Current activities and future directions of comprehensive hepatitis control measures in Japan: The supportive role of the Hepatitis Information Center in building a solid foundation

Patient and physician preferences for treatment of hepatitis C virus infection in Japan: a discrete choice experiment

AIMS

This study was performed to evaluate patients' and physicians' preferences regarding hepatitis C virus (HCV) treatment in Japan, particularly focusing on direct-acting antivirals. Understanding these preferences is important for maintaining adherence to treatment necessary for achieving HCV elimination.

METHODS

A discrete choice experiment was conducted to identify patients' and physicians' preferences for HCV treatment in Japan. Eligible participants completed a preference survey via an online questionnaire. Eight attributes and their respective levels - pertaining to dosing regimen/schedule, safety, and out-of-pocket costs - were identified. The primary and secondary endpoints were the relative attribute importance (RAI) and utility value of attribute levels, which were compared between patients and physicians to highlight differences.

RESULTS

Both patients (n = 95) and physicians (n = 118) showed the greatest concern for total out-of-pocket treatment costs, followed by safety risks. While patients and physicians generally shared similar treatment preferences, patients placed a higher RAI on total out-of-pocket costs than did physicians (50.4% vs. 39.4%). Conversely, patients assigned lower RAI values to the risks of nasopharyngitis and pruritus (15.2% vs. 17.9% and 11.7% vs. 16.2%, respectively). The RAI for the number of tablets taken daily was higher than that for treatment duration among patients (11.6% vs. 0.2%), but nearly equal among physicians.

LIMITATIONS

The study had potential non-response bias, physicians not being actual care providers for surveyed patients, a small sample size, reliance on predefined DCE attributes, and limited participant diversity from online panels.

CONCLUSIONS

This study highlights the importance of patient-centered care in HCV treatment and the need to raise awareness of the public subsidy for hepatitis, and to ensure an effective access scheme for the patients. Simplifying regimens like once-daily pills and minimal monitoring may enhance treatment convenience. Improved patient-physician communication supports optimized strategies, aiding Japan's goal of HCV elimination by 2030.

Unveiling the dynamics of hepatitis C virus transmission among injection drug users and men who have sex with men: A comprehensive study in Japan

AIM

In Japan, despite low nationwide hepatitis C (HCV) incidence, new infections among people who inject drugs (PWID) and men who have sex with men (MSM) hinder HCV elimination. We explored HCV transmission dynamics and screened HCV recombination within these populations.

METHODS

This cross-sectional study recruited HCV-infected patients from Osaka National Hospital, Osaka, Japan, from January 2010 to September 2023. Data from questionnaires and medical records were analyzed. Serum samples collected before anti-HCV treatment underwent HCV RNA extraction, and sequencing of full core (576 bp) and NS5B (267 bp) regions using the Sanger method. Genotype distribution was determined by phylogenetic analysis, and recombinant screening was conducted.

RESULTS

A total of 115 patients were categorized into non-MSM PWID (31), MSM PWID (15), MSM non-PWID (25), and non-MSM non-PWID (44). Positive amplification rates were 99.1% (114/115) for the full-core region, and 96.5% (111/115) for NS5B. No intergenotypic recombination was detected. The predominant genotype in non-MSM PWID was 2a (58%), whereas genotype 1b was most common in MSM PWID, MSM non-PWID, and non-MSM non-PWID groups (79%, 64%, and 68%, respectively). Nucleotide sequence similarity of 94.75%-100% was found in HCV strains from MSM PWID and MSM non-PWID in both full-core and NS5B regions, whereas strains from non-MSM PWID and non-MSM non-PWID were distinct.

CONCLUSION

The findings suggest that the transmission route in PWID is determined by MSM status, whereas MSM groups showed the same transmission route regardless of PWID. HCV control measures should be focused not only on PWID, but also on MSM to achieve HCV elimination in Japan.

Higher FIB-4 index at baseline predicts development of liver cancer in a community-based cohort with viral hepatitis

Hepatitis B and C (HBV and HCV) testing has been performed in Japan since 2002 and is subsidized by central and prefectural governments. A follow-up program for HBV- or HCV-infected persons was started at that time in Ishikawa Prefecture. This study analyzed the long-term follow-up data from this program. In total, 1029 participants in the Ishikawa Hepatitis Follow-up Program (HBV-infected, n = 535; HCV-infected, n = 494) were enrolled. Clinical data between the first visit and the most recent visit by March 2019 were collected. In the HBV-infected group, 384 persons (71.8%) were asymptomatic carriers, 133 (24.9%) developed chronic hepatitis, 15 (2.8%) developed compensated liver cirrhosis, and 3 (0.6%) developed decompensated liver cirrhosis. Ninety (16.8%) were treated with nucleotide/nucleoside analogs. Sixteen (3.0%) developed liver cancer. In the HCV-infected group, 427 persons (86.4%) developed chronic hepatitis, 46 (9.3%) developed compensated liver cirrhosis, and 21 (4.3%) developed decompensated liver cirrhosis. Forty-eight (9.7%) developed liver cancer. Three hundred and seventy-eight (76.5%) received antiviral therapy (a direct-acting antiviral in 166, interferon-based treatment followed by a direct-acting antiviral in 73, and interferon-based treatment in 139). The subsidy system was used by 270 persons (71.4%). Sustained virological response was confirmed in 340 persons (68.8%). A higher FIB-4 index at the first visit was a significant risk factor for liver cancer in HBV-infected and HCV-infected persons. The Ishikawa Hepatitis Follow-up Program has revealed the clinical course of HBV and HCV infection in community-dwelling individuals. The results will be used for micro-elimination at a prefectural level.

High prevalence of hepatitis C virus among criminals in rehabilitation facilities in Japan

OBJECTIVE

There is a high prevalence of hepatitis C virus (HCV) carriers in prison in several developed countries, but the situation in Japan has not been well reported. This study aimed to determine the state of HCV infection among criminals in Japan.

METHODS

We enrolled 533 criminals in rehabilitation facilities (354 men and 179 women) who underwent a medical check-up from April 2014 to March 2022. Their records of blood tests, medical history, and drug injection use were retrospectively analyzed.

RESULTS

The HCV-antibody positive rate was 11.1 % (59/533), with rates of 8.2 % (29/354) in men and 16.8 % (30/179 in women. Approximately half of the HCV-infected residents had a history of drug injection, and this rate did not vary by age or by sex. Although an opportunity to treat HCV infection with medical assistance from government was provided to all residents who were positive for HCV RNA, 26.5 % of them abandoned the treatment.

CONCLUSION

In spite of the generous economical support to treat HCV infection by the government and the free access system in Japan, eliminating HCV in criminals appears to be difficult. The reason for this problem might be the criminals' negligent attitude to life.

Integrated policy of medical expense subsidies and clinical registry for patients with liver cancer and decompensated cirrhosis in Japan

Chronic hepatitis B and C are among the most significant infectious diseases worldwide, and are major risk factors for liver cirrhosis and liver cancer. In Japan, comprehensive hepatitis measures are implemented for the testing and treatment of viral hepatitis, thus enabling the early diagnosis of liver cancer. Nevertheless, patients with decompensated cirrhosis and liver cancer often have unfavorable prognoses and require repetitive long-term treatment. In fiscal year 2018, an integrated policy of medical expense subsidies and research was established in Japan that aimed to alleviate patients' financial burden and launch the clinical registry of advanced liver disease. Over time, updates to the eligibility for the subsidy increased access to patients and has led to an increased number of beneficiaries. Additionally, the accumulation of clinical data in the registry has revealed the treatment choices for these diseases. However, the disparities in efforts across prefectures have also become evident. Raising public awareness of the policy and tightening the multisector healthcare network are keys to success in supporting qualifying patients with advanced liver disease.

Prevalence of hepatitis B and C, and their linkage to care among drug abusers attending psychiatric hospital in Hiroshima, Japan

Towards the WHO goal for hepatitis elimination, understanding the prevalence and management of hepatitis B and C viruses (HBV, HCV) among drug abusers is crucial. However, in Japan, where drug abuse is less prevalent than in other countries, there is a dearth of epidemiological studies on this topic. This study aimed to fill this gap by investigating virus prevalence and the testing and treatment landscape for drug abusers in Japan. We conducted a cross-sectional sero-epidemiological study at a psychiatric hospital in Hiroshima where approaching drug abusers was feasible. Blood samples and questionnaire on HBV/HCV testing and treatment were collected from drug abusers (n = 35, 85.7% male, mean age 55.4 years) and control group (n = 45, 71.1%, 48.2 years). Prevalence of HCV-Ab and HCV RNA in drug abusers was 60.0% (95% CI: 43.8-76.2%) and 28.6% (13.6-43.5%), respectively, which was significantly higher than in the control group (2.2%, 0.0%, respectively). All HCV-Ab positive drug abusers had undergone prior hepatitis virus testing, but only 42.9% of those eligible for HCV treatment were connected to it. For HBV, while prevalence of HBsAg was similar between groups (2.9% vs. 2.2%), prevalence of HBc-Ab was higher in drug abusers (34.3% vs. 17.8%), indicating a greater likelihood of exposure to HBV infection. In conclusion, HCV prevalence among drug abusers in psychiatric care is notably high. Although testing is accessible, a recognized challenge is the insufficient connection to treatment. Enhancing collaboration between psychiatric hospitals and hepatologists is crucial. Disregarding this issue is not an option for hepatitis elimination.

Sex and ethnic disparities in hepatitis B evaluation and treatment across the world

BACKGROUND & AIMS

Oral antiviral therapy with nucleos(t)ide analogues (NAs) for chronic hepatitis B (CHB) is well-tolerated and lifesaving, but real-world data on utilization are limited. We examined rates of evaluation and treatment in patients from the REAL-B consortium.

METHODS

This was a cross-sectional study nested within our retrospective multinational clinical consortium (2000-2021). We determined the proportions of patients receiving adequate evaluation, meeting AASLD treatment criteria, and initiating treatment at any time during the study period. We also identified factors associated with receiving adequate evaluation and treatment using multivariable logistic regression analyses.

RESULTS

We analyzed 12,566 adult treatment-naïve patients with CHB from 25 centers in 9 countries (mean age 47.1 years, 41.7% female, 96.1% Asian, 49.6% Western region, 8.7% cirrhosis). Overall, 73.3% (9,206 patients) received adequate evaluation. Among the adequately evaluated, 32.6% (3,001 patients) were treatment eligible by AASLD criteria, 83.3% (2,500 patients) of whom were initiated on NAs, with consistent findings in analyses using EASL criteria. On multivariable logistic regression adjusting for age, sex, cirrhosis, and ethnicity plus region, female sex was associated with adequate evaluation (adjusted odds ratio [aOR] 1.13, p = 0.004), but female treatment-eligible patients were about 50% less likely to initiate NAs (aOR 0.54, p <0.001). Additionally, the lowest evaluation and treatment rates were among Asian patients from the West, but no difference was observed between non-Asian patients and Asian patients from the East. Asian patients from the West (vs. East) were about 40-50% less likely to undergo adequate evaluation (aOR 0.60) and initiate NAs (aOR 0.54) (both p <0.001).

CONCLUSIONS

Evaluation and treatment rates were suboptimal for patients with CHB in both the East and West, with significant sex and ethnic disparities. Improved linkage to care with linguistically competent and culturally sensitive approaches is needed.

IMPACT AND IMPLICATIONS

Significant sex and ethnic disparities exist in hepatitis B evaluation and treatment, with female treatment-eligible patients about 50% less likely to receive antiviral treatment and Asian patients from Western regions also about 50% less likely to receive adequate evaluation or treatment compared to Asians from the East (there was no significant difference between Asian patients from the East and non-Asian patients). Improved linkage to care with linguistically competent and culturally sensitive approaches is needed.

Real-world safety and effectiveness of tenofovir alafenamide for 144 weeks in Japanese patients with chronic hepatitis B

Tenofovir alafenamide (TAF), a prodrug of tenofovir, delivers high levels of active drug to hepatocytes and is given in a lower dose than tenofovir disoproxil fumarate (TDF). TAF reduces viral replication in patients with chronic hepatitis B (CHB) similar to TDF and has shown a lower risk of the renal and bone toxicities associated with TDF use. This post-marketing surveillance study examined the safety and effectiveness of TAF in treatment-naïve and -experienced CHB patients who received TAF for 144 weeks at real-world clinical sites in Japan. Safety assessments included the incidence of adverse drug reactions (ADRs), renal and bone events, and changes in selected laboratory parameters. Effectiveness was based on the proportion of patients with HBV DNA levels below the lower limit of quantitation or <29 IU/mL. This analysis included 580 patients; 18.4% of whom were treatment-naïve. The cumulative incidence of ADRs was 0.21 per 100 person-months, and the incidence of serious ADRs was 0.01 (95% CI, 0.00-0.04) per 100 person-months. There were no ADRs of declines in estimated glomerular filtration rates, renal failure or proximal tubulopathy. The most common ADR was hypophosphataemia in seven (1.2%) patients. Two (0.4%) patients each had decreased blood phosphorus, bone mineral density decreased, dizziness and alopecia. Overall, the proportion of virologically suppressed patients increased from 68.8% at baseline to 97.5% at Week 144. These results confirm the real-world safety and effectiveness of TAF in Japanese patients with CHB and are consistent with the findings of other evaluations of the safety and efficacy of TAF in CHB.

Development of performance indicators for hepatitis countermeasures as a tool for the assessment and promotion of liver cancer prevention in Japan

BACKGROUND

Hepatitis countermeasures are being promoted by governments in Japan. We aimed to develop performance indicators (PIs) to assess the process and outcome of such countermeasures implemented for the prevention of viral hepatitis-related liver cancer at the national and prefectural government levels.

METHODS

We developed 19 PIs for hepatitis countermeasures implemented by local governments, covering the morbidity and mortality of liver cancer, hepatitis testing, subsidy programs for examinations and antiviral treatment, and education on hepatitis patient care to healthcare workers. We analyzed the PIs for each prefecture from Fiscal Year (FY) 2018-2020.

RESULTS

The morbidity and mortality of liver cancer significantly decreased in the study period. The percentage of municipalities conducting hepatitis screening was already high at 95% in FY2017. The usage rate of government-subsidized screenings did not change. The subsidy usage rate for periodic viral hepatitis examination significantly increased. Meanwhile, the subsidy usage rate for antiviral treatment of hepatitis B increased, whereas that for hepatitis C decreased. The number of certified healthcare workers providing care for hepatitis patients increased significantly, and these workers were efficiently placed at regional core centers, institutions specialized in liver diseases, health care centers, and municipal governments. Liver cancer mortality was positively correlated with hepatitis screening, subsidies for periodic examinations, and the number of hepatitis medical care coordinators but was negatively correlated with subsidies for anti-HCV therapy, suggesting that rigorous countermeasures were implemented in prefectures with high liver cancer mortality.

CONCLUSIONS

The developed PIs could be a useful tool for monitoring government efforts and achievements, thereby providing basic data for setting practical goals in liver cancer prevention.

Global, regional, and national burden and quality of care index of liver cirrhosis by cause from global burden of disease 1990-2019

BACKGROUND AND AIM

Cirrhosis and other chronic liver diseases are complex disorders with a known burden. Currently health systems have different approaches to dealing with this issue. The objective of this study is to describe the burden attributed to and quality of care for cirrhosis and other chronic liver diseases.

METHODS

Data of cirrhosis and other chronic liver diseases extracted from Global-Burden-of-Diseases 2019. Four indicators, including mortality to incidence ratio, prevalence to incidence ratio, disability-adjusted-life-years (DALYs) to prevalence ratio, and years-of-life-lost (YLLs) to years-lived-with-disability (YLDs) ratio, were defined and combined by the principal-components-analysis to construct the Quality-of-Care-Index (QCI).

RESULTS

The global QCI of cirrhosis increased from 71.0 in 1990 to 79.3 in 2019. The QCI showed a favorable situation in higher SDI countries compared with lower SDI countries, with a QCI of 86.8 in high SDI countries and 60.1 in low SDI countries. The highest QCI was found in Western Pacific Region (90.2), and the lowest was for African Region (60.4). Highest QCI belonged to the 50-54 age group (99.5), and the lowest was for the 30.34 age group (70.9). Among underlying causes of cirrhosis, the highest QCI belonged to alcohol use, followed by hepatitis C and NAFLD with QCIs of 86.1, 85.3, and 81.1.

CONCLUSIONS

There was a considerable variation in the QCI of cirrhosis and other chronic liver diseases. Countries with low QCI, mainly located in developing regions, need organized action to control the burden of cirrhosis and its underlying causes and improve their quality of care.

Liver cirrhosis in Japan: Future global trends in the era of progressive antiviral therapy

In Japan, viral hepatitis is the main cause of chronic liver diseases, including liver cirrhosis. Due to the availability of highly effective antiviral drugs in combination with antihepatitis measures, Japan has become one of the most successful countries in the world with regard to hepatitis virus elimination. In Japan, there are many elderly patients who have been infected with hepatitis C virus for a long time, and antihepatitis measures have been in place since the 2000s. Thus, the medical situation in Japan is expected to reflect the future situation in other countries where hepatitis countermeasures have been recently initiated and the infected population is aging. Our nationwide survey clarified the changes in the etiologies of liver cirrhosis in Japan. Although viral hepatitis remains a major cause of liver cirrhosis in Japan, nonviral cirrhosis is suggested to increasingly contribute to the etiologies of liver cirrhosis, as opposed to viral hepatitis‐related liver cirrhosis. The changing etiology of liver cirrhosis in Japan may help to predict future global trends in chronic liver diseases.

Education and Awareness Activities Regarding Hepatitis B and C Among Japanese Dental Health Workers in the Oita Prefecture

Objectives: Hepatitis B virus (HBV) and Hepatitis C virus (HCV) infections are known to pose a major threat for dental health workers (DHWs). Previously, we reported that the HBV and HCV infection rates among DHWs in the Oita Prefecture in Japan were higher than those among the general population. The aim of this study was to disseminate knowledge about hepatitis and its prevention among the DHWs.

Materials and Methods: Educational booklets were mailed to 2,197 DHWs working in 487 dental clinics. After anonymously responding to online questions about their experience with HBV and HCV testing, Hepatitis B vaccination, and percutaneous injury, the subjects were required to respond to additional questions about their understanding of hepatitis.

Results: A total of 521 DHWs (205 males and 316 females) responded to the questionnaires. Among them, 61.6% had experienced percutaneous injuries, but only 19.4% were fully aware of how to deal with them before reading the booklet, and also 10.6% had sufficient knowledge about hepatitis. The past Hepatitis B vaccination, past HBV testing rate, and past HCV testing rate were 62.4%, 71.8%, and 43.2%, respectively. The DHWs who are not dentists (n = 293) had significantly lower rates of past testing for their own hepatitis virus, knowledge about treatment of percutaneous injuries, and awareness of hepatitis as compared to dentists (n = 228). After reading the booklet, 99.5% of subjects found the booklet useful and 87.3% said it would influence their future hepatitis testing.

Conclusion: The educational booklet was effective way to increase DHWs' knowledge about Hepatitis B and C and how to manage percutaneous injuries.

Burden of chronic hepatitis B and C infections in 2015 and future trends in Japan: A simulation study

Background

Determining the number of chronic hepatitis B (HBV) and C virus (HCV) infections is essential to assess the progress towards the World Health Organization 2030 viral hepatitis elimination goals. Using data from the Japanese National Database (NDB), we calculated the number of chronic HBV and HCV infections in 2015 and predicted the trend until 2035.

Methods

NDB and first-time blood donors data were used to calculate the number of chronic HBV and HCV infections in 2015. A Markov simulation was applied to predict chronic infections until 2035 using transition probabilities calculated from NDB data.

Findings

The total number of chronic HBV and HCV infections in 2015 in Japan was 1,905,187–2,490,873 (HCV:877,841–1,302,179, HBV:1,027,346–1,188,694), of which 923,661–1,509,347 were undiagnosed or diagnosed but not linked to care (“not engaged in care”), and 981,526 were engaged in care. Chronic HBV and HCV infections are expected to be 923,313–1,304,598 in 2030, and 739,118–1,045,884 in 2035. Compared to 2015, by 2035, the number of persons with HCV not engaged in care will decline by 59·8 – 76·1% and 86·5% for patients in care. For HBV, a 47·3 – 49·3% decrease is expected for persons not engaged in care and a decline of 26·0% for patients engaged in care.

Interpretation

Although the burden of HBV and HCV is expected to decrease by 2035, challenges in controlling hepatitis remain. Improved and innovative screening strategies with linkage to care for HCV cases, and a functional cure for HBV are needed.

Funding

Japan Ministry of Health, Labour and Welfare.

Development of an intervention system for linkage-to-care and follow-up for hepatitis B and C virus carriers

BACKGROUND

Poor connections in the cascade of viral hepatitis care have been discussed around the world. In 2011 in Japan, 500,000 to 1.25 million hepatitis B and C virus carriers needed to consult with hepatologists, so linkage-to-care (LTC) needs to be promoted. Therefore, in this study, to improve LTC and care-seeking behaviors, we attempted to establish a community-based intervention system and evaluate its effectiveness by analyzing behavior modifications.

METHODS

In a model city, Okazaki (population: 387,887 as of 2019), LTC was encouraged among HBV and HCV carriers by annually mailed brochures, and their care-seeking behaviors were followed up through questionnaires for 8 years (2012-2019). Their behavior modifications and demographic characteristics were analyzed anonymously in cooperation with community health workers, hepatologists, and researchers.

RESULTS

Through regional HBsAg and anti-HCV screening, 333 HBV and 208 HCV carriers were identified. Before the intervention, only 34.7% (25/72) of HBV- and 34.3% (24/70) of HCV-positive individuals had consulted with hepatologists. However, in 2019, after the intervention, these proportions increased to 79.8% (91/114) and 91.2% (52/57), respectively. Access to outpatient care and treatment uptake also continuously improved. However, individuals over 70 years of age were significantly less likely to engage in care-seeking behaviors (p < 0.05), and significantly fewer HCV-positive females received treatment (p = 0.03).

CONCLUSIONS

A paper-based reiterative intervention encouraging LTC and follow-up successfully improved the care-seeking behaviors of hepatitis virus-positive individuals and enabled their behavior modifications to be monitored. Further trials are required to advance the system by age- and gender-specific interventions.

International comparison of trends in cancer mortality: Japan has fallen behind in screening-related cancers

While the age-standardized mortality rate in Japan is decreasing for all cancers as a whole, this is not the case for some major site-specific cancers. We descriptively compared trends in all-cancer and site-specific cancer mortality in Japan and selected countries. Data on age-standardized cancer mortality rates in six countries (Japan, the USA, the UK, Canada, Australia and the Republic of Korea) in 1980-2016 were obtained from the World Health Organization mortality database. While stomach and liver cancer mortality rates in Japan and Korea were initially much higher than those in non-Asian countries, they have rapidly decreased over the long term. By contrast, colorectal, pancreatic and cervical cancer mortality rates in Japan, which were initially lower than those in other countries, have increased such that they are now similar or higher than the rates in non-Asian countries. For male lung cancer, Japan's initially lower mortality rate is now comparable to that in non-Asian countries as a result of slower decline. Meanwhile, the mortality rate of female breast cancer in Japan and Korea has increased and is nearing the rates observed in non-Asian countries, which by contrast have shown a steady decrease. Thus, while Japan has been successful in reducing the burden of stomach and liver cancers, it is falling behind in reducing the mortality rate of screening-related cancers such as colorectal, female breast and cervical cancers. Control measures for these cancers need to be strengthened.

Use of information and communication technology in the support of viral hepatitis patients in Japan

In Ishikawa Prefecture, Japan, the regional core center for hepatitis care coordination (Kanazawa University Hospital, the only regional core center in the prefecture) conducts follow-ups with people who tested positive for viral hepatitis at screenings organized primarily by municipal governments. This program, called the Ishikawa Hepatitis Follow-up Program, has been operating since 2010. The regional core center has conventionally verified the status of program participants using a paper-based system of "examination letters" which specialized institutes mail to the regional core center when a program participant visits a physician there. However, only a low 40% to 50% of examination letters were returned to the regional core center. The program is now using the information and communication technology tool ID-Link to help the regional core center participate in care and provide support through mutual sharing of clinical information with specialized institutes. Currently, 1,632 of the 3,202 people who had tested positive for hepatitis testing since 2002 have consented to participate in the Ishikawa Hepatitis Follow-up Program, and as of the end of March 2021, information about 132 among those 1,632 people is being shared between specialized institutes and the regional core center using ID-link. Sharing of clinical information between the regional core center and specialized institutes enabled by ID-Link provided a more accurate picture of how many people who tested positive for viral hepatitis had visited a specialized institute compared with the previous paper-based system of examination letters, making follow-up more efficient.

Seamless support from screening to anti-HCV treatment and HCC/ decompensated cirrhosis: Subsidy programs for HCV elimination

Viral hepatitis poses a major public health problem in Japan. Chronic viral hepatitis is a progressive liver disease that eventually develops into liver cirrhosis and liver cancer. Since nucleic acid analog therapy for hepatitis B and interferon-free therapy for hepatitis C have made it possible to control the disease status or eliminate the viruses, it is very important that more people receive hepatitis virus tests to confirm the presence of infection at an early stage, and that patients with hepatitis detected by the tests receive appropriate medical care. Currently, the government of Japan is implementing comprehensive measures for hepatitis control based on five key strategies. Moreover, the goal listed in the Basic Guidelines on Hepatitis Measures is to reduce the frequency of progression of hepatitis to cirrhosis or liver cancer through a scheme consisting of testing people for hepatitis, getting those who test positive to visit a medical institution and receive treatment, and providing appropriate and high-quality hepatitis care through specialized medical institutions and regional core centers for the management of liver disease. To achieve the goal, various subsidy programs including an expense subsidy system for hepatitis treatment have been implemented in Japan. It is important for healthcare professionals to have sufficient knowledge of public support for efficient hepatitis C virus (HCV)-related liver disease detection and care.

Epidemiology of viral hepatitis C: Road to elimination in Japan

Although HCV infection was the main cause of HCC in Japan contributing 70% over two decades after its first cloning in 1989, it was markedly decreased to 49% in 2013 and expected to decrease continuously. Based on blood donor national database, the new incident cases were 0.4/100,000 person-years, the prevalence was 0.13% and the total number was 890,902-1,302,179 in 2015. Establishment of blood donor screening with anti-HCV measurement and nucleic acid test introduced by Japanese Red Cross as pioneer, high-level medical and surgical care, and the government's policy under the Basic Act on Hepatitis Control have changed its epidemiology and outbreak trend and also enforced the disruption of potential transmission cascades. HCV prevalence among the younger generation was extremely low in all regions, and the predominant age for HCC has shifted to over 60 years old population. Considering such changes, HCV induced HCC occurrence is supposed to be ultimately suppressed in the near future. However, taking into account society changes, regulating intravenous drugs users and monitoring high-risk groups such as tattoos, and men who have sex with men are indeed required in Japan. Understanding the epidemiological changes in HCV is important in assigning, modifying, and designating effective response systems. Selective or national action plans, strategic approaches, and cooperation between government sectors have a positive impact on HCV prevention and control. A dramatic decrease in total number of HCV carriers, increase in number of people treated with highly effective DAA, and subsequent high SVR indicates Japan might achieve WHO's target of HCV elimination by 2030.

Messages from Japan policy for viral hepatitis

In Japan, the estimated number of chronic HBV infections was 1.1-1.2 million and that of chronic HCV was 0.9-1.3 million in 2015. The mortality of hepatocellular carcinoma (HCC) had been increasing and hit a peak at around 2002, which subsequently started to decrease. Japan has a national action plan for addressing viral hepatitis called, "Basic Act on Hepatitis Measures", established in 2009. "Basic Guidelines for Promotion of Control Measures for Hepatitis" was issued in 2011 and was updated in 2016, comprising 9 principles in order to promote measures to prevent hepatitis B and C. According to these guidelines, national and local government share screening costs for testing HBV and HCV for those residents who are over 40 years old. Thus, out-of-pocket expenses from examinees are free of charge or reduced to a minimum. In addition, for patients with chronic hepatitis B or C being treated: drug prices of nucleotide analogues, interferon treatment or direct antiviral agents, and examination expenses should be covered by a special program for viral hepatitis. From December 2018, the special coverage program of medical expenses, shared by central and local government, has started for patients with HBV- or HCV-induced liver cancer and decompensated cirrhosis. However, in the cascade-of-care of viral hepatitis in Japan, significant gaps still remain in the diagnosis, treatment and transition to patients in need. Several advantages have prevailed in Japanese health care systems for patients with viral liver disease compared to those in other countries in the Western Pacific Region. Therefore, Japan should take a lead in helping the implementation of a practical hepatitis action plan for each country in need.

Testing, diagnosis of viral hepatitis, and the follow-up policy in Japan

Viral hepatitis is one of the major infectious diseases in Japan and causes liver cirrhosis and liver cancer. Therefore, screening for hepatitis viruses was started in 2002, based on the geriatric health care program. The screening plan has now been transferred to the Health Promotion Project and it is estimated that more than half of the population has been tested for hepatitis viruses. The Basic Act on Hepatitis Measures was enacted in 2009 and the Basic Guidelines for Promotion of Control Measures for hepatitis was issued in 2011. It reported that there were about 770,000 positive people who were unaware that they were infected, and about 0.5 to 1.2 million positive people who knew they were infected but did not continue to receive medical examinations. Ten years have passed since that report and it is estimated that the number of hepatitis virus-positive individuals who need medical examination/treatment is decreasing. Therefore, in order to eradicate viral hepatitis, it is essential to identify areas and age groups in which hepatitis virus testing is inadequate, to encourage people to undergo testing and to promptly send positive patients to hepatologists for continued medical care. This review describes the current status and challenges of hepatitis virus testing measures in Japan, led by the Ministry of Health, Labour and Welfare, and the promotion of visits to medical institutions by positive patients.

Nationwide awareness-raising program for viral hepatitis in Japan: the "Shitte kan-en" project

Chronic viral hepatitis is one of the most widespread infectious diseases in Japan. In the 2009 financial year, the Japanese government enacted the Basic Act on Hepatitis Measures, followed by the Basic Guidelines for Promotion of Control Measures for Hepatitis 2 years later. The guidelines emphasize the importance of provision and dissemination of accurate information on viral hepatitis and public awareness-raising. A subsidy program on hepatitis was therefore launched by the Ministry of Health, Labour and Welfare in 2011, called "Shitte kan-en" (in English, "Let's learn about hepatitis"), and involves popular Japanese actors and singers. The project started awareness-raising activities in the 2013 financial year, as the "National Campaign Project for Hepatitis Measures". It aims to communicate concise and accurate information about hepatitis and the necessity of testing for viral hepatitis. It also encourages citizens to take a positive approach to early detection and treatment. To date, the main initiatives of the project are as follows: i) celebrity visits to prefectural governors to draw attention to the condition, ii) educational events in cooperation with hepatologists in regional core hospitals, iii) support for partner companies' hepatitis awareness activities in workplaces, and iv) support for the activities of program promoters. Targeting approaches to particular groups is likely to be key to success for general awareness-raising. Evaluation of the effectiveness of this multifaceted approach is warranted to reduce the undiagnosed population and improve the link between testing and care for viral hepatitis in Japan.

Hepatitis medical care coordinators: Comprehensive and seamless support for patients with hepatitis

Chronic liver disease, especially viral hepatitis, is an urgent issue in Japan. Human resource management is important to promote appropriate care for patients with chronic liver disease in medical institutions and in the community. In 2011 the Ministry of Health, Labour and Welfare in Japan started training hepatitis medical care coordinators (HMCCs). Various medical professionals (such as public health nurses, general nurses, and clinical technicians), patients, and ordinary citizens are certified as HMCCs by the prefectural government after learning about liver diseases in a training program. The training program can be optimized in accordance with the regional circumstances and basic knowledge and skills of the applicants. HMCCs encourage residents and patients to undergo a hepatitis screening test, after which positive patients undergo detailed examination, treatment, and follow-up. HMCCs contribute to the expansion of knowledge about hepatitis in their workplace and community. By 2018, there were HMCCs in all 47 prefectures of Japan. There were 20,049 HMCCs in 2019. The most common professions of HMCCs were public health nurses, followed by general nurses, hospital pharmacists, laboratory technicians, and medical social workers. After certification, the activities of HMCCs vary; to ensure that HMCCs are adequately used in medical institutions, the supervisor and physicians must recognize the importance of HMCCs and generate opportunities for HMCC activity. The training and effective utilization of HMCCs is a promising way to decrease the prevalence and mortality of chronic liver diseases in Japan.

Follow-up after Direct-acting Antiviral Treatment for Chronic Hepatitis C Virus Infection: Most Patients Are Followed Appropriately

Objective Chronic hepatitis C virus (HCV) infection carries a residual risk of hepatocarcinogenesis even after viral elimination, so appropriate follow-up is necessary. The present study investigated the current hospital visits and hepatocarcinogenesis status of patients who received daclatasvir plus asunaprevir treatment (DCV+ASV) to determine whether or not appropriate follow-up was being performed. Methods We retrospectively analyzed hepatocarcinogenesis, the overall survival, and the length of hospital visits in 442 patients who applied for the medical expense subsidy system for viral hepatitis and received DCV+ASV treatment in Gunma Prefecture between October 2014 and December 2015. This also included 61 patients who had a history of hepatocellular carcinoma (HCC). Results Among 442 patients, 388 achieved a sustained viral response (SVR) by DCV+ASV therapy (87.8%), and 95.9% achieved an SVR if additional treatment was included. HCC was found in 75 cases (17.0%). A history of HCC, the FIB-4 index and the treatment effect SVR were determined to be factors affecting the incidence of HCC. Regarding the follow-up rate, 89.9% of patients continued to regularly visit the hospital after 5 years of treatment. However, patients ≤60 years old had significantly lower persistence rates than older patients. The persistence rate of hospital visits to the same institution was 67.7% over a 5-year period, which was significantly better in small and medium-sized institutions than in large, specialized institutions (71.7% vs. 63.9%, p=0.039). Conclusion Patients with direct-acting antiviral treatment generally received adequate follow-up, but younger patients had a slightly higher rate of follow-up interruption and were considered to need support.

Trends in hepatitis C virus-associated mortality rates in Japan, 1998-2017

BACKGROUND AND AIM

The current prevalence of hepatitis C virus infection and hepatitis C virus-associated mortality in Japan falls short of the World Health Organization goal of viral hepatitis elimination by 2030. We aimed to evaluate the trends in hepatitis C virus-associated mortality in Japan.

METHODS

This nationwide observational study used the Japanese Vital Statistics from 1998 to 2017 and included all Japanese hepatitis C virus-associated deaths (84 936) of adults aged ≥ 40 years. We calculated the crude and age-standardized mortality rates per 100 000 persons by age and sex. Joinpoint regression analysis was used to identify significant changing points in trends and to estimate the annual percentage changes and the average annual percentage changes for the entire study period.

RESULTS

The crude mortality rate per 100 000 persons (annual death number) increased from 5.5 (3548) in 1998 to 7.0 (4843) in 2005 and decreased to 4.0 (3095) in 2017. By 2017, the crude mortality rates per 100 000 persons among men and women had dropped to 3.6 and 4.3, respectively. The age-standardized mortality rate was higher in women than in men. The average annual percentage change was -3.8% (95% confidence interval: -5.0 to -2.5). The declining trend was more rapid in men (-4.5%, 95% confidence interval: -5.3 to -3.6) than in women (-2.7%, 95% confidence interval: -3.8 to -1.6).

CONCLUSIONS

Trends in hepatitis C virus-associated mortality rates have declined in an accelerating manner in Japan, especially among men.

The estimated burden of 15 vaccine-preventable diseases from 2008 to 2020 in Japan: A transition by the COVID-19 pandemic

BACKGROUND

Evaluating the national burdens across multiple vaccine-preventable diseases (VPDs) can be informative to identify the areas for improvements in the national immunization program.

METHODS

The annual burden of diseases from 2008 to 2020 in Japan were calculated with the incidence- and pathogen-based approach for the 15 VPDs (hepatitis B virus infection, human papillomavirus (HPV), influenza, invasive pneumococcal disease, invasive Haemophilus influenzae type b (Hib) disease, invasive meningococcal disease, Japanese encephalitis, measles, mumps, pertussis, rotavirus, rubella, tetanus, tuberculosis and varicella), using disability-adjusted life year (DALY).

RESULTS

The average annual burden between 2008 and 2020 is the highest in influenza (114,129 DALY/year), followed by HPV infection, hepatitis B virus infection, tuberculosis and mumps (109,782, 69,883, 23,855 and 5693 DALY/year). In the pre-COVID-19 period (2008-2019), the decreasing trend of burden was observed in hepatitis B virus infection, invasive pneumococcal disease, invasive Hib disease, tuberculosis and varicella. HPV infection is the only VPD which had more than 100,000 DALY/year for all years during the study period. In 2020, the estimated annual burdens are decreased in influenza (71%), invasive pneumococcal disease (51%), invasive Hib diseases (54%), invasive meningococcal disease (64%), measles (98%), mumps (47%) pertussis (83%), rotavirus infection (95%), rubella (94%) and varicella (35%) compared with those in 2019.

CONCLUSIONS

The study demonstrated decreasing trends of burdens for some VPDs, while a persistently high burden has been observed for other VPDs, including HPV infection. The COVID-19 pandemic has caused dramatic reductions in the burdens of many VPDs in 2020.

Cost-effectiveness of a "treat-all" strategy using Direct-Acting Antivirals (DAAs) for Japanese patients with chronic hepatitis C genotype 1 at different fibrosis stages

Aim

To evaluate the cost-effectiveness of therapeutic strategies initiated at different stages of liver fibrosis using three direct-acting antivirals (DAAs), sofosbuvir-ledipasvir (SL), glecaprevir-pibrentasvir (GP), and elbasvir plus grazoprevir (E/G), for Japanese patients with chronic hepatitis C (CHC) genotype 1.

Methods

We created an analytical decision model reflecting the progression of liver fibrosis stages to evaluate the cost-effectiveness of alternative therapeutic strategies applied at different fibrosis stages. We compared six treatment strategies: treating all patients regardless of fibrosis stage (TA), treating individual patients with one of four treatments starting at four respective stages of liver fibrosis progression (F1S: withholding treatment at stage F0 and starting treatment from stage F1 or higher, and three successive options, F2S, F3S, and F4S), and administering no antiviral treatment (NoRx). We adopted a lifetime horizon and Japanese health insurance payers’ perspective.

Results

The base case analysis showed that the incremental quality-adjusted life years (QALY) gain of TA by SL, GP, and E/G compared with the strategies of starting treatments for patients with the advanced fibrosis stage, F2S, varied from 0.32 to 0.33, and the incremental cost-effectiveness ratios (ICERs) were US$24,320, US$18,160 and US$17,410 per QALY, respectively. On the cost-effectiveness acceptability curve, TA was most likely to be cost-effective, with the three DAAs at the willingness to pay thresholds of US$50,000.

Conclusions

Our results suggested that administration of DAA treatment for all Japanese patients with genotype 1 CHC regardless of their liver fibrosis stage would be cost-effective under ordinary conditions.

Increasing hepatitis virus screening uptake at worksites in Japan using nudge theory and full subsidies

BACKGROUND

Despite the importance of hepatitis screening for decreasing liver cancer mortality, screening rates remain low in Japan. Previous studies show that full subsidies increase screening uptake, but full subsidies are costly and difficult to implement in low-resource settings. Alternatively, applying nudge theory to the message design could increase screening at lower costs. This study examined the effects of both methods in increasing hepatitis virus screening rates at worksites.

METHODS

1496 employees from a Japanese transportation company received client reminders for an optional hepatitis virus screening before their general health checkups. Groups A and B received a client reminder designed based on the principles of "Easy" and "Attractive," while the control group received a client reminder not developed using nudge theory. Additionally, hepatitis virus screening was offered to the control group and group A for a co-payment of JPY 612, but was fully subsidized for group B. The hepatitis virus screening rates among the groups were compared using a Chi-square test with Bonferroni correction, and the risk ratios of group A and group B to the control group were also calculated. To adjust for unobservable heterogeneity per cluster, the regression analysis was performed using generalized linear mixed models.

RESULTS

The screening rate was 21.2%, 37.1%, and 86.3% for the control group, group A, and group B, respectively. And the risk ratio for group A was 1.75 (95% confidence interval [CI] 1.45-2.12) and that of group B was 4.08 (95% CI 3.44-4.83). The parameters of group A and group B also were significant when estimated using generalized linear mixed models. However, the cost-effectiveness (incremental cost-effectiveness ratio (ICER)) of the nudge-based reminder with the full subsidies was lower than that of only the nudge-based reminder.

CONCLUSIONS

While fully subsidized screening led to the highest hepatitis screening rates, modifying client reminders using nudge theory significantly increased hepatitis screening uptake at lower costs per person.

Establishing Efficient Systems through Electronic Medical Records to Promote Intra-hospital Referrals of Hepatitis Virus Carriers to Hepatology Specialists: A Multicenter Questionnaire-based Survey of 1,281 Healthcare Professionals

Objective Persistent hepatitis B virus (HBV) and hepatitis C virus (HCV) infections are major causative factors of hepatic cirrhosis and hepatocellular carcinoma. However, the development of antiviral treatment has enabled their suppression. Therefore, the early detection and treatment of these infections are important. The objective of this study was to assess the level of awareness among healthcare professionals about hepatitis virus infection and electronic medical records alert system. Methods We surveyed healthcare professionals from 10 institutions with electronic medical records alert systems. All participants attended a lecture about the reactivation risk due to HBV infections, the most recent antiviral treatment for HCV infections, and the electronic medical records alert system. They participated in a questionnaire-based survey about their awareness of these infections, current status of intra-hospital referral, need for intra-hospital referrals before and after the lecture, and reasons for non-referral of patients to specialists. Results Responses were received from 1,281 healthcare professionals. Physicians and pharmacists had a high level of awareness about HBV and HCV. Among physicians, the level of awareness of those in the surgical field and other fields was significantly lower than that of the professionals in the internal medicine field. The awareness of the need to refer patients to hepatologists increased from 84.7-85.4% before to 93.0% after the lecture. The most frequent reasons for not referring patients previously were "I had no knowledge and/or interest" (28.1% of responses) and "All I did was explain the results orally" (24.2%). Conclusion More widespread education of healthcare personnel is important to increase the number of individuals receiving appropriate treatment from specialist physicians.

The transition in the etiologies of hepatocellular carcinoma-complicated liver cirrhosis in a nationwide survey of Japan

BACKGROUND

We recently reported the real-world changes in the etiologies of liver cirrhosis (LC) based on nationwide survey data and assessed the etiologies of LC with hepatocellular carcinoma (HCC).

METHODS

Fifty-five participants from 68 institutions provided data on 23,637 patients with HCC-complicated LC. The changing trends in etiologies were assessed. We further analyzed the data from 29 hospitals that provided the annual number of newly identified HCC-complicated LC patients from 2008 to 2016 (N = 9362) without any missing years and assessed the transition in the real number of newly identified HCC-complicated LC cases.

RESULTS

In the overall cohort, hepatitis C virus (HCV) infection (60.3%) and hepatitis B virus (HBV) infection (12.9%) were the leading and third-most common causes of HCC-complicated LC in Japan, respectively. HCV infection was found to be the leading cause throughout Japan. The rate of viral hepatitis-related HCC decreased from 85.3 to 64.4%. Among non-viral etiologies, notable increases were observed in nonalcoholic steatohepatitis (NASH)-related HCC (from 1.5 to 7.2%) and alcoholic liver disease (ALD)-related HCC (from 8.5 to 18.6%). Regarding the real number of newly diagnosed patients, the number of patients with viral hepatitis-related HCC decreased, while the number of patients with non-viral HCC, particularly NASH-related HCC, increased.

CONCLUSIONS

Viral hepatitis has remained the main cause of HCC in Japan. However, the decrease in viral hepatitis-related HCC, particularly HCV-related HCC highly contributed to the etiological changes. In addition, the increased incidence of non-viral HCC, particularly NASH-related HCC, was involved in the changing etiologies of HCC-complicated LC in Japan.

High dropout rate from aftercare program of antihepatitis C therapy for patients with history of injection drug use

BACKGROUND AND AIM

We assessed direct-acting antiviral (DAA) treatment for patients with hepatitis C virus (HCV) and a history of injection drug use (IDU) in Japan.

METHOD

This retrospective observational study was based on clinical records. Overall, 804 DAA-naïve HCV-infected patients were enrolled, treated with a 12-week regimen of DAAs, and had available information about a history of IDU. Anti-HCV efficacy was defined as a sustained viral response 12 weeks post-treatment (SVR12) only in patients who were assessed after 12 weeks [modified intention-to-treat (ITT) analyses]. We compared the antiviral effect between patients with (past-IDU) and without a history of IDU (non-IDU). We also evaluated the characteristics of each group, including the overall dropout rate and economic background.

RESULTS

Overall, 78 (9.7%) patients had a history of IDU. Compared to the non-IDU group at baseline, the past-IDU group consisted of predominantly male and younger patients infected with HCV genotype 2. Overall, 3% (3/78) and 16% (116/726) of the patients had cirrhosis in the past-IDU and non-IDU group, respectively. There was a significantly higher rate of welfare recipients in the past-IDU group. SVR rate was 97% (59/61) in the past-IDU group and 99% (689/699) in the non-IDU group. The cumulative rate of dropout from an aftercare program was high in the past-IDU group (P < 0.01).

CONCLUSIONS

DAAs had a remarkable anti-HCV effect in patients with past-IDU who continued in an aftercare program. It is necessary to understand the characteristics of past-IDU patients to establish a support system for aftercare programs.

A nationwide cross-sectional survey on hepatitis B and C screening among workers in Japan

In Japan, there is no publicly funded screening for hepatitis B virus (HBV) and hepatitis C virus (HCV) infections (using HBs antigen and HCV antibody, respectively) among workers, and workplace health programmes play a crucial role in reducing viral hepatitis-related deaths. The national number of hepatitis screening tests conducted in the workplace is unknown. To provide baseline data for policy formulation, we conducted a nationwide survey to estimate these parameters using data from approximately 10.5 million workers (6.8 million men and 3.8 million women) who underwent mandatory health examinations in their workplaces between April 2016 and March 2017. Among these workers, 494,303 (5.23%, 95% confidence interval [CI] 5.22%-5.24%) and 313, 193 (3.82%, 95% CI 3.81%-3.84%) were screened for HBV and HCV, respectively. Among those who were screened, 0.28% (95% CI 0.27-0.30%) and 0.35% (95% CI 0.33-0.37%) tested positive for HBs antigen and HCV antibody, respectively. According to the age-specific prevalence from the survey an estimated 0.30 and 0.14 million workers in Japan require treatment for HBV and HCV, respectively. To reduce viral hepatitis-related deaths by efficiently identifying workers who need treatment and promoting access to treatment, one-time hepatitis screening of all workers should be considered.

Estimating the cost-effectiveness of screening for hepatitis C virus infection in Japan

AIM

The management of hepatitis C virus (HCV) has changed with the advent of interferon (IFN)-free treatment and the declining prevalence of HCV infection, which may impact the cost-effectiveness of the screening. We aimed to compare the cost-effectiveness and clinical outcomes of three screening strategies in the Japanese general population: no screening, screening plus IFN-based therapy, and screening plus IFN-free therapy.

METHODS

We developed a decision analytic Markov model for screening intervention and natural history of HCV. Model parameters were derived from published literature. A lifetime horizon and the healthcare payer perspective were taken. Subanalyses included high screening scenario with improved rates of screening and attending referral, in addition to heterogeneity analysis by age subgroup.

RESULTS

In the base case, the incremental cost-effectiveness ratio in the Japanese general population aged 40-89 years was ¥1 124 482 and ¥1 085 183 per quality-adjusted life year gained for screening plus IFN-free therapy compared with no screening and screening plus IFN-based therapy, respectively. Screening plus IFN-free therapy remained cost-effective below ¥5 000 000 per quality-adjusted life year gained in sensitivity analyses. Incremental cost-effectiveness ratios were lower in the younger population. Nearly 0.2% of HCV-related deaths were avoided by 1.5% of the general population screened followed by IFN-free therapy relative to no screening; the impact was greater with improved rates of screening and attending referral.

CONCLUSIONS

Screening and subsequent IFN-free therapy for HCV appears to be cost-effective. Early diagnosis and treatment would produce a favorable incremental cost-effectiveness ratio. Improved rates of screening and attending referral would result in further reduction of disease progression.

Transition in the etiology of liver cirrhosis in Japan: a nationwide survey

BACKGROUND

To assess the recent real-world changes in the etiologies of liver cirrhosis (LC) in Japan, we conducted a nationwide survey in the annual meeting of the Japan Society of Hepatology (JSH).

METHODS

We investigated the etiologies of LC patients accumulated from 68 participants in 79 institutions (N = 48,621). We next assessed changing trends in the etiologies of LC by analyzing cases in which the year of diagnosis was available (N = 45,834). We further evaluated the transition in the real number of newly identified LC patients by assessing data from 36 hospitals with complete datasets for 2008-2016 (N = 18,358).

RESULTS

In the overall data, HCV infection (48.2%) was the leading cause of LC in Japan, and HBV infection (11.5%) was the third-most common cause. Regarding the transition in the etiologies of LC, the contribution of viral hepatitis-related LC dropped from 73.4 to 49.7%. Among the non-viral etiologies, alcoholic-related disease (ALD) and nonalcoholic steatohepatitis (NASH)-related LC showed a notable increase (from 13.7 to 24.9% and from 2.0 to 9.1%, respectively). Regarding the real numbers of newly diagnosed patients from 2008 to 2016, the numbers of patients with viral hepatitis-related LC decreased, while the numbers of patients with non-viral LC increased.

CONCLUSIONS

HCV has remained the main cause of LC in Japan; however, the contribution of viral hepatitis as an etiology of LC is suggested to have been decreasing. In addition, non-viral LC, such as ALD-related LC and NASH-related LC, is suggested to have increased as etiologies of LC in Japan.

Nationwide survey on activities of regional core centers for the management of liver disease in Japan: Cumulative analyses by the Hepatitis Information Center 2009-2017

AIM

Regional core centers for the management of liver disease, which are located in every prefecture in Japan, not only take the lead in hepatitis care in their respective regions, but also serve a wide range of other functions, such as education, promotion of hepatitis testing, treatment, and research.

METHOD

Since fiscal year 2010, the Hepatitis Information Center has conducted surveys of regional core centers throughout Japan regarding information about their facilities, programs for patient support, training, and education of medical personnel.

RESULTS

By compiling and analyzing the results of these surveys, we have elucidated the status of regional core centers and the issues they currently have. We found that regional core centers have come to play widely varied roles in hepatitis treatment and have expanded their programs. These surveys also suggest that uniform accessibility of hepatitis treatment has been implemented throughout Japan.

CONCLUSION

To continue serving their diverse roles, regional core centers require further development of hepatitis care networks that include specialized institutions, primary care physicians, and local and central governments; as well as collaboration with other professions and groups.

Liver diseases in the Asia-Pacific region: a Lancet Gastroenterology & Hepatology Commission

The Asia-Pacific region is home to more than half of the global population and accounted for 62·6% of global deaths due to liver diseases in 2015. 54·3% of global deaths due to cirrhosis, 72·7% of global deaths due to hepatocellular carcinoma, and more than two-thirds of the global burden of acute viral hepatitis occurred in this region in 2015. Chronic hepatitis B virus (HBV) infection caused more than half of the deaths due to cirrhosis in the region, followed by alcohol consumption (20·8%), non-alcoholic fatty liver disease (NAFLD; 12·1%), and chronic infection with hepatitis C virus (HCV; 15·7%). In 2015, HBV accounted for about half the cases of hepatocellular carcinoma in the region. Preventive strategies for viral hepatitis-related liver disease include increasing access to clean drinking water and sanitation. HBV vaccination programmes for neonates have been implemented by all countries, although birth-dose coverage is extremely suboptimal in some. Availability of screening tests for blood and tissue, donor recall policies, and harm reduction strategies are in their initial stages in most countries. Many governments have put HBV and HCV drugs on their essential medicines lists and the availability of generic versions of these drugs has reduced costs. Efforts to eliminate viral hepatitis as a public health threat, together with the rapid increase in per-capita alcohol consumption in countries and the epidemic of obesity, are expected to change the spectrum of liver diseases in the Asia-Pacific region in the near future. The increasing burden of alcohol-related liver diseases can be contained through government policies to limit consumption and promote less harmful patterns of alcohol use, which are in place in some countries but need to be enforced more strictly. Steps are needed to control obesity and NAFLD, including policies to promote healthy lifestyles and regulate the food industry. Inadequate infrastructure and insufficient health-care personnel trained in liver diseases are issues that also need to be addressed in the Asia-Pacific region. The policy response of most governments to liver diseases has thus far been inadequate and poorly funded. There must be a renewed focus on prevention, early detection, timely referral, and research into the best means to introduce and improve health interventions to reduce the burden of liver diseases in the Asia-Pacific region.

Generation Gap for Screening and Treatment of Hepatitis C Virus in Saga Prefecture, Japan: An Administrative Database Study of 35,625 Subjects

Objective Despite recent advances in hepatitis C virus (HCV) treatment, some HCV-positive individuals are unaware of their infection. The present study aimed to assess the rate and age distribution in Saga Prefecture regarding i) HCV infection and HCV screening and ii) direct acting anti-viral (DAA) treatment. Methods HCV screening data collected at a medical institution or in the workplace were obtained from the administrative database in Saga Prefecture between April 1, 2008 and March 31, 2014. DAA treatment data from Saga Prefecture were obtained from the DAA treatment reimbursement recipient database between October 2014 and March 2017. Results There were 35,625 individuals who underwent HCV screening, and the HCV positive rate was 1.18% (421 individuals), which increased in an age-related manner. The screening rate in the screened populations peaked at 45-74 years of age (approximately 6%) and decreased in the younger and older generations. The estimated percentage of DAA treatment peaked at 65-74 years old (65.8%) and significantly decreased inversely with age in the younger generations; only 9.4% of HCV carriers received DAA treatment in the 20- to 34-year age group. The proportion of subjects who received a complete physical examination for DAA treatment was higher in the subjects who were screened at a medical institution than in those screened at the workplace. Conclusion The rate of subjects who underwent HCV screening and DAA treatment was not high, especially in the younger generation, in Saga Prefecture. This group should be targeted for HCV screening and treatment.

Efficient and practical dissemination of information on viral hepatitis in Japan: an effort by the Hepatitis Information Center, National Center for Global Health and Medicine

One of the important missions of the Hepatitis Information Center is to disseminate information regarding liver disease. The Hepatitis Information Center, National Center for Global Health and Medicine (NCGM) has been endeavoring to ensure that reliable and up-to-date information on liver disease is accessible to all people, regardless of age, disability, and background. Described here are several initiatives with regard to the dissemination of information about liver disease including: i) Education tool for youth, ii) Conversion of materials on liver diseases into audio format for the visually impaired, and iii) Hepatic Disease Medical Navigation System (Hepatic Navi). Hepatic Navi is a web-based search tool that informs users of the location and other information concerning medical centers where people can be tested for the hepatitis virus for free or at reduced cost. Hepatic Navi consolidates data from 47 prefectures into one database. The system depicts data via an interface that can be accessed anywhere with a PC, tablet, smart phone, or mobile phone. As a result, it has become possible for anyone from anywhere to access information on hepatitis virus testing. By using Hepatic Navi, it is anticipated that general people in need feel free to access to the testing and further treatment for virus hepatitis.

Countermeasures against viral hepatitis B and C in Japan: An epidemiological point of view

Although the mortality rate due to hepatocellular carcinoma (HCC) has been gradually decreasing in Japan, approximately 30 000 people died of HCC in 2016. In 2007, the dominant etiology was persistent hepatitis C virus (HCV) infection, which accounted for 65% of total HCC deaths, and 15% of cases were due to chronic hepatitis B virus (HBV) infection. In managing chronic HBV and HCV infection, it is critically important to know the exact number of infected individuals in a particular country, which then assists in evaluating medical and financial needs in the foreseeable future. Therefore, from an epidemiological perspective, we estimated the numbers of HBV and HCV carriers in four categories: (i) undiagnosed carriers; (ii) carriers who were already hospitalized as patients or were receiving outpatient medical attention; (iii) diagnosed carriers who had not consulted any medical facility, or had discontinued consultation; and (iv) newly infected carriers. From these estimates we determined the current HBV and HCV burden and then reviewed the existing countermeasures for their prevention and control in Japan. While continuing the surveillance on the dynamics of hepatitis virus infections linked with preventive measures against hepatitis virus infection, it is crucially important to promote appropriate measures for each of the four groups of hepatitis virus carriers in society.

Meta-regression Analysis of Sex- and Birth Year-Specific Prevalence of HBsAg and Anti-HCV Among Un-diagnosed Japanese: Data From the First-time Blood Donors, Periodical Health Checkup, and the Comprehensive Health Checkup With Lifestyle Education (Ningen Dock)

Background

This study was aimed to precisely estimate the prevalence of hepatitis B surface antigen (HBsAg) and anti-hepatitis C virus antibody (anti-HCV) stratified by sex and birth year in Japan.

Methods

Three large-scaled cohorts: first-time blood donors, periodic health check-up, and comprehensive health check-up with lifestyle education (Ningen dock) were used for pooled prevalence of HBsAg and anti-HCV using meta-regression.

Results

Trends of birth year-specific prevalence of HBsAg and anti-HCV among the three cohorts were similar to one another, while birth year-specific pooled prevalence of HBsAg peaked in the 1941–1950 birth cohort. Prevalence of anti-HCV showed a decreasing trend by birth year.

Conclusion

We could estimate the pooled prevalence of HBsAg and anti-HCV based on nationwide data. The results can be used as reference data for various countermeasures for hepatitis eradication.

Categorization and Characterization of Activities Designed to Help Health-care Professionals Involved in Hepatitis Care Increase Their Awareness of the Disease: The Classification of Hepatitis Medical Care Coordinators

Objective This study aimed to investigate the current state of the activities performed by hepatitis medical care coordinators, categorize coordinators according to the activities they perform, and determine the backgrounds of these coordinators. Methods A self-administered questionnaire survey was completed by 414 coordinators. The surveyed items included gender, occupation, activity items performed, and barriers that inhibited the performance of these activities. A hierarchical cluster analysis was applied, and cases were classified based on the contents of the activities in question. Results The coordinators were classified into four groups (A-D). Group A, consisting primarily of public health nurses, was classified as "the type that conducted activities aimed at providing information and recommendations." Group B, which included registered dieticians and clerks, was classified as "the type that uses multidisciplinary collaboration to perform their tasks." Group C, which included clinical nurses, was classified as "the type that was more likely to perform activities as leaders in an organization." Group D, consisting primarily of pharmacists, was classified as "the type that promoted activities centered on providing instructions regarding medication dosage and administration." Conclusion Our study showed that coordinators' professional skills and abilities are reflected in the contents of the activities they conduct, and that, to adequately perform their roles, they must acquire skills in addition to those required in their original occupations. To implement high-quality hepatitis countermeasures, there is a need to foster an environment that facilitates cooperation between coordinators, as well as relationship-building.

Clinical and Economic Burden of Patients with Chronic Hepatitis C with Versus Without Antiviral Treatment in Japan: An Observational Cohort Study Using Hospital Claims Data

Introduction

Japan has one of the highest prevalence rate of chronic hepatitis C (CHC) in the industrialized world. However, the burden of CHC treatment is poorly understood. Thus, the healthcare resource utilization and costs of treated versus untreated patients, and patients with early versus delayed treatment initiation, were assessed in Japan.

Methods

Adult patients with ≥ 2 CHC diagnoses were identified from the Medical Data Vision hospital claims database (1 April 2008–31 May 2016). The presence or absence of antiviral treatment claims was used to form the treated and untreated cohorts, respectively. Among treated patients, the presence of a cirrhosis-related diagnosis was used as an indicator of delayed treatment. The index date was defined as the date of the first antiviral claim for treated patients and randomized to any date with a medical visit for untreated patients. Annualized total healthcare costs and costs associated with hepatic manifestations (HMs) or extrahepatic manifestations (EHMs) were evaluated from the index date to the last observed medical visit.

Results

Of 100,125 patients with CHC, 12,984 were treated (early: 8104, delayed: 4880) and 87,141 were untreated. After adjusting for covariates, untreated patients had ¥613,034 ($5456 USD; ¥1 = $0.0089) higher annual medical costs compared with treated patients (P < 0.001), a difference driven by higher inpatient costs. Between 65% (treated patients) and 70% (untreated patients) of medical costs were EHM-related and between 14% (untreated patients) and 15% (treated patients) were HM-related. Patients in the delayed treatment cohort had ¥114,347 ($1018) higher annual medical costs (P < 0.001) versus those in the early treatment cohort. About 95% of these costs were EHM-related, and 64% were HM-related.

Conclusion

Withholding or delaying antiviral treatment initiation for Japanese patients with CHC increases the clinical and economic burden associated with HMs and EHMs.

Funding

AbbVie.

Incidence rates of hepatitis C virus infection among blood donors in Japan: a nationwide retrospective cohort study

BACKGROUND

The classification of many new cases of hepatitis virus infection as overt hepatitis does not reflect the true incidence of infection because the disease takes an asymptomatic course in some cases. In this retrospective cohort study, we aimed to estimate the incidence rates of new hepatitis C virus (HCV) infections among the blood donors.

STUDY DESIGN AND METHOD

A 5-year retrospective cohort study was conducted to estimate the incidence rates by using the medical records of the blood donors between 2008 and 2013 for HCV infection. HCV seroconversions were investigated using a chemiluminescent enzyme immunoassay and then confirmed by nucleic acid amplification tests.

RESULTS

The incidence rate of HCV infection was 0.40 per 100,000 person-years (95% confidence interval, 0.27-0.57) for HCV RNA seroconversion only and 7.32 per 100,000 person-years (95% confidence interval, 6.73-7.95) if either HCV RNA or anti-HCV seroconversion were taken into consideration. No significant difference of new HCV infections was found between the sexes.

CONCLUSION

The incidence rate of HCV infection of this study was lower than that detected in a previous 1994-2004 study in which HCV incidence was 1.86 per 100,000 person-year, which reflects the presence of an effective blood screening system and health strategies targeting hepatitis control and prevention.

Treatment of hepatitis C virus leads to economic gains related to reduction in cases of hepatocellular carcinoma and decompensated cirrhosis in Japan

Hepatocellular carcinoma (HCC) is a serious complication of hepatitis C virus (HCV) infection. Sustained virologic response (SVR) for HCV is associated with a reduction in cirrhosis, HCC and mortality and their associated costs. Japanese HCV patients are older with higher prevalence of HCC. Here we used a decision-analytic Markov model to estimate the economic benefit of HCV cure by reducing HCC and DCC burden in Japan. A cohort of 10 000 HCV genotype 1b (GT1b) Japanese patients was modelled with a hybrid decision tree and Markov state-transition model capturing natural history of HCV over a lifetime horizon. Treatment options were approved all-oral direct-acting anti-virals (DAAs) vs no treatment. Treatment efficacy was based on clinical trials and transition rates and costs obtained from Japan-specific data. Cases of HCC, decompensated cirrhosis (DCC) and quality-adjusted life years (QALYs) were projected for patients treated with DAAs vs NT. QALYs were monetized using a willingness-to-pay threshold of ¥4-to-¥6 million. Incremental savings with treatment were calculated by adding the projected cost of complications avoided to the monetized gains in QALYs. The model showed that DAA treatment vs no treatment, reduces 2057 cases of HCC and 1478 cases of decompensated cirrhosis and saves ¥850 446.73 and ¥338 229.90 per patient (ppt). Additionally, treatment can lead to additional 2.64 QALYs gained per patient. The indirect economic gains associated with treatment-related QALY improvements were ¥10 576 000, ¥13 220 000 and ¥15 864 000 ppt (willingness-to-pay thresholds of ¥4 million, ¥5 million and ¥6 million). Total economic savings of treatment with DAAs (vs no treatment) was ¥7 526 372.63, ¥10 170 372.63 and ¥12 814 372.63, at these different willingness-to-pay thresholds. In conclusion treatment of HCV GT1b with all-oral DAAs in Japan can lead to significant direct and indirect savings related to avoidance of HCC and DCC.

Evaluation of pharmaceutical intervention in direct-acting antiviral agents for hepatitis C virus infected patients in an ambulatory setting: a retrospective analysis

Background

Direct-acting antivirals (DAAs) are known to improve tolerability and have higher efficacy and shorter treatment durations compared with conventional interferon (IFN)-based treatments for hepatitis C virus (HCV) infection. Management of drug interactions and maintenance of patient adherence are important to achieve adequate therapeutic effects, sustained virological response (SVR). In order to maximize the benefits of oral DAA therapy, we established an ambulatory care pharmacy practice, a model of integrated collaboration between physicians and pharmacists, for patients receiving IFN-free DAA therapy. In this study, we evaluated pharmaceutical intervention for patients visiting the ambulatory care pharmacy practice.

Methods

HCV-infected outpatients who visited our ambulatory care pharmacy practice between September 2014 and May 2017 were eligible for inclusion in the study. When IFN-free DAAs were first prescribed, the physicians recommended all patients to visit the ambulatory care pharmacy practice after their clinical examination. Subsequently, at the second visit or later, the patients visited the pharmacy service before the physician's examination. The primary endpoint was SVR, defined as HCV RNA below the lower limit of quantification after the completion of treatment. We also evaluated the adherence rate to DAAs, suggestions to the physicians by the pharmacists, and questions from the patients. All data were obtained retrospectively using an electronic medical record system.

Results

Among the 401 study subjects, 386 patients completed the IFN-free DAA therapy. A total of 365 patients have reached 12 or 24 weeks after completing the treatment. The overall SVR rate was 98.1% (358/365). The proportion of patients with adherence ≥90% was 99.3% (398/401). Two-hundred and sixty-seven (84%) among 318 suggestions of prescription made by the pharmacists mainly to manage the adverse events were accepted by the physicians. The pharmacists received and answered 1072 questions on DAA therapy from the patients.

Conclusions

This study indicates that the pharmaceutical intervention may contribute to enhanced adherence to DAAs and higher SVR rates in comparison with previous reports. This study also demonstrates that collaboration between physicians and pharmacists in an ambulatory setting provides favorable outcomes for patients receiving IFN-free DAAs.

Trends in the total numbers of HBV and HCV carriers in Japan from 2000 to 2011

We estimated the total number of undiagnosed HBV and HCV carriers and patients with hepatitis virus-related disease in Japan according to 6 different groups classified by their natural histories during 2011. In 2011, the total number of carriers and patients infected with HBV or HCV was estimated according to 6 groups using government reports and reports from the hepatitis epidemiology research group of The Ministry of Health, Labor and Welfare in Japan. In 2011, the total number of hepatitis virus carriers was estimated to be 2 090 128-2 840 128 in which the estimated number of undiagnosed HCV and HBV carriers was 776 826 (HBV: 481 470; HCV: 295 356). The total number of treated patients, as either inpatients or outpatients, was estimated to be 811588 (HBV: 303 366; HCV: 520 600) in 2011. It is presumed that many carriers shirk consultation for many reasons, such as patients' misunderstanding, lack of awareness and forgetfulness of their positive status. The numbers of infected patients who did not seek treatment increased gradually to 501 714-1 251 714 (HBV: 333 791-483 791; HCV: 167 923-767 923) in 2011. Compared to 2000, the number of undiagnosed carriers was significantly reduced in 2011 probably because of the well-organized, effective national hepatitis virus screening system that has been launched by the Japanese government since 2002. Moreover, the increase in the number of untreated persons who are aware of their positive status shows that more effort should be invested in improving the referral system from screening centres to core hospitals.