Cascade of care during the first 36 months of the treatment as prevention for hepatitis C (TraP HepC) programme in Iceland: a population-based study

BACKGROUND

WHO has set targets to eliminate hepatitis C virus (HCV) infection as a global health threat by 2030 through a 65% reduction in HCV-related deaths and 80% reduction in HCV incidence. To achieve these goals, WHO set service coverage targets of 90% of the infected population being diagnosed and 80% of eligible patients being treated. In February, 2016, Iceland initiated a nationwide HCV elimination programme known as treatment as prevention for hepatitis C (TraP HepC), which aimed to maximise diagnosis and treatment access. This analysis reports on the HCV cascade of care in the first 3 years of the programme.

METHODS

This population-based study was done between Feb 10, 2016, and Feb 10, 2019. Participants aged 18 years or older with permanent residence in Iceland and PCR-confirmed HCV were offered direct-acting antiviral (DAA) therapy. The programme used a multidisciplinary team approach in which people who inject drugs were prioritised. Nationwide awareness campaigns, improved access to testing, and harm reduction services were scaled up simultaneously. The number of infected people in the national HCV registry was used in combination with multiple other data sources, including screening of low-risk groups and high-risk groups, to estimate the total number of HCV infections. The number of people diagnosed, linked to care, initiated on treatment, and cured were recorded during the study. This study is registered with ClinicalTrials.gov, NCT02647879.

FINDINGS

In February, 2016, at the onset of the programme, 760 (95% CI 690-851) individuals were estimated to have HCV infection, with 75 (95% CI 6-166) individuals undiagnosed. 682 individuals were confirmed to be HCV PCR positive. Over the next 3 years, 183 new infections (including 42 reinfections) were diagnosed, for a total of 865 infections in 823 individuals. It was estimated that more than 90% of all domestic HCV infections had been diagnosed as early as January, 2017. During the 3 years, 824 (95·3%) of diagnosed infections were linked to care, and treatment was initiated for 795 (96·5%) of infections linked to care. Cure was achieved for 717 (90·2%) of 795 infections.

INTERPRETATION

By using a multidisciplinary public health approach, involving tight integration with addiction treatment services, the core service coverage targets for 2030 set by WHO have been reached. These achievements position Iceland to be among the first nations to subsequently achieve the WHO goal of eliminating HCV as a public health threat.

FUNDING

The Icelandic Government and Gilead Sciences.

928. Major Decrease in Prevalence of Hepatitis C Viremia in Key Populations following the Second Year of Treatment as Prevention for Hepatitis C (TraP HepC) Program in Iceland

Background

Hepatitis C Virus (HCV) commonly affects people who inject drugs (PWID) and/or with history of injection drug use (IDU). They are also disproportionately represented in addiction treatment centers and the penitentiary system. In order to curtail spread of HCV it is therefore important to approach these groups. PWID and prisoners have been prioritized in the TraP HepC program. The impact can thus be assessed by monitoring HCV prevalence at sentinel sites, such as addiction hospitals and prisons.

Methods

TraP HepC offers direct-acting antiviral agents (DAAs) to all HCV patients in Iceland, starting in January 2016. HCV PCR is performed at the end of treatment and 12 weeks later (SVR12). PWID and prisoners are monitored for reinfection and retreated if needed. We compared the prevalence of HCV viremia among PWID admitted for treatment at Vogur addiction hospital and inmates of the penitentiary system, before and after 2 years of TraP HepC.

Results

Two years into the program 667 patients had been evaluated of which 632 were initiated on their first course of DAAs and 7 were pending, representing 80% of the estimated total patient population. Of those who completed first treatment according to guidelines the SVR12 is 95.5%. Drop-out from first treatment was 8.2%; nevertheless, the SVR12 was >40% and most of the remaining viremic patients completed or are undergoing retreatment. In 2012–2015, prior to TraP HepC the prevalence of HCV viremia among actively injecting PWID admitted for addiction treatment was 47.9%, dropping to 39.8% in 2016 and 16.2% in 2017 (P < 0.001). Likewise, the prevalence of viremia among patients with history of IDU but not recently injecting fell from 27.4% (2012–2015) to 19.8% in 2016 and 4.1% in 2017 (P < 0.001). The prevalence of viremia among inmates of the penitentiary system was 29% prior to initiation of TraP HepC, dropping to 7% in 2017 (P < 0.01). These results are not explained by declining IDU in the community.

Conclusion

On a population level the domestic transmission of HCV can be reduced by DAAs when combined with other efforts. Two years into the TraP HepC program the prevalence of viremia among two of the most important drivers of the epidemic has been markedly reduced. The program is ongoing, with further emphasis on increased intensity of screening, retreatment and harm reduction.

Disclosures

All authors: No reported disclosures.

Treatment as Prevention for Hepatitis C (TraP Hep C) - a nationwide elimination programme in Iceland using direct-acting antiviral agents

A nationwide programme for the treatment of all patients infected with hepatitis C virus (HCV) was launched in Iceland in January 2016. By providing universal access to direct-acting antiviral agents to the entire patient population, the two key aims of the project were to (i) offer a cure to patients and thus reduce the long-term sequelae of chronic hepatitis C, and (ii) to reduce domestic incidence of HCV in the population by 80% prior to the WHO goal of HCV elimination by the year 2030. An important part of the programme is that vast majority of cases will be treated within 36 months from the launch of the project, during 2016-2018. Emphasis is placed on early case finding and treatment of patients at high risk for transmitting HCV, that is people who inject drugs (PWID), as well as patients with advanced liver disease. In addition to treatment scale-up, the project also entails intensification of harm reduction efforts, improved access to diagnostic tests, as well as educational campaigns to curtail spread, facilitate early detection and improve linkage to care. With these efforts, Iceland is anticipated to achieve the WHO hepatitis C elimination goals well before 2030. This article describes the background and organization of this project. Clinical trial number: NCT02647879.

Treatment as Prevention for Hepatitis C (TraP HepC). A Real-world Experience from the First 12 Months of a Nationwide Elimination Program in Iceland

Background

Hepatitis C virus (HCV) infection is associated with significant morbidity and mortality. Iceland, an island with a population of 330,000 has a HCV seroprevalence of 0.3% and an estimated total of 800–1000 patients. There is good access to health care among people who inject drugs (PWID) and Iceland thus serves as an ideal setting for a proof of concept intervention, aiming for elimination of the disease as a public health threat. If elimination is to be achieved PWID, who are key drivers of transmission, need to be a focus of treatment scale up.

Methods

All patients in the country infected with HCV were offered direct-acting antiviral agents (DAAs) starting in 01/2016. The regimens are chosen according to national guidelines; SOF/LDV +/−RBV through October 2016 and SOF/VEL +/− RBV thereafter. People with recent injection drug use (IDU), prisoners and patients with advanced liver disease are prioritized. PWID receive additional support to facilitate compliance. Various strategies are employed to enhance case detection and harm reduction. The goal is to initiate treatment for every patient in Iceland within 36 months (end-2018), aiming for elimination of domestic transmission of HCV.

Results

Twelve months after launching the nationwide program 527 patients had been evaluated, 53–66% of the estimated total patient population. The mean age is 42 years (range, 17–70 years, 2 males to every female). The reported main route of infection was IDU (90%). At the time of evaluation, 33% reported recent (within 6 months) IDU, 6% were homeless, and 5% in prison. Stimulants were the preferred IV drug among 84% of PWID but opiates by only 14%; overall 15% were receiving opiate substitution therapy (OST). During the first 12 months of the study period treatment with DAAs was initiated in 480 patients and 322 were scheduled to complete protocol. Drop-out rate is 6.5%. Sustained virological response at 12 weeks (SVR12) for the entire group, including patients who dropped out or are lost to follow-up is 90%. It is significantly lower among the homeless (60%) and active IDU (83% vs. 93%, P = 0.007).

Conclusion

A relatively large proportion of HCV infected patients in the community, including people actively injecting drugs, can be initiated on treatment in a short period of time. Current drug use does not preclude treatment success.

Disclosures

M. Gottfredsson, Gilead: Grant Investigator and Scientific Advisor, Consulting fee and Research support; Astellas: Consultant, Speaker honorarium

Psychometric properties of the Icelandic NEO-FFI in a general population sample compared to a sample recruited for a study on the genetics of addiction

Personality traits are major determinants of social behavior influencing various diseases including addiction. Twin and family studies suggest personality and addiction to be under genetic influence. Identification of DNA susceptibility variants relies on valid and reliable phenotyping approaches. We present results of psychometric testing of the Icelandic NEO-FFI in a population sample (N=657) and a sample recruited for a study on addiction genetics (N=3,804). The Icelandic NEO-FFI demonstrated internal consistency and temporal stability. Factor analyses supported the five-factor structure. Icelandic norms were compared to American norms and language translations selected for geographical and cultural proximity to Iceland. Multiple discriminant function analysis using NEO-FFI trait scores and gender as independent variables predicted membership in recruitment groups for 47.3% of addiction study cases (N=3,804), with accurate predictions made for 69.5% of individuals with treated addiction and 43.3% of their first-degree relatives. Correlations between NEO-FFI scores and the discriminant function suggested a combination of high neuroticism, low conscientiousness and low agreeableness predicted membership in the Treated group.

Standardized documentation in physical therapy: testing of validity and reliability of the PT-ITC and mapping it to the Metathesaurus

Purpose of this study, conducted in Iceland 2006, was to assess utility of a new physical therapy intervention term collection (PT-ITC) and map to the UMLS Metathesaurus using MetaMap. A questionnaire was used to test validity and reliability. Translation, from Icelandic to English, was necessary for the mapping. The PT-ITC in Icelandic and English is valid and reliable. It can be mapped to several sources in the Metathesaurus.

The effects of tobacco smoking and rheumatoid factor seropositivity on disease activity and joint damage in early rheumatoid arthritis

OBJECTIVE

To study the effect of tobacco smoking and rheumatoid factor (RF) isotypes on disease activity and joint damage in early rheumatoid arthritis (RA).

METHODS

One hundred early RA patients were followed prospectively for 2 yr. They were evaluated at recruitment and at 6 and 24 months. Sociodemographic information included smoking history, and radiographs of hands and feet were obtained. RF was monitored by IgM- and IgA-specific RF enzyme-linked immunosorbent assay and by agglutination, and serial measurements were also obtained for C-reactive protein. The influence of tobacco smoking and RF positivity on disease outcome was evaluated using multivariate analysis. Covariates for the regression analysis included sex, age, coffee consumption and IgA-RF positivity.

RESULTS

A gradient of increase in disease activity was observed from never smokers to former smokers to current smokers during the 2 yr of observation, defined by number of swollen joints (SJC), tender joints (TJC) and visual analogue scale for pain (P<0.001, P=0.02 and P=0.005, respectively), but smoking status did not influence radiological progression. Ever smokers were more often IgA RF positive (P<0.05). IgA RF-positive patients had more active disease (SJC P=0.002, TJC P=0.01) and showed more radiological progression (P<0.0001) compared with IgA RF-negative patients. Of the RF-positive patients 22% had elevated IgM RF without IgA RF and these patients showed similar disease activity and radiological joint progression to the RF-negative patients. None of these associations were explained by possible confounders.

CONCLUSION

Tobacco smoking has an adverse effect on patients with early RA and this is possibly immunologically mediated. IgM RF does not predict poorer prognosis in RA unless it is associated with a concomitant elevation of IgA RF.

Persistent organochlorines, sedentary occupation, obesity and human male subfertility

BACKGROUND

Studies have suggested that the quality of human semen has been declining over recent decades, presumably because of lifestyle or environmental factors.

METHODS

Polychlorinated biphenyls and organochlorine pesticides were analysed in the plasma of 25 men with poor semen quality, 20 men with normal semen quality and idiopathic subfertility and 27 men with normal semen quality and female factor subfertility. Samples of seminal fluid were also analysed to assess the relationship between the levels in blood and semen.

RESULTS

The results indicate no difference in the levels of organochlorines between the groups. The levels of organochlorines in seminal fluid were proportional to the levels in plasma, but approximately 40 times lower. Men with poor semen quality were three times more likely to be obese than men with normal semen quality. There was also a significant negative correlation between semen quality parameters and body mass index among men with normal semen quality. The prevalence of sedentary work was lowest among men with the best semen quality.

CONCLUSIONS

Poor semen quality was found to be associated with sedentary work and obesity but not with plasma levels of persistent organochlorines. More research is needed to assess whether sedentary lifestyle and obesity are causal factors in the decline of semen quality.

Recognition of vertebral fracture in a clinical setting

Osteoporosis-related vertebral fractures have important health consequences for older individuals, including disability and increased mortality. Because these fractures can be prevented with appropriate medications, recognition and treatment of high-risk patients is warranted. A cross-sectional survey was carried out in a large, regional hospital in New England to examine the frequency with which vertebral fractures are identified and treated by clinicians in a population of hospitalized older women who have radiographic evidence of fractures. The study population consisted of 934 women aged 60 years and older who were hospitalized between October 1, 1995 and March 31, 1997, and who had a chest radiograph obtained. Vertebral fractures in the thoracic region were identified by two radiologists. Discharge diagnoses, medical record notes and radiology reports were compared with the results of the radiologists' readings to determine the frequency with which fractures were identified and appropriate, osteoporosis-preventing medications prescribed. Moderate or severe vertebral fractures were identified for 132 (14.1%) study subjects, but only 17 (1.8%) of the 934 participants had a discharge diagnosis of vertebral fracture. Of these 132, only 17% had fracture noted in the medical record or discharge summary; 50% of contemporaneous radiology reports identified a fracture as present; and 23% of the time it was found in the radiologist's summary impression. Only 18% of medical records indicated that fracture patients had been prescribed calcium, vitamin D, estrogen replacement or an antiresorptive agent. Relatively few hospitalized older women with radiographically demonstrated vertebral fractures were thus identified or treated by clinicians, suggesting a need for improved recognition.