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.

Lifetime alcohol intake and pattern of alcohol consumption in patients with alcohol-induced pancreatitis in comparison with patients with alcohol use disorder

OBJECTIVE

To examine lifetime drinking patterns in men and women with alcohol-induced pancreatitis (AIP) in comparison with patients with alcoholic use disorder (AUD) without pancreatic disease.

METHODS

Alcohol consumption patterns were assessed using a validated questionnaire, the Lifetime Drinking History (LDH), during an outpatient visit. Patients diagnosed with AIP were matched for gender and age (+/- 5 years) with patients with AUD in addiction treatment.

RESULTS

A total of 45 patients with AIP (35 males, 10 females) and 45 AUD patients were included. Alcohol consumption patterns were not significantly different between males and females with AIP and those with history of acute AIP and chronic pancreatitis (CP). Alcohol consumption patterns of AIP and AUD patients were similar in terms of onset age and duration of alcohol consumption, lifetime alcohol intake and drinks per drinking day. A higher proportion of binge drinking was found among patients with AUD than those with AIP (median 1.00 vs. 0.94, p = .01). Males with AUD had lower onset age (15 vs. 16 years, p = .03), higher total amount of spirits (35520 vs. 10450 drinks, p = .04) and higher proportion of binge drinking (1.00 vs. 0.97, p = .01) than males with AIP, whereas females with AIP and AUD had similar drinking patterns.

CONCLUSIONS

Alcohol drinking patterns and lifetime drinking history was similar in patients with AIP and patients with AUD. Males with AIP had lower total amount of spirits and lower proportion of binge drinking than those with AUD, suggesting the idiosyncratic etiology of AIP.

Etiology unknown: Qualitative analysis of patient attributions of causality in scleroderma

Background

Questions about the etiology of disease can concern patients living with any chronic disease and may impact disease-related adjustment. These causal attributions may be of particular interest when individuals are living with diseases for which etiologies have not been definitively identified, such as scleroderma. This study qualitatively explored patient attributions of causality for scleroderma.

Methods:

Patients with confirmed diagnoses of scleroderma responded to an open-ended prompt. The cross-sectional sample of scleroderma patients ( N = 114) was recruited through registries maintained at the University of California, Los Angeles and University of California, San Diego Schools of Medicine and the Virginia Mason Medical Center. Content analysis was used to analyze the qualitative data and group the responses via an inductively derived codebook using the text analysis tool Dedoose Version 4.5.

Results:

Patients provided a variety of possible causes for scleroderma, which grouped into seven themes: (1) stress, (2) environment, (3) genetics, (4) medical conditions or surgeries, (5) diet, (6) medications or substance use, and (7) spirituality.

Conclusion:

Patients’ causal attributions for scleroderma were varied, but many patients identified stress as a cause of scleroderma, often focusing on acute or chronic stressors that were present before disease onset. Identifying patient theories of causality for scleroderma can contribute to an increased understanding of disease-related behaviors and adjustment.

Modelling the elimination of hepatitis C as a public health threat in Iceland: A goal attainable by 2020

BACKGROUND & AIMS

In Iceland a nationwide program has been launched offering direct-acting antiviral (DAA) treatment for everyone living with hepatitis C virus (HCV). We estimate (i) the time and treatment scale-up required to achieve the World Health Organization's HCV elimination target of an 80% reduction in incidence; and (ii) the ongoing frequency of HCV testing and harm reduction coverage among people who inject drugs (PWID) required to minimize the likelihood of future HCV outbreaks occurring.

METHODS

We used a dynamic compartmental model of HCV transmission, liver disease progression and the HCV cascade of care, calibrated to reproduce the epidemic of HCV in Iceland. The model was stratified according to injecting drug use status, age and stage of engagement. Four scenarios were considered for the projections.

RESULTS

The model estimated that an 80% reduction in domestic HCV incidence was achievable by 2030, 2025 or 2020 if a minimum of 55/1,000, 75/1,000 and 188/1,000 PWID were treated per year, respectively (a total of 22, 30 and 75 of the estimated 400 PWID in Iceland per year, respectively). Regardless of time frame, this required an increased number of PWID to be diagnosed to generate enough treatment demand, or a 20% scale-up of harm reduction services to complement treatment-as-prevention incidence reductions. When DAA scale-up was combined with annual antibody testing of PWID, the incidence reduction target was reached by 2024. Treatment scale-up with no other changes to current testing and harm reduction services reduced the basic reproduction number of HCV from 1.08 to 0.59, indicating that future outbreaks would be unlikely.

CONCLUSION

HCV elimination in Iceland is achievable by 2020 with some additional screening of PWID. Maintaining current monitoring and harm reduction services while providing ongoing access to DAA therapy for people diagnosed with HCV would ensure that outbreaks are unlikely to occur once elimination targets have been reached.

LAY SUMMARY

In Iceland, a nationwide program has been launched offering treatment for the entire population living with hepatitis C virus (HCV). A mathematical model was used to estimate the additional health system requirements to achieve the HCV elimination targets of the World Health Organization (WHO), as well as the year that this could occur. With some additional screening of people who inject drugs, Iceland could reach the WHO targets by 2020, becoming one of the first countries to achieve HCV elimination. The model estimated that once elimination targets were reached, maintaining current monitoring and harm reduction services while providing ongoing access to DAA therapy for people diagnosed with HCV would ensure that future HCV outbreaks are unlikely to occur.

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.

Polygenic risk scores for schizophrenia and bipolar disorder associate with addiction

We use polygenic risk scores (PRSs) for schizophrenia (SCZ) and bipolar disorder (BPD) to predict smoking, and addiction to nicotine, alcohol or drugs in individuals not diagnosed with psychotic disorders. Using PRSs for 144 609 subjects, including 10 036 individuals admitted for in‐patient addiction treatment and 35 754 smokers, we find that diagnoses of various substance use disorders and smoking associate strongly with PRSs for SCZ (P = 5.3 × 10⁻⁵⁰–1.4 × 10⁻⁶) and BPD (P = 1.7 × 10⁻⁹–1.9 × 10⁻³), showing shared genetic etiology between psychosis and addiction. Using standardized scores for SCZ and BPD scaled to a unit increase doubling the risk of the corresponding disorder, the odds ratios for alcohol and substance use disorders range from 1.19 to 1.31 for the SCZ‐PRS, and from 1.07 to 1.29 for the BPD‐PRS. Furthermore, we show that as regular smoking becomes more stigmatized and less prevalent, these biological risk factors gain importance as determinants of the behavior.

Lifetime drinking history in patients with alcoholic liver disease and patients with alcohol use disorder without liver disease

OBJECTIVE

To determine the differences in lifetime alcohol intake (LAI) and drinking patterns between patients with alcoholic liver disease (ALD) and alcohol use disorder (AUD) without notable liver injury and between males and females with ALD.

METHODS

Alcohol drinking patterns were assessed using the Lifetime Drinking History (LDH) a validated questionnaire, during an outpatient visit. Patients with AUD, currently in addiction treatment, were matched for gender and age (±5 years) with the ALD group.

RESULTS

A total of 39 patients with ALD (26 males and 13 females; median age 58) and equal number of AUD patients were included (median age 56 years). The onset age for alcohol drinking and duration of alcohol consumption was similar in ALD and AUD. The number of drinking days was higher in women with ALD than in women with AUD: 4075 [(3224-6504) versus 2092 (1296-3661), p = .0253]. The LAI and drinks per drinking day (DDD) were not significantly different between patients with ALD and AUD. Females with ALD had lower LAI than males with ALD: 32,934 (3224-6504) versus 50,923 (30,360-82,195), p = .0385, fewer DDD (p = .0112), and lower proportion of binge drinking as compared to males with ALD (p = .0274).

CONCLUSIONS

The total LAI was similar in patients with ALD and AUD. The number of drinking days over the lifetime was associated with the development of ALD in females. Females with ALD had significantly lower alcohol consumption than men with ALD despite similar duration in years of alcohol intake which supports the concept of female propensity of ALD.

The Manifestations of Sleep Disturbances 16 Years Post-Trauma

STUDY OBJECTIVES

Limited data exist on the association between trauma and sleep across developmental stages, particularly trauma experienced in childhood and sleep in adulthood. We assessed sleep quality across the developmental spectrum among avalanche survivors 16 years after exposure as compared to a matched comparison cohort.

METHODS

Participants were survivors of two avalanche-affected towns (n = 286) and inhabitants of non-exposed towns (n = 357). Symptoms were assessed with respect to the survivors' developmental stage at the time of the disaster: childhood (2-12), adolescence (13-19), young adult (20-39), and adult (≥ 40). The Posttraumatic Diagnostic Scale, Pittsburgh Sleep Quality Index and Pittsburgh Sleep Quality Index PTSD Addendum were used.

RESULTS

Overall PTSD symptoms were not associated with avalanche exposure in any age groups under study. However, survivors who were children at the time of the disaster were 2.58 times (95% CI 1.33-5.01) more likely to have PTSD-related sleep disturbances (PSQI-A score ≥ 4) in adulthood than their non-exposed peers, especially symptoms of acting out dreams (aRR = 3.54; 95% CI 1.15-10.87). Those who were adults at time of the exposure had increased risk of trauma-related nightmares (aRR = 2.69; 95% CI 1.07-6.79 for young adults aRR = 3.07; 95% CI 1.51-6.24 for adults) compared to their non-exposed peers.

CONCLUSIONS

Our data indicate a chronicity of PTSD-related sleep disturbances, particularly among childhood trauma survivors. REM sleep disturbances may have different manifestations depending on the developmental stage at the time of trauma exposure.

Sixteen-year follow-up of childhood avalanche survivors

BACKGROUND

Every year a substantial number of children are affected by natural disasters worldwide. However, data are scarce on long-term psychological impact of natural disasters on children's health. Identifying risk factors and outcomes associated with the long-term sequelae of posttraumatic stress disorder (PTSD) can provide a gateway to recovery as well as enhancement of preventive measures.

OBJECTIVE

Among childhood avalanche survivors, we aimed to investigate risk factors for PTSD symptoms and the relationship between socioeconomic status (SES) and PTSD symptoms in adulthood.

METHODS

Childhood survivors (aged 2-19 at the time of exposure) of two avalanches were identified through nationwide registers 16 years later. The Posttraumatic Diagnostic Scale was used to assess current PTSD symptoms. One-way ANOVA was used to explore PTSD symptoms by background and trauma-specific factors, as well as associations with current SES. Predictors of PTSD symptoms were examined by multivariable regression analysis.

RESULTS

Response rate was 66% (108/163). Results from univariate ANOVA analysis revealed that female sex was associated with PTSD symptoms (F=5.96, p<0.05). When adjusted for age and sex, PTSD symptoms were associated with lower education (F=7.62, p<0.001), poor financial status (F=12.21, p<0.001), and unemployment and/or disability (F=3.04, p<0.05). In a multivariable regression model, when adjusting for age and sex, lack of social support (t=4.22, p<0.001) and traumatic reactions of caregivers (t=2.49, p<0.05) in the aftermath of the disaster independently predicted PTSD 16 years post-trauma.

CONCLUSIONS

Lingering PTSD symptoms after childhood exposure to a disaster may negatively influence socioeconomic development in adulthood. Strengthening children's support systems post-disaster may prevent the long-term sequelae of symptoms.

Posttraumatic stress and other health consequences of catastrophic avalanches: A 16-year follow-up of survivors

To date, no study has investigated the effects of avalanches on survivor's health beyond the first years. The aim of this study was to examine long-term health status 16 years after exposure to avalanches using a matched cohort design. Mental health, sleep quality and somatic symptoms among avalanche survivors (n=286) and non-exposed controls (n=357) were examined. Results showed that 16% of survivors currently experience avalanche-specific PTSD symptoms (PDS score>14). In addition, survivors presented with increased risk of PTSD hyperarousal symptoms (>85th percentile) (aRR=1.83; 98.3% CI [1.23-2.74]); sleep-related problems (PSQI score>5) (aRR=1.34; 95% CI [1.05-1.70]); PTSD-related sleep disturbances (PSQI-A score≥4) (aRR=1.86; 95% CI [1.30-2.67]); musculoskeletal and nervous system problems (aRR 1.43; 99% CI 1.06-1.93) and gastrointestinal problems (aRR 2.16; 99% CI 1.21-3.86) compared to the unexposed group. Results highlight the need for treatment for long-term PTSD symptoms and sleep disruption in disaster communities.

The Adult Reading History Questionnaire (ARHQ) in Icelandic: Psychometric Properties and Factor Structure

This article describes psychometric testing of an Icelandic adaptation of the Adult Reading History Questionnaire (ARHQ), designed to detect a history of reading difficulties indicative of dyslexia. Tested in a large and diverse sample of 2,187 adults, the Icelandic adaptation demonstrated internal consistency reliability (Cronbach's alpha = .92) and test-retest reliability (r = .93). Validity was established by comparing scores of adults who as children received ICD-10 diagnoses of specific reading disorder (F81.0; n = 419) to those of adults defined as nondyslexics (n = 679). ROC curve analysis resulted in an area under the curve of .92 (95% CI = .90, .93, p < .001) and a cutoff score of .43 with sensitivity of 84.5% and specificity of 83.7%. An exploratory factor analysis (n = 2,187) suggested three subscales, Dyslexia Symptoms, Current Reading, and Memory, the mean scores of which differed significantly among diagnosed dyslexics, relatives of dyslexics, and population controls. Our results support the applicability of the ARHQ in Icelandic as a self-report screening tool for adult dyslexia in Iceland.

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.

A variant associated with nicotine dependence, lung cancer and peripheral arterial disease

Smoking is a leading cause of preventable death, causing about 5 million premature deaths worldwide each year. Evidence for genetic influence on smoking behaviour and nicotine dependence (ND) has prompted a search for susceptibility genes. Furthermore, assessing the impact of sequence variants on smoking-related diseases is important to public health. Smoking is the major risk factor for lung cancer (LC) and is one of the main risk factors for peripheral arterial disease (PAD). Here we identify a common variant in the nicotinic acetylcholine receptor gene cluster on chromosome 15q24 with an effect on smoking quantity, ND and the risk of two smoking-related diseases in populations of European descent. The variant has an effect on the number of cigarettes smoked per day in our sample of smokers. The same variant was associated with ND in a previous genome-wide association study that used low-quantity smokers as controls, and with a similar approach we observe a highly significant association with ND. A comparison of cases of LC and PAD with population controls each showed that the variant confers risk of LC and PAD. The findings provide a case study of a gene-environment interaction, highlighting the role of nicotine addiction in the pathology of other serious diseases.

Medical signs and symptoms associated with disability, pain, and psychosocial adjustment in systemic sclerosis

OBJECTIVE

To examine physician-assessed medical signs and patient-reported medical symptoms as correlates of 3 quality of life (QOL) outcomes in patients with systemic sclerosis (SSc): disability, pain, and psychosocial adjustment.

METHODS

One hundred fourteen patients with SSc underwent a comprehensive clinical examination including determination of skin thickening [Modified Rodnan Skin Score (MRSS)]. Patients reported current symptoms and completed standardized questionnaires assessing disability and pain (Health Assessment Questionnaire) and psychosocial adjustment (Psychosocial Adjustment to Illness Scale). Regression analysis was used to examine physician-determined and patient-reported correlates of the 3 outcomes.

RESULTS

MRSS was a significant correlate of all outcomes, although it explained only a small amount of the variance in psychosocial adjustment. Patient-reported postprandial bloating was the strongest correlate of psychosocial adjustment, explaining more than twice as much variance as MRSS. After accounting for MRSS, patient-reported dependent edema significantly correlated with all outcomes. For disability, significant correlates were physician-determined joint tenderness and number of tender points, and patient-reported joint pain on motion, joint contracture, extremity ulcers other than digital, and dyspnea. Patient-reported joint tenderness was significantly associated with pain. Regression analysis supported a model in which disability and pain mediated the relationship between MRSS and psychosocial adjustment.

CONCLUSION

Skin score is strongly associated with disability and pain, but only weakly associated with psychosocial adjustment. Dependent edema has negative implications across quality-of-life outcomes. Disability and pain mediate the relationship between disease severity and psychosocial adjustment to disease. Assessment (including self-report of patient symptoms) of specific medical signs and symptoms may indicate SSc patients experiencing diminished QOL.

Concepts of illness in Icelandic children

OBJECTIVE

To investigate the development of illness concepts among healthy Icelandic children.

METHODS

Participants were 68 schoolchildren, 6-7, 10-11, and 14-15 years of age, and their parents. Cognitive developmental level and understanding of physical illness were assessed within a Piagetian framework. In addition, illness experience and illness behaviors (Child Illness Behavior Questionnaire) were assessed.

RESULTS

Results were consistent with previous studies in that the development of illness concepts among Icelandic children was consistent with Piaget's theory of cognitive development. No relation was found between illness experience and understanding of illness. A more mature understanding of illness was related to willingness to report the onset of illness.

CONCLUSIONS

The results suggest that findings from previous studies may be generalized to a broader population.