatitis virus C, or HIV infection before initiation of systemic cancer therapy. Data were from a multicenter prospective cohort study of 3051 patients with newly diagnosed cancer (SWOG-S1204) enrolled between 2013 and 2017. Patients completed a survey with questions pertaining to personal history and behavioral, socioeconomic, and demographic risk factors for viral hepatitis or HIV. We derived a risk model to predict the presence of viral infection in a random set of 60% of participants using best subset selection. The derived model was validated in the remaining 40% of participants. Logistic regression was used.

RESULTS

A model with 7 risk factors was identified, and a risk score with 4 levels was constructed. In the validation cohort, each increase in risk level was associated with a nearly threefold increased risk of viral positivity (odds ratio = 2.85, 95% confidence interval = 2.26 to 3.60, P < .001). Consistent findings were observed for individual viruses. Participants in the highest risk group (with >3 risk factors), comprised of 13.4% of participants, were 18 times more likely to be viral positive compared with participants with no risk factors (odds ratio = 18.18, 95% confidence interval = 8.00 to 41.3, P < .001).

CONCLUSIONS

A risk-stratified screening approach using a limited set of questions could serve as an effective strategy to streamline screening for individuals at increased risk of viral infection.

Seroprevalence and risk factors associated with hepatitis C: a cross-sectional study of persons who inject drugs in Puerto Rico, 2018

BACKGROUND

People Who Inject Drugs (PWID) are at a higher risk of acquiring bloodborne infections. We aimed to estimate the seroprevalence of the Hepatitis C Virus (HCV) in PWID and identify correlates and risk factors using data from the Puerto Rico National HIV Behavioral Surveillance System, PWID cycle 5, conducted in 2018.

METHODS

A total of 502 San Juan Metropolitan Statistical Area participants were recruited through the Respondent Driven Sampling method. Sociodemographic, health-related, and behavioral characteristics were assessed. Testing for HCV antibodies was completed after the face-to-face survey. Descriptive and logistic regression analyses were performed.

RESULTS

Overall seroprevalence of HCV was 76.5% (95% CI: 70.8-81.4%). A significantly (p < 0.05) higher HCV seroprevalence was observed among PWID with the following characteristics: heterosexuals (78.5%), high school graduates (81.3%), tested for sexually transmitted infections (STI) in the past 12 months (86.1%), frequent speedball injection (79.4%), and knowing the HCV serostatus of the last sharing partner (95.4%). Adjusted logistic regression models showed that having completed high school and reported STI testing in the past 12 months were significantly associated with HCV infection (OR_a = 2.23; 95% CI: 1.06-4.69; OR_a = 2.14; 95% CI: 1.06-4.30, respectively).

CONCLUSIONS

We report a high seroprevalence of HCV infection in PWID. Social health disparities and potential missed opportunities validate the continuing call for local action for public health and prevention strategies.

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.

Disparities in health utilities among hepatitis C patients receiving care in different settings

BACKGROUND: Although chronic hepatitis C (CHC) disproportionately affects marginalized individuals, most health utility studies are conducted in hospital settings which are difficult for marginalized patients to access. We compared health utilities in CHC patients receiving care at hospital-based clinics and socio-economically marginalized CHC patients receiving care through a community-based program. METHODS: We recruited CHC patients from hospital-based clinics at the University Health Network and community-based sites of the Toronto Community Hep C Program, which provides treatment, support, and education to patients who have difficulty accessing mainstream health care. We elicited utilities using six standardized instruments (EuroQol-5D-3L [EQ-5D], Health Utilities Index Mark 2/Mark 3 [HUI2/HUI3], Short Form-6D [SF-6D], time trade-off [TTO], and Visual Analogue Scale [VAS]). Multivariable regression analysis was performed to examine factors associated with differences in health utility. RESULTS: Compared with patients recruited from the hospital setting (n = 190), patients recruited from the community setting (n = 101) had higher unemployment (87% versus 67%), history of injection drug use (88% versus 42%), and history of mental health issue(s) (79% versus 46%). Unadjusted health utilities were lower in community than hospital patients (e.g., EQ-5D: 0.722 [SD 0.209] versus 0.806 [SD 0.195]). Unemployment and a history of mental health issue(s) were significant predictors of low health utility. CONCLUSIONS: Socio-economically marginalized CHC patients have lower health utilities than patients typically represented in the CHC utility literature. Their utilities should be incorporated into future cost-utility analyses to better represent the population living with CHC in health policy decisions.

Liver-related complications before and after successful treatment of chronic hepatitis C virus infection in people with inherited bleeding disorders

INTRODUCTION

With availability of direct-acting antivirals (DAA), most persons with inherited bleeding disorders are currently cured of hepatitis C virus (HCV) infection. The risk of liver-related complications following HCV cure has not been reported for this population.

AIM

Reporting liver-related complications during long-term chronic HCV infection and following sustained virological response (SVR) in this population.

METHODS

Retrospective follow-up of a prospective single-centre cohort of HCV antibody-positive persons with inherited bleeding disorders. Primary endpoint was liver-related complications [hepatocellular carcinoma (HCC), decompensated cirrhosis, bleeding gastroesophageal varices]. Liver-related complications were reported separately during chronic HCV and following SVR, stratified for interferon-based and DAA-based SVR.

RESULTS

In total 309/381 (81%) HCV antibody-positive individuals developed chronic HCV infection. Median follow-up was 44 years [interquartile range (IQR): 34-50]. Liver-related complications occurred in 36/309 (12%) of individuals with chronic HCV infection after median 31 years of chronic infection. Of 199 individuals with SVR, 97 were cured with interferon-based regimens and 102 with DAA after median infection durations of 29 and 45 years, respectively. At end of follow-up, respectively, 21% and 42% had advanced fibrosis or cirrhosis. Post-SVR, seven (4%) individuals had a liver-related complication, mainly HCC (n = 4). Incidence of liver-related complications per 100 patient-years post-SVR follow-up was .2 for interferon-cured and 1.0 for DAA-cured individuals (p = .01).

CONCLUSION

Successful HCV treatment does not eliminate the risk of liver-related complications in persons with inherited bleeding disorders. Due to higher baseline risk, incidence was higher after DAA than interferon-based SVR. We advise continuing HCC surveillance post-SVR in all with advanced fibrosis or cirrhosis.

Perceived Stress in Hepatitis C Virus Infected Patients under the DAA-Based Therapy

The Hepatitis C Virus (HCV) infection often associates medical and mental health conditions which lead to increased levels of distress. Our study aimed at assessing the level of perceived stress on a sample of 90 HCV infected patients treated with Direct-Acting Antiviral (DAA) agents for 12 weeks, and its possible correlations with clinical and evolutionary elements. The evaluation was conducted in three phases: before administration of the DAAs (BSL), at the End of the Treatment (EOT), and 24 weeks after the BSL (Sustained Viral Response—SVR). The perceived stress was measured using the Perceived Stress Scale (PSS). The efficiency of the DAA treatment reduced the levels of stress (98.99% moderate and high stress at BSL to 70.00% at SVR). It was observed, for the entire study period (BSL to SVR), that the decrease in the perceived stress severity was significantly associated with demographic items such as gender (p < 0.01), urban environment (p < 0.001), the age of the subjects (p < 0.05), and clinical data such as F4 degree of fibrosis (p = 0.001) and overweight or obesity class II (p < 0.01). The perceived stress is directly associated with the severity of the HCV infection, and it could be significantly lowered by an efficient therapeutic approach, as DAAs are nowadays.

Prevalence and assessment of the associated risk factors of hepatitis B and C infections in the low socioeconomic communities

Aim: This study determined the prevalence and risk factors associated with hepatitis B and C among the low socioeconomic population. Materials & methods: A total of 1004 participants were screened for hepatitis B/C infection and risk factors from six different localities of Islamabad, Pakistan Results: The prevalence rate of hepatitis B and C was 1 and 4%, respectively. Chi-square test showed hepatitis B/C infection was related with marital status, hepatitis B vaccination, blood recipients and family income. Multivariable analysis showed hepatitis B vaccination, exposure to therapeutic injections, dental visits, exposure to HCV patients and age of participants were independently associated with hepatitis C infection. Conclusion: The risk of hepatitis B/C infection is multifactorial and the population needs to be vaccinated at a larger scale to avoid outbreaks.

Analysis of the association between areal socioeconomic deprivation levels and viral hepatitis B and C infections in Japanese municipalities

Background

We investigated the association between municipal socioeconomic deprivation levels and the positivity of hepatitis B surface antigen (HBsAg) and the prevalence of hepatitis C virus (HCV) among individuals who have never participated in hepatitis screening using Japanese national screening data.

Methods

The hepatitis virus screening data analyzed included the 5-year age group-specific number of participants aged 40 years or older, number of HBsAg-positive persons, and number of HCV carriers for each municipality from 2013 to 2017. Principal component analysis was used to derive a socioeconomic deprivation level using the socioeconomic characteristics of municipalities. Bayesian spatial Poisson regression analysis was conducted to investigate the association between the socioeconomic deprivation level and the results of screening. Data on 1,660 municipalities were used in the analysis.

Results

The data of 4,233,819 participants in the HBV screening and 4,216,720 in the HCV screening were used in the analysis. A principal component interpreted as level of rurality (principal component 1) and another principal component interpreted as level of low socioeconomic status among individuals (principal component 2) were extracted as the major principal components. Their principal component scores were used as the deprivation levels of municipalities. Spatial regression analysis showed that the deprivation level derived from the sum of the scores of principal components 1 and 2 was significantly and positively associated with HBsAg positivity and HCV prevalence. In addition, the deprivation level derived only from the score of principal component 2 was also significantly and positively associated with the outcomes. Conversely, the deprivation level derived only from the score of principal component 1 was not associated with the outcomes. Moreover, population density was significantly and positively associated with HBsAg positivity and HCV prevalence.

Conclusions

This study suggested that participation in hepatitis virus screening is important and meaningful, particularly for areas with a higher lower socioeconomic level in Japan.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13089-w.

Targeting population groups with heavier burden of hepatocellular carcinoma incidence: a nationwide descriptive epidemiological study in Sweden

Contemporary European studies examining associations between socioeconomic status and hepatocellular carcinoma (HCC) incidence are scarce. We aimed to target population groups with a heavier burden of HCC by assessing associations of individual‐level sociodemographic variables and neighbourhood deprivation with all‐stage and stage‐specific HCC incidence rates (IR). Patient and population data stratified by calendar year (2012‐2018), sex, age (5‐year groups), household income (low, medium and high), country of birth (Nordic, non‐Nordic) and neighbourhood deprivation (national quintiles Q1‐Q5) were retrieved from Swedish registers. HCC stages were defined by Barcelona Clinic Liver Cancer stages 0 to A (early‐stage) and B to D (late‐stage). IR (per 100 000 person‐years) were estimated by Poisson regression models. Men had four times higher IR than women. IRs increased markedly with lower household income as well as with neighbourhood deprivation. Seven times higher IR was observed among people with a low household income living in the most deprived neighbourhoods (IR 3.90, 95% confidence interval [CI] 3.28‐4.64) compared to people with a high household income living in the least deprived neighbourhoods (IR 0.58, 95% CI 0.46‐0.74). The gradient across income categories was more pronounced for late‐stage than early‐stage HCC. IR reached 30 (per 100 000 person‐years) for people in the age span 60 to 79 years with low income and 20 for 60 to 79 year old people living in the most deprived neighbourhoods (regardless of income). Men with low household income and/or living in the most deprived neighbourhoods might be considered as primary targets in studies evaluating the cost‐effectiveness of screening for early‐stage HCC detection.

Emissions of dioxins and dioxin-like compounds and incidence of hepatocellular carcinoma in the United States

Ambient dioxin exposure from industrial sources, excluding exposures from occupations and accidental releases/contamination, may be associated with risk of developing hepatocellular carcinoma (HCC). The objective of this study was to examine the association between county-level ambient dioxin air emissions from industrial sources and HCC risk in the US. We obtained information on 90,359 incident HCC cases diagnosed between 2000 and 2016 from population-based cancer registries across the US in the Surveillance, Epidemiology, and End Results (SEER) database. Dioxin emissions from 1987 to 2007 from a nationwide spatial database of historical dioxin-emitting facilities were linked to the SEER county of residence at diagnosis using a geographic information system (GIS). Poisson regression with robust variance estimation was used to calculate incidence rate ratios (IRRs) and 95% confidence intervals (CIs) for the association between county-level dioxin emissions and HCC rates adjusting for individual-level age at diagnosis, sex, race/ethnicity, year of diagnosis, SEER registry, and county-level information on health conditions, lifestyle factors, and socioeconomic status. There was no association between dioxin emissions based on the number of dioxin-emitting facilities within a county or average annual emissions within a county and HCC risk. In analyses by facility type, there were positive associations between county-level dioxin emissions from coal-fired power plants (adjusted IRR 1.09, 95% CI 1.01-1.17), but not with the number of these facilities. Similarly, positive associations for industrial boilers and sewage sludge incinerators were evident, but not consistent across both exposure metrics. Future research should incorporate individual-level data to further explore the findings suggested by these ecologic analyses.

Analysis of risk factors for mental health problems of inpatients with chronic liver disease and nursing strategies: A single center descriptive study

The number of patients with chronic liver disease (CLD) is large. The social and economic burdens due to CLD have increased. The mental health problems of patients with CLD are prominent and deserve our attention and care. This study analyzed 320 patients with CLD who were hospitalized between January 2018 and January 2020. Questionnaire surveys were used to assess mental health status, including the Self-Rating Anxiety Scale (SAS), Self-Rating Depression Scale (SDS), and Symptom Checklist-90 (SCL-90). At the same time, basic data and potential related factors were collected. Data were analyzed using descriptive statistics and logistic regression. Among the 320 patients with CLD, 240 (75%) had mental health problems; among the total patients, education levels, occupations, course of disease, annual hospitalizations, complications, and nursing satisfaction were significantly different between the two groups (p < .05). The education levels and occupations of the group without mental health problems were significantly different within the group (p < .05). The SCL-90 found that the four factors with the highest scores were anxiety (ANX: 33.3%), depression (DEPR: 20.4%), somatization (SOM: 12.9%), and sleep and diet (SD: 9.6%). Logistic regression analysis showed that education levels, course of disease, annual hospitalizations, complications, and nursing satisfaction levels were independent risk factors for the mental health of patients with CLD. Model fitness was checked using the Hosmer-Lemeshow test. The receiver operating characteristic (ROC) curve showed that the area under the curve was 0.84. Patients with CLD have prominent mental health problems and experience many risk factors. It is necessary to adopt individualized psychological interventions and care to improve the quality of life of these patients.

Comparison of Clinical Features and Outcomes Between Intrahepatic Cholangiocarcinoma and Hepatocellular Carcinoma in the United States

BACKGROUND AND AIMS

Intrahepatic cholangiocarcinoma (iCCA) and hepatocellular carcinoma (HCC) are the most common primary liver cancers (PLCs). Differences in their clinical features and outcomes are open for investigation in a large-scale study. We aim to investigate the differences in clinical features and outcomes between iCCA and HCC.

APPROACH AND RESULTS

The Surveillance, Epidemiology, and End Results Program 18 Database (2000-2017) was used to extract demographic and clinical features of HCC and iCCA patients. Logistic regression analysis was performed to identify factors associated with iCCA diagnosis versus HCC. Cox regression analysis was used to assess factors affecting overall survival (OS). There were 13,611 iCCA and 96,151 HCC patients. Half of iCCA (50.7%) and three quarters of HCC (76.3%) patients were male. Diagnosis in recent year, age (<50 or ≥65), female sex, non-Hispanic White race, higher income, rural area, and higher tumor burden were independently associated with iCCA diagnosis versus HCC. Patients with iCCA had worse OS than those with HCC (9 vs. 13 months; P < 0.001). However, OS was comparable between iCCA and HCC in multivariable analysis (adjusted hazard ratio [aHR] = 1.02; 95% CI = 0.99-1.05). In subgroup analyses, iCCA was associated with better OS than HCC in patients with tumor ≥5 cm (aHR = 0.83; 95% CI = 0.80-0.86), lymph node involvement (aHR = 0.76; 95% CI = 0.72-0.81), distant metastasis (aHR = 0.76; 95% CI = 0.73-0.79), poorly/undifferentiated tumors (aHR = 0.88; 95% CI = 0.83-0.94), and those receiving noncurative treatment (aHR = 0.96; 95% CI = 0.93-0.98).

CONCLUSIONS

We identified the demographic, socioeconomic, and clinical features associated with iCCA diagnosis over HCC among patients with PLC. Although iCCA patients presented at an advanced stage, OS was similar between iCCA and HCC in multivariable analysis. iCCA was associated with longer OS for subgroups with poor prognostic features.

Distribution of HCV Genotypes Among People Who Inject Drugs in Tunisia: New Evidence for Scaling Up Prevention and Treatment Toward National Elimination Goal

Little is known about the distribution of hepatitis C virus (HCV) genotypes among people who inject drugs (PWID) in North African countries, including Tunisia. This study aims to describe HCV genotypes circulating among Tunisian PWID. A cross-sectional study was conducted, and 128 HCV-positive PWID were recruited between 2018 and 2019 from community-based harm reduction centers. After informed consent, sociodemographic characteristics and risk behavior data were obtained using an interviewer-administrated questionnaire. Blood samples were collected for further serological and molecular testing. Overall, five women and 123 men were included. The median age was 39.5 years. The majority of PWID (56.3%) had less than a secondary level of education, were single (57%), were unemployed (65.6%), were incarcerated at least once (93.0%), and had a history of residency in at least one foreign country (50.8%). During the previous 12 months, 82.0% reported having reused syringes at least once, 43.8% shared syringes at least once, while 56.2% had at least one unprotected sexual relation, and 28.1% had more than two different sexual partners. Tattooing was reported among 60.2%. All positive results for HCV-infection by rapid testing were confirmed by enzyme-linked immunosorbent assay (ELISA). HCV-RNA was detectable in 79.7%. Genotyping showed a predominance of genotype 1 (52%) followed by genotype 3 (34%) and genotype 4 (10%). Four patients (4%) had an intergenotype mixed infection. Subtyping showed the presence of six different HCV subtypes as follows: 1a (53.2%), 1b (6.4%), 3a (33.0%), 4a (3.2%), and 4d (4.3%). This is the first study describing circulating HCV genotypes among PWID in Tunisia. The distribution of HCV genotypes is distinct from the general population with a predominance of subtypes 1a and 3a. These findings can be used to guide national efforts aiming to optimize the access of PWID to relevant HCV prevention and treatment measures including pangenotypic regimens for patients infected with HCV genotype 3.

Long-term exposure to air pollution and liver cancer incidence in six European cohorts

Particulate matter air pollution and diesel engine exhaust have been classified as carcinogenic for lung cancer, yet few studies have explored associations with liver cancer. We used six European adult cohorts which were recruited between 1985 and 2005, pooled within the "Effects of low-level air pollution: A study in Europe" (ELAPSE) project, and followed for the incidence of liver cancer until 2011 to 2015. The annual average exposure to nitrogen dioxide (NO₂ ), particulate matter with diameter <2.5 μm (PM_2.5 ), black carbon (BC), warm-season ozone (O₃ ), and eight elemental components of PM_2.5 (copper, iron, zinc, sulfur, nickel, vanadium, silicon, and potassium) were estimated by European-wide hybrid land-use regression models at participants' residential addresses. We analyzed the association between air pollution and liver cancer incidence by Cox proportional hazards models adjusting for potential confounders. Of 330 064 cancer-free adults at baseline, 512 developed liver cancer during a mean follow-up of 18.1 years. We observed positive linear associations between NO₂ (hazard ratio, 95% confidence interval: 1.17, 1.02-1.35 per 10 μg/m³ ), PM_2.5 (1.12, 0.92-1.36 per 5 μg/m³ ), and BC (1.15, 1.00-1.33 per 0.5 10^-5 /m) and liver cancer incidence. Associations with NO₂ and BC persisted in two-pollutant models with PM_2.5 . Most components of PM_2.5 were associated with the risk of liver cancer, with the strongest associations for sulfur and vanadium, which were robust to adjustment for PM_2.5 or NO₂ . Our study suggests that ambient air pollution may increase the risk of liver cancer, even at concentrations below current EU standards.

Evaluating the impact of social deprivation on Press Ganey® Outpatient Medical Practice Survey Scores

Background

Social deprivation has been shown to affect access to health care services, and influences outcomes for a variety of physical and psychological conditions. However, the impact on patient satisfaction remains less clear. The objective of this study was to determine if social deprivation is an independent predictor of patient satisfaction, as measured by the Press Ganey® Outpatient Medical Practice Survey (PGOMPS).

Methods

We retrospectively reviewed unique new adult patient (≥ 18 years of age) seen at a tertiary academic hospital and rural/urban outreach hospitals/clinics between January 2014 and December 2017. Satisfaction was defined a priori as achieving a score above the 33rd percentile. The 2015 Area Deprivation Index (ADI) was used to determine social deprivation (lower score signifies less social deprivation). Univariate and multivariable binary logistic regression were used to determine the impact of ADI on PGOMPS total and provider sub-scores while controlling for variables previously shown to impact scores (wait time, patient age, sex, race, specialty type, provider type, and insurance status).

Results

Univariate analysis of PGOMPS total scores revealed a 4% decrease in odds of patient satisfaction per decile increase in ADI (p < 0.001). Patients within the most deprived quartile were significantly less likely to report satisfaction compared to the least deprived quartile (OR 0.79, p < 0.001). Multivariable analysis revealed that the odds of achieving satisfaction decreased 2% for each decile increase in ADI on the Total Score (p < 0.001), independent of other variables previously shown to impact scores. For PGOMPS Provider Sub-Score, univariate analysis showed that patients in the lowest ADI quartile were significantly less likely be satisfied, as compared to the least deprived quartile (OR 0.77; 95% CI 0.70–0.86; p < 0.001). A 5% decrease in a patient being satisfied was observed for each decile increase in ADI (OR 0.95; 95% CI 0.94–0.96; p < 0.001).

Conclusions

Social deprivation was an independent predictor of outpatient visit dissatisfaction, as measured by the Press Ganey® Outpatient Medical Practice Survey. These results necessitate consideration when developing health care delivery policies that serve to minimize inequalities between patients of differing socioeconomic groups.

Racial, Gender, and Socioeconomic Disparities in Liver Transplantation

Liver transplantation (LT) is a life-saving therapy; therefore, equitable distribution of this scarce resource is of paramount importance. We searched contemporary literature on racial, gender, and socioeconomic disparities across the LT care cascade in referral, waitlist practices, allocation, and post-LT care. We subsequently identified gaps in the literature and future research priorities. Studies found that racial and ethnic minorities (Black and Hispanic patients) have lower rates of LT referral, more advanced liver disease and hepatocellular carcinoma at diagnosis, and are less likely to undergo living donor LT (LDLT). Gender-based disparities were observed in waitlist mortality and LT allocation. Women have lower LT rates after waitlisting, with size mismatch accounting for much of the disparity. Medicaid insurance has been associated with higher rates of chronic liver disease and poor waitlist outcomes. After LT, some studies found lower overall survival among Black compared with White recipients. Studies have also shown lower literacy and limited educational attainment were associated with increased posttransplant complications and lower use of digital technology. However, there are notable gaps in the literature on disparities in LT. Detailed population-based estimates of the advanced liver disease burden and LT referral and evaluation practices, including for LDLT, are lacking. Similarly, little is known about LT disparities worldwide. Evidence-based strategies to improve access to care and reduce disparities have not been comprehensively identified. Prospective registries and alternative "real-world" databases can provide more detailed information on disease burden and clinical practices. Modeling and simulation studies can identify ways to reduce gender disparities attributed to size or inaccurate estimation of renal function. Mixed-methods studies and clinical trials should be conducted to reduce care disparities across the transplant continuum.

Behavioral interventions to improve population health outreach for hepatitis C screening: randomized clinical trial

OBJECTIVE

To evaluate whether opt out framing, messaging incorporating behavioral science concepts, or electronic communication increases the uptake of hepatitis C virus (HCV) screening in patients born between 1945 and 1965.

DESIGN

Pragmatic randomized controlled trial.

SETTING

43 primary care practices from one academic health system (Philadelphia, PA, USA) between April 2019 and May 2020.

PARTICIPANTS

Patients born between 1945 and 1965 with no history of screening and at least two primary care visits in the two years before the enrollment period.

INTERVENTIONS

This multilevel trial was divided into two studies. Substudy A included 1656 eligible patients of 17 primary care clinicians who were randomized in a 1:1 ratio to a mailed letter about HCV screening (letter only), or a similar letter with a laboratory order for HCV screening (letter+order). Substudy B included the remaining 19 837 eligible patients followed by 417 clinicians. Active electronic patient portal users were randomized 1:5 to receive a mailed letter about HCV screening (letter), or an electronic patient portal message with similar content (patient portal); inactive patient portal users were mailed a letter. In a factorial design, patients in substudy B were also randomized 1:1 to receive standard content (usual care), or content based on principles of social norming, anticipated regret, reciprocity, and commitment (behavioral content).

MAIN OUTCOME MEASURES

Proportion of patients who completed HCV testing within four months.

RESULTS

21 303 patients were included in the intention-to-treat analysis. Among the 1642 patients in substudy A, 19.2% (95% confidence interval 16.5% to 21.9%) completed screening in the letter only arm and 43.1% (39.7% to 46.4%) in the letter+order arm (P<0.001). Among the 19 661 patients in substudy B, 14.6% (13.9% to 15.3%) completed screening with usual care content and 13.6% (13.0% to 14.3%) with behavioral science content (P=0.06). Among active patient portal users, 17.8% (16.0% to 19.5%) completed screening after receiving a letter and 13.8% (13.1% to 14.5%) after receiving a patient portal message (P<0.001).

CONCLUSIONS

Opt out framing and effort reduction by including a signed laboratory order with outreach increased screening for HCV. Behavioral science messaging content did not increase uptake, and mailed letters achieved a greater response rate than patient portal messages.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03712553.

Cannabis use is associated with a lower risk of diabetes in chronic hepatitis C-infected patients (ANRS CO22 Hepather cohort)

Chronic hepatitis C virus (HCV) infection is a risk factor of insulin resistance, and HCV-infected patients are at a high risk of developing diabetes. In the general population, research has shown the potential benefit of cannabis use for the prevention of diabetes and related metabolic disorders. We aimed to test whether cannabis use is associated with a lower risk of diabetes in chronic HCV-infected patients. Chronic HCV-infected patients (n = 10 445) were selected from the French national, multicenter, observational ANRS CO22 Hepather cohort. Cross-sectional data collected at cohort enrollment were used to assess the association between patients' clinical and behavioural characteristics and the risk of diabetes. Logistic regression model was performed with cannabis use as the main independent variable and a significance level set at 5%. A similar model stratified by the presence of advanced liver fibrosis (FIB-4 > 3.25) was also run. After multivariable adjustment, current (AOR [95%CI]: 0.49 [0.38-0.63]) and former (0.81 [0.67-0.98], P < .001) cannabis use were both associated with a reduced odds of diabetes. Conversely, male gender, tobacco use, elevated BMI, poverty, being a migrant and advanced fibrosis were associated with increased odds of diabetes. The association between cannabis use and diabetes was maintained in the stratified analysis. In this large cross-sectional study of chronic HCV-infected patients, cannabis use was associated with a lower risk of diabetes independently of clinical and socio-behavioural factors. Further studies are needed to elucidate a potential causal link and shed light on cannabis compounds and mechanisms involved in this relationship.

Socioeconomic and marital status among liver cirrhosis patients and associations with mortality: a population-based cohort study in Sweden

Background

The importance of socioeconomic status for survival in cirrhosis patients is more or less pronounced within different populations, most likely due to cultural and regional differences combined with dissimilarities in healthcare system organisation and accessibility. Our aim was to study the survival of patients with cirrhosis in a population-based Swedish cohort, using available data on marital status, employment status, and occupational skill level.

Methods

We conducted a retrospective cohort study of 582 patients diagnosed with cirrhosis in the Region of Halland (total population 310,000) between 2011 and 2018. Medical and histopathologic data, obtained from registries, were reviewed. Cox regression models were used to estimate associations between survival and marital status (married, never married, previously married), employment status (employed, pensioner, disability retired, unemployed), and occupational skill level (low-skilled: level I; medium-skilled: level II; medium-high skilled: level III; professionals: level IV); adjusting for sex, age, aetiology, Model for End-stage Liver Disease (MELD) score, Child-Pugh class, and comorbidities.

Results

Alcohol was the most common aetiology (51%). Most patients were male (63%) and the median age was 66 years. Occupational skill level was associated with the severity of cirrhosis at diagnosis and the prevalence of Child-Pugh C gradually increased from professionals through low-skilled. The mean survival for professionals (6.39 years, 95% CI 5.54–7.23) was higher than for low-skilled (3.00 years, 95% CI 2.33–3.67) and medium-skilled (4.04 years, 95% CI 3.64–4.45). The calculated hazard ratios in the multivariate analysis were higher for low-skilled (3.43, 95% CI 1.89–6.23) and medium-skilled (2.48, 95% CI 1.48–4.12), compared to professionals. When aggregated, low- and medium-skilled groups also had poorer mean survival (3.79 years, 95% CI 3.44–4.14; vs 5.64 years, 95% CI 5.00–6.28) and higher hazard ratios (1.85, 95% CI 1.32–2.61) compared to the aggregated medium-high skilled and professional groups. Marital and employment status were not statistically significant predictors of mortality in the multivariate analysis.

Conclusions

Occupational skill level was strongly associated with mean survival and mortality risk. Poorer prognosis among patients with low and medium occupational skill level could not be explained by differences in sex, age, marital status, employment status, MELD score, Child-Pugh class, or comorbidity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-020-09783-2.

Determinants of stigma among patients with hepatitis C virus infection

Stigma around hepatitis C virus (HCV) infection is an important and understudied barrier to HCV treatment and elimination. The determinants of HCV-related stigma, including the impacts of stage of HCV treatment (ie spontaneously cleared; diagnosed, untreated; previously treated, not cured; currently being treated; and treated, cured) and coinfection with human immunodeficiency virus (HIV), remain unknown. To address these gaps, we conducted a cross-sectional study among patients with a history of HCV infection (n = 270) at outpatient clinics in Philadelphia from July 2018 to May 2019. We evaluated stigma using the validated HCV Stigma Scale, adapted from the Berger HIV Stigma Scale. Associations among HCV-related stigma and hypothesized demographic, behavioural, and clinical risk factors were evaluated by multivariable linear regression. Most participants (95.5%) experienced HCV-related stigma. Mean stigma scores did not differ significantly between HCV-monoinfected and HIV/HCV-coinfected participants (P = .574). However, we observed significant interactions between HIV status and multiple determinants; therefore, we stratified analyses by HIV status. Among HIV/HCV-coinfected participants, previous HCV treatment without cure, female gender, Hispanic/Latinx ethnicity and some college education were significantly associated with higher HCV-stigma scores. An annual income of $10 000-$40 000 was associated with significantly lower stigma scores. No significant associations were observed among HCV-monoinfected participants. We found that most participants experienced stigma associated with HCV diagnosis. While stigma scores were similar between HCV-monoinfected and HIV/HCV-coinfected participants, the determinants associated with HCV stigma differed by HIV status. Understanding how experiences of stigma differ between HCV-monoinfected and HIV/HCV-coinfected patients may aid in the development of targeted interventions to address the HCV epidemic.

Preliminary Results of the Micro-Elimination Project of Hepatitis C in a Disadvantaged Town in South-West of Romania-Orşova

Despite all recent advances in the diagnosis and treatment of hepatitis C virus infection, the incidence remains high, motivating the present study to improve the prognosis of the disease through early diagnosis of asymptomatic patients with possible detectable risk factors. The aim of this study is to identify HCV infection in a disadvantaged population before the onset of symptoms and guide to specialized services for initiation of antiviral therapy, thus adhering to the WHO goal of elimination the infection. Materials and Methods: In the first two weeks after the start of the study, 320 patients with detectable risk factors for HCV were tested using rapid tests, in a southwestern city of Romania, Orşova, with the participation of four doctors, via Family Medicine Offices. Results: As a percentage, the amount of detection based on rapid tests was 2.5%, the positive results have apparently been achieved exclusively among female subjects. All patients have been informed about the result and included in the diagnostic trial, where they were fully evaluated to determine if they were eligible for therapy. Conclusions. Population screening contributes to the diagnosis and elimination of an underdiagnosed pathology, in a disadvantaged area with limited access to medical care. The positive feedback that has been received in just a few weeks after its beginning, once again has motivated to emphasis the population screening, with real considerations on the possibility of expanding this program on a large scale.

Association of Direct-Acting Antiviral Treatment With Mortality Among Medicare Beneficiaries With Hepatitis C

Importance

Direct-acting antiviral (DAA) drugs are highly effective in curing hepatitis C virus (HCV) infection. Previous simulations showed extended life as a key health advantage of DAA drugs, but real-world evidence on the association between DAA treatment and reduced mortality is limited.

Objectives

To examine the association of DAA treatment with mortality among Medicare beneficiaries with hepatitis C.

Design, Setting, and Participants

This cohort study used Medicare claims data of beneficiaries who sought hepatitis C care for the first time between January 1, 2014, and December 31, 2016, after at least a 1-year washout period. Medicare Part D files were used in identifying DAA therapy initiation and completion. Death dates, demographic data, and indicators of health risks were obtained from the Master Beneficiary Summary Files. Beneficiaries with hepatitis C were considered as patients with DAA treatment if they initiated DAA therapy during the study period. Beneficiaries with hepatitis C who did not initiate DAA therapy during the study period were considered as patients without DAA treatment. Patients without DAA treatment were selected using 1-to-1 propensity score matching. Data were analyzed between September 1, 2019, and March 31, 2020.

Exposures

Completion of DAA treatment.

Main Outcomes and Measures

Time to death from the index date of seeking hepatitis C care after at least a 1-year washout period. Cox proportional hazards regression models with time-varying exposure were used to compare mortality rates between propensity score-matched cohorts of patients with DAA treatment and those without DAA treatment. Separate analyses were performed for patients with or without cirrhosis. Heterogeneity in the association between DAA treatment and mortality by sex and dual-eligibility status was examined.

Results

A propensity score-matched sample of 51 478 Medicare beneficiaries with a mean (SD) age of 59.4 (11.1) years and 30 473 men (59.2%) was assessed. Of this total, 8240 patients (16.0%) had cirrhosis (5224 men [63.4%]; mean [SD] age, 62.3 [9.7] years) and 43 238 patients (84.0%) had no cirrhosis (25 249 men [58.4%]; mean [SD] age, 58.8 [11.3] years). The adjusted hazard ratio (HR) of dying between patients with DAA treatment and those without DAA treatment in the cirrhosis group was 0.51 (95% CI, 0.46-0.57). The association of DAA treatment with mortality did not differ by sex (women vs men: HR, 0.46 [95% CI, 0.38-0.56] vs HR, 0.53 [95% CI, 0.47-0.60]; P = .27) or dual-eligibility status (non-dual-eligible HR, 0.52 [95% CI, 0.43-0.63] vs dual-eligible HR, 0.50 [95% CI, 0.44-0.57]; P = .80) in the cirrhosis group. The adjusted HR of dying between patients with DAA treatment and those without DAA treatment among patients without cirrhosis was 0.54 (95% CI, 0.50-0.58). The association of DAA treatment with mortality did not differ by sex (women vs men: HR, 0.53 [95% CI, 0.46-0.60] vs HR, 0.55 [95% CI, 0.50-0.60]; P = .66) among patients without cirrhosis. However, the survival advantage associated with DAAs for non-dual-eligible beneficiaries was statistically significantly higher than for dual-eligible beneficiaries among patients without cirrhosis (HR, 0.47 [95% CI, 0.41-0.55] vs HR, 0.57 [95% CI, 0.52-0.62]; P = .02).

Conclusions and Relevance

In this cohort study, DAA treatment appeared to be associated with a decrease in mortality among Medicare beneficiaries with or without cirrhosis. These findings suggest that increasing access to DAA drugs for all patients with HCV infection, regardless of disease progression, could improve population health.

The association between education level and chronic liver disease of any etiology

BACKGROUND

The potential link between educational level and chronic liver diseases (CLD) were explored using the mortality records of liver cirrhosis, which lack accuracy and are unable to identify the different etiological factors of liver cirrhosis. Information on the association of low educational level with the severity of CLD is lacking.

AIM

To evaluate the potential association linking education level to etiology and clinical stage of CLD cases.

METHODS

Consecutive enrolment of 11,107 subjects with CLD aged≥18 years prospectively recruited in two national surveys in 2001 and 2014 at one of the participating Italian liver units throughout the country. Subjects were pooled in two groups: low education level (less than high school) and high education level (completed high school or beyond). The association of demographic, etiological, and clinical stage of subjects with educational level was assessed using logistic regression analysis. In the analysis low educational level was the outcome variable.

RESULTS

A total of 11,107 subjects born in Italy (mean age 55.5 years, sex ratio 1.5) were evaluated. Multiple logistic regression analysis shows that chronic HCV infection (O.R.1,38:95%,C.I.1.23-1.55), risky alcohol intake (O.R.1.96;95%,C.I.1.73-2.21) and liver cirrhosis (O.R.1.65;95%,C.I.1.46-1.85) all resulted independently associated with less than a completed high school education. HBV infection resulted independently associated with high education level (O.R.0.74;95%,C.I.0.64-0.86), reflecting changes in HBV modes of transmission in recent decades. No association was found with CLD related to non-alcoholic fatty liver disease (O.R.1.03;95%, C.I.0.81-1.30).

CONCLUSIONS

These findings show an independent association linking education level with viruses and alcohol-related CLD. Low educational level is associated with the severity of CLD.

Enablers and barriers for the provision of community-based HCV treatment: A case study of a real-world practice

BACKGROUND

Although the availability of fully funded direct-acting antivirals (DAAs) and the eligibility of primary care providers (PCPs) to provide hepatitis C virus (HCV) have removed barriers related to access to hospital-based HCV treatment in Australia, there are still many barriers to the provision of HCV treatment in community settings. There is a lack of knowledge regarding the barriers to, and enablers of HCV treatment in community settings in Australia. This study aimed to identify barriers and enablers for the provision of community-based HCV treatment.

METHODS

This study was a part of a mixed-method case study of the Cure-It programme. The programme was studied to better understand barriers and enablers experienced by stakeholders of such programmes. The programme is delivered through the Prince Charles Hospital in Brisbane, Australia, and aimed to improve access to HCV treatment in community settings. Data were collected using semi-structured interviews with 12 healthcare providers and nine patients between July and December 2018. Purposive sampling was used to ensure diverse views were captured. The interview transcripts were analysed using inductive thematic analysis.

RESULTS

Ease of access to specialist support, easy and high value treatment, co-location with or providing other services and motivated patients enabled PCPs to be engaged with the Cure-It programme. Several interconnected factors related to patients' characteristics and health system acted synergistically to enable patients to initiate and complete treatment. These included a desire to remove HCV as a source of shame, having children, awareness of HCV consequences, access to DAAs for free, ease of access to general practices and drug and alcohol services, and access to a safe and enabling environment. The identified barriers were interconnected at the levels of patients, PCPs and primary care systems and acted synergistically to prevent patients and PCPs from becoming engaged with HCV treatment. PCPs' related barriers included a lack of knowledge, their perception of HCV as a specialist area and of patients with HCV as 'hard to manage' patients along with the practice preferences and priorities. Patients' related barriers included their socioeconomic characteristics, internalized stigma, perception of not being sick and lack of knowledge. Additionally, the unavailability of support for patients and existence of stigma in primary health care, along with poor communication between the hospital and primary care system, and the unavailability of FibroScan^® in primary care discouraged PCPs and patients engagement specifically with the provision of community-based HCV treatment.

CONCLUSION

Various strategies are needed to improve PCPs and patients' knowledge and awareness of HCV treatment. Training and support for PCPs need to be easy to access and should cover both clinical and social aspect of HCV. Connecting PCPs to other related services may improve PCPs' and patients' engagement with HCV treatment.

The Ethics of Screening and Treating Persons with Hepatitis C: A Canadian Perspective

In this article, I argue that the Canadian government’s position against screening for hepatitis C virus (HCV) and publicly funding HCV treatment is ethically unjustifiable. Cost of medication and likelihood of widening existing health inequality are the government’s argument for not funding HCV treatment and for also not having a screening program. I object to this position and argue in favour of a screening program and public funding of HCV treatment. I argue that these barriers are ethically unjust. Conclusively, being denied screening and early treatment is to be denied the best possible outcome.

Direct-Acting Antiviral Therapy for Hepatitis C Infection in a Large Immigrant Community

Hepatitis C treatment has rapidly evolved with the arrival of direct-acting antiviral therapy. Sustained virologic response (SVR) rates in clinical trials are high but it is unknown how this translates to the immigrant community. Data from December 2013 to September 2015 was collected from a Midwest academic and community practice with a large immigrant population. There were 802 patients with an overall SVR rate of 88%. Ledipasvir/sofosbuvir was associated with favorable response among genotype 1 and 4 patients compared to other regimens (p < 0.001 and p = 0.05). Factors associated with treatment failure included advanced liver disease, male gender, East African/Middle Eastern ethnicity, and non-compliance. Patients with genotype 4 had lower SVR rates than other genotypes (58% vs. 89%, p < 0.001), particularly among East Africans (40% vs. 82% for other ethnicities). Our SVR rate for genotype 4 infection is lower than clinical trials and may be related to cultural, biologic and socioeconomic factors.

The distribution and socioeconomic burden of Hepatitis C virus in South Australia: a cross-sectional study 2010-2016

BACKGROUND

Hepatitis C virus infection (HCV) is a communicable disease of increasing global importance with 1.75 million new infections and 400,000 related deaths annually. Until recently, treatment options have had low uptake and most infected people remain untreated. New Direct Acting Antiviral medications can clear the virus in around 95% of cases, with few side-effects. These medications are restricted in most countries but freely accessible in Australia, yet most people still remain untreated. This study applies a cross-sectional research design to investigate the socio-spatial distribution of HCV in South Australia, to identify vulnerable populations, and examine epidemiological factors to potentially inform future targeted strategies for improved treatment uptake.

METHOD

HCV surveillance data were sourced from South Australia's Communicable Diseases Control Branch and socio-economic population data from the Australian Bureau of Statistics from January 2010 to December 2016 inclusive. HCV cases were spatially mapped at postcode level. Multivariate logistic regression identified independent predictors of demographic risks for HCV notification and notification source.

RESULTS

HCV notifications (n = 3356) were seven times more likely to be from people residing in the poorest areas with high rates of non-employment (75%; n = 1876) and injecting drug use (74%; n = 1862) reported. Notifications among Aboriginal and Torres Strait Islander people were around six times that of non-Indigenous people. HCV notifications negatively correlated (Spearman's rho - 0.426; p < 0.001) with socio-economic status (residential postcode socio-economic resources Index). History of imprisonment independently predicted HCV diagnoses in lesser economically-resourced areas (RR1.5; p < 0.001). Independent predictors of diagnosis elsewhere than in general practices were non-employment (RR 4.6; p = 0.028), being male (RR 2.5; p < 0.001), and younger than mean age at diagnosis (RR 2.1; p = 0.006).

CONCLUSIONS

Most people diagnosed with HCV were from marginalised sub-populations. Given general practitioners are pivotal to providing effective HCV treatment for many people in Australia a most concerning finding was that non-employed people were statistically less likely to be diagnosed by general practitioners. These findings highlight a need for further action aimed at improving healthcare access and treatment uptake to help reduce the burden of HCV for marginalised people, and progress the vision of eliminating HCV as a major public health threat.

Novel non-invasive score to predict cirrhosis in the era of hepatitis C elimination: A population study of ex-substance users in Singapore

BACKGROUND

Chronic hepatitis C infection is common among people with history of substance use. Liver fibrosis assessment is a barrier to linkage to care, particularly among those with history of substance users. The use of non-invasive scores can be helpful in predicting liver cirrhosis in the era of HCV elimination, especially in countries where transient elastography (TE) is not available. We compared the commonly used non-invasive scores with a novel non-invasive score in predicting liver cirrhosis in this population.

METHODS

HCV patients with history of substance use between 2011 and 2016 were analyzed. All patients had TE for liver fibrosis assessment. Clinical performance of established non-invasive scores for fibrosis assessment and novel score were compared. Youden's index was used to determine optimal cut-off of the novel score.

RESULTS

A total of 579 patients were included. In multivariate logistic regression, cirrhosis on TE was associated with age (P = 0.002), aspartate aminotransferase (AST) (P = 0.004), and platelet count (P < 0.001), but not alanine aminotransferase (ALT) (P = 0.896). These form the components of modified AST-to-platelet ratio index (APRI) score. Modified APRI was superior to APRI in predicting cirrhosis (AUROC, 0.796 vs. 0.770, P = 0.007), but not fibrosis-4 score (FIB-4) (P = 1.00). Modified APRI at cut-off of 4 has sensitivity, specificity and negative predictive value (NPV) of 94.4%, 26.9% and 92.6%, respectively, and at 19, has sensitivity, specificity and positive predictive value (PPV) of 33.3%, 96.2% and 77.1%, respectively. FIB-4 has a NPV and PPV of 88.6%, 41.8% and 78.5%, 77.6%, at cut-off of 1.45 and 3.25, respectively. Using the cut-off of 4 and 14 for modified APRI, 32.5% of patients can be correctly classified and misses out only 5.6% of cirrhosis patients.

CONCLUSIONS

Modified APRI score is superior in predicting cirrhosis in HCV population, with 32.5% of the population being correctly classified using cut-off of 4 and 14. Further studies are required to validate the findings.

The health equity implementation framework: proposal and preliminary study of hepatitis C virus treatment

BACKGROUND

Researchers could benefit from methodological advancements to advance uptake of new treatments while also reducing healthcare disparities. A comprehensive determinants framework for healthcare disparity implementation challenges is essential to accurately understand an implementation problem and select implementation strategies.

METHODS

We integrated and modified two conceptual frameworks-one from implementation science and one from healthcare disparities research to develop the Health Equity Implementation Framework. We applied the Health Equity Implementation Framework to a historical healthcare disparity challenge-hepatitis C virus (HCV) and its treatment among Black patients seeking care in the US Department of Veterans Affairs (VA). A specific implementation assessment at the patient level was needed to understand any barriers to increasing uptake of HCV treatment, independent of cost. We conducted a preliminary study to assess how feasible it was for researchers to use the Health Equity Implementation Framework. We applied the framework to design the qualitative interview guide and interpret results. Using quantitative data to screen potential participants, this preliminary study consisted of semi-structured interviews with a purposively selected sample of Black, rural-dwelling, older adult VA patients (N = 12), living with HCV, from VA medical clinics in the Southern part of the USA.

RESULTS

The Health Equity Implementation Framework was feasible for implementation researchers. Barriers and facilitators were identified at all levels including the patient, provider (recipients), patient-provider interaction (clinical encounter), characteristics of treatment (innovation), and healthcare system (inner and outer context). Some barriers reflected general implementation issues (e.g., poor care coordination after testing positive for HCV). Other barriers were related to healthcare disparities and likely unique to racial minority patients (e.g., testimonials from Black peers about racial discrimination at VA). We identified several facilitators, including patient enthusiasm to obtain treatment because of its high cure rates, and VA clinics that offset HCV stigma by protecting patient confidentiality.

CONCLUSION

The Health Equity Implementation Framework showcases one way to modify an implementation framework to better assess health equity determinants as well. Researchers may be able to optimize the scientific yield of research inquiries by identifying and addressing factors that promote or impede implementation of novel treatments in addition to eliminating healthcare disparities.

Prevalence of hepatitis C virus among street children in Iran

Background

Street children are forced to spend a lot of time away from their homes and some of them do not have homes at all, due to economic and family problems, which makes them exposed to many health problems, such as the hepatitis C virus (HCV) infection. Iran, like many other countries in the world, experiences the burden of street children, however, the rate of HCV among street children is virtually unknown. This study aimed to determine the prevalence of HCV among street children in Iran.

Main body

This systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The study protocol of this review was registered in PROSPERO under identification term CRD42018082336. A comprehensive literature search was conducted to identify published studies reporting on the prevalence of HCV among street children in Iran. Several international scholarly databases, including Web of Science, PubMed®/MEDLINE®, Embase, Scopus®, Google Scholar and Directory of Open Access Journals, as well as Iranian databases such as MagIran and Barakathns were searched. Studies published between 1988 and December 2017 with any of the following keywords were selected: (street OR homeless OR labour) AND (children OR child OR infant) AND (hepatitis C OR hepatitis C virus OR HCV OR viral hepatitis OR hepatitis OR hepacivirus) AND Iran. Moreover, a grey literature search was performed in order to obtain other potentially relevant studies. The search was carried out without any language restrictions. Four studies, surveying a total of 1691 street children, conducted between 2006 and 2017 were found to be eligible for inclusion in the review and therefore analysed. Three studies were conducted in Tehran and one in Isfahan. The prevalence of HCV among street children in Iran was found to be high, at 2.4% (95% CI: 1.8–3.3).

Conclusions

Since the prevalence of HCV among street children in Iran is quite high, health decision- and policy-makers should pay more attention to street children and widen support channels, both social and economic. Further studies should be conducted among street children in different cities of Iran to add to the knowledge base of HCV among street children in the country. The health system should provide facilities for street children to be screened to quickly diagnose illnesses and prevent them from developing complications.

Electronic supplementary material

The online version of this article (10.1186/s40249-018-0469-5) contains supplementary material, which is available to authorized users.

Increasing hepatitis C screening in a large integrated health system: science and policy in concert

OBJECTIVES

To evaluate whether the updated 2013 US Preventive Services Task Force (USPSTF) hepatitis C virus (HCV) screening recommendations, related Affordable Care Act provisions, and the impending availability of efficacious therapies were associated with increased screening in an integrated health system.

STUDY DESIGN

We analyzed 665,339 records of adult patients visiting Kaiser Permanente Mid-Atlantic States clinics from 2003 to 2014.

METHODS

We used Cox proportional hazards to estimate time to HCV screening and confirmation after June 1, 2013, compared with prior.

RESULTS

HCV screening steadily increased over time, but it jumped 29% (P <.01) from 2013 to 2014 versus 4% (P <.01) from 2012 to 2013. The adjusted hazard ratio for HCV screening since June 2013 was 2.40 (95% CI, 2.34-2.47) times higher than it was pre-intervention among the birth cohort (those born 1945-1965) and 2.00 (95% CI, 1.96-2.04) times higher in those born in other years, representing a 1.20-fold (95% CI, 1.17-1.24) greater increase in the screening rate among the birth cohort. We also identified variability in those thought to be at higher risk of HCV infection.

CONCLUSIONS

HCV screening has been increasing in our healthcare system, more so since June 2013 and among the birth cohort. The availability of efficacious therapies and coverage policies coincident with the USPSTF recommendations may have facilitated access to screening and treatment in ways that were absent at the time of the 2012 CDC recommendations. Health systems must also be poised to make resources available to clinicians and patients in order to incentivize screening. Future research should inform a better understanding of incentives and barriers to screening and linkage to care from all stakeholder perspectives.

Evolution of acute hepatitis C virus infection in a large European city: Trends and new patterns

The aims of this study were to describe the evolution of acute hepatitis C virus (HCV) infections since 2004 and to determine its associated factors. Acute HCV infections diagnosed in Barcelona from 2004 to 2015 were included. Incidence ratios (IR) were then estimated for sex and age groups. Cases were grouped between 2004-2005, 2006-2011 and 2012-2015, and their incidence rate ratios (IRR) were calculated. In addition, risk factors for acute HCV infection were identified using multinomial logistic regression for complete, available and multiple imputed data. 204 new HCV cases were identified. Two peaks of higher IR of acute HCV infection in 2005 and 2013 were observed. Men and those aged 35-54 had higher IR. IRR for men was 2.9 times greater than in women (95% confidence intervals (CI): 1.8 ‒ 4.7). Factors related to the period 2012-2015 (versus 2006-2011) were: a) sexual risk factor for transmission versus nosocomial (relative-risk ratio (RRR): 13.0; 95% CI: 2.3 ‒ 72.1), b) higher educated versus lower (RRR: 5.4; 95% CI: 1.6 ‒ 18.7), and c) HIV co-infected versus not HIV-infected (RRR: 53.1; 95% CI: 5.7 ‒ 492.6). This is one of the few studies showing IR and RRRs of acute HCV infections and the first focused on a large city in Spain. Sexual risk for transmission between men, higher educational level and HIV co-infection are important factors for understanding current HCV epidemic. There has been a partial shift in the pattern of the risk factor for transmission from nosocomial to sexual.

Use of Rapid Response Teams in Psychiatry: Variables that Impact Safety

OBJECTIVE

The addition of rapid response teams (RRTs) has emerged as a treatment option for medically deteriorating psychiatric inpatients. The goal of this study was to identify risk factors for use of RRTs at the time of initial psychiatric evaluation and develop measures to predict use of this emergent medical intervention. We have not located any studies that have previously addressed this issue.

METHODS

We studied the use of RRTs and code teams (CTs) on inpatient general and specialty psychiatric services in a large urban academic psychiatric hospital. RRT or CT calls were made for 60 patients on these units between January, 2010 and December, 2012. Our retrospective chart review study compared the cases of these 60 patients with 120 matched controls. Using χ and the Fisher exact tests, we identified variables that differed significantly between the case and control groups. Next, we used a forward stepwise regression model to create prediction tools to risk stratify patients at the time of initial assessment.

RESULTS

Bivariate analyses identified 14 independent statistically significant patient variables. We created 2 risk prediction tools: (1) an "exhaustive" tool (which used 12 of the total 38 factors we considered) based on a stepwise regression model that yielded an area under the receiver operating curve (AUC) of 0.91, and (2) a simplified tool referred to by the acronym "SCHEME" with 6 factors and an AUC of 0.76.

CONCLUSIONS

We propose the acronym SCHEME to refer to a tool that can be used to quickly and easily assess medical risk in prospective psychiatric inpatients at the time of admission, which can help reduce the use of RRTs and CTs.

Assessment of hepatitis C virus infection in two adjacent Thai provinces with drastically different seroprevalence

Improved awareness of the hepatitis C virus (HCV) transmission has contributed to the overall decline in the HCV infection rate in some developing countries including Thailand. Chronic HCV infection in some rural Thai communities, however, presents a challenge in the efforts to treat and manage HCV-related diseases. Published and unpublished studies have suggested an unusually high incidence of HCV infection in a Thai province of Phetchabun compared to elsewhere in Thailand. To determine the magnitude of HCV infection and identify potential factors contributing to the higher rate of HCV infection in this province, we performed a population-based study in Phetchabun (n = 1667) and the neighboring Khon Kaen province (n = 1410) where HCV prevalence is much lower. Individuals between 30 and 64 years old completed detailed questionnaires designed to identify HCV risk factors and provided blood samples for anti-HCV antibody screening. The anti-HCV seropositive rates were 15.5% (259/1667) in Phetchabun and 3.6% (51/1410) in Khon Kaen. Positive samples were subsequently genotyped for HCV core gene sequence and assessed for the hepatitis B virus surface antigen (HBsAg) and human immunodeficiency virus antigen/antibody (HIV Ag/Ab). More individuals in Phetchabun possessed the combined presence of HBsAg (5.0%) and HIV Ag/Ab (0.4%) than those in Khon Kaen (3.9% HBsAg and 0.0% HIV Ag/Ab). While male gender, intravenous drug use (IVDU) and tattoos were significant HCV risk factors in both provinces (p <0.05), education less than high school and agriculture-related occupation were additionally associated with HCV in Phetchabun. HCV genotypes 6, 3, and 1 were identified in similar frequency in both provinces. We estimated that prevalence of HCV seropositivity and viremic carriers were higher in Phetchabun (143 and 111 per 1000) than in Khon Kaen (34 and 22 per 1000). Finally, we derived a simple risk factor-based scoring system as a useful preclinical tool to screen individuals at risk of chronic HCV infection prior to intervention. Knowledge gained from this study will assist in HCV screening and promote access to anti-viral treatment in high-risk groups.

Role of primary T-cell immunodeficiency and hepatitis B coinfection on spontaneous clearance of hepatitis C: The BC Hepatitis Testers Cohort

T-cell host immune response against hepatitis C virus (HCV) has been suggested to play an important role in determining HCV infection outcome. However, data from human studies are not available. This study examined the effect of primary T-cell deficiency along with other factors on the spontaneous clearance of HCV in a large population-based cohort in British Columbia, Canada. The BC Hepatitis Testers Cohort includes all individuals tested for HCV in BC in 1990-2013 linked with data on their medical visits, hospitalizations and prescription drugs. HCV-positive individuals with at least one valid HCV PCR test on/after HCV diagnosis (n=46 783) were included in this study. To examine factors associated with the spontaneous clearance of HCV, multivariable logistic regression was fitted on the full sample, and Cox proportional hazards model on the HCV seroconverters. Spontaneous clearance was observed in 25.1% (n=11 737) of those tested for HCV. After adjusting for potential confounders, the odds of spontaneous clearance of HCV was lower in people with primary T-cell immunodeficiency (adjusted odds ratio [aOR]: 0.55, 95% CI: 0.32-0.94), and higher in females (aOR: 1.61, 95% CI: 1.54-1.68) and in those coinfected with HBV (aOR: 2.31, 95% CI: 1.93-2.77). Similar results were observed in HCV seroconverters except HBV coinfection was not significant. In conclusion, primary T-cell immunodeficiency is associated with a lower spontaneous clearance of HCV while female sex and coinfection with HBV are associated with a higher spontaneous clearance.

FIB-4 and imaging for measuring fibrosis in hepatitis C virus

OBJECTIVES

Noninvasive measures are widely used to assess fibrosis and may be used to prioritize hepatitis C virus (HCV) treatment. We examined risks for likely fibrosis in patients with chronic HCV infection using fibrosis-4 (FIB-4) and imaging.

PATIENTS AND METHODS

A HCV screening program diagnosed chronic HCV in patients born from 1945 to 1965 admitted in a safety net hospital. Likely fibrosis was based on FIB-4 (≥1.45) alone or combined with imaging interpreted as fibrosis or cirrhosis. Logistic regression was used to calculate adjusted odds ratios (AORs) for demographic, clinical, and insurance factors associated with each outcome. Using multiple linear regression among patients with likely fibrosis, we examined associations with higher Model for End-Stage Liver Disease (MELD) scores.

RESULTS

Using FIB-4 alone, 57% (83/146) of patients had likely fibrosis versus 43% (63/148) using FIB-4 plus imaging. Obesity/overweight and Hispanic ethnicity had over three-fold to four-fold higher AORs for fibrosis, respectively, based on FIB-4 plus imaging, but both AORs were only two-fold greater with FIB-4 alone. Being uninsured was significantly associated with fibrosis based on FIB-4 alone [AOR=2.40 (95% confidence interval 1.01-5.70)] but not with imaging. Heavy alcohol use and older age were associated with higher AORs of fibrosis with both measures (all P<0.004). MELD scores were ∼3 points higher for uninsured patients, regardless of measure (both P<0.05).

CONCLUSIONS

Using FIB-4 plus imaging to identify fibrosis in chronic HCV, higher risks are seen for Hispanics and overweight/obese individuals than using FIB-4 alone. Higher MELD scores at diagnosis for the uninsured indicate delayed access to care.

Hepatitis C virus infection and the risk of cancer among elderly US adults: A registry-based case-control study

BACKGROUND

Hepatitis C virus (HCV) infection causes hepatocellular carcinoma (HCC) and subtypes of non-Hodgkin lymphoma (NHL). Associations with other cancers are not established. The authors systematically assessed associations between HCV infection and cancers in the US elderly population.

METHODS

This was a registry-based case-control study using Surveillance, Epidemiology, and End Results (SEER)-Medicare data in US adults aged ≥66 years. Cases (n = 1,623,538) were patients who had first cancers identified in SEER registries (1993-2011). Controls (n = 200,000) were randomly selected, cancer-free individuals who were frequency-matched to cases on age, sex, race, and calendar year. Associations with HCV (documented by Medicare claims) were determined using logistic regression.

RESULTS

HCV prevalence was higher in cases than in controls (0.7% vs 0.5%). HCV was positively associated with cancers of the liver (adjusted odds ratio [aOR] = 31.5; 95% confidence interval [CI], 29.0-34.3), intrahepatic bile duct (aOR, 3.40; 95% CI, 2.52-4.58), extrahepatic bile duct (aOR, 1.90; 95% CI, 1.41-2.57), pancreas (aOR, 1.23; 95% CI, 1.09-1.40), and anus (aOR, 1.97; 95% CI, 1.42-2.73); nonmelanoma nonepithelial skin cancer (aOR, 1.53; 95% CI, 1.15-2.04); myelodysplastic syndrome (aOR, 1.56; 95% CI, 1.33-1.83); and diffuse large B-cell lymphoma (aOR, 1.57; 95% CI, 1.34-1.84). Specific skin cancers associated with HCV were Merkel cell carcinoma (aOR, 1.92; 95% CI, 1.30-2.85) and appendageal skin cancers (aOR, 2.02; 95% CI, 1.29-3.16). Inverse associations were observed with uterine cancer (aOR, 0.64; 95% CI, 0.51-0.80) and prostate cancer (aOR, 0.73; 95% CI, 0.66-0.82). Associations were maintained in sensitivity analyses conducted among individuals without documented alcohol abuse, cirrhosis, or hepatitis B or human immunodeficiency virus infections and after adjustment for socioeconomic status. Associations of HCV with other cancers were not observed.

CONCLUSIONS

HCV is associated with increased risk of cancers other than HCC in the US elderly population, notably bile duct cancers and diffuse large B-cell lymphoma. These results support a possible etiologic role for HCV in an expanded group of cancers. Cancer 2017;123:1202-1211. © 2016 American Cancer Society.

Mortality in hepatitis C patients who achieve a sustained viral response compared to the general population

BACKGROUND & AIMS

The number of people living with previous hepatitis C infection that have attained a sustained viral response (SVR) is expected to grow rapidly. So far, the prognosis of this group relative to the general population is unclear.

METHODS

Individuals attaining SVR in Scotland in 1996-2011 were identified using a national database. Through record-linkage, we obtained cause-specific mortality data complete to Dec 2013. We calculated standardised mortality ratios (SMRs) to compare the frequency of mortality in SVR patients to the general population. In a parallel analysis, we used Cox regression to identify modifiable patient characteristics associated with post-SVR mortality.

RESULTS

We identified 1824 patients, followed on average for 5.2years after SVR. In total, 78 deaths were observed. Overall, all-cause mortality was 1.9 times more frequent for SVR patients than the general population (SMR: 1.86; 95% confidence interval (CI): 1.49-2.32). Significant cause-specific elevations were seen for death due to primary liver cancer (SMR: 23.50; 95% CI: 12.23-45.16), and death due to drug-related causes (SMR: 6.58, 95% CI: 4.15-10.45). Together these two causes accounted for 66% of the total excess death observed. All of the modifiable characteristics associated with increased mortality were markers either of heavy alcohol use or injecting drug use. Individuals without these behavioural markers (32.8% of cohort) experienced equivalent survival to the general population (SMR: 0.70; 95% CI: 0.41-1.18) CONCLUSIONS: Mortality in Scottish SVR patients is higher overall than the general population. The excess was driven by death from drug-related causes and liver cancer. Health risk behaviours emerged as important modifiable determinants of mortality in this population.

LAY SUMMARY

Patients cured of hepatitis C through treatment had a higher mortality rate overall than the general population. Most of the surplus mortality was due to drug-related causes and death from liver cancer. A history of heavy alcohol and injecting drug use were associated with a higher mortality risk.

Reduced ability to work both before and after infectious spondylodiscitis in working-age patients

BACKGROUND

As little is known about the ability to work in patients with infectious spondylodiscitis, we compared the relation between the workforce before infection with that of a reference population and described the patients' ability to work after infection including predictors of return to work (RTW).

METHODS

We identified all patients aged 20-57 years treated for infectious spondylodiscitis January 1994-May 2009 at hospitals in Funen County, Denmark. The work status of each week from 2 years before until 2 years after index date was compared with that of a reference population. Time to RTW was described using cumulative incidence curves and univariate cause-specific Cox-regression analyses (hazard ratios - HRs).

RESULTS

Of 112 identified patients, 8 (7%) died within the first year and 48 (43%) were part of the workforce 1 year before index. Through the entire observation period, the patients had lower affiliation to the workforce compared with the reference population. During the observation period, the proportion of patients on permanent disability pension increased from 24% to 38% and the proportion of self-supporters decreased from 58% to 33%. Seventy-three per cent of the patients being part of the workforce 1 year before index returned to the workforce within the 2 year follow-up. Main predictor of RTW was being part of the workforce 1 year before index (HR = 7.8; CI: 2.4-25.3).

CONCLUSIONS

Patients with infectious spondylodiscitis were less likely to be part of the workforce before infection compared with a reference population and infection further lowered their ability to RTW.

Health Disparities in Hepatitis C Screening and Linkage to Care at an Integrated Health System in Southeast Michigan

With recommended screening for hepatitis C among the 1945–1965 birth cohort and advent of novel highly effective therapies, little is known about health disparities in the Hepatitis C care cascade. Our objective was to evaluate hepatitis C screening rates and linkage to care, among patients who test positive, at our large integrated health system. We used electronic medical records to retrospectively identify patients, in the birth cohort, who were seen in 21 Internal Medicine clinics from July 2014 to June 2015. Patients previously screened for hepatitis C and those with established disease were excluded. We studied patients’ sociodemographic and medical conditions along with provider-specific factors associated with likelihood of screening. Patients who tested positive for HCV antibody were reviewed to assess appropriate linkage to care and treatment. Of 40,561 patients who met inclusion criteria, 21.3% (8657) were screened, 1.3% (109) tested positive, and 30% (30/100) completed treatment. Multivariate logistic regression showed that African American race, male gender, electronic health engagement, residency teaching clinic visit, and having more than one clinic visit were associated with higher odds of screening. Patients had a significant decrease in the likelihood of screening with sequential interval increase in their Charlson comorbidity index. When evaluating hepatitis C treatment in patients who screened positive, electronic health engagement was associated with higher odds of treatment whereas Medicaid insurance was associated with significantly lower odds. This study shows that hepatitis C screening rates and linkage to care continue to be suboptimal with a significant impact of multiple sociodemographic and insurance factors. Electronic health engagement emerges as a tool in linking patients to the hepatitis C care cascade.

Prevalence and risk factors of HCV infection in a metropolitan area in southern Italy: Tail of a cohort infected in past decades

Data on the prevalence of HCV infection in Italy are often outdated and from non-urban populations. This study assessed the prevalence and risk factors for HCV infection in a large metropolitan area in southern Italy. A random 1:3 systematic sample of the adult general population of Naples was selected from three general practitioner patient registers in three different city districts. Socioeconomic indicators and risk factors for HCV infection were collected. Anti-HCV and HCV-RNA assays were performed. Logistic regression analysis was used to identify independent predictors of HCV infection. Of 1,500 randomly selected subjects, 1,315 (87.7%) participated in the study. Forty subjects (3.0%; 95%CI: 2.1-4.0) were anti-HCV-positive, with HCV-RNA detected by PCR in 31 (77.5%) of these. Anti-HCV prevalence increased with age, peaking (8.2%) in people born during the years 1945-1955. It was 1.7% in people residing in the better socioeconomic districts; but 5.7% in those residing in the district with lower socioeconomic status (P < 0.01). In multivariate analysis, age ≥60 years (OR 2.8, 95%CI: 1.3-6.1) and lower educational level (OR 3.6; 95%CI: 1.4-9.3), which is a proxy of low socioeconomic status, were the only independent predictors of the likelihood of anti-HCV positivity. Overall, 22.5% of anti-HCV positive subjects were previously unaware of their status. In the large city of Naples, infection with HCV is most common in people aged older than 60 years. Differences in socioeconomic conditions have played an important role in the spread of this infection. HCV positive subjects born during the years 1945-1955 are those who may benefit, to a greater extent, to be identified in order to receive the new effective therapy. J. Med. Virol. 89:291-297, 2017. © 2016 Wiley Periodicals, Inc.

Impact of eradicating hepatitis C virus on the work productivity of chronic hepatitis C (CH-C) patients: an economic model from five European countries

CH-C negatively affects work productivity (WP), creating a large economic burden. The aim of this study was to model the impact of sustained virologic response (SVR) on WP in CHC genotype 1 (GT1) patients in five European countries (EU5). Work Productivity and Activity Index-Specific Health Problem questionnaire was administered to patients across the ION clinical trials (n = 629 European patients). The analysis modelled a population of GT1 CHC patients over one year, who had been either not treated or treated with LDV/SOF. Sensitivity analyses assessed the possibility that CHC patients' labour costs were lower than the general population's and presented results by fibrosis stage. Before initiation of treatment, EU patients with CHC GT1 exhibited absenteeism and presenteeism impairments of 3.54% and 9.12%, respectively. About 91.8% of EU patients in the ION trials achieved SVR and improved absenteeism and presenteeism impairments by 16.3% and 19.5%, respectively. Monetizing these data, treatment with LDV/SOF resulted in an annual productivity gain of €435 million and a weighted average per-employed patient (PEP) gain of €900 in the EU5. PEP gains from treatment are projected to be higher in cirrhotic than in noncirrhotic patients. If CHC patients are assumed to earn 20% less than the general population, gains of €348 million (€720 PEP) annually are projected. CHC results in a significant economic burden to European society. Due to improvements in WP, SVR with treatment could provide substantial economic gains, partly offsetting the direct costs related to its widespread use.