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Cooke GS, Flower B, Cunningham E, Marshall AD, Lazarus JV, Palayew A, Jia J, Aggarwal R, Al-Mahtab M, Tanaka Y, Jeong SH, Poovorawan K, Waked I, Hiebert L, Khue PM, Grebely J, Alcantara-Payawal D, Sanchez-Avila JF, Mbendi C, Muljono DH, Lesi O, Desalegn H, Hamid S, de Araujo A, Cheinquer H, Onyekwere CA, Malyuta R, Ivanchuk I, Thomas DL, Pimenov N, Chulanov V, Dirac MA, Han H, Ward JW. Progress towards elimination of viral hepatitis: a Lancet Gastroenterology & Hepatology Commission update. Lancet Gastroenterol Hepatol 2024; 9:346-365. [PMID: 38367629 DOI: 10.1016/s2468-1253(23)00321-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 09/11/2023] [Accepted: 09/14/2023] [Indexed: 02/19/2024]
Abstract
The top 20 highest burdened countries (in disability-adjusted life years) account for more than 75% of the global burden of viral hepatitis. An effective response in these 20 countries is crucial if global elimination targets are to be achieved. In this update of the Lancet Gastroenterology & Hepatology Commission on accelerating the elimination of viral hepatitis, we convene national experts from each of the top 20 highest burdened countries to provide an update on progress. Although the global burden of diseases is falling, progress towards elimination varies greatly by country. By use of a hepatitis elimination policy index conceived as part of the 2019 Commission, we measure countries' progress towards elimination. Progress in elimination policy has been made in 14 of 20 countries with the highest burden since 2018, with the most substantial gains observed in Bangladesh, India, Indonesia, Japan, and Russia. Most improvements are attributable to the publication of formalised national action plans for the elimination of viral hepatitis, provision of publicly funded screening programmes, and government subsidisation of antiviral treatments. Key themes that emerged from discussion between national commissioners from the highest burdened countries build on the original recommendations to accelerate the global elimination of viral hepatitis. These themes include the need for simplified models of care, improved access to appropriate diagnostics, financing initiatives, and rapid implementation of lessons from the COVID-19 pandemic.
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Affiliation(s)
- Graham S Cooke
- Department of Infectious Disease, Faculty of Medicine, Imperial College London, London, UK; Department of Health Metrics Sciences, University of Washington, Seattle, WA, USA.
| | - Barnaby Flower
- Department of Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
| | | | | | - Jeffrey V Lazarus
- CUNY Graduate School of Public Health and Health Policy, New York, NY, USA; Barcelona Institute for Global Health, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Adam Palayew
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Jidong Jia
- Liver Research Centre, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Rakesh Aggarwal
- Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Mamum Al-Mahtab
- Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Yashuito Tanaka
- Department of Gastroenterology and Hepatology, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Sook-Hyang Jeong
- Department of Internal Medicine, Seoul National University Bundang Hospital, College of Medicine, Seoul National University, Seongnam, South Korea
| | - Kittiyod Poovorawan
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Mahidol Oxford Research Unit, Faculty of Tropical Medicine, Mahidol University, Thailand
| | - Imam Waked
- Hepatology Department, National Liver Institute, Shibin El Kom, Egypt
| | - Lindsey Hiebert
- Coalition for Global Hepatitis Elimination, Task Force for Global Health, Decatur, GA, USA
| | - Pham M Khue
- Faculty of Public Health, Haiphong University of Medicine and Pharmacy, Haiphong, Viet Nam
| | - Jason Grebely
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
| | - Diana Alcantara-Payawal
- Department of Internal Medicine, Fatima University Medical Center, Valenzuela, Philippines; Committee on Hepatology, Section of Gastroenterology, Cardinal Santos Medical Center, San Juan, Philippines
| | - Juan F Sanchez-Avila
- Global Health and Emerging Diseases Investigation Group, Escuela de Medicina y Ciencias de la Salud, Tecnologico de Monterrey Monterrey, Mexico
| | - Charles Mbendi
- Service of Gastroenterology, Internal Medicine, University Clinic of Kinshasa, Faculty of Medicine, University of Kinshasa, Kinshasha, DR Congo
| | - David H Muljono
- Ministry of Health, Jakarta, Indonesia; Faculty of Medicine, Universitas Hasanuddin, Makassar, Indonesia; Indonesian Academy of Sciences, Jakarta, Indonesia
| | - Olufunmilayo Lesi
- Gastroenterology and Hepatology Unit, College of Medicine, University of Lagos and Lagos University Teaching Hospital, Lagos, Nigeria
| | - Hailemichael Desalegn
- Department of Internal Medicine, St Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Saeed Hamid
- Clinical Trials Unit, Aga Khan University, Karachi, Pakistan
| | - Alexandre de Araujo
- Universidade Federal do Rio Grande do Sul, Gastroenterology and Hepatology Unit of Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Hugo Cheinquer
- Universidade Federal do Rio Grande do Sul, Gastroenterology and Hepatology Unit of Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Charles A Onyekwere
- Deparment Of Medicine, Lagos State University College of Medicine, Lagos, Nigeria
| | | | - Iryna Ivanchuk
- Department of Viral Hepatitis Control at National Institute of Public Health, Kyiv, Ukraine
| | - David L Thomas
- Divison of Infectious Diseases, John Hopkins School of Medicine, Baltimore, MD, USA
| | - Nikolay Pimenov
- National Medical Research Center of Tuberculosis and Infectious Diseases, Moscow, Russia
| | | | - Mae Ashworth Dirac
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA; Department of Health Metrics Sciences, University of Washington, Seattle, WA, USA; Department of Family Medicine, University of Washington, Seattle, WA, USA
| | - Hannah Han
- Department of Epidemiology, University of Washington, Seattle, WA, USA; Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - John W Ward
- Coalition for Global Hepatitis Elimination, Task Force for Global Health, Decatur, GA, USA; Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
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Qureshi H, Mahmood H, Sabry A, Hermez J. Barriers and Strategies for Hepatitis B and C Elimination in Pakistan. J Infect Dis 2023; 228:S204-S210. [PMID: 37703344 DOI: 10.1093/infdis/jiad022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 01/21/2023] [Indexed: 09/15/2023] Open
Abstract
BACKGROUND Pakistan has a high hepatitis burden for both hepatitis C virus (HCV) and hepatitis B virus (HBV). To achieve World Health Organization (WHO) 2030 targets for hepatitis elimination, there is a need to constitute progress in the country, find the barriers and strategies for HCV elimination, and take actions to address the gaps. METHODS We collected data from (1) WHO estimates in 2020, (2) midterm review questionnaire of the WHO regional action plan, and (3) WHO estimates on immunization. We analyzed these data to inform (1) the burden defined as prevalence and mortality and (2) response in 3 thematic areas: governance, policy, and finance; strategic information; and service delivery. RESULTS The prevalence of hepatitis B in the general population is 1.6% with 12 000 deaths/year. The prevalence of hepatitis C in the general population is 7.5% with 19 000 deaths and 545 000 new cases (incidence)/year. The selected indicators to monitor progress on viral hepatitis in Pakistan were governance and financing, policies and guidelines, and strategic information. The overall governance indicators are good with a focal point, a national hepatitis strategy, an operational plan, strategy for price reduction, and involvement of civil society but the costed action plan and the advocacy strategy are missing. The indicators on policies and guidelines are also adequately addressed. The hepatitis B and C testing and treatment guidelines are available, there is a policy to screen all blood donations, and there is an injection safety policy, but the policy for timely hepatitis B vaccine birth dose and hepatitis B vaccination for the vulnerable is missing. Both indicators regarding strategic information, that is measures of key hepatitis indicators and regular data review, are missing. The status of 5 key interventions in Pakistan show that the hepatitis B vaccination coverage is 74% and only 3% of newborn children are given the hepatitis B vaccine birth dose. Only 22% of HCV cases have been diagnosed and 2% have received treatment. Treatment response is 96%. Same-day testing and treatment of hepatitis C reduced the overall dropout rate and improved the cascade of care. Decentralization and task shifting are important tools to improve service delivery and reach communities. Finances to implement hepatitis elimination is a major barrier. CONCLUSIONS Pakistan has the highest hepatitis disease burden. With the current pace, hepatitis elimination appears impossible. Introduction of the birth dose of hepatitis B vaccine and improving access and affordability of testing can improve the testing and treatment numbers. Finances need to be mobilized from within the country and outside to support disease elimination.
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Affiliation(s)
- Huma Qureshi
- Gastroenterologist and National Focal Point Hepatitis, Hepatitis Control, Ministry of National Health Services, Regulations and Coordination, Islamabad, Pakistan
| | - Hassan Mahmood
- In-Charge Hepatitis Planning, Development and Monitoring Unit, USAID Funded GHSC PSM Project seconded at Ministry of Health, Hepatitis Control, Ministry of National Health Services, Regulations and Coordination, Islamabad, Pakistan
| | - Ahmed Sabry
- Universal Health Coverage/Department of Communicable Disease Prevention and Control, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt
| | - Joumana Hermez
- Universal Health Coverage/Department of Communicable Disease Prevention and Control, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt
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Rivera Saldana CD, Abramovitz D, Beletsky L, Borquez A, Kiene S, Marquez LK, Patton T, Strathdee S, Zúñiga ML, Martin NK, Cepeda J. Estimating the impact of a police education program on hepatitis C virus transmission and disease burden among people who inject drugs in Tijuana, Mexico: A dynamic modeling analysis. Addiction 2023; 118:1763-1774. [PMID: 37039246 PMCID: PMC10524658 DOI: 10.1111/add.16203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 03/23/2023] [Indexed: 04/12/2023]
Abstract
BACKGROUND AND AIMS Criminalization of drug use and punitive policing are key structural drivers of hepatitis C virus (HCV) risk among people who inject drugs (PWID). A police education program (Proyecto Escudo) delivering training on occupational safety together with drug law content was implemented between 2015 and 2016 in Tijuana, Mexico, to underpin drug law reform implementation. We used data from a longitudinal cohort of PWID in Tijuana to inform epidemic modeling and assess the long-term impact of Escudo on HCV transmission and burden among PWID in Tijuana. METHODS We developed a dynamic, compartmental model of HCV transmission and incarceration among PWID and tracked liver disease progression among current and former PWID. The model was calibrated to data from Tijuana, Mexico, with 90% HCV seroprevalence. We used segmented regression analysis to estimate impact of Escudo on recent incarceration among an observational cohort of PWID. By simulating the observed incarceration trends, we estimated the potential impact of the implemented (2-year reduction in incarceration) and an extended (10-year reduction in incarceration) police education program over a 50-year follow-up (2016-2066) on HCV outcomes (incidence, cirrhosis, HCV-related deaths and disability adjusted life-years averted) compared with no intervention. RESULTS Over the 2-year follow-up, Proyecto Escudo reduced HCV incidence among PWID from 21.5 per 100 person years (/100py) (95% uncertainty interval [UI] = 15.3-29.7/100py) in 2016 to 21.1/100py (UI = 15.0-29.1/100py) in 2018. If continued for 10 years, Escudo could reduce HCV incidence to 20.0/100py (14.0-27.8/100py) by 2026 and avert 186 (32-389) new infections, 76 (UI = 12-160) cases of cirrhosis and 32 (5-73) deaths per 10 000 PWID compared with no intervention over a 50-year time horizon. CONCLUSIONS In Tijuana, Mexico, implementation of a police education program delivering training on occupational safety and drug law content appears to have reduced hepatitis C virus incidence among people who inject drugs.
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Affiliation(s)
- Carlos D Rivera Saldana
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, La Jolla, California, USA
- School of Public Health, San Diego State University, San Diego, California, USA
| | - Daniela Abramovitz
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Leo Beletsky
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, La Jolla, California, USA
- School of Law and Bouve College of Health Sciences, Northeastern University, Boston, Massachusetts, USA
| | - Annick Borquez
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Susan Kiene
- School of Public Health, San Diego State University, San Diego, California, USA
| | - Lara K Marquez
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Thomas Patton
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Steffanie Strathdee
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - María Luisa Zúñiga
- School of Social Work, San Diego State University, San Diego, California, USA
| | - Natasha K Martin
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, La Jolla, California, USA
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Javier Cepeda
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Babigumira JB, Karichu JK, Clark S, Cheng MM, Garrison LP, Maniecki MB, Hamid SS. Assessing the potential cost-effectiveness of centralised versus point-of-care testing for hepatitis C virus in Pakistan: a model-based comparison. BMJ Open 2023; 13:e066770. [PMID: 37142306 PMCID: PMC10163545 DOI: 10.1136/bmjopen-2022-066770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/06/2023] Open
Abstract
OBJECTIVES Pakistan has a hepatitis C virus (HCV) infection prevalence of 6%-9% and aims to achieve World Health Organisation (WHO) targets for elimination of HCV by the year 2030. We aim to evaluate the potential cost-effectiveness of a reference laboratory-based (centralised laboratory testing; CEN) confirmatory testing approach versus a molecular near-patient point-of-care (POC) confirmatory approach to screen the general population for HCV in Pakistan. STUDY DESIGN We used a decision tree-analytic model from a governmental (formal healthcare sector) perspective. STUDY SETTING Individuals were assumed to be initially screened with an anti-HCV test at home, followed by POC nucleic acid test (NAT) at nearby district hospitals or followed by NAT at centralised laboratories. PARTICIPANTS We included the general testing population for chronic HCV in Pakistan. INTERVENTION Screening with an anti-HCV antibody test (Anti-HCV) followed by either POC NAT (Anti-HCV-POC), or reference laboratory NAT (Anti-HCV-CEN), was compared, using data from published literature and the Pakistan Ministry of Health. MEASURES Outcome measures included: number of HCV infections identified per year, percentage of individuals correctly classified, total costs, average costs per individual tested, and cost-effectiveness (assessed as cost per additional HCV infection identified). Sensitivity analysis was also performed. RESULTS At a national level (25 million annual screening tests), the Anti-HCV-CEN strategy would identify 142 406 more HCV infections in 1 year and increase correct classification of individuals by 0.57% compared with the Anti-HCV-POC strategy. The total annual cost of HCV testing was reduced using the Anti-HCV-CEN strategy by US$7.68 million (US$0.31/person). Thus, incrementally, the Anti-HCV-CEN strategy costs less and identifies more HCV infections than Anti-HCV-POC. The incremental difference in HCV infections identified was most sensitive to the probability of loss to follow-up (for POC confirmatory NAT). CONCLUSIONS Anti-HCV-CEN would provide the best value for money when scaling up HCV testing in Pakistan.
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Affiliation(s)
- Joseph B Babigumira
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | | | - Samantha Clark
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, University of Washington Seattle Campus, Seattle, Washington, USA
| | - Mindy M Cheng
- Roche Molecular Systems Inc, Pleasanton, California, USA
| | - Louis P Garrison
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, University of Washington Seattle Campus, Seattle, Washington, USA
- VeriTech Corporation, Mercer Island, Washington, USA
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Carty PG, Teljeur C, De Gascun CF, Gillespie P, Harrington P, McCormick A, O'Neill M, Smith SM, Ryan M. Another Step Toward Hepatitis C Elimination: An Economic Evaluation of an Irish National Birth Cohort Testing Program. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2022; 25:1947-1957. [PMID: 35778325 DOI: 10.1016/j.jval.2022.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 04/14/2022] [Accepted: 05/05/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVES We aimed to evaluate the cost-effectiveness of offering once-off birth cohort testing for hepatitis C virus (HCV) to people in Ireland born between 1965 and 1985, the cohort with the highest reported prevalence of undiagnosed chronic HCV infection. METHODS Systematic and opportunistic HCV birth cohort testing programs, implemented over a 4-year timeframe, were compared with the current practice of population risk-based testing only in a closed-cohort decision tree and Markov model hybrid over a lifetime time horizon. Outcomes were expressed in quality-adjusted life-years (QALYs). Costs were presented from the health system's perspective in 2020 euro (€). Uncertainty was assessed via deterministic, probabilistic, scenario, and threshold analyses. RESULTS In the base case, systematic testing yielded the largest cost and health benefits, followed by opportunistic testing and risk-based testing. Compared with risk-based testing, the incremental cost-effectiveness ratio for opportunistic testing was €14 586 (95% confidence interval €4185-€33 527) per QALY gained. Compared with opportunistic testing, the incremental cost-effectiveness ratio for systematic testing was €16 827 (95% confidence interval €5106-€38 843) per QALY gained. These findings were robust across a range of sensitivity analyses. CONCLUSIONS Both systematic and opportunistic birth cohort testing would be considered an efficient use of resources, but systematic testing was the optimal strategy at willingness-to-pay threshold values typically used in Ireland. Although cost-effective, any decision to introduce birth cohort testing for HCV (in Ireland or elsewhere) must be balanced with considerations regarding the feasibility and budget impact of implementing a national testing program given high initial costs and resource use.
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Affiliation(s)
- Paul G Carty
- RCSI University of Medicine and Health Sciences, Dublin, Ireland; Health Information and Quality Authority, Dublin, Ireland.
| | - Conor Teljeur
- Health Information and Quality Authority, Dublin, Ireland
| | - Cillian F De Gascun
- National Virus Reference Laboratory, University College Dublin, Dublin, Ireland
| | - Paddy Gillespie
- Health Economics & Policy Analysis Centre, National University of Ireland Galway, Galway, Ireland; CÚRAM, The SFI Research Centre for Medical Devices (12/RC/2073_2), National University of Ireland Galway, Galway, Ireland
| | | | | | | | - Susan M Smith
- Department of Public Health and Primary Care, School of Medicine, Trinity College Dublin, Ireland
| | - Mairin Ryan
- Health Information and Quality Authority, Dublin, Ireland; Department of Pharmacology and Therapeutics, Trinity College Dublin, Trinity Health Sciences, St James's Hospital, Dublin, Ireland
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Saldana CDR, Beletsky L, Borquez A, Kiene SM, Marquez LK, Strathdee SA, Zúñiga ML, Cepeda J, Martin NK. Modelling the contribution of incarceration and public health oriented drug law reform to HCV transmission and elimination among PWID in Tijuana, Mexico. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2022; 110:103878. [PMID: 36242829 PMCID: PMC9841890 DOI: 10.1016/j.drugpo.2022.103878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 09/27/2022] [Accepted: 10/03/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Incarceration is associated with increased risk of hepatitis C virus (HCV) among people who inject drugs (PWID). Mexico's previous attempt in implementing a public health-oriented drug law reform resulted in minimal impact on incarceration among PWID. However, implementation of reforms alongside Mexico's HCV elimination program has the potential to reshape the HCV epidemic among PWID in the next decade. We use data from a cohort of PWID in Tijuana, Mexico, to inform epidemic modeling to assess the contribution of incarceration and fully implemented drug reform on HCV transmission and elimination among PWID. METHODS We developed a dynamic, deterministic model of incarceration, HCV transmission and disease progression among PWID. The model was calibrated to data from Tijuana, Mexico, with 90% HCV seroprevalence among 10,000 PWID. We estimated the 10-year population attributable fraction (PAF) of incarceration to HCV incidence among PWID and simulated, from 2022, the potential impact of the following scenarios: 1) decriminalization (80% reduction in incarceration rates); 2) fully implemented drug law reform (decriminalization and diversion to opiate agonist therapy [OAT]); 3) fully implemented drug law reform with HCV treatment (direct-acting antivirals [DAA]). We also assessed the number DAA needed to reach the 80% incidence reduction target by 2030 under these scenarios. RESULTS Projections suggest a PAF of incarceration to HCV incidence of 5.4% (95% uncertainty interval [UI]:0.6-11.9%) among PWID in Tijuana between 2022-2032. Fully implemented drug reforms could reduce HCV incidence rate by 10.6% (95%UI:3.1-19.2%) across 10 years and reduce the number of DAA required to achieve Mexico's HCV incidence reduction goal by 14.3% (95%UI:5.3-17.1%). CONCLUSIONS Among PWID in Tijuana, Mexico, incarceration remains an important contributor to HCV transmission. Full implementation of public health-oriented drug law reform could play an important role in reducing HCV incidence and improve the feasibility of reaching the HCV incidence elimination target by 2030.
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Affiliation(s)
- Carlos D Rivera Saldana
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, La Jolla, CA, 92093, United States; School of Public Health, San Diego State University, San Diego, CA, 92182, United States.
| | - Leo Beletsky
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, La Jolla, CA, 92093, United States; School of Law and Bouve College of Health Sciences, Northeastern University, Boston, MA, 02115, United States
| | - Annick Borquez
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, La Jolla, CA, 92093, United States
| | - Susan M Kiene
- School of Public Health, San Diego State University, San Diego, CA, 92182, United States
| | - Lara K Marquez
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, La Jolla, CA, 92093, United States
| | - Steffanie A Strathdee
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, La Jolla, CA, 92093, United States
| | - María Luisa Zúñiga
- School of Social Work, San Diego State University, San Diego, CA, 92182, United States
| | - Javier Cepeda
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205, United States
| | - Natasha K Martin
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, La Jolla, CA, 92093, United States; Population Health Sciences, University of Bristol, Bristol BS8 1QU, United Kingdom
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Characterizing trends and associations for hepatitis C virus antibody prevalence in the Middle East and North Africa: meta-regression analyses. Sci Rep 2022; 12:20637. [PMID: 36450850 PMCID: PMC9712517 DOI: 10.1038/s41598-022-25086-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 11/24/2022] [Indexed: 12/12/2022] Open
Abstract
This study characterized population-level trends and associations with hepatitis C virus (HCV) antibody (Ab) prevalence in the Middle East and North Africa (MENA). Data source was the standardized and systematically gathered MENA HCV Epidemiology Synthesis Project Database. Random-effects univariable and multivariable meta-regressions were conducted. 2,621 HCV Ab prevalence measures on 49,824,108 individuals were analyzed. In the analysis including all populations, 71% of the variation in prevalence was explained, mostly by at-risk population type. Compared to the general population, prevalence was 23-fold higher among people who inject drugs, and 14-fold higher among high-risk clinical populations. In the analysis including only the general population, 67% of the variation in prevalence was explained, mostly by country/subregion. Compared to Afghanistan, prevalence was highest in Egypt and Pakistan. Prevalence in the general population was declining at a rate of 4% per year, but outside the general population, the decline was at only 1% per year. HCV Ab prevalence in MENA is declining rapidly, but this decline is largely occurring in the general population following introduction of blood and injection safety measures. The decline in populations at higher risk of exposure is slow and below the level needed to achieve HCV elimination by 2030.
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Alaama AS, Khattabi H, Mugisa B, Atta H, Hermez J, Hutin YJ. Progress towards elimination of viral hepatitis by 2030 in the WHO Eastern Mediterranean Region, 2019. Lancet Gastroenterol Hepatol 2022; 7:862-870. [PMID: 35817075 DOI: 10.1016/s2468-1253(22)00082-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 02/13/2022] [Accepted: 02/23/2022] [Indexed: 02/08/2023]
Abstract
The WHO Global Health Sector Strategy and hepatitis regional action plan for the WHO Eastern Mediterranean Region (EMR) proposed strategic directions for countries to progress towards the elimination of viral hepatitis by 2030. In 2019, we reviewed progress to gain a picture of current pressures and identify priority actions for member states to reach this goal. We collected data from country, regional, and global reports published in 2015-19, questionnaires completed by countries, and convened a regional consultation with programme managers and partners. We analysed these data along three thematic areas: governance and finance, strategic information, and service delivery. 15 of the 22 EMR countries completed the review. Of these, 10 (67%) had a national strategy and six (40%) allocated funds to it. 11 (73%) countries had testing and treatment guidelines in line with WHO recommendations. Ten (67%) countries had burden and coverage estimates, four (27%) reported on the cascade of care for hepatitis C virus (HCV), three (20%) reported on the cascade of care for hepatitis B (HBV), and three (20%) had mortality estimates. By 2019, the regional hepatitis B vaccination coverage among infants was 82% for the third dose and 33% for the timely birth dose. For harm reduction, 27 syringes were distributed per injecting drug user per year. Between 2015 and 2019, HCV diagnosis increased from 18% to 33% and treatment for hepatitis C increased from 12% to 26%. Within the same time period, diagnosis of HBV diagnosis increased from 2% to 14% and treatment initiation increased from less than 1% to 2%. EMR countries made progress in governance, policy development, coverage of the third dose of the hepatitis B vaccine, and testing and treatment for HCV infection. However, birth dose vaccination, injection safety, harm reduction, and testing and treatment are limited by insufficient financing. Core interventions need to be included within national universal health coverage packages as an initial move towards elimination.
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Affiliation(s)
- Ahmed Sabry Alaama
- Universal Health Coverage: Department of Communicable Disease Prevention and Control, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt.
| | | | - Bridget Mugisa
- Universal Health Coverage: Department of Communicable Disease Prevention and Control, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt
| | - Hoda Atta
- Universal Health Coverage: Department of Communicable Disease Prevention and Control, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt
| | - Joumana Hermez
- Universal Health Coverage: Department of Communicable Disease Prevention and Control, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt
| | - Yvan J Hutin
- Universal Health Coverage: Department of Communicable Disease Prevention and Control, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt
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Dopico E, Rodriguez-Frias F, Ubillos I, Rando-Segura A, Garcia-Cehic D, Gregori J, Rando-Matos Y, Solsona L, Niubó J, Esteban JI, Costa J, Martínez MJ, Quer J. Prevalence of Hepatitis C Virus Infection, Genotypes and Subtypes in Migrants from Pakistan in Barcelona, Spain. Infect Drug Resist 2022; 15:4637-4644. [PMID: 36003985 PMCID: PMC9394658 DOI: 10.2147/idr.s367715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 07/26/2022] [Indexed: 11/23/2022] Open
Abstract
Background Hepatitis C virus (HCV) is a major cause of chronic liver infection with 71 million people infected worldwide. Pakistan has the second highest prevalence of HCV infection and more than half (52%) of Pakistani living in Spain reside in Barcelona. The aim of this study was to analyse the seroprevalence and viraemic rate and determine the genotypes and subtypes of HCV among Pakistanis living in the southern metropolitan area of Barcelona. Methods We included all Pakistani patients seeking primary healthcare in the southern metropolitan area of Barcelona from August 2011 to July 2014. Serum samples were screened for HCV antibodies. HCV viral load was determined by reverse transcription polymerase chain reaction and genotypes and subtypes were performed using Versant HCV Genotype and/or deep-sequencing. Screening for hepatitis B virus (HBV) was also carried out. Results Among 5877 Pakistani patients, 565 (9.61%) were screened for anti-HCV antibodies, with 68 (12.04%) being positive. The viral load was determined in 65, with 31 presenting active infection and the viraemic rate was 47.69% (95% confidence interval 36.02-59.62). HCV genotyping and subtyping were performed in 24 individuals. Most infections corresponded to HCV genotype 3 (91.67%), and high resolution HCV subtyping was performed in 18 samples, 16 of which presented subtype 3a. One subject presented HBV coinfection with undetectable HBV DNA. During the study period, we identified a possible case of HCV vertical transmission followed by spontaneous viraemia clearance in a chronically infected mother with a C/T IL28B genetic polymorphism. Conclusion These results suggest that general HCV screening protocols in patients from high prevalence countries, such as Pakistan, would be helpful to identify and treat active HCV infections. This could avoid further transmission and contribute to building targeted health policies for micro-elimination of HCV infection in specific communities.
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Affiliation(s)
- Eva Dopico
- Microbiology Department, Laboratori Clínic Territorial Metropolitana Sud, Hospital Universitari de Bellvitge, Institut Català de la Salut (ICS), Hospitalet de Llobregat, Barcelona, Spain.,Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Francisco Rodriguez-Frias
- Biochemistry Department, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain.,Biochemistry and Molecular Biology Department, Universitat Autònoma de Barcelona (UAB), Bellaterra, Spain
| | - Itziar Ubillos
- Laboratory Clínic Territorial Metropolitana Sud, Institut Català de la Salut (ICS), Hospitalet de Llobregat, Barcelona, Spain
| | - Ariadna Rando-Segura
- Biochemistry Department, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Damir Garcia-Cehic
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain.,Liver Diseases-Viral Hepatitis, Liver Unit, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Josep Gregori
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain.,Liver Diseases-Viral Hepatitis, Liver Unit, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Yolanda Rando-Matos
- Equip d'Atenció Primària Florida Nord, Gerència d'Àmbit d'Atenció Primària Metropolitana Sud, Institut Català de la Salut (ICS), Hospitalet de Llobregat, Barcelona, Spain.,Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
| | - Luis Solsona
- Equip d'Atenció Primària Florida Nord, Gerència d'Àmbit d'Atenció Primària Metropolitana Sud, Institut Català de la Salut (ICS), Hospitalet de Llobregat, Barcelona, Spain.,Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
| | - Jordi Niubó
- Microbiology Department, Laboratori Clínic Territorial Metropolitana Sud, Hospital Universitari de Bellvitge, Institut Català de la Salut (ICS), Hospitalet de Llobregat, Barcelona, Spain.,Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Juan Ignacio Esteban
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain.,Liver Diseases-Viral Hepatitis, Liver Unit, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Josep Costa
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain.,Microbiology Department, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Miguel J Martínez
- Microbiology Department, Hospital Clínic, University of Barcelona, Barcelona, Spain.,ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | - Josep Quer
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain.,Biochemistry and Molecular Biology Department, Universitat Autònoma de Barcelona (UAB), Bellaterra, Spain.,Liver Diseases-Viral Hepatitis, Liver Unit, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
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10
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Henriot P, Castry M, Luong Nguyen LB, Shimakawa Y, Jean K, Temime L. Meta-analysis: risk of hepatitis C virus infection associated with hospital-based invasive procedures. Aliment Pharmacol Ther 2022; 56:558-569. [PMID: 35758763 PMCID: PMC9543323 DOI: 10.1111/apt.17106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 06/08/2022] [Accepted: 06/13/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND Healthcare settings, where invasive procedures are frequently performed, may play an important role in the transmission dynamics of blood-borne pathogens when compliance with infection control precautions is suboptimal. AIMS To understand and quantify the role of hospital-based invasive procedures on hepatitis C virus (HCV) transmission. METHODS We conducted a systematic review and meta-analysis to identify recent studies reporting association measures of HCV infection risk that are linked to iatrogenic procedures. Based on expert opinion, invasive procedures were categorised into 10 groups for which pooled measures were calculated. Finally, the relationship between pooled measures and the country-level HCV prevalence or the Healthcare Access and Quality (HAQ) index was assessed by meta-regression. RESULTS We included 71 studies in the analysis. The most frequently evaluated procedures were blood transfusion (66 measures) and surgery (43 measures). The pooled odds ratio (OR) of HCV infection varied widely, ranging from 1.46 (95% confidence interval: 1.14-1.88) for dental procedures to 3.22 (1.7-6.11) for transplantation. The OR for blood transfusion was higher for transfusions performed before 1998 (3.77, 2.42-5.88) than for those without a specified/recent date (2.20, 1.77-2.75). In procedure-specific analyses, the HCV infection risk was significantly negatively associated with the HAQ for endoscopy and positively associated with HCV prevalence for endoscopy and surgery. CONCLUSIONS Various invasive procedures were significantly associated with HCV infection. Our results provide a ranking of procedures in terms of HCV risk that may be used for prioritisation of infection control interventions, especially in high HCV prevalence settings.
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Affiliation(s)
- Paul Henriot
- MESuRS LaboratoryConservatoire National des Arts et MétiersParisFrance,PACRI UnitConservatoire National des Arts et Métiers/Institut PasteurParisFrance
| | | | | | - Yusuke Shimakawa
- PACRI UnitConservatoire National des Arts et Métiers/Institut PasteurParisFrance,Unité d'Epidémiologie des Maladies ÉmergentesInstitut PasteurParisFrance
| | - Kévin Jean
- MESuRS LaboratoryConservatoire National des Arts et MétiersParisFrance,PACRI UnitConservatoire National des Arts et Métiers/Institut PasteurParisFrance
| | - Laura Temime
- MESuRS LaboratoryConservatoire National des Arts et MétiersParisFrance,PACRI UnitConservatoire National des Arts et Métiers/Institut PasteurParisFrance
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11
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Sahibzada KI, Ganova-Raeva L, Dimitrova Z, Ramachandran S, Lin Y, Longmire G, Arthur L, Xia GL, Khudyakov Y, Khan I, Sadaf S. Hepatitis C virus transmission cluster among injection drug users in Pakistan. PLoS One 2022; 17:e0270910. [PMID: 35839216 PMCID: PMC9286280 DOI: 10.1371/journal.pone.0270910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 06/21/2022] [Indexed: 11/19/2022] Open
Abstract
Hepatitis C virus (HCV) infections are public health problem across the globe, particularly in developing countries. Pakistan has the second highest prevalence of HCV infection worldwide. Limited data exist from Pakistan about persons who inject drugs (PWID) and are at significant risk of exposure to HCV infection and transmission. Serum specimens (n = 110) collected from PWID residing in four provinces were tested for molecular markers of HCV infection. Next generation sequencing (NGS) of the hypervariable region (HVR1) of HCV and Global Hepatitis Outbreak and Surveillance Technology (GHOST) were used to determine HCV genotype, genetic heterogeneity, and construct transmission networks. Among tested specimens, 47.3% were found anti-HCV positive and 34.6% were HCV RNA-positive and belonged to four genotypes, with 3a most prevalent followed by 1a, 1b and 4a. Variants sampled from five cases formed phylogenetic cluster and a transmission network. One case harbored infection with two different genotypes. High prevalence of infections and presence of various genotypes indicate frequent introduction and transmission of HCV among PWID in Pakistan. Identification of a transmission cluster across three provinces, involving 20% of all cases, suggests the existence of a countrywide transmission network among PWIDs. Understanding the structure of this network should assist in devising effective public health strategies to eliminate HCV infection in Pakistan.
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Affiliation(s)
- Kashif Iqbal Sahibzada
- School of Biochemistry and Biotechnology, University of the Punjab, Lahore, Pakistan
- Division of Viral Hepatitis, Center of Disease Control and Prevention, Molecular Epidemiology and Bioinformatics, Atlanta, GA, United States of America
| | - Lilia Ganova-Raeva
- Division of Viral Hepatitis, Center of Disease Control and Prevention, Molecular Epidemiology and Bioinformatics, Atlanta, GA, United States of America
| | - Zoya Dimitrova
- Division of Viral Hepatitis, Center of Disease Control and Prevention, Molecular Epidemiology and Bioinformatics, Atlanta, GA, United States of America
| | - Sumathi Ramachandran
- Division of Viral Hepatitis, Center of Disease Control and Prevention, Molecular Epidemiology and Bioinformatics, Atlanta, GA, United States of America
| | - Yulin Lin
- Division of Viral Hepatitis, Center of Disease Control and Prevention, Molecular Epidemiology and Bioinformatics, Atlanta, GA, United States of America
| | - Garrett Longmire
- Division of Viral Hepatitis, Center of Disease Control and Prevention, Molecular Epidemiology and Bioinformatics, Atlanta, GA, United States of America
| | - Leonard Arthur
- Division of Viral Hepatitis, Center of Disease Control and Prevention, Molecular Epidemiology and Bioinformatics, Atlanta, GA, United States of America
| | - Guo-liang Xia
- Division of Viral Hepatitis, Center of Disease Control and Prevention, Molecular Epidemiology and Bioinformatics, Atlanta, GA, United States of America
| | - Yury Khudyakov
- Division of Viral Hepatitis, Center of Disease Control and Prevention, Molecular Epidemiology and Bioinformatics, Atlanta, GA, United States of America
| | - Idrees Khan
- University of Peshawar, Peshawar, KPK, Pakistan
| | - Saima Sadaf
- School of Biochemistry and Biotechnology, University of the Punjab, Lahore, Pakistan
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12
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Artenie A, Luhmann N, Lim AG, Fraser H, Ward Z, Stone J, MacGregor L, Walker JG, Trickey A, Marquez LK, Abu-Raddad LJ, Ayoub HH, Walsh N, Hickman M, Martin NK, Easterbrook P, Vickerman P. Methods and indicators to validate country reductions in incidence of hepatitis C virus infection to elimination levels set by WHO. Lancet Gastroenterol Hepatol 2022; 7:353-366. [PMID: 35122713 PMCID: PMC10644895 DOI: 10.1016/s2468-1253(21)00311-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 08/13/2021] [Accepted: 08/17/2021] [Indexed: 12/22/2022]
Abstract
One of the main goals of the 2016 Global Health Sector Strategy on viral hepatitis is the elimination of hepatitis C virus (HCV) as a public health problem by 2030, defined as an 80% reduction in incidence and 65% reduction in mortality relative to 2015. Although monitoring HCV incidence is key to validating HCV elimination, use of the gold-standard method, which involves prospective HCV retesting of people at risk, can be prohibitively resource-intensive. Additionally, few countries collected quality data in 2015 to enable an 80% decrease by 2030 to be calculated. Here, we first review different methods of monitoring HCV incidence and discuss their resource implications and applicability to various populations. Second, using mathematical models developed for various global settings, we assess whether trends in HCV chronic prevalence or HCV antibody prevalence or scale-up levels for HCV testing, treatment, and preventative interventions can be used as reliable alternative indicators to validate the HCV incidence target. Third, we discuss the advantages and disadvantages of an absolute HCV incidence target and suggest a suitable threshold. Finally, we propose three options that countries can use to validate the HCV incidence target, depending on the available surveillance infrastructure.
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Affiliation(s)
- Adelina Artenie
- Department of Population Health Sciences and National Institute for Health Research Health Protection Research Unit in Behavioural Science and Evaluation, University of Bristol, Bristol, UK.
| | - Niklas Luhmann
- Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, WHO, Geneva, Switzerland
| | - Aaron G Lim
- Department of Population Health Sciences and National Institute for Health Research Health Protection Research Unit in Behavioural Science and Evaluation, University of Bristol, Bristol, UK
| | - Hannah Fraser
- Department of Population Health Sciences and National Institute for Health Research Health Protection Research Unit in Behavioural Science and Evaluation, University of Bristol, Bristol, UK
| | - Zoe Ward
- Department of Population Health Sciences and National Institute for Health Research Health Protection Research Unit in Behavioural Science and Evaluation, University of Bristol, Bristol, UK
| | - Jack Stone
- Department of Population Health Sciences and National Institute for Health Research Health Protection Research Unit in Behavioural Science and Evaluation, University of Bristol, Bristol, UK
| | - Louis MacGregor
- Department of Population Health Sciences and National Institute for Health Research Health Protection Research Unit in Behavioural Science and Evaluation, University of Bristol, Bristol, UK
| | - Josephine G Walker
- Department of Population Health Sciences and National Institute for Health Research Health Protection Research Unit in Behavioural Science and Evaluation, University of Bristol, Bristol, UK
| | - Adam Trickey
- Department of Population Health Sciences and National Institute for Health Research Health Protection Research Unit in Behavioural Science and Evaluation, University of Bristol, Bristol, UK
| | - Lara K Marquez
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, CA, USA
| | | | - Houssein H Ayoub
- Department of Mathematics, Statistics, and Physics, Qatar University, Doha, Qatar
| | - Nick Walsh
- Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, WHO, Geneva, Switzerland
| | - Matthew Hickman
- Department of Population Health Sciences and National Institute for Health Research Health Protection Research Unit in Behavioural Science and Evaluation, University of Bristol, Bristol, UK
| | - Natasha K Martin
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, CA, USA
| | - Philippa Easterbrook
- Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, WHO, Geneva, Switzerland
| | - Peter Vickerman
- Department of Population Health Sciences and National Institute for Health Research Health Protection Research Unit in Behavioural Science and Evaluation, University of Bristol, Bristol, UK
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13
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Saleem U, Aslam N, Siddique R, Iqbal S, Manan M. Hepatitis C virus: Its prevalence, risk factors and genotype distribution in Pakistan. EUR J INFLAMM 2022. [DOI: 10.1177/1721727x221144391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Hepatitis C is a dangerous liver disease transmitted by Hepatitis C virus (HCV). HCV constitutes an important health issue in Pakistan. In Pakistani setting HCV is found frequently and is recognized as an alarming health problem. In this cross sectional study we reviewed published data regarding the seroprevalence of hepatitis C in general community, blood donors and pregnant females and risk factors linked with its occurrence in Pakistan. Data retrieved from163 studies published from 2001 to 2022 was utilized and weighted mean was calculated. Data of 1,875,232 individuals was collected and arranged into three groups, depending upon the population type such as (1) general population, (2) pregnant women, (3) blood donors. General population (765,426) and blood donors (973,260) formed the most of population. Mean Hepatitis C virus prevalence in general public and blood donors was 16.47% and 8.2% respectively. In pregnant females (136,546) the mean frequency was 9.3%. This study exhibits that the frequency of Hepatitis C in general population, pregnant females and blood donors groups was 11.32%. The data suggested that risks factors for transmitting HCV infection in Pakistan include unsterilized needle use, blood transfusions, shaving by barbers, lack of trained staff, needle stick injuries, injection drug users, household contacts/spousal transmission, unsterilized dental and surgical Instruments, improper disposal of hospital waste, poor infra-structure and others. The frequency of HCV infection is distressing in Pakistan. Health education and awareness programs are needed for decreasing Hepatitis C infection in Pakistan. The data necessitate the implementation of preventive and remedial approaches to decrease the disease load and mortality in Pakistan.
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Affiliation(s)
- Uzma Saleem
- Department of Pharmacology, Faculty of Pharmaceutical Sciences, Government College University Faisalabad, Faisalabad, Pakistan
| | - Nosheen Aslam
- Department of Biochemistry, Government College University Faisalabad, Faisalabad, Pakistan
| | - Rida Siddique
- Department of Pharmacology, Faculty of Pharmaceutical Sciences, Government College University Faisalabad, Faisalabad, Pakistan
| | - Shabnoor Iqbal
- Department of Zoology, Government College University Faisalabad, Faisalabad, Pakistan
| | - Maria Manan
- Department of Pharmacology, Faculty of Pharmaceutical Sciences, Government College University Faisalabad, Faisalabad, Pakistan
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14
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Lestari D, Megawati NY, Susyanto N, Adi-Kusumo F. Qualitative behaviour of a stochastic hepatitis C epidemic model in cellular level. MATHEMATICAL BIOSCIENCES AND ENGINEERING : MBE 2022; 19:1515-1535. [PMID: 35135215 DOI: 10.3934/mbe.2022070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
In this paper, a mathematical model describing the dynamical of the spread of hepatitis C virus (HCV) at a cellular level with a stochastic noise in the transmission rate is developed from the deterministic model. The unique time-global solution for any positive initial value is served. The Ito's Formula, the suitable Lyapunov function, and other stochastic analysis techniques are used to analyze the model dynamics. The numerical simulations are carried out to describe the analytical results. These results highlight the impact of the noise intensity accelerating the extinction of the disease.
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Affiliation(s)
- Dwi Lestari
- Department of Mathematics, Universitas Gadjah Mada, Yogyakarta, Indonesia
- Department of Mathematics Education, Universitas Negeri Yogyakarta, Yogyakarta, Indonesia
| | | | - Nanang Susyanto
- Department of Mathematics, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Fajar Adi-Kusumo
- Department of Mathematics, Universitas Gadjah Mada, Yogyakarta, Indonesia
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15
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Maqsood S, Iqbal S, Zakar R, Zakar MZ, Fischer F. Determinants of overall knowledge and health behaviours in relation to hepatitis B and C among ever-married women in Pakistan: evidence based on Demographic and Health Survey 2017-18. BMC Public Health 2021; 21:2328. [PMID: 34969379 PMCID: PMC8719411 DOI: 10.1186/s12889-021-12406-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 12/10/2021] [Indexed: 11/29/2022] Open
Abstract
Background In 2019, around 5 million and 10 million people were affected by hepatitis B virus (HBV) and hepatitis C virus (HCV) respectively in Pakistan. On World Hepatitis Day 2019, Pakistan’s Government announced the Prime Minister’s Plan to eliminate HBV and HCV from the country by 2030. In order to achieve this goal, adequate knowledge about HBV and HCV regarding mode of transmission, symptoms of the disease, and awareness about available treatments and vaccines is imperative. The present study aims to investigate the determinants related to overall knowledge about and behaviour in relation to HBV and HCV amongst married women in Pakistan. Methods Secondary data analysis was carried out using the Pakistan Demographic and Health Survey (PDHS) 2017–18. A series of questions regarding women’s knowledge about how to avoid HBV and HCV and their health behaviour in relation to HBV and HCV were posed to 12,364 ever-married women of reproductive age (15–49 years). Bivariate and multivariable logistic and linear regression was applied to examine the effects of sociodemographic characteristics and covariates on women’s overall knowledge and health behaviour regarding HBV and HCV. Results The findings highlight that the majority of women (88.3%) have heard of HBV and HCV. Nonetheless, only 34.8% had comprehensive knowledge about how to avoid HBV and HCV. Few women (11.3%) had been tested for HBV or HCV during the year preceding the survey. Furthermore, the results indicate that women living in urban areas, being older, and having more than 10 years of schooling, reported better knowledge and health behaviours regarding HBV and HCV. Conclusion This study provides evidence that women’s sociodemographic characteristics create differences in their overall knowledge about and attitudes towards HBV and HCV. This research emphasized that there is a need to create awareness about the causes and prevention of HBV and HCV in order to achieve the goal of eliminating these diseases in Pakistan by 2030.
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Affiliation(s)
- Sidra Maqsood
- Department of Sociology, Government College University, Lahore, Pakistan
| | - Sarosh Iqbal
- Institute of Social & Cultural Studies, University of the Punjab, Lahore, Pakistan
| | - Rubeena Zakar
- Institute of Social & Cultural Studies, University of the Punjab, Lahore, Pakistan
| | | | - Florian Fischer
- Institute of Public Health, Charité - Universitätsmedizin Berlin, Berlin, Germany. .,Institute of Gerontological Health Services and Nursing Research, Ravensburg-Weingarten University of Applied Sciences, Weingarten, Germany.
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16
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Rashid M, Ismail H. HCV extinction analysis in district Gujrat, Pakistan by using SARIMA and linear regression models. Medicine (Baltimore) 2021; 100:e28193. [PMID: 34889300 PMCID: PMC8663847 DOI: 10.1097/md.0000000000028193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 11/17/2021] [Accepted: 11/19/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND To investigate the track of Gujrat, a District of Pakistan is very essential, either it follow-up World Health Organization (WHO) Hepatitis C Virus (HCV) elimination plan or not. This study aimed to find out HCV extinction analysis by time series forecast from District Gujrat, Pakistan. METHODS From January 1, 2016 to December 31, 2020 total n-5,111 numbers of HCV real-time polymerase chain reaction (RT-PCR) tests were performed in Gujrat. For extinction analysis we used 2 different models, the first model was seasonal auto-regressive integrated moving average (SARIMA) and the second linear regression (LR) model. First, we fitted both models then these fitted and valid models were used to predict future HCV percentage in District Gujrat. RESULTS In District Gujrat, the men HCV infected ratio is high with a higher viral load as compared with women, from year 2016 to 2020 male to female ratio was (53.75:53.19), (45.67:43.84), (39.67:39.36), (41.94:35.88), (37.70:31.38) respectively. HCV percentage is decreasing from 2016 to 2020 with an average of 4.98%. Our both fitted models SARIMAX (0,1,1)(0,1,1,6) at 95% confidence intervals and LR model Y = -0.379 X + 53.378 at 99% confidence intervals (P-value = .00) revealed that in June 2029 and in August 2027 respectively HCV percentage will be 0 from district Gujrat, Pakistan. CONCLUSIONS This study concluded that both SARIMA and LR models showed an effective modeling process for forecasting yearly HCV incidence. District Gujrat, Punjab, Pakistan is on track to achieve the WHO HCV elimination plan, before 2030 HCV will be extinct from this region.
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17
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Lim AG, Scott N, Walker JG, Hamid S, Hellard M, Vickerman P. Health and economic benefits of achieving hepatitis C virus elimination in Pakistan: A modelling study and economic analysis. PLoS Med 2021; 18:e1003818. [PMID: 34665815 PMCID: PMC8525773 DOI: 10.1371/journal.pmed.1003818] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 09/16/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Modelling suggests that achieving the WHO incidence target for hepatitis C virus (HCV) elimination in Pakistan could cost US$3.87 billion over 2018 to 2030. However, the economic benefits from integrating services or improving productivity were not included. METHODS AND FINDINGS We adapt a HCV transmission model for Pakistan to estimate the impact, costs, and cost-effectiveness of achieving HCV elimination (reducing annual HCV incidence by 80% by 2030) with stand-alone service delivery, or partially integrating one-third of initial HCV testing into existing healthcare services. We estimate the net economic benefits by comparing the required investment in screening, treatment, and healthcare management to the economic productivity gains from reduced HCV-attributable absenteeism, presenteeism, and premature deaths. We also calculate the incremental cost-effectiveness ratio (ICER) per disability-adjusted life year (DALY) averted for HCV elimination versus maintaining current levels of HCV treatment. This is compared to an opportunity cost-based willingness-to-pay threshold for Pakistan (US$148 to US$198/DALY). Compared to existing levels of treatment, scaling up screening and treatment to achieve HCV elimination in Pakistan averts 5.57 (95% uncertainty interval (UI) 3.80 to 8.22) million DALYs and 333,000 (219,000 to 509,000) HCV-related deaths over 2018 to 2030. If HCV testing is partially integrated, this scale-up requires an investment of US$1.45 (1.32 to 1.60) billion but will result in US$1.30 (0.94 to 1.72) billion in improved economic productivity over 2018 to 2030. This elimination strategy is highly cost-effective (ICER = US$29 per DALY averted) by 2030, with it becoming cost-saving by 2031 and having a net economic benefit of US$9.10 (95% UI 6.54 to 11.99) billion by 2050. Limitations include uncertainty around what level of integration is possible within existing primary healthcare services as well as a lack of Pakistan-specific data on disease-related healthcare management costs or productivity losses due to HCV. CONCLUSIONS Investment in HCV elimination can bring about substantial societal health and economic benefits for Pakistan.
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Affiliation(s)
- Aaron G. Lim
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | | | - Josephine G. Walker
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | | | | | - Peter Vickerman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
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18
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Next-generation sequencing studies on the E1-HVR1 region of hepatitis C virus (HCV) from non-high-risk HCV patients living in Punjab and Khyber Pakhtunkhwa, Pakistan. Arch Virol 2021; 166:3049-3059. [PMID: 34448937 DOI: 10.1007/s00705-021-05203-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 06/17/2021] [Indexed: 11/09/2022]
Abstract
The incidence rate of hepatitis C virus (HCV) infection in Pakistan is very high. In this study, we evaluated the genetic heterogeneity of HCV hypervariable region 1 (HVR1) from the HCV-infected Pakistani population and compare the isolated genotypes with representative sequences from internationally diverse geographic regions. We also investigated potential transmission events in non-high-risk HCV patients. Next-generation sequencing (NGS) data from the E1-HVR1 region from 30 HCV patients were used for phylogenetic analysis. Reference sequences were retrieved from the Los Alamos HCV and GenBank databases. NGS data were analyzed to examine HCV HVR1 sequence diversity and identify transmission links among HCV-infected individuals using Global Hepatitis Outbreak and Surveillance Technology (GHOST). Phylogenetic analysis showed the predominance of HCV genotype 3a (86.6%), followed by 1a (6.6%), 1b (3.3%), and 3b (3.3%). NGS of HVR1 displayed significant genetic heterogeneity of HCV populations within each patient. The average nucleotide sequence diversity for HVR1 was 0.055. JR781281 was found to be the most diverse (0.14) of the specimens. Phylogenetic analysis demonstrated that all HCV specimens sequenced in this study were more similar to each other and showed variations from the representative sequences. The GHOST results suggested genetic relatedness between two (6.6%) HCV cases, possibly defining an incipient outbreak in a non-high-risk population. We urge rigorous countrywide investigation of outbreaks to identify transmission clusters and their sources to incorporate preventive measures for disease control.
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Dzingirai B, Katsidzira L, Matyanga CMJ, Postma MJ, van Hulst M, Mafirakureva N. Progress on the elimination of viral hepatitis in Zimbabwe: A review of the policies, strategies and challenges. J Viral Hepat 2021; 28:994-1002. [PMID: 33797190 PMCID: PMC8252795 DOI: 10.1111/jvh.13510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 03/16/2021] [Accepted: 03/18/2021] [Indexed: 12/22/2022]
Abstract
Very few low-income countries have developed national plans to achieve the viral hepatitis elimination targets set in the World Health Organization (WHO) strategy. We reviewed the policy environment, strategies and challenges on the fight against viral hepatitis in Zimbabwe. The review focussed on the Ministry of Health and Child Care (MoHCC) policy documents, strategic plans and reports. We performed key informant interviews to enhance evidence generated from the document review. Twelve documents were reviewed and interviews with 10 key informants were completed. The MoHCC established a technical working group to work towards elimination of viral hepatitis. The technical working group drafted a strategic plan for elimination of viral hepatitis; however, it is still awaiting implementation. Key strategies that are working well include screening of donated blood for transfusion, safe injection practices and hepatitis B virus (HBV) three-dose vaccination. Current challenges in the drive towards elimination of viral hepatitis include poor to non-existent surveillance systems, lack of epidemiological data, absence of the HBV vaccine birth dose and lack of systematic screening and treatment services for viral hepatitis. In conclusion, despite political will demonstrated towards achieving viral hepatitis elimination, substantial investment and work are required to implement the strategic plan and realize significant success.
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Affiliation(s)
- Blessing Dzingirai
- School of PharmacyUniversity of ZimbabweHarareZimbabwe,Department of Health SciencesUniversity Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
| | - Leolin Katsidzira
- Department of MedicineCollege of Health Sciences University of ZimbabweHarareZimbabwe
| | | | - Maarten Jacobus Postma
- Department of Health SciencesUniversity Medical Center GroningenUniversity of GroningenGroningenThe Netherlands,Department of Economics, Econometrics & FinanceFaculty of Economics and BusinessUniversity of GroningenGroningenThe Netherlands
| | - Marinus van Hulst
- Department of Health SciencesUniversity Medical Center GroningenUniversity of GroningenGroningenThe Netherlands,Department of Clinical Pharmacy and ToxicologyMartini HospitalGroningenThe Netherlands
| | - Nyashadzaishe Mafirakureva
- Health Economics and Decision ScienceSchool of Health and Related ResearchUniversity of SheffieldUnited Kingdom
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20
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Marquez LK, Chaillon A, Soe KP, Johnson DC, Zosso JM, Incerti A, Loarec A, Nguyen A, Walker JG, Mafirakureva N, Lo Re Iii V, Wynn A, McIntosh C, Kiene SM, Brodine S, Garfein RS, Vickerman P, Martin NK. Cost and cost-effectiveness of a real-world HCV treatment program among HIV-infected individuals in Myanmar. BMJ Glob Health 2021; 6:bmjgh-2020-004181. [PMID: 33627360 PMCID: PMC7908309 DOI: 10.1136/bmjgh-2020-004181] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 01/16/2021] [Accepted: 01/30/2021] [Indexed: 12/16/2022] Open
Abstract
Introduction Over half of those hepatitis C virus (HCV)/HIV coinfected live in low-income and middle-income countries, and many remain undiagnosed or untreated. In 2016, Médecins Sans Frontières (MSF) established a direct-acting antiviral (DAA) treatment programme for people HCV/HIV coinfected in Myanmar. The purpose of our study was to evaluate the real-world cost and cost-effectiveness of this programme, and potential cost-effectiveness if implemented by the Ministry of Health (MoH). Methods Costs (patient-level microcosting) and treatment outcomes were collected from the MSF prospective cohort study in Dawei, Myanmar. A Markov model was used to assess cost-effectiveness of the programme compared with no HCV treatment from a health provider perspective. Estimated lifetime and healthcare costs (in 2017 US$) and health outcomes (in disability-adjusted life-years (DALYs)) were simulated to calculate the incremental cost-effectiveness ratio (ICER), compared with a willingness-to-pay threshold of per capita Gross Domestic Product in Myanmar ($1250). We evaluated cost-effectiveness with updated quality-assured generic DAA prices and potential cost-effectiveness of a proposed simplified treatment protocol with updated DAA prices if implemented by the MoH. Results From November 2016 to October 2017, 122 with HIV/HCV-coinfected patients were treated with DAAs (46% with cirrhosis), 96% (n=117) achieved sustained virological response. Mean treatment costs were $1229 (without cirrhosis) and $1971 (with cirrhosis), with DAA drugs being the largest contributor to cost. Compared with no treatment, the program was cost-effective (ICER $634/DALY averted); more so with updated prices for quality-assured generic DAAs (ICER $488/DALY averted). A simplified treatment protocol delivered by the MoH could be cost-effective if associated with similar outcomes (ICER $316/DALY averted). Conclusions Using MSF programme data, the DAA treatment programme for HCV among HIV-coinfected individuals is cost-effective in Myanmar, and even more so with updated DAA prices. A simplified treatment protocol could enhance cost-effectiveness if further rollout demonstrates it is not associated with worse treatment outcomes.
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Affiliation(s)
- Lara K Marquez
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, California, USA .,School of Public Health, San Diego State University, San Diego, California, USA
| | - Antoine Chaillon
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, California, USA
| | - Kyi Pyar Soe
- Medical Department, Dawei Project, Doctors Without Borders, Dawei, Myanmar
| | - Derek C Johnson
- Medical Department, Myanmar Project, Doctors Without Borders, Yangon, Myanmar
| | - Jean-Marc Zosso
- Finance Department, Myanmar Project, Doctors Without Borders, Yangon, Myanmar
| | - Andrea Incerti
- Medical Department, Doctors Without Borders, Geneva Operational Center, Geneva, Switzerland
| | - Anne Loarec
- Epidemiology, Epicentre, Paris, Île-de-France, France
| | - Aude Nguyen
- Medical Department, Doctors Without Borders, Geneva Operational Center, Geneva, Switzerland.,Department of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland
| | | | | | - Vincent Lo Re Iii
- Division of Infectious Diseases, Department of Medicine, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Adriane Wynn
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, California, USA
| | - Craig McIntosh
- School of Global Policy and Strategy, University of California San Diego, La Jolla, California, USA
| | - Susan M Kiene
- School of Public Health, San Diego State University, San Diego, California, USA
| | - Stephanie Brodine
- School of Public Health, San Diego State University, San Diego, California, USA
| | - Richard S Garfein
- Department of Family Medicine and Public Health, University of California San Diego, La Jolla, CA, USA
| | - Peter Vickerman
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Natasha K Martin
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, California, USA
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21
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Akiyama MJ, Kronfli N, Cabezas J, Sheehan Y, Thurairajah PH, Lines R, Lloyd AR. Hepatitis C elimination among people incarcerated in prisons: challenges and recommendations for action within a health systems framework. Lancet Gastroenterol Hepatol 2021; 6:391-400. [PMID: 33857445 DOI: 10.1016/s2468-1253(20)30365-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 11/10/2020] [Accepted: 11/16/2020] [Indexed: 12/13/2022]
Abstract
Hepatitis C virus (HCV) is a global public health problem in correctional settings. The International Network on Health and Hepatitis in Substance Users-Prisons Network is a special interest group committed to advancing scientific knowledge exchange and advocacy for HCV prevention and care in correctional settings. In this Review, we highlight seven priority areas and best practices for improving HCV care in correctional settings: changing political will, ensuring access to HCV diagnosis and testing, promoting optimal models of HCV care and treatment, improving surveillance and monitoring of the HCV care cascade, reducing stigma and tackling the social determinants of health inequalities, implementing HCV prevention and harm reduction programmes, and advancing prison-based research.
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Affiliation(s)
- Matthew J Akiyama
- Department of Medicine, Divisions of General Internal Medicine and Infectious Disease, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York, NY, USA.
| | - Nadine Kronfli
- Department of Medicine, Division of Infectious Diseases and Chronic Viral Illness Service, McGill University, Montreal, QC, Canada; Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Joaquin Cabezas
- Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, Santander, Spain; Marques de Valdecilla Research Institute, Santander, Spain
| | - Yumi Sheehan
- Viral Immunology Systems Program, Kirby Institute for Infection and Immunity, University of New South Wales, Sydney, NSW, Australia
| | - Prem H Thurairajah
- Department of Gastroenterology and Hepatology, Yong Loo Lin School of Medicine, National University Hospital, Singapore, Singapore
| | | | - Andrew R Lloyd
- Viral Immunology Systems Program, Kirby Institute for Infection and Immunity, University of New South Wales, Sydney, NSW, Australia
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22
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Chaillon A, Thurairajah PH, Hsiang JC, Martin NK. What is required for achieving hepatitis C virus elimination in Singapore? A modeling study. J Gastroenterol Hepatol 2021; 36:1110-1117. [PMID: 32777859 PMCID: PMC8174139 DOI: 10.1111/jgh.15211] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 07/09/2020] [Accepted: 08/05/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIM The vast majority of hepatitis C virus (HCV) infection in Singapore is among those with a history of injecting drug use (IDU), yet harm reduction is not available and what is required to achieve the World Health Organization (WHO) HCV elimination targets (80% incidence reduction and 65% mortality reduction by 2030) is unknown. We model the intervention scale-up required to achieve WHO targets in Singapore. METHODS A dynamic model of HCV transmission and progression among those with a history of IDU was calibrated to Singapore, a setting with declining IDU and no harm reduction (~11 000 people with IDU history in 2017 and 45% HCV seropositive). We projected HCV treatment scale-up from 2019 required to achieve WHO targets with varying prioritization scenarios, with/without opiate substitution therapy scale-up (to 40% among people who inject drugs [PWID]). RESULTS We estimated 3855 (95% confidence interval: 2635-5446) chronically HCV-infected individuals with a history of IDU and 148 (87-284) incident HCV cases in Singapore in 2019. Reaching the HCV incidence target requires 272 (187-384) treatments in 2019, totaling 2444 (1683-3452) across 2019-2030. By prioritizing PWID or PWID and cirrhotics, 60% or 30% fewer treatments are required, respectively, whereas the target cannot be achieved with cirrhosis prioritization. Opiate substitution therapy scale-up reduces treatments required by 21-24%. Achieving both WHO targets requires treating 631 (359-1047) in 2019, totaling 3816 (2664-5423) across 2019-2030. CONCLUSIONS Hepatitis C virus elimination is achievable in Singapore but even with declining IDU requires immediate treatment scale-up among PWID. Harm reduction provision reduces treatments required and provides additional benefits.
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Affiliation(s)
- Antoine Chaillon
- Division of Infectious Diseases and Global Public Health, University of California, 9500 Gilman Dr La Jolla, CA 92093-0507
| | | | - John C Hsiang
- Department of Gastroenterology, Sengkang General Hospital, Singapore, 110 Sengkang E Way Singapore 544886
| | - Natasha K Martin
- Division of Infectious Diseases and Global Public Health, University of California, 9500 Gilman Dr La Jolla, CA 92093-0507,Population Health Sciences, University of Bristol, Senate House, Tyndall Ave Bristol BS8 1TH UK
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23
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Mafirakureva N, Lim AG, Khalid GG, Aslam K, Campbell L, Zahid H, Van den Bergh R, Falq G, Fortas C, Wailly Y, Auat R, Donchuk D, Loarec A, Coast J, Vickerman P, Walker JG. Cost-effectiveness of screening and treatment using direct-acting antivirals for chronic Hepatitis C virus in a primary care setting in Karachi, Pakistan. J Viral Hepat 2021; 28:268-278. [PMID: 33051950 PMCID: PMC7821258 DOI: 10.1111/jvh.13422] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 09/07/2020] [Accepted: 09/28/2020] [Indexed: 12/13/2022]
Abstract
Despite the availability of effective direct-acting antiviral (DAA) treatments for Hepatitis C virus (HCV) infection, many people remain undiagnosed and untreated. We assessed the cost-effectiveness of a Médecins Sans Frontières (MSF) HCV screening and treatment programme within a primary health clinic in Karachi, Pakistan. A health state transition Markov model was developed to estimate the cost-effectiveness of the MSF programme. Programme cost and outcome data were analysed retrospectively. The incremental cost-effectiveness ratio (ICER) was calculated in terms of incremental cost (2016 US$) per disability-adjusted life year (DALY) averted from the provider's perspective over a lifetime horizon. The robustness of the model was evaluated using deterministic and probabilistic sensitivity analyses (PSA). The ICER for implementing testing and treatment compared to no programme was US$450/DALY averted, with 100% of PSA runs falling below the per capita Gross Domestic Product threshold for cost-effective interventions for Pakistan (US$1,422). The ICER increased to US$532/DALY averted assuming national HCV seroprevalence (5.5% versus 33% observed in the intervention). If the cost of liver disease care was included (adapted from resource use data from Cambodia which has similar GDP to Pakistan), the ICER dropped to US$148/DALY, while it became cost-saving if a recently negotiated reduced drug cost of $75/treatment course was assumed (versus $282 in base-case) in addition to cost of liver disease care. In conclusion, screening and DAA treatment for HCV infection are expected to be highly cost-effective in Pakistan, supporting the expansion of similar screening and treatment programmes across Pakistan.
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Affiliation(s)
| | - Aaron G. Lim
- Population Health SciencesBristol Medical SchoolUniversity of BristolBristolUK
| | | | - Khawar Aslam
- Operational Center BrusselsMédecins Sans FrontièresIslamabadPakistan
| | - Linda Campbell
- Population Health SciencesBristol Medical SchoolUniversity of BristolBristolUK
| | - Hassaan Zahid
- Operational Center BrusselsMédecins Sans FrontièresIslamabadPakistan
| | | | | | | | - Yves Wailly
- Operational Center BrusselsMédecins Sans FrontièresBrusselsBelgium
| | - Rosa Auat
- Operational Center BrusselsMédecins Sans FrontièresBrusselsBelgium
| | - Dmytro Donchuk
- Operational Center BrusselsMédecins Sans FrontièresBrusselsBelgium
| | | | - Joanna Coast
- Population Health SciencesBristol Medical SchoolUniversity of BristolBristolUK
| | - Peter Vickerman
- Population Health SciencesBristol Medical SchoolUniversity of BristolBristolUK,NIHR Health Protection Research Unit in Behavioural Science and EvaluationUniversity of BristolBristolUK
| | - Josephine G. Walker
- Population Health SciencesBristol Medical SchoolUniversity of BristolBristolUK
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24
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Marquez LK, Cepeda JA, Bórquez A, Strathdee SA, Gonzalez-Zúñiga PE, Fleiz C, Rafful C, Garfein RS, Kiene SM, Brodine S, Martin NK. Is hepatitis C virus (HCV) elimination achievable among people who inject drugs in Tijuana, Mexico? A modeling analysis. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 88:102710. [PMID: 32165050 PMCID: PMC8133359 DOI: 10.1016/j.drugpo.2020.102710] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 02/08/2020] [Accepted: 02/16/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND In 2019, Mexico became the first Latin American country committed to hepatitis C virus (HCV) elimination, but the amount of intervention scale-up required is unclear. In Tijuana, HCV among people who inject drugs (PWID) is high; yet there is minimal and intermittent harm reduction, and involuntary exposure to compulsory abstinence programs (CAP) occurs which is associated with increased HCV risk. We determined what combination intervention scale-up can achieve HCV elimination among current and former PWID in Tijuana. METHODS We constructed a dynamic, deterministic model of HCV transmission, disease progression, and harm reduction among current and former PWID parameterized to Tijuana (~10,000 current PWID, 90% HCV seropositive, minimal opiate agonist therapy [OAT] or high coverage needle/syringe programs [HCNSP]). We evaluated the number of direct-acting antiviral (DAA) treatments needed from 2019 to achieve elimination targets (80% incidence reduction, 65% mortality reduction by 2030) with: (a) DAAs alone, (b) DAAs plus scale-up of OAT+HCNSP (up to 50% coverage of OAT and HCNSP separately, producing 25% of PWID receiving both), (c) DAAs plus CAP scale-up to 50%. Scenarios examined the number of DAAs required if prioritized to current PWID or provided regardless of current injection status, and impact of harm reduction interruptions. RESULTS Modeling suggests among ~30,000 current and former PWID in Tijuana, 16,160 (95%CI: 12,770-21,610) have chronic HCV. DAA scale-up can achieve the incidence target, requiring 770 treatments/year (95%CI: 640-970) if prioritized to current PWID. 40% fewer DAAs are required with OAT+HCNSP scale-up to 50% among PWID, whereas more are required with involuntary CAP scale-up. Both targets can only be achieved through treating both current and former PWID (1,710 treatments/year), and impact is reduced with harm reduction interruptions. CONCLUSIONS Elimination targets are achievable in Tijuana through scale-up of harm reduction and DAA therapy, whereas involuntary CAP and harm reduction interruptions hamper elimination.
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Affiliation(s)
- Lara K Marquez
- Department of Family Medicine & Public Health, University of California San Diego, La Jolla, California, United States; School of Public Health, San Diego State University, San Diego, California, United States.
| | - Javier A Cepeda
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, California, United States
| | - Annick Bórquez
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, California, United States
| | - Steffanie A Strathdee
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, California, United States
| | - Patricia E Gonzalez-Zúñiga
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, California, United States
| | - Clara Fleiz
- National Institute of Psychiatry Ramon de la Fuente Muniz, Huipulco, Tlalpan, Mexico City, United States
| | - Claudia Rafful
- Faculty of Psychology, Universidad Nacional Autónoma de México, Mexico City, United States; Center on Global Mental Health Research, National Institute of Psychiatry, Mexico City, United States; Centre on Drug Policy Evaluation, St. Michael's Hospital, Toronto, OH, Canada
| | - Richard S Garfein
- Department of Family Medicine & Public Health, University of California San Diego, La Jolla, California, United States
| | - Susan M Kiene
- School of Public Health, San Diego State University, San Diego, California, United States
| | - Stephanie Brodine
- School of Public Health, San Diego State University, San Diego, California, United States
| | - Natasha K Martin
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, California, United States; Population Health Sciences, University of Bristol, Bristol, United Kingdom
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25
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Hashmi ZY, Zia MQ, Bajwa A, Ahmed M, Anwer N, Raza M, Baqar JB. New drugs and new concerns: Gaining insight through Pharmacovigilance of direct acting Anti-Viral's in chronic HCV patients. Pak J Med Sci 2021; 37:299-304. [PMID: 33679903 PMCID: PMC7931287 DOI: 10.12669/pjms.37.2.3400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective The study aimed to assess the safety profile of Direct Acting Anti-Viral's (DAAs) among patients with chronic Hepatitis C Virus (HCV). Methods This multicenter, analytical cross-sectional study was conducted in six gastroenterology and Hepatology centers including Liver Center Faisalabad, Allama Iqbal Medical Institute and Liver Center DHQ Hospital Sialkot, Isra Hospital Hyderabad, Allied Hospital Faisalabad and Rehman Medical Institute Peshawar, between May 2018 and May 2019. The data regarding patient demographics, treatment plan and the frequency of Adverse Events (AEs), and their severity was collected using a pre-designed questionnaire and analyzed through SPSS version 20.0. Results A total of 511 HCV patients were enrolled, with an overall male majority. Around 66.3% patients experienced a total of 419 AEs, out of which 61 events were suspected from DAAs while remaining 317 events were associated with Ribavirin. Pyrexia (24.6%) and fatigue (14.8%) were the most commonly reported AEs among patients receiving DAAs. Factors such as Ribavirin-based treatments and the presence of Cirrhosis were more likely to promote AEs occurrence OR [95%CI] i.e. 5.2(2.3-9.1) and 1.9(1.1-3.1) respectively (p < 0.05). Conclusion It is concluded from the study results that DAAs have displayed promising outcomes due to the minimal and minor AEs reported.
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Affiliation(s)
| | - Muhammad Qasim Zia
- Muhammad Qasim Zia, FCPS Allama Iqbal Memorial Teaching Hospital, Sialkot, Pakistan
| | - Akram Bajwa
- Akram Bajwa, Ph.D. Liaquat University of Medical & Health Sciences, Hyderabad, Pakistan
| | - Maqsood Ahmed
- Maqsood Ahmed, FCPS Allied Hospital Faisalabad, Pakistan
| | - Naveed Anwer
- Naveed Anwer, MRCP Rehman Medical Institute Peshawar, Pakistan
| | - Mahwish Raza
- Mahwish Raza, Pharm-D Shaheed Zulfikar Ali Bhutto Institute of Science and Technology, Karachi, Pakistan
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26
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Mushtaq S, Mansoor A, Umar M, Khan A, Siddiqi S, Manzoor S. Direct-acting antiviral agents in the treatment of chronic hepatitis C-Real-life experience from clinical practices in Pakistan. J Med Virol 2020; 92:3475-3487. [PMID: 32129507 DOI: 10.1002/jmv.25745] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 03/01/2020] [Indexed: 02/05/2023]
Abstract
This study aims to evaluate the clinical effectiveness in terms of sustained virological response (SVR), predictors of SVR and safety of available second-generation generic direct-acting antivirals in Pakistani chronic hepatitis C patients. This is a retrospective study conducted in multiple centers of Pakistan from January 2015 to January 2019. The samples include patients infected with chronic hepatitis C virus, regardless of virus genotype, cirrhosis, or prior treatment. A total of 993 patients were included in the present study, with the majority receiving sofosbuvir with daclatasvir (95%), sofosbuvir with daclatasvir and ribavirin (4%), and sofosbuvir with ribavirin (1%). There were 96% cases of chronic hepatitis, 3% cases compensated cirrhosis, and 1% cases of decompensated cirrhosis. Genotype 3 (99.6%) was the most common genotype. Overall SVR after 12 weeks was 98% for all treatment regimens. High SVR12 was observed with sofosbuvir in combination with daclatasvir (98.5%), then sofosbuvir in combination with daclatasvir and ribavirin (90.2%) and sofosbuvir in combination with ribavirin (75%). SVR rates were high in chronic hepatitis C patients (98.2%) as compared with cirrhotic patients (92.1%) and it was high in treatment-naive (98.8%) then interferon experienced patients (90.1%). In multivariate binary logistic regression analysis, patients' education status, treatment strategy, viral load, and alanine aminotransferase had a statistically significant association with SVR at 12 weeks. No major adverse events occurred which required treatment discontinuation. Generic oral direct acting antiviralss (sofosbuvir with daclatasvir) achieved higher SVR12 rates and were well tolerated in this large real-world cohort of genotype 3 infected patients.
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Affiliation(s)
- Saima Mushtaq
- Department of Healthcare Biotechnology, Atta-ur-Rahman School of Applied Biosciences, National University of Sciences and Technology, Islamabad, Pakistan
| | - Atika Mansoor
- Institute of Biomedical and Genetic Engineering, Islamabad, Pakistan
| | - Muhammad Umar
- Centre for Liver and Digestive Diseases, Holy Family Hospital, Rawalpindi Medical College and Allied Hospitals, Rawalpindi, Pakistan
| | - Amjad Khan
- Department of Pharmacy, Quaid-i-Azam University, Islamabad, Pakistan
| | - Saima Siddiqi
- Institute of Biomedical and Genetic Engineering, Islamabad, Pakistan
| | - Sobia Manzoor
- Department of Healthcare Biotechnology, Atta-ur-Rahman School of Applied Biosciences, National University of Sciences and Technology, Islamabad, Pakistan
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Kamani L, Ahmad BS, Kalwar HA. Hepatitis-C Infection: Are we really committed to eliminate? Could it become the second Polio for Pakistan? Pak J Med Sci 2020; 36:1742-1744. [PMID: 33235608 PMCID: PMC7674893 DOI: 10.12669/pjms.36.7.2804] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Pakistan’s hepatitis C virus (HCV) burden is one of the highest in the world. Around eight million people live with HCV in Pakistan according to a National Hepatitis Survey. Most HCV-infected people are unaware of their infection status culminating in delayed diagnosis and treatment, progressing to end stage liver disease, cirrhosis, and hepatocellular carcinoma (HCC), thereby raising the disease load for a developing country with limited resources. Blood transfusions and injections with reused syringes lead to increased HCV rates in Pakistan. According to a survey viral infections like hepatitis C, hepatitis B and HIV were not screened in more than half of the blood transfusions done in Pakistan. Hepatitis C elimination requires financial support from the local government and private organizations, commitment from civil societies across the world and a dedicated political will. Without defining effective planning and strategy it is our fear that it could become the second Polio for Pakistan.
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Affiliation(s)
- Lubna Kamani
- Lubna Kamani, MBBS, FCPS, MRCP (UK), FRCP (London), FACG. Associate Professor and Director GI Residency Program, Department of Gastroenterology, Liaquat National Hospital, Karachi, Pakistan
| | - Baseer Sultan Ahmad
- Baseer Sultan Ahmad. FCPS(Gastro). Assistant Professor, Department of Gastroenterology. Liaquat National Hospital, Karachi, Pakistan
| | - Hamid Ali Kalwar
- Hamid Ali Kalwar. FCPS(Gastro). Consultant, Murshid Hospital, Karachi, Pakistan
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Ishtiaq A, Shah S, Iftikhar S, Baig-Ansari N, Ashraf H. Relationship of FIB-4 index with transient elastography in chronic hepatitis C patients having APRI ≥ 0.5 - ≤2 in a resource-limited setting in Pakistan. J Family Med Prim Care 2020; 9:5564-5573. [PMID: 33532396 PMCID: PMC7842428 DOI: 10.4103/jfmpc.jfmpc_1294_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 08/20/2020] [Accepted: 08/30/2020] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE We aimed to study the extent of liver fibrosis in chronic hepatitis C patients with indeterminate APRI score of ≥ 0.5 - ≤2 (between higher and lower cut off value) and correlate it to transient elastography (TE) and FIB 4 index. METHOD A cross-sectional study, 80 patients with CHC mono infection, APRI score ≥ 0.5 - ≤2 were interviewed from the cohort visiting the CHC program clinic at a tertiary care hospital in Karachi, Pakistan. Data were analyzed using STATA 14.0 and R 3.5.2 and SPSS 24.0 software according to their capabilities. RESULT Of 80 patients, 50 (62.5%) were females and 30 (37.5%) were males with mean (±SD) ages of 41.73 (±11.5) years and 41.16 (±9.24) years respectively. The FIB 4 value among indeterminate APRI was reported as 1.47 (IQR 1.05-2.43). TE categories was reported: F0-F1 (n = 29; 36%), F1-F2 (n = 10; 12.5%), F2 (n = 9; 11.2%) F3 (n = 13; 16.2%), F3-F4 (n = 1; 1.2%) F4 (n = 18; 22.5%). FIB4 had a moderate positive correlation with TE while a weak positive correlation was found between APRI and TE (0.488, P < 0.0001 and 0.289, P < 0.001, respectively). TE was taken as a gold standard and compared with FIB4. The model constructed reported FIB4 as a good prediction for liver fibrosis with diagnostic accuracy 72%. CONCLUSION The combination of two serum markers proves to be a low-cost noninvasive testing strategy for CHC patients having an indeterminate APRI score. By being readily accessible both biochemical scores can simplify liver assessment in lower middle-income countries (LMIC) and help family physicians to take appropriate decisions about treatment initiation with minimum delays.
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Affiliation(s)
- Annum Ishtiaq
- Department of Family Medicine, Indus Health Network, Karachi, Pakistan
| | - Sabeen Shah
- Global Health Directorate, Indus Health Network, Karachi, Pakistan
| | - Sundus Iftikhar
- Indus Hospital Research Center (IHRC), Indus Health Network, Karachi, Pakistan
| | - Naila Baig-Ansari
- Indus Hospital Research Center (IHRC), Indus Health Network, Karachi, Pakistan
| | - Hiba Ashraf
- Department of Family Medicine, Indus Health Network, Karachi, Pakistan
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Mushtaq S, Akhter TS, Khan A, Sohail A, Khan A, Manzoor S. Efficacy and Safety of Generic Sofosbuvir Plus Daclatasvir and Sofosbuvir/Velpatasvir in HCV Genotype 3-Infected Patients: Real-World Outcomes From Pakistan. Front Pharmacol 2020; 11:550205. [PMID: 32982753 PMCID: PMC7493013 DOI: 10.3389/fphar.2020.550205] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 08/17/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Direct-acting antivirals (DAAs) therapeutic regimens are highly effective against chronic hepatitis C virus (HCV) infection. However, HCV patients with genotype 3 (GT3) respond in a suboptimal way. This study aims to identify which of the DAAs-based therapeutic regimens are the best option for GT3. METHODS Multiple governments and private tertiary care hospitals were involved in this real-life study of HCV-GT3 patients treated with DAAs. The efficacy and safety of generic sofosbuvir+daclatasvir±ribavirin (SOF+DCV±RBV) and sofosbuvir/velpatasvir±ribavirin (SOF/VEL±RBV) were assessed under the National Hepatitis C Program of Pakistan. RESULTS Out of 1,388 participants, 70% of patients received SOF+DCV in government tertiary care hospitals and 30% received SOF/VEL in private tertiary care hospitals. The overall sustained virological responses (SVR) was 95.5%. The SVR rates at 12 weeks were comparable between SOF+DCV (94.4%) and SOF/VEL (94.7%) in chronic HCV patients. However, The SVR rates at 24 weeks were high in cirrhotic patients treated with SOF/VEL+RBV (88%) then SOF+DCV+RBV (83%). Non-responders were high in SOF-DCV than SOF-VEL (4.1 vs 3.8%, P = 0.05) regimen. In multivariate models, the significant predictors of non-SVR were age >60 years (odds ratio [OR] 4.46; 95% CI, 2.35-8.46, P = <0.001) and cirrhosis (OR 53.91; 95% CI, 26.49-109.6, P = <0.001). Skin rash (51 vs 44%) and oral ulcers (45 vs 40%) were high in patients receiving SOF-DCV then SOF-VEL. CONCLUSIONS Overall, the generic SOF+DCV ±RBV and SOF/VEL ± RBV achieved equally high SVR12 rates. However, SOF/VEL+RBV achieved a high SVR rate in cirrhotic patients then SOF+DCV+RBV. Old age and cirrhosis were significant predictors of reduced odds of SVR regardless of the regimen. Furthermore, the regimens were well tolerated in chronic HCV patients.
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Affiliation(s)
- Saima Mushtaq
- Department of Healthcare Biotechnology, Atta-ur-Rahman School of Applied Biosciences, National University of Sciences and Technology, Islamabad, Pakistan
| | - Tayyab Saeed Akhter
- Centre for Liver and Digestive Diseases, Holy Family Hospital, Rawalpindi Medical College and Allied Hospitals, Rawalpindi, Pakistan
| | - Amjad Khan
- Department of Pharmacy, Quaid-i-Azam University, Islamabad, Pakistan
| | - Aamir Sohail
- Department of Medicine, Karachi Institute of Medical Sciences, Combined Military Hospital, Karachi, Pakistan
| | - Arshad Khan
- Department of Neurosurgery, Medical Teaching Institution, Lady Reading Hospital, Peshawar, Pakistan
| | - Sobia Manzoor
- Department of Healthcare Biotechnology, Atta-ur-Rahman School of Applied Biosciences, National University of Sciences and Technology, Islamabad, Pakistan
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Abbas Z, Abbas M. The cost of eliminating hepatitis C in Pakistan. LANCET GLOBAL HEALTH 2020; 8:e323-e324. [PMID: 32087161 DOI: 10.1016/s2214-109x(20)30036-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 01/24/2020] [Indexed: 01/17/2023]
Affiliation(s)
- Zaigham Abbas
- Department of Hepato-Gastroenterology, Dr Ziauddin University Hospital, Clifton Karachi 75600, Pakistan.
| | - Minaam Abbas
- School of Clinical Medicine and The Gurdon Institute, University of Cambridge, Cambridge, UK
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Khalid GG, Kyaw KWY, Bousquet C, Auat R, Donchuk D, Trickey A, Hamid S, Qureshi H, Mazzeo V, Aslam K, Khowaja S, Van den Bergh R. From risk to care: the hepatitis C screening and diagnostic cascade in a primary health care clinic in Karachi, Pakistan-a cohort study. Int Health 2020; 12:19-27. [PMID: 30597008 PMCID: PMC6964233 DOI: 10.1093/inthealth/ihy096] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Revised: 10/25/2018] [Accepted: 11/30/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND In the high-prevalence setting of Pakistan, screening, diagnosis and treatment services for chronic hepatitis C (CHC) patients are commonly offered in specialized facilities. We aimed to describe the cascade of care in a Médecins Sans Frontières primary health care clinic offering CHC care in an informal settlement in Karachi, Pakistan. METHODS This was a retrospective cohort analysis using routinely collected data. Three different screening algorithms were assessed among patients with one or more CHC risk factors. RESULTS Among the 87 348 patients attending the outpatient clinic, 5003 (6%) presented with one or more risk factors. Rapid diagnostic test (RDT) positivity was 38% overall. Approximately 60% of the CHC patients across all risk categories were in the early stage of the disease, with an aspartate aminotransferase:platelet ratio index score <1. The sequential delays in the cascade differed between the three groups, with the interval between screening and treatment initiation being the shortest in the cohort tested with GeneXpert onsite. CONCLUSIONS Delays between screening and treatment can be reduced by putting in place more patient-centric testing algorithms. New strategies, to better identify and treat the hidden at-risk populations, should be developed and implemented.
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Affiliation(s)
- Gul Ghuttai Khalid
- Operational Center Brussels, Médecins Sans Frontières, Islamabad, Pakistan
| | - Khine Wut Yee Kyaw
- Department of Operational Research, International Union Against Tuberculosis and Lung Disease, Mandalay, Myanmar
| | - Christine Bousquet
- Operational Center Brussels, Médecins Sans Frontières, Islamabad, Pakistan
| | - Rosa Auat
- Operational Center Brussels, Brussels, Belgium
| | | | - Adam Trickey
- School of Social and Population Sciences, University of Bristol, Bristol, UK
| | - Saeed Hamid
- Department of Medicine, Agha Khan Medical University, Karachi, Pakistan
| | - Huma Qureshi
- Pakistan Health Research Council, Islamabad, Pakistan
| | - Valentina Mazzeo
- Operational Center Brussels, Médecins Sans Frontières, Islamabad, Pakistan
| | - Khawar Aslam
- Operational Center Brussels, Médecins Sans Frontières, Islamabad, Pakistan
| | - Salima Khowaja
- Operational Center Brussels, Médecins Sans Frontières, Islamabad, Pakistan
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32
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Lim AG, Walker JG, Mafirakureva N, Khalid GG, Qureshi H, Mahmood H, Trickey A, Fraser H, Aslam K, Falq G, Fortas C, Zahid H, Naveed A, Auat R, Saeed Q, Davies CF, Mukandavire C, Glass N, Maman D, Martin NK, Hickman M, May MT, Hamid S, Loarec A, Averhoff F, Vickerman P. Effects and cost of different strategies to eliminate hepatitis C virus transmission in Pakistan: a modelling analysis. Lancet Glob Health 2020; 8:e440-e450. [PMID: 32087176 PMCID: PMC7295205 DOI: 10.1016/s2214-109x(20)30003-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 10/07/2019] [Accepted: 01/06/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND The WHO elimination strategy for hepatitis C virus advocates scaling up screening and treatment to reduce global hepatitis C incidence by 80% by 2030, but little is known about how this reduction could be achieved and the costs of doing so. We aimed to evaluate the effects and cost of different strategies to scale up screening and treatment of hepatitis C in Pakistan and determine what is required to meet WHO elimination targets for incidence. METHODS We adapted a previous model of hepatitis C virus transmission, treatment, and disease progression for Pakistan, calibrating using available data to incorporate a detailed cascade of care for hepatitis C with cost data on diagnostics and hepatitis C treatment. We modelled the effect on various outcomes and costs of alternative scenarios for scaling up screening and hepatitis C treatment in 2018-30. We calibrated the model to country-level demographic data for 1960-2015 (including population growth) and to hepatitis C seroprevalence data from a national survey in 2007-08, surveys among people who inject drugs (PWID), and hepatitis C seroprevalence trends among blood donors. The cascade of care in our model begins with diagnosis of hepatitis C infection through antibody screening and RNA confirmation. Diagnosed individuals are then referred to care and started on treatment, which can result in a sustained virological response (effective cure). We report the median and 95% uncertainty interval (UI) from 1151 modelled runs. FINDINGS One-time screening of 90% of the 2018 population by 2030, with 80% referral to treatment, was projected to lead to 13·8 million (95% UI 13·4-14·1) individuals being screened and 350 000 (315 000-385 000) treatments started annually, decreasing hepatitis C incidence by 26·5% (22·5-30·7) over 2018-30. Prioritised screening of high prevalence groups (PWID and adults aged ≥30 years) and rescreening (annually for PWID, otherwise every 10 years) are likely to increase the number screened and treated by 46·8% and decrease incidence by 50·8% (95% UI 46·1-55·0). Decreasing hepatitis C incidence by 80% is estimated to require a doubling of the primary screening rate, increasing referral to 90%, rescreening the general population every 5 years, and re-engaging those lost to follow-up every 5 years. This approach could cost US$8·1 billion, reducing to $3·9 billion with lowest costs for diagnostic tests and drugs, including health-care savings, and implementing a simplified treatment algorithm. INTERPRETATION Pakistan will need to invest about 9·0% of its yearly health expenditure to enable sufficient scale up in screening and treatment to achieve the WHO hepatitis C elimination target of an 80% reduction in incidence by 2030. FUNDING UNITAID.
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Affiliation(s)
- Aaron G Lim
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.
| | - Josephine G Walker
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | | | | | - Hassan Mahmood
- Pakistan Health Research Council, Islamabad, Pakistan; WHO, Islamabad, Pakistan
| | - Adam Trickey
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Hannah Fraser
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | | | | | | | - Ammara Naveed
- Department of Gastroenterology and Hepatology, Pakistan Kidney and Liver Institute and Research Center, Lahore, Pakistan
| | - Rosa Auat
- Médecins Sans Frontières, Brussels, Belgium
| | - Quaid Saeed
- National AIDS Control Programme, Islamabad, Pakistan
| | - Charlotte F Davies
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Nancy Glass
- Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - David Maman
- Epicentre, Médecins Sans Frontières, Paris, France
| | - Natasha K Martin
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, CA, USA
| | - Matthew Hickman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Margaret T May
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Anne Loarec
- Epicentre, Médecins Sans Frontières, Paris, France
| | - Francisco Averhoff
- Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Peter Vickerman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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Walker JG, Kuchuloria T, Sergeenko D, Fraser H, Lim AG, Shadaker S, Hagan L, Gamkrelidze A, Kvaratskhelia V, Gvinjilia L, Aladashvili M, Asatiani A, Baliashvili D, Butsashvili M, Chikovani I, Khonelidze I, Kirtadze I, Kuniholm MH, Otiashvili D, Sharvadze L, Stvilia K, Tsertsvadze T, Zakalashvili M, Hickman M, Martin NK, Morgan J, Nasrullah M, Averhoff F, Vickerman P. Interim effect evaluation of the hepatitis C elimination programme in Georgia: a modelling study. Lancet Glob Health 2020; 8:e244-e253. [PMID: 31864917 PMCID: PMC7025283 DOI: 10.1016/s2214-109x(19)30483-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 10/21/2019] [Accepted: 10/25/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Georgia has a high prevalence of hepatitis C, with 5·4% of adults chronically infected. On April 28, 2015, Georgia launched a national programme to eliminate hepatitis C by 2020 (90% reduction in prevalence) through scaled-up treatment and prevention interventions. We evaluated the interim effect of the programme and feasibility of achieving the elimination goal. METHODS We developed a transmission model to capture the hepatitis C epidemic in Georgia, calibrated to data from biobehavioural surveys of people who inject drugs (PWID; 1998-2015) and a national survey (2015). We projected the effect of the administration of direct-acting antiviral treatments until Feb 28, 2019, and the effect of continuing current treatment rates until the end of 2020. Effect was estimated in terms of the relative decrease in hepatitis C incidence, prevalence, and mortality relative to 2015 and of the deaths and infections averted compared with a counterfactual of no treatment over the study period. We also estimated treatment rates needed to reach Georgia's elimination target. FINDINGS From May 1, 2015, to Feb 28, 2019, 54 313 patients were treated, with approximately 1000 patients treated per month since mid 2017. Compared with 2015, our model projects that these treatments have reduced the prevalence of adult chronic hepatitis C by a median 37% (95% credible interval 30-44), the incidence of chronic hepatitis C by 37% (29-44), and chronic hepatitis C mortality by 14% (3-30) and have prevented 3516 (1842-6250) new infections and averted 252 (134-389) deaths related to chronic hepatitis C. Continuing treatment of 1000 patients per month is predicted to reduce prevalence by 51% (42-61) and incidence by 51% (40-62), by the end of 2020. To reach a 90% reduction by 2020, treatment rates must increase to 4144 (2963-5322) patients initiating treatment per month. INTERPRETATION Georgia's hepatitis C elimination programme has achieved substantial treatment scale-up, which has reduced the burden of chronic hepatitis C. However, the country is unlikely to meet its 2020 elimination target unless treatment scales up considerably. FUNDING CDC Foundation, National Institute for Health Research, National Institutes of Health.
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Affiliation(s)
- Josephine G Walker
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.
| | - Tinatin Kuchuloria
- Centers for Disease Control and Prevention Foundation, Tbilisi, Georgia; TEPHINET, Tbilisi, Georgia
| | - David Sergeenko
- Ministry of Labor Health and Social Affairs of Georgia, Tbilisi, Georgia
| | - Hannah Fraser
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Aaron G Lim
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Shaun Shadaker
- Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Liesl Hagan
- Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Amiran Gamkrelidze
- National Center for Disease Control and Public Health of Georgia, Tbilisi, Georgia
| | | | - Lia Gvinjilia
- Centers for Disease Control and Prevention Foundation, Tbilisi, Georgia; TEPHINET, Tbilisi, Georgia
| | - Malvina Aladashvili
- Infectious Diseases, AIDS and Clinical Immunology Research Center, Tbilisi, Georgia
| | - Alexander Asatiani
- National Center for Disease Control and Public Health of Georgia, Tbilisi, Georgia
| | - Davit Baliashvili
- National Center for Disease Control and Public Health of Georgia, Tbilisi, Georgia; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | | | | | - Irma Khonelidze
- National Center for Disease Control and Public Health of Georgia, Tbilisi, Georgia
| | - Irma Kirtadze
- Addiction Research Center Alternative Georgia, Tbilisi, Georgia; Ilia State University, Faculty of Arts and Sciences, Institute of Addiction Studies, Tbilisi, Georgia
| | - Mark H Kuniholm
- Department of Epidemiology and Biostatistics, University at Albany, State University of New York, Rensselaer, NY, USA
| | | | | | - Ketevan Stvilia
- National Center for Disease Control and Public Health of Georgia, Tbilisi, Georgia
| | - Tengiz Tsertsvadze
- Infectious Diseases, AIDS and Clinical Immunology Research Center, Tbilisi, Georgia
| | | | - Matthew Hickman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Natasha K Martin
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; Division of Infectious Diseases and Global Public Health, UC San Diego, California, USA
| | - Juliette Morgan
- Division of Global Health Protection, South Caucasus Centers for Disease Control and Prevention Office, Tbilisi, Georgia
| | - Muazzam Nasrullah
- Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Francisco Averhoff
- Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Peter Vickerman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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Hiebert L, Azzeri A, Dahlui M, Hecht R, Mohamed R, Hana Shabaruddin F, McDonald SA. Estimating the Population Size of People Who Inject Drugs in Malaysia for 2014 and 2017 Using the Benchmark-Multiplier Method. Subst Use Misuse 2020; 55:871-877. [PMID: 31933411 DOI: 10.1080/10826084.2019.1708943] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background: As hepatitis C elimination efforts are launched, national strategies for screening and treatment scale-up in countries, such as Malaysia, must be designed and implemented. Strategic information, including estimates of the total number of patients chronically-infected with hepatitis C virus (HCV) and the size of key populations, such as people who inject drugs (PWID), is critical to informing these efforts. For Malaysia, the estimate of the PWID population size most frequently reported in global systematic reviews is for the year 2009. Objectives: To support ongoing national HCV planning efforts, we aimed to estimate the national population size of active PWID in Malaysia, for the years 2014 and 2017. Methods: To estimate the PWID population size, we applied standard benchmark-multiplier methodology, frequently used for PWID population size estimation, and extended it by adjusting for cessation of injecting drug use within the benchmark and calculating statistical uncertainty intervals. Results: The estimated active PWID population size was 153,000 (95% uncertainty interval (UI): 136,000-172,000) for 2014 and 156,000 (95% UI: 137,000-188,000) for 2017. Conclusions/importance: This updated estimate of the active PWID population size in Malaysia will help inform effective planning for the scale-up of HCV screening and treatment services. The proposed methodology is applicable to other countries that maintain national HIV registries and have conducted Integrated Biological and Behavioral Surveys among active PWID.
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Affiliation(s)
| | - Amirah Azzeri
- Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Maznah Dahlui
- Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.,Julius Centre, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Robert Hecht
- Pharos Global Health Advisors, Boston, Massachusetts, USA
| | | | | | - Scott A McDonald
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, Netherlands.,School of Health & Life Sciences, Glasgow Caledonian University, Glasgow, Scotland
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35
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Khan A, Afzal S, Yaqoob A, Fatima R, Ul Haq M, Junaid K, Nadir A. Epidemiology of viral hepatitis B and C in Punjab, Pakistan: a multicenter cross-sectional study, 2017-18. F1000Res 2019. [DOI: 10.12688/f1000research.20174.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Background: Globally, approximately 240 million people are chronically infected with hepatitis B virus (HBV) and hepatitis C virus (HCV), which are responsible for 96% of all hepatitis-related mortality. Pakistan has the second highest prevalence of HCV in the world. Methods: We conducted this study to ascertain the prevalence and potential risk factors associated with HBV and HCV infections in Punjab. A multi-center cross-sectional study was conducted, involving 24 Hepatitis Prevention and Treatment Clinics of the Pakistan Kidney and Liver Institute and Research Center clinics, Lahore. A total of 141,705 individuals who visited the clinics during 2017-18 were included for seroprevalence analysis of hepatitis B (HBsAg) and C (Anti-HCV). In addition, 12,427 individuals from the main group underwent detailed face-to-face interviews based on a predesigned questionnaire for risk factor assessment. Results: The overall prevalence for HBV and HCV was 8.4% and 42.7%, respectively. Of those with HCV infection, 4.2% had a co-infection. The transgender population had a higher seroprevalence of HBV (11.8%) and HCV (58.8%). Higher HBV seroprevalence was found in a younger age group (16-30 years), while the older age group (>61 years) had a higher HCV seroprevalence. Geographically, Muzaffargarh district had the highest HBV seroprevalence at 26%, followed by Rajanpur district (20.3%). HCV seroprevalence was significantly (P value <0.05) higher in Shujabad district (66.4%), followed by Muzaffargarh (65.2%). Using multivariable logistic regression analysis, age, gender, intravenous injections, hijama therapy, dental procedure, circumcision by barbers, barber shaving, hospitalization and having had surgical procedures were all found to be significant risk factors (OR >1; p<0.05) for HBV and HCV. Conclusions: There is an urgent need for proper implementation of preventive and control strategies, as well as formal evaluation and monitoring mechanisms. Sustainable and adequate funding of public-sector hepatitis programs is also an extremely important area that should not be neglected.
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36
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Trickey A, Fraser H, Lim AG, Walker JG, Peacock A, Colledge S, Leung J, Grebely J, Larney S, Martin NK, Degenhardt L, Hickman M, May MT, Vickerman P. Modelling the potential prevention benefits of a treat-all hepatitis C treatment strategy at global, regional and country levels: A modelling study. J Viral Hepat 2019; 26:1388-1403. [PMID: 31392812 PMCID: PMC10401696 DOI: 10.1111/jvh.13187] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 07/01/2019] [Accepted: 07/15/2019] [Indexed: 12/18/2022]
Abstract
The World Health Organization (WHO) recently produced guidelines advising a treat-all policy for HCV to encourage widespread treatment scale-up for achieving HCV elimination. We modelled the prevention impact achieved (HCV infections averted [IA]) from initiating this policy compared with treating different subgroups at country, regional and global levels. We assessed what country-level factors affect impact. A dynamic, deterministic HCV transmission model was calibrated to data from global systematic reviews and UN data sets to simulate country-level HCV epidemics with ongoing levels of treatment. For each country, the model projected the prevention impact (in HCV IA per treatment undertaken) of initiating four treatment strategies; either selected randomly (treat-all) or targeted among people who inject drugs (PWID), people aged ≥35, or those with cirrhosis. The IA was assessed over 20 years. Linear regression was used to identify associations between IA per treatment and demographic factors. Eighty-eight countries (85% of the global population) were modelled. Globally, the model estimated 0.35 (95% credibility interval [95%CrI]: 0.16-0.61) IA over 20 years for every randomly allocated treatment, 0.30 (95%CrI: 0.12-0.53) from treating those aged ≥35 and 0.28 (95%CrI: 0.12-0.49) for those with cirrhosis. Globally, treating PWID achieved 1.27 (95%CrI: 0.68-2.04) IA per treatment. The IA per randomly allocated treatment was positively associated with a country's population growth rate and negatively associated with higher HCV prevalence among PWID. In conclusion, appreciable prevention benefits could be achieved from WHO's treat-all strategy, although greater benefits per treatment can be achieved through targeting PWID. Higher impact will be achieved in countries with high population growth.
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Affiliation(s)
- Adam Trickey
- Population Health Sciences, University of Bristol, Bristol, UK.,National Institute of Health Research (NIHR) Health Protection Research Unit (HPRU) in Evaluation of Interventions, Bristol, UK
| | - Hannah Fraser
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Aaron G Lim
- Population Health Sciences, University of Bristol, Bristol, UK
| | | | - Amy Peacock
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, NSW, Australia
| | - Samantha Colledge
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, NSW, Australia
| | - Janni Leung
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, NSW, Australia.,Centre for Youth Substance Abuse Research, Faculty of Health and Behavioural Sciences, The University of Queensland, Brisbane, QLD, Australia.,Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, United States
| | - Jason Grebely
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, United States.,The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
| | - Sarah Larney
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, NSW, Australia
| | - Natasha K Martin
- Population Health Sciences, University of Bristol, Bristol, UK.,Division of Infectious Diseases and Global Public Health, University of California, San Diego, CA, USA
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, NSW, Australia
| | - Matthew Hickman
- Population Health Sciences, University of Bristol, Bristol, UK.,National Institute of Health Research (NIHR) Health Protection Research Unit (HPRU) in Evaluation of Interventions, Bristol, UK
| | - Margaret T May
- Population Health Sciences, University of Bristol, Bristol, UK.,National Institute of Health Research (NIHR) Health Protection Research Unit (HPRU) in Evaluation of Interventions, Bristol, UK.,National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Peter Vickerman
- Population Health Sciences, University of Bristol, Bristol, UK.,National Institute of Health Research (NIHR) Health Protection Research Unit (HPRU) in Evaluation of Interventions, Bristol, UK
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Pitcher AB, Borquez A, Skaathun B, Martin NK. Mathematical modeling of hepatitis c virus (HCV) prevention among people who inject drugs: A review of the literature and insights for elimination strategies. J Theor Biol 2019; 481:194-201. [PMID: 30452959 PMCID: PMC6522340 DOI: 10.1016/j.jtbi.2018.11.013] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 11/13/2018] [Accepted: 11/15/2018] [Indexed: 02/07/2023]
Abstract
In 2016, the World Health Organization issued global elimination targets for hepatitis C virus (HCV), including an 80% reduction in HCV incidence by 2030. The vast majority of new HCV infections occur among people who inject drugs (PWID), and as such elimination strategies require particular focus on this population. As governments urgently require guidance on how to achieve elimination among PWID, mathematical modeling can provide critical information on the level and targeting of intervention are required. In this paper we review the epidemic modeling literature on HCV transmission and prevention among PWID, highlight main differences in mathematical formulation, and discuss key insights provided by these models in terms of achieving WHO elimination targets among PWID. Overall, the vast majority of modeling studies utilized a deterministic compartmental susceptible-infected-susceptible structure, with select studies utilizing individual-based network transmission models. In general, these studies found that harm reduction alone is unlikely to achieve elimination targets among PWID. However, modeling indicates elimination is achievable in a wide variety of epidemic settings with harm reduction scale-up combined with modest levels of HCV treatment for PWID. Unfortunately, current levels of testing and treatment are generally insufficient to achieve elimination in most settings, and require further scale-up. Additionally, network-based treatment strategies as well as prison-based treatment and harm reduction provision could provide important additional population benefits. Overall, epidemic modeling has and continues to play a critical role in informing HCV elimination strategies worldwide.
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Affiliation(s)
| | - Annick Borquez
- Division of Infectious Diseases and Global Public Health, University of California San Diego, CA, USA
| | - Britt Skaathun
- Division of Infectious Diseases and Global Public Health, University of California San Diego, CA, USA
| | - Natasha K Martin
- Division of Infectious Diseases and Global Public Health, University of California San Diego, CA, USA.
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Lazarus JV, Pericàs JM, Picchio C, Cernosa J, Hoekstra M, Luhmann N, Maticic M, Read P, Robinson EM, Dillon JF. We know DAAs work, so now what? Simplifying models of care to enhance the hepatitis C cascade. J Intern Med 2019; 286:503-525. [PMID: 31472002 DOI: 10.1111/joim.12972] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Globally, some 71 million people are chronically infected with hepatitis C virus (HCV). Marginalized populations, particularly people who inject drugs (PWID), have low testing, linkage to care and treatment rates for HCV. Several models of care (MoCs) and service delivery interventions have the potential to improve outcomes across the HCV cascade of care, but much of the relevant research was carried out when interferon-based treatment was the standard of care. Often it was not practical to scale-up these earlier models and interventions because the clinical care needs of patients taking interferon-based regimens imposed too much of a financial and human resource burden on health systems. Despite the adoption of highly effective, all-oral direct-acting antiviral (DAA) therapies in recent years, approaches to HCV testing and treatment have evolved slowly and often remain rooted in earlier paradigms. The effectiveness of DAAs allows for simpler approaches and has encouraged countries where the drugs are widely available to set their sights on the ambitious World Health Organization (WHO) HCV elimination targets. Since a large proportion of chronically HCV-infected people are not currently accessing treatment, there is an urgent need to identify and implement existing simplified MoCs that speak to specific populations' needs. This article aims to: (i) review the evidence on MoCs for HCV; and (ii) distil the findings into recommendations for how stakeholders can simplify the path taken by chronically HCV-infected individuals from testing to cure and subsequent care and monitoring.
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Affiliation(s)
- J V Lazarus
- Barcelona Institute for Global Health (ISGlobal), Barcelona, Spain
| | - J M Pericàs
- Infectious Diseases and Clinical Microbiology Territorial Direction, Translational Research Group on Infectious Diseases of Lleida (TRIDLE), Biomedical Research Institute Dr Pifarré Foundation, Lleida, Spain
| | - C Picchio
- Barcelona Institute for Global Health (ISGlobal), Barcelona, Spain
| | - J Cernosa
- Clinic for Infectious Diseases and Febrile Illnesses, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - M Hoekstra
- Barcelona Institute for Global Health (ISGlobal), Barcelona, Spain
| | - N Luhmann
- Médecins du Monde France, Paris, France
| | - M Maticic
- Clinic for Infectious Diseases and Febrile Illnesses, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - P Read
- Kirketon Road Centre, Sydney, NSW, Australia
| | - E M Robinson
- Division of Molecular and Clinical Medicine, School of Medicine, Ninewells Hospital, University of Dundee, Dundee, UK
| | - J F Dillon
- Division of Molecular and Clinical Medicine, School of Medicine, Ninewells Hospital, University of Dundee, Dundee, UK
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39
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Spearman CW, Dusheiko GM, Hellard M, Sonderup M. Hepatitis C. Lancet 2019; 394:1451-1466. [PMID: 31631857 DOI: 10.1016/s0140-6736(19)32320-7] [Citation(s) in RCA: 241] [Impact Index Per Article: 48.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 07/30/2019] [Accepted: 08/09/2019] [Indexed: 02/06/2023]
Abstract
Hepatitis C is a global health problem, and an estimated 71·1 million individuals are chronically infected with hepatitis C virus (HCV). The global incidence of HCV was 23·7 cases per 100 000 population (95% uncertainty interval 21·3-28·7) in 2015, with an estimated 1·75 million new HCV infections diagnosed in 2015. Globally, the most common infections are with HCV genotypes 1 (44% of cases), 3 (25% of cases), and 4 (15% of cases). HCV transmission is most commonly associated with direct percutaneous exposure to blood, via blood transfusions, health-care-related injections, and injecting drug use. Key high-risk populations include people who inject drugs, men who have sex with men, and prisoners. Approximately 10-20% of individuals who are chronically infected with HCV develop complications, such as cirrhosis, liver failure, and hepatocellular carcinoma over a period of 20-30 years. Direct-acting antiviral therapy is now curative, but it is estimated that only 20% of individuals with hepatitis C know their diagnosis, and only 15% of those with known hepatitis C have been treated. Increased diagnosis and linkage to care through universal access to affordable point-of-care diagnostics and pangenotypic direct-acting antiviral therapy is essential to achieve the WHO 2030 elimination targets.
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Affiliation(s)
- C Wendy Spearman
- Division of Hepatology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
| | - Geoffrey M Dusheiko
- Liver Unit, Kings College Hospital, London, UK; Division of Medicine, University College London Medical School, London, UK
| | - Margaret Hellard
- Disease Elimination Program, Burnet Institute, Melbourne, VIC, Australia
| | - Mark Sonderup
- Division of Hepatology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Mahmud S, Al Kanaani Z, Abu-Raddad LJ. Characterization of the hepatitis C virus epidemic in Pakistan. BMC Infect Dis 2019; 19:809. [PMID: 31521121 PMCID: PMC6744714 DOI: 10.1186/s12879-019-4403-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 08/25/2019] [Indexed: 02/06/2023] Open
Abstract
Background With one in every 20 Pakistanis already infected, Pakistan has the second largest number of hepatitis C virus (HCV) infections globally. The aim of this study was to present a quantitative and analytical characterization of the HCV epidemic in Pakistan. Methods A standardized database of HCV antibody incidence and prevalence and HCV genotypes in all subpopulations was systematically assembled. Random-effects meta-analyses and random-effects meta-regressions were performed. Shannon Diversity Index was calculated to determine genotype diversity. Results The database included two incidence, 309 prevalence, and 48 genotype measures. Pooled mean HCV prevalence ranged between 7.0% (95% confidence interval (CI): 5.8–8.3%) in Sindh and 0.9% (95% CI: 0.1–2.4%) in Federally Administered Tribal Areas (F.A.T.A). Estimated number of chronically-infected persons ranged between 4.2 million in Punjab and 0.03 million in F.A.T.A. HCV prevalence was stable over time [adjusted odds ratio (AOR) of 1.0 (95% CI: 1.0–1.0)]. Population classification was the strongest predictor of HCV prevalence, explaining 51.8% of prevalence variation. Relative to the general population, HCV prevalence was higher in people who inject drugs [AOR of 23.8 (95% CI: 13.0–43.6)], populations with liver-related conditions [AOR of 22.3 (95% CI: 15.7–31.6)], and high-risk clinical populations [AOR of 7.8 (95% CI: 4.8–12.7)]. Low genotype diversity was observed (Shannon diversity index of 0.67 out of 1.95; 34.5%). There were only minor differences in genotype diversity by province, with genotype 3 being most common in all provinces. Conclusion Pakistan’s HCV epidemic shows homogeneity across the provinces, and over time. HCV prevalence is strikingly persistent at high level, with no evidence for a decline over the last three decades. Scale up of HCV treatment and prevention is urgently needed. Electronic supplementary material The online version of this article (10.1186/s12879-019-4403-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sarwat Mahmud
- Infectious Disease Epidemiology Group, Weill Cornell Medicine-Qatar, Qatar Foundation - Education City, Cornell University, P.O. Box 24144, Doha, Qatar.
| | - Zaina Al Kanaani
- Infectious Disease Epidemiology Group, Weill Cornell Medicine-Qatar, Qatar Foundation - Education City, Cornell University, P.O. Box 24144, Doha, Qatar
| | - Laith J Abu-Raddad
- Infectious Disease Epidemiology Group, Weill Cornell Medicine-Qatar, Qatar Foundation - Education City, Cornell University, P.O. Box 24144, Doha, Qatar. .,Department of Healthcare Policy & Research, Weill Cornell Medicine, Cornell University, New York, USA. .,College of Health and Life Sciences, Hamad bin Khalifa University, Doha, Qatar.
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Hayashi T, Hutin YJF, Bulterys M, Altaf A, Allegranzi B. Injection practices in 2011-2015: a review using data from the demographic and health surveys (DHS). BMC Health Serv Res 2019; 19:600. [PMID: 31455315 PMCID: PMC6712605 DOI: 10.1186/s12913-019-4366-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 07/22/2019] [Indexed: 12/19/2022] Open
Abstract
Background Reuse of injection devices to give healthcare injections decreased from 39.8 to 5.5% between 2000 and 2010, but trends since 2011 have not been described. We reviewed results of Demographic and Health Surveys (DHS) to describe injection practices worldwide from 2011 to 2015. Methods We searched the DHS Internet site for data published on injection practices conducted in countries from 2011 to 2015, extracted information on frequency (number of healthcare injections per person in the last 12 months) and safety (proportion of syringes and needles taken from a new, unopened package). We compared gender groups and WHO regions in terms of frequency and safety. For countries with data available, we compared injection practices 2004–2010 and 2011–2015. Results Since 2011, 40 of 92 countries (43%) that conducted DHS surveys reported on injection practices. On average, the frequency of injection was 1.64 per person per year (from 3.84 in WHO Eastern Mediterranean region to 1.18 in WHO African region). Among those, 96.1% of injections reportedly used new injection devices (from 90.2% in the WHO Eastern Mediterranean region to 98.8% in the WHO Western Pacific region). On average, women received more injections per year (1.85) than men (1.41). Among 16 (40%) countries with data in 2004–2010 and 2011–2015, 69% improved in terms of safety. The annual number of unsafe injections reduced in 81% of countries. In Pakistan, the number of unsafe injections was the highest and did not decrease between 2006 and 2012. Conclusions Injection practices have continued to improve in most countries worldwide, although the Eastern Mediterranean region in particular still faces unsafe practices that are not improving. Further efforts are needed to eliminate unsafe injection practices in health care settings, including through the use of reuse-prevention devices. Despite some limitations, DHS is an easily available method to measure progress over time.
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Affiliation(s)
- Tomoyuki Hayashi
- Global Hepatitis Programme, World Health Organization, Geneva, Switzerland. .,Department of Gastroenterology, Kanazawa University and WHO Collaborating Center for Chronic Hepatitis and Liver Cancer, Kanazawa, Ishikawa, Japan.
| | - Yvan J-F Hutin
- Global Hepatitis Programme, World Health Organization, Geneva, Switzerland
| | - Marc Bulterys
- Global Hepatitis Programme, World Health Organization, Geneva, Switzerland
| | - Arshad Altaf
- Integrated Service Delivery, World Health Organization, Western Pacific Region, Manila, Philippines
| | - Benedetta Allegranzi
- Infection Prevention and Control, World Health Organization, Geneva, Switzerland
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Cost-effectiveness and budgetary impact of HCV treatment with direct-acting antivirals in India including the risk of reinfection. PLoS One 2019; 14:e0217964. [PMID: 31170246 PMCID: PMC6553784 DOI: 10.1371/journal.pone.0217964] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 05/22/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND HCV direct-acting antivirals (DAAs) are produced in India at low cost. However, concerns surrounding reinfection and budgetary impact limit treatment scale-up in India. We evaluate the cost-effectiveness and budgetary impact of HCV treatment in India, including reinfection. METHODS A closed cohort Markov model of HCV disease progression, treatment, and reinfection was parameterized. We compared treatment by fibrosis stage (F2-F4 or F0-F4) to no treatment from a health care payer perspective. Costs (2017 USD$, based on India-specific data) and health utilities (in quality-adjusted life years, QALYs) were attached to each health state. We assumed DAAs with 90% sustained viral response at $900/treatment and 1%/year reinfection, varied in the sensitivity analysis from 0.1-15%. We deemed the intervention cost-effective if the incremental cost-effectiveness ratio (ICER) fell below India's per capita GDP ($1,709). We assessed the budgetary impact of treating all diagnosed individuals. RESULTS HCV treatment for diagnosed F2-F4 individuals was cost-saving (net costs -$2,881 and net QALYs 3.18/person treated; negative ICER) compared to no treatment. HCV treatment remained cost-saving with reinfection rates of 15%/year. Treating all diagnosed individuals was likely cost-effective compared to delay until F2 (mean ICER $1,586/QALY gained, 67% of simulations falling under the $1,709 threshold) with 1%/year reinfection. For all scenarios, annual retesting for reinfection was more cost-effective than the current policy (one-time retest). Treating all diagnosed individuals and reinfections results in net costs of $445-1,334 million over 5 years (<0.25% of total health care expenditure over 5 years), and cost-savings within 14 years. CONCLUSIONS HCV treatment was highly cost-effective in India, despite reinfection. Annual retesting for reinfection was cost-effective, supporting a policy change towards more frequent retesting. A comprehensive HCV treatment scale-up plan is warranted in India.
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Trickey A, Fraser H, Lim AG, Peacock A, Colledge S, Walker JG, Leung J, Grebely J, Larney S, Martin NK, Hickman M, Degenhardt L, May MT, Vickerman P. The contribution of injection drug use to hepatitis C virus transmission globally, regionally, and at country level: a modelling study. Lancet Gastroenterol Hepatol 2019; 4:435-444. [PMID: 30981685 PMCID: PMC6698583 DOI: 10.1016/s2468-1253(19)30085-8] [Citation(s) in RCA: 134] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 02/18/2019] [Accepted: 02/18/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND WHO aims to eliminate the hepatitis C virus (HCV) as a public health threat by 2030. Injection drug use is an important risk factor for HCV transmission, but its contribution to country-level and global epidemics is unknown. We estimated the contribution of injection drug use to risk for HCV epidemics globally, regionally, and at country level. METHODS We developed a dynamic deterministic HCV transmission model to simulate country-level HCV epidemics among people who inject drugs and the general population. Each country's model was calibrated using country-specific data from UN datasets and systematic reviews on the prevalence of HCV and injection drug use. The population attributable fraction of HCV transmission associated with injection drug use was estimated-defined here as the percentage of HCV infections prevented if additional HCV transmission due to injection drug use was removed between 2018 and 2030. FINDINGS The model included 88 countries (85% of the global population). The model predicted 0·23% (95% credibility interval [CrI] 0·16-0·31) of the global population were injection drug users in 2017, and 8% (5-12) of prevalent HCV infections were among people who currently inject drugs. Globally, if the increased risk for HCV transmission among people who inject drugs was removed, an estimated 43% (95% CrI 25-67) of incident HCV infections would be prevented from 2018 to 2030, varying regionally. This population attributable fraction was higher in high-income countries (79%, 95% CrI 57-97) than in countries of low and middle income (38%, 24-64) and was associated with the percentage of a country's prevalent HCV infections that are among people who inject drugs. INTERPRETATION Unsafe injecting practices among people who inject drugs contribute substantially to incident HCV infections globally. Any intervention that can reduce HCV transmission among people who inject drugs will have a pronounced effect on country-level incidence of HCV. FUNDING None.
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Affiliation(s)
- Adam Trickey
- Population Health Sciences, University of Bristol, Bristol, UK; National Institute for Health Research Health Protection Research Unit in Evaluation of Interventions, UK.
| | - Hannah Fraser
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Aaron G Lim
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Amy Peacock
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, NSW, Australia
| | - Samantha Colledge
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, NSW, Australia
| | | | - Janni Leung
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, NSW, Australia; Centre for Youth Substance Abuse Research, Faculty of Health and Behavioural Sciences, The University of Queensland, Brisbane, QLD, Australia; Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Jason Grebely
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA; The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
| | - Sarah Larney
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, NSW, Australia
| | - Natasha K Martin
- Population Health Sciences, University of Bristol, Bristol, UK; Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, CA, USA
| | - Matthew Hickman
- Population Health Sciences, University of Bristol, Bristol, UK; National Institute for Health Research Health Protection Research Unit in Evaluation of Interventions, UK
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, NSW, Australia
| | - Margaret T May
- Population Health Sciences, University of Bristol, Bristol, UK; National Institute for Health Research Health Protection Research Unit in Evaluation of Interventions, UK; National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Peter Vickerman
- Population Health Sciences, University of Bristol, Bristol, UK; National Institute for Health Research Health Protection Research Unit in Evaluation of Interventions, UK
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Abstract
OBJECTIVE Direct-acting antivirals have opened an opportunity for controlling hepatitis C virus (HCV) infection in Pakistan, where 10% of the global infection burden is found. We aimed to evaluate the implications of five treatment programme scenarios for HCV treatment as prevention (HCV-TasP) in Pakistan. DESIGN An age-structured mathematical model was used to evaluate programme impact using epidemiological and programme indicators. SETTING Total Pakistan population. PARTICIPANTS Total Pakistan HCV-infected population. INTERVENTIONS HCV treatment programme scenarios from 2018 up to 2030. RESULTS By 2030 across the five HCV-TasP scenarios, 0.6-7.3 million treatments were administered, treatment coverage reached between 3.7% and 98.7%, prevalence of chronic infection reached 2.4%-0.03%, incidence reduction ranged between 41% and 99%, program-attributed reduction in incidence rate ranged between 7.2% and 98.5% and number of averted infections ranged between 126 221 and 750 547. Annual incidence rate reduction in the first decade of the programme was around 6%-18%. Number of treatments needed to prevent one new infection ranged between 4.7-9.8, at a drug cost of about US$900. Cost of the programme by 2030, in the most ambitious elimination scenario, reached US$708 million. Stipulated WHO target for 2030 cannot be accomplished without scaling up treatment to 490 000 per year, and maintaining it for a decade. CONCLUSION HCV-TasP is a highly impactful and potent approach to control Pakistan's HCV epidemic and achieve elimination by 2030.
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Affiliation(s)
- Houssein H Ayoub
- Department of Mathematics, Statistics, and Physics, Qatar University, Doha, Qatar
| | - Laith J Abu-Raddad
- Infectious Disease Epidemiology Group, Weill Cornell Medicine-Qatar, Doha, Qatar
- Department of Healthcare Policy and Research, Weill Cornell Medicine, Cornell University, New York, USA
- College of Health and Life Sciences, Hamad bin Khalifa University, Doha, Qatar
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Chhatwal J, Chen Q, Wang X, Ayer T, Zhuo Y, Janjua NZ, Kanwal F. Assessment of the Feasibility and Cost of Hepatitis C Elimination in Pakistan. JAMA Netw Open 2019; 2:e193613. [PMID: 31074817 PMCID: PMC6512462 DOI: 10.1001/jamanetworkopen.2019.3613] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
IMPORTANCE Chronic hepatitis C virus (HCV) infection is a global health problem. The World Health Assembly recently pledged to eliminate HCV by 2030. However, in Pakistan, a country with one of the highest prevalence rates, the feasibility and cost of HCV elimination are not known. OBJECTIVES To investigate whether and under what conditions HCV elimination is feasible in Pakistan and to estimate the cost of such elimination. DESIGN, SETTING, AND PARTICIPANTS This decision analytical model study used a microsimulation model of the HCV epidemic in Pakistan from 2015 to 2030. Using Pakistan-specific variables, the model simulated the landscape of HCV in Pakistan and evaluated the minimum required screening and treatment rates needed to eliminate HCV in Pakistan. The study used simulated individuals chronically infected with HCV from 2015 to 2030. The analysis was performed in 2018. INTERVENTIONS The status quo and 7 scenarios that can lead to HCV elimination in Pakistan by 2030, which were defined by different combinations of tests for screening, detection of viremia before treatment, and confirmation of treatment response. MAIN OUTCOMES AND MEASURES Temporal trends in HCV infection prevalence, mortality, and disability-adjusted life-years and total cost of HCV infection care under the status quo and scenarios that can eliminate HCV by 2030. RESULTS Under the status quo, from 2015 to 2030, 1.44 million people are projected to die of HCV infection; 48% of deaths would be among people younger than 50 years. To achieve HCV elimination in Pakistan, HCV testing would need to be scaled up to at least 25 million people to diagnose 900 000 persons and treatment to 700 000 people per year. Compared with the status quo, the elimination scenario would avert 323 000 liver-related deaths and 13.0 million HCV-associated disability-adjusted life-years from 2015 to 2030. The elimination scenario was associated with cost savings of $2.6 billion from 2018 to 2030 with use of a point-of-care test for population-wide antibody screening and detection of viremia and treatment response. CONCLUSIONS AND RELEVANCE Substantial scale-up of HCV testing and treatment may be essential to eliminate HCV infection in Pakistan, and such a strategy may be associated with cost savings in the near future. Although HCV elimination in Pakistan may be ambitious, strategic planning and strong support from the government may aid in its elimination.
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Affiliation(s)
- Jagpreet Chhatwal
- Harvard Medical School, Boston, Massachusetts
- Massachusetts General Hospital Institute for Technology Assessment, Boston
| | - Qiushi Chen
- Harvard Medical School, Boston, Massachusetts
- Massachusetts General Hospital Institute for Technology Assessment, Boston
- Harold and Inge Marcus Department of Industrial and Manufacturing Engineering, Pennsylvania State University, University Park
| | - Xiaojie Wang
- Department of Industrial and Systems Engineering, University of Florida, Gainesville
| | - Turgay Ayer
- H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta
| | - Yueran Zhuo
- Massachusetts General Hospital Institute for Technology Assessment, Boston
| | - Naveed Z. Janjua
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Fasiha Kanwal
- Houston Veterans Affairs Health Services Research and Development Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
- Department of Medicine, Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas
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Estimation of hepatitis C prevalence in the Punjab province of Pakistan: A retrospective study on general population. PLoS One 2019; 14:e0214435. [PMID: 30943224 PMCID: PMC6447227 DOI: 10.1371/journal.pone.0214435] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Accepted: 03/03/2019] [Indexed: 12/29/2022] Open
Abstract
Background Hepatitis C virus (HCV) infections are amongst the leading public health concerns in Pakistan with a high disease burden. Despite the availability of effective antiviral treatments in the country the disease burden in general population has not lowered. This could be attributed to the asymptomatic nature of this infection that results in lack of diagnosis until the late symptomatic stage. To better estimate and map HCV infections in the country a population-based analysis is necessary for an effective control of the infection. Methods Serologic samples of ~66,000 participants from all major cities of the Punjab province were tested for anti-HCV antibodies. The antibody-based seroprevalence was associated with socio-demographic variables including geographical region, age, gender and sex, and occupation. Results Overall serological response to HCV surface antigens was observed in over 17% of the population. Two of the districts were identified with significantly high prevalence in general population. Analysis by occupation showed significantly high prevalence in farmers (over 40%) followed by jobless and retired individuals, laborers and transporters. A significant difference in seroprevalence was observed in different age groups amongst sex and genders (male, female and transgender) with highest response in individuals of over 40 years of age. Moreover, most of the tested IDUs showed positive response for anti-HCV antibody. Conclusion This study represents a retrospective analysis of HCV infections in general population of the most populated province of Pakistan to identify socio-demographic groups at higher risk. Two geographical regions, Faisalabad and Okara districts, and an occupational group, farmers, were identified with significantly high HCV seroprevalence. These socio-demographic groups are the potential focused groups for follow-up studies on factors contributing to the high HCV prevalence in these groups towards orchestrating effective prevention, control and treatment.
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Heffernan A, Cooke GS, Nayagam S, Thursz M, Hallett TB. Scaling up prevention and treatment towards the elimination of hepatitis C: a global mathematical model. Lancet 2019; 393:1319-1329. [PMID: 30704789 PMCID: PMC6484702 DOI: 10.1016/s0140-6736(18)32277-3] [Citation(s) in RCA: 178] [Impact Index Per Article: 35.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 08/13/2018] [Accepted: 09/12/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND The revolution in hepatitis C virus (HCV) treatment through the development of direct-acting antivirals (DAAs) has generated international interest in the global elimination of the disease as a public health threat. In 2017, this led WHO to establish elimination targets for 2030. We evaluated the impact of public health interventions on the global HCV epidemic and investigated whether WHO's elimination targets could be met. METHODS We developed a dynamic transmission model of the global HCV epidemic, calibrated to 190 countries, which incorporates data on demography, people who inject drugs (PWID), current coverage of treatment and prevention programmes, natural history of the disease, HCV prevalence, and HCV-attributable mortality. We estimated the worldwide impact of scaling up interventions that reduce risk of transmission, improve access to treatment, and increase screening for HCV infection by considering six scenarios: no change made to existing levels of diagnosis or treatment; sequentially adding the following interventions: blood safety and infection control, PWID harm reduction, offering of DAAs at diagnosis, and outreach screening to increase the number diagnosed; and a scenario in which DAAs are not introduced (ie, treatment is only with pegylated interferon and oral ribavirin) to investigate the effect of DAA use. We explored the effect of varying the coverage or impact of these interventions in sensitivity analyses and also assessed the impact on the global epidemic of removing certain key countries from the package of interventions. FINDINGS By 2030, interventions that reduce risk of transmission in the non-PWID population by 80% and increase coverage of harm reduction services to 40% of PWID could avert 14·1 million (95% credible interval 13·0-15·2) new infections. Offering DAAs at time of diagnosis in all countries could prevent 640 000 deaths (620 000-670 000) from cirrhosis and liver cancer. A comprehensive package of prevention, screening, and treatment interventions could avert 15·1 million (13·8-16·1) new infections and 1·5 million (1·4-1·6) cirrhosis and liver cancer deaths, corresponding to an 81% (78-82) reduction in incidence and a 61% (60-62) reduction in mortality compared with 2015 baseline. This reaches the WHO HCV incidence reduction target of 80% but is just short of the mortality reduction target of 65%, which could be reached by 2032. Reducing global burden depends upon success of prevention interventions, implemention of outreach screening, and progress made in key high-burden countries including China, India, and Pakistan. INTERPRETATION Further improvements in blood safety and infection control, expansion or creation of PWID harm reduction services, and extensive screening for HCV with concomitant treatment for all are necessary to reduce the burden of HCV. These findings should inform the ongoing global action to eliminate the HCV epidemic. FUNDING Wellcome Trust.
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Affiliation(s)
- Alastair Heffernan
- MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Faculty of Medicine, Imperial College London, London, UK
| | - Graham S Cooke
- Division of Infectious Diseases, St Mary's Hospital, Imperial College London, London, UK
| | - Shevanthi Nayagam
- MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Faculty of Medicine, Imperial College London, London, UK; Division of Digestive Diseases, St Mary's Hospital, Imperial College London, London, UK
| | - Mark Thursz
- Division of Digestive Diseases, St Mary's Hospital, Imperial College London, London, UK
| | - Timothy B Hallett
- MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Faculty of Medicine, Imperial College London, London, UK.
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48
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Lim AG, Trickey A, Vickerman P. Screening Strategies for Hepatitis C Virus. Hepatol Commun 2019; 3:321-324. [PMID: 30859145 PMCID: PMC6396359 DOI: 10.1002/hep4.1330] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 02/07/2019] [Indexed: 12/28/2022] Open
Affiliation(s)
- Aaron G. Lim
- Department of Population Health Sciences Bristol Medical SchoolUniversity of BristolBristolUnited Kingdom
| | - Adam Trickey
- Department of Population Health Sciences Bristol Medical SchoolUniversity of BristolBristolUnited Kingdom
| | - Peter Vickerman
- Department of Population Health Sciences Bristol Medical SchoolUniversity of BristolBristolUnited Kingdom
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49
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Khaliq S, Raza SM. Current Status of Direct Acting Antiviral Agents against Hepatitis C Virus Infection in Pakistan. MEDICINA (KAUNAS, LITHUANIA) 2018; 54:E80. [PMID: 30400604 PMCID: PMC6262417 DOI: 10.3390/medicina54050080] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 10/20/2018] [Accepted: 10/31/2018] [Indexed: 02/06/2023]
Abstract
In Pakistan, the burden of the hepatitis C virus (HCV) infection is the second highest in the world with the development of chronic hepatitis. Interferon-based combination therapy with ribavirin was the only available treatment until a few years back, with severe side-effects and high failure rates against different genotypes of HCV. Interferon-free all-oral direct-acting antiviral agents (DAAs) approved by the FDA have revolutionized the HCV therapeutic landscape due to their efficiency in targeting different genotypes in different categories of patients, including treatment naïve, treatment failure and relapsing patients, as well as patients with compensated and decompensated cirrhosis. The availability and use of these DAAs is limited in the developing world. Sofosbuvir (SOF), a uridine nucleotide analogue and inhibitor of HCV encoded NS5B polymerase, is now a widely available and in-use DAA in Pakistan; whereas daclatasvir was recently added in the list. According to the documented results, there is hope that this disease can be effectively cured in Pakistan, although a few concerns still remain. The aim of this article is to review the effectiveness of DAAs and the current status of this treatment against HCV genotype 3 infection in Pakistan; various factors associated with SVR; its limitations as an effective treatment regime; and future implications.
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Affiliation(s)
- Saba Khaliq
- Department of Physiology and Cell Biology, University of Health Sciences, Lahore 54600, Pakistan.
| | - Syed Mohsin Raza
- Institute of Biomedical and Allied Health Sciences, University of Health Sciences, Lahore 54600, Pakistan.
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