Hepatitis C screening beyond CDC guidelines in an Egyptian immigrant community

Hepatitis C Virus Treatment in Children: A Challenge for Hepatitis C Virus Elimination

Hepatitis C is a global public health threat. The introduction of direct-acting antivirals (DAAs) brings the prospect of curing the 71 million people living with the disease, dramatically changing the landscape of hepatitis C. The World Health Organization developed a roadmap for the elimination and cure of hepatitis C by 2030 with a clear goal with measurable targets. However, there is a lack of a well-defined strategy to tackle the hepatitis C virus (HCV) problem in children and adolescents vis-à-vis the adult population. Hepatitis C in children and adolescents can be addressed as part of a national policy for elimination in the whole population, namely macroelimination, or could be fragmented into a microelimination approach targeting the high-risk population groups. Children born to HCV-infected mothers, adolescents who are injecting drugs, migrants, and those suffering from inherited blood diseases are important target populations. After the U.S. Food and Drug Administration approval for the use of DAAs in children aged 3 years and above, evidence from clinical trials and real-world experience was accumulated using brand and generic medicines, with sustained virological response rates exceeding 95%. The evidence created should guide policies on the management of hepatitis C in children and adolescents. There are many challenges in managing HCV in this left-behind marginalized population. The lack of awareness and epidemiological data, consent age, prohibitive prices of medicines, and absence of policies on access to diagnostics, treatment, and linkage to care are among the many barriers to service delivery that should be addressed to achieve the elimination goal by 2030.

Epidemiology and management of hepatitis C virus infections in immigrant populations

BACKGROUND

At present, there is a continuous flow of immigrants from the south of the world to north-western countries. Often immigrants originate from areas of high-prevalence of viral hepatitis and pose a challenge to the healthcare systems of the host nations. Aims of this study is to evaluate the prevalence and virological and clinical characteristics of hepatitis C virus (HCV) infection in immigrants and the strategies to identify and take care of the immigrants infected with HCV.

MAIN BODY

We conducted an electronic literature search in several biomedical databases, including PubMed, Google Scholar, Scopus, Web of Science, using different combinations of key words: "HCV infection; chronic hepatitis C, immigrants; low-income countries". We included studies written in English indicating the epidemiological data of HCV infection in the immigrant population, studies that assessed the clinical presentation, clinical management and treatment with directly acting antiviral agent in immigrants, HCV infection is unevenly distributed in different countries, with worldwide prevalence in the general population ranging from 0.5 to 6.5%. In Western countries and Australia this rate ranges from 0.5 to 1.5%, and reaches 2.3% in countries of south-east Asia and eastern Mediterranean regions, 3.2% in China, 0.9% in India, 2.2% in Indonesia and 6.5% in Pakistan; in sub-Saharan Africa the prevalence of HCV infection varies from 4 to 9%. Immigrants and refugees from intermediate/high HCV endemic countries to less- or non-endemic areas are more likely to have an increased risk of HCV infection due to HCV exposure in their countries of origin. Because of the high HCV endemicity in immigrant populations and of the high efficacy of directly acting antiviral agent therapy, a campaign could be undertaken to eradicate the infection in this setting.

CONCLUSIONS

The healthcare authorities should support screening programs for immigrants, performed with the help of cultural mediators and including educational aspects to break down the barriers limiting access to treatments, which obtain the HCV clearance in 95% of cases and frequently prevent the development of liver cirrhosis and hepatocellular carcinoma.

The Effectiveness and Cost-Effectiveness of Hepatitis C Screening for Migrants in the EU/EEA: A Systematic Review

Chronic hepatitis C (HCV) is a public health priority in the European Union/European Economic Area (EU/EEA) and is a leading cause of chronic liver disease and liver cancer. Migrants account for a disproportionate number of HCV cases in the EU/EEA (mean 14% of cases and >50% of cases in some countries). We conducted two systematic reviews (SR) to estimate the effectiveness and cost-effectiveness of HCV screening for migrants living in the EU/EEA. We found that screening tests for HCV are highly sensitive and specific. Clinical trials report direct acting antiviral (DAA) therapies are well-tolerated in a wide range of populations and cure almost all cases (>95%) and lead to an 85% lower risk of developing hepatocellular carcinoma and an 80% lower risk of all-cause mortality. At 2015 costs, DAA based regimens were only moderately cost-effective and as a result less than 30% of people with HCV had been screened and less 5% of all HCV cases had been treated in the EU/EEA in 2015. Migrants face additional barriers in linkage to care and treatment due to several patient, practitioner, and health system barriers. Although decreasing HCV costs have made treatment more accessible in the EU/EEA, HCV elimination will only be possible in the region if health systems include and treat migrants for HCV.

The Health of Arab Americans in the United States: An Updated Comprehensive Literature Review

Background: Arab Americans are a historically understudied minority group in the United States and their health needs and risks have been poorly documented. We aim to provide an updated comprehensive review of the literature on Arab American physical and mental health and provide suggestions for future work in this field.

Methods: A comprehensive review of the English language medical and public health literature published prior to 2017 identified through multiple database searches was conducted with search terms describing Arab Americans and health outcomes and behaviors. The literature was qualitatively summarized by health behavior (vaccination, tobacco use, drug and alcohol use, and physical activity), health outcome (diabetes, mental health, cardiovascular disease, cancer, women's, and child health), and populations at increased risk of poor health outcomes (adolescents and the elderly).

Results: The majority of studies identified exploring Arab American health have been published since 2009 with an increase in the number of longitudinal and intervention studies done with this population. The majority of research is being undertaken among individuals living in ethnic enclaves due to the lack of an ethnic or racial identifier that may help identify Arab Americans from population-based studies. Studies highlight the conflicting evidence in the prevalence of diabetes and cardiovascular disease based on study sample, an increased understanding of cancer incidence and barriers to identification, and an increased level of knowledge regarding mental health and sexual health needs in the population. Information on health behaviors has also increased, with a better understanding of physical activity, alcohol and drug use, and vaccination.

Conclusion: More research on Arab American health is needed to identify risks and needs of this marginalized population given the current social and political climate in the United States, especially with regard to acculturation status and immigrant generation status. We provide recommendations on approaches that may help improve our understanding of Arab American health.

Addressing hepatitis C in the foreign-born population: A key to hepatitis C virus elimination in Canada

Hepatitis C virus (HCV) is the leading cause of death from infectious disease in Canada. Immigrants are an important group who are at increased risk for HCV; they account for a disproportionate number of all HCV cases in Canada (~30%) and have approximately a twofold higher prevalence of HCV (~2%) than those born in Canada. HCV-infected immigrants are more likely to develop cirrhosis and hepatocellular carcinoma and are more likely to have a liver-related death during a hospitalization than HCV-infected non-immigrants. Several factors, including lack of routine HCV screening programs in Canada for immigrants before or after arrival, lack of awareness on the part of health practitioners that immigrants are at increased risk of HCV and could benefit from screening, and several patient- and health system-level barriers that affect access to health care and treatment likely contribute to delayed diagnosis and treatment uptake. HCV screening and engagement in care among immigrants can be improved through reminders in electronic medical records that prompt practitioners to screen for HCV during clinical visits and implementation of decentralized community-based screening strategies that address cultural and language barriers. In conclusion, early screening and linkage to care for immigrants from countries with an intermediate or high prevalence of HCV would not only improve the health of this population but will be key to achieving HCV elimination in Canada. This article describes the unique barriers encountered by the foreign-born population in accessing HCV care and approaches to overcoming these barriers.

Hepatitis C Virus Prevalence in Egyptian Americans in Southern California

BACKGROUND

Hepatitis C virus (HCV) is a global medical health concern. Egypt has the highest HCV prevalence. Few studies have assessed the HCV prevalence rates among Egyptian-born expatriates. We sought to define the HCV prevalence Egyptian-born individuals residing in the Southern California area.

PATIENTS AND METHODS

We screened Egyptian-born individuals in houses of worship in the Southern California area using a point of care test HCV antibody test. Results were confirmed by testing the blood for viral load. Demographic information including risk factors were also collected. Individuals were contacted with their results, and those found to be detectable HCV antibodies were referred for further testing and additional care.

RESULTS

Three hundred twenty-six Egyptian expatriates from 7 houses of worship in Southern California were screened for the HCV infection. Most of the participants were screened at Coptic Churches. Nine of these individuals were found to be HCV infected (2.8%). We found an increased HCV seroprevalence in subjects were male and born in Egyptian urban areas. Five of the 9 subjects (56%) who tested positive were not baby boomers and only 2 of these 9 subjects (22%) had recognized Center for Disease Control risk factors.

CONCLUSIONS

The HCV prevalence rate of Egyptian-born individuals living in the Southern California area was lower compared with the prevalence rate in the general Egyptian population, but higher than that seen in the general US population. The utility of using Center for Disease Control risk factors to define individuals at risk of HCV among Egyptian expatriates is not applicable.

A systematic model improves hepatitis C virus birth cohort screening in hospital-based primary care

Despite national and local governing board recommendations in the United States of America to perform an HCV screening test in baby boomers, screening rates remain low. Our goal was to study the impact of an HCV screening and link-to-care programme with patient navigation in two New York City primary care practices. This was a 2-year prospective study of patients born between 1945-1965 ("baby boomers") with encounters at two primary care practices at the Mount Sinai Hospital between November 1, 2013 and November 30, 2015. Baseline HCV screening rates were collected for four months. A multifaceted intervention was sequentially implemented involving electronic alerts, housestaff education, data feedback and patient navigation. HCV screening rates and link to care, defined as attending an appointment with a viral hepatitis specialist, were compared before and after these interventions. There were 14 642 primary care baby boomer patients of which 4419 (30.2%) were newly screened during the study. There was a significant increase in HCV screening rates from 55% to 75% (P<.01) with an HCV seropositive rate of 3.3%. Factors associated with being HCV seropositive included older age (P<.01), male sex (P<.01), African American race (P<.01) and receiving care in the housestaff practice (P<.01). With patient navigation, 78 of 84 (93%) newly diagnosed HCV-infected persons were referred to a specialist and 60 (77%) attended their first appointment. A structured, multifaceted HCV screening programme using well-studied principles identifies a large number of undiagnosed baby boomers within hospital-based primary care and improves access to specialty providers in a timely manner.

Improving Healthcare Systems to Reduce Healthcare Disparities in Viral Hepatitis

Chronic hepatitis B (CHB) and C (CHC) represent significant public health problems worldwide. Combined, over 7 million persons in the USA are chronically infected with either the hepatitis B or the hepatitis C virus. Although the populations affected by the viruses differ, both CHB and CHC are ideal conditions for preventive screening because of a high prevalence and low rate of diagnosis; an early asymptomatic period; highly sensitive and specific test; and treatments which have been shown to result in improved clinical outcomes including liver-related mortality and hepatocellular carcinoma. Improving healthcare delivery for CHB and CHC requires interventions that will increase screening for the infections, expanded capacity for evaluation and monitoring of the infection, and ultimately improved access to treatment. Many of these interventions may leverage opportunities within electronic health records, but must also address unique social, cultural, and language barriers that may prevent effective implementation of novel interventions. Herein, we will review current knowledge related to strategies employed to improve healthcare systems to reduce disparities in viral hepatitis.

Epidemiology of hepatitis C virus in the Arabian Gulf countries: Systematic review and meta-analysis of prevalence

OBJECTIVE

The aims of this study were to perform a systematic review and synthesize epidemiological data on hepatitis C virus (HCV) in the Arabian Gulf countries, and to assess the country-specific prevalence among nationals and expatriate populations.

METHODS

A systematic review of HCV antibody prevalence and incidence in the Arabian Gulf countries was conducted, based on the items outlined in the PRISMA statement. Meta-analyses were performed incorporating inverse variance weighting and using a random-effects model to pool summary estimates of HCV prevalence among general population groups, for nationals and the entire resident population.

RESULTS

A total of 557 prevalence measures and one incidence measure were identified for the Arabian Gulf countries. HCV prevalence among nationals was 0.24% (95% confidence interval (CI) 0.02-0.63) in the United Arab Emirates (UAE), 0.44% (95% CI 0.29-0.62) in Kuwait, 0.51% (95% CI 0.43-0.59) in Qatar, and 1.65% (95% CI 1.40-1.91) in Saudi Arabia. No data were available for Bahrain or Oman. Among the entire resident populations, HCV prevalence was 0.30% (95% CI 0.23-0.38) in Bahrain, 0.41% (95% CI 0.35-0.46) in Oman, 1.06% (95% CI 0.51-1.81) in Qatar, 1.45% (95% CI 0.75-2.34) in Kuwait, 1.63% (95% CI 1.42-1.84) in Saudi Arabia, and 1.64% (95% CI 0.96-2.49) in UAE. A higher prevalence was observed among expatriate populations such as Egyptians. Among the high-risk populations, HCV prevalence was as high as 78.6% in the multi-transfused and 74.6% in people who inject drugs.

CONCLUSIONS

National-level HCV prevalence in the Arabian Gulf region is comparable to global levels. A higher prevalence is found in specific expatriate populations, reflecting the prevalence in their countries of origin. Most exposures appear to occur in high-risk groups and these are often linked to medical care.

Immigration and viral hepatitis

WHO estimates reveal that the global prevalence of viral hepatitis may be as high as 500 million, with an annual mortality rate of up to 1.3 million individuals. The majority of this global burden of disease is borne by nations of the developing world with high rates of vertical and iatrogenic transmission of HBV and HCV, as well as poor access to healthcare. In 2013, 3.2% of the global population (231 million individuals) migrated into a new host nation. Migrants predominantly originate from the developing countries of the south, into the developed economies of North America and Western Europe. This mass migration of individuals from areas of high-prevalence of viral hepatitis poses a unique challenge to the healthcare systems of the host nations. Due to a lack of universal standards for screening, vaccination and treatment of viral hepatitis, the burden of chronic liver disease and hepatocellular carcinoma continues to increase among migrant populations globally. Efforts to increase case identification and treatment among migrants have largely been limited to small outreach programs in urban centers, such that the majority of migrants with viral hepatitis continue to remain unaware of their infection. This review summarizes the data on prevalence of viral hepatitis and burden of chronic liver disease among migrants, current standards for screening and treatment of immigrants and refugees, and efforts to improve the identification and treatment of viral hepatitis among migrants.

Reexamination of the relationship between the prevalence of hepatitis C virus and parenteral antischistosomal therapy among Egyptians resident in Qatar

Egypt has the highest prevalence of recorded hepatitis C virus (HCV) worldwide, estimated nationally at 14.7%, which is attributed to extensive iatrogenic transmission during the era of parenteral antischistosomal therapy (PAT) mass-treatment campaigns. The objective of our study was to attempt to highlight to what extent HCV transmission is ongoing and discuss the possible risk factors. We studied the prevalence of HCV among 7.8% of Egyptians resident in Qatar in relation to age, socioeconomic status, and PAT and discuss the possible risk factors. HCV testing was conducted in 2,335 participants, and results were positive for 13.5%, and 8.5% for those aged below 35 years. The prevalence of HCV in the PAT-positive population was 23.7% (123 of 518, 95% confidence interval [CI] 20.2%-27.6%) compared with 11.2% in the PAT-negative group. Significantly higher HCV prevalence occurred in participants who were older than 50 years (23%, 95% CI 19.3%-27.1%) compared to those aged 45-50 years (19.3%, 95% CI 15.2%-23.8%), 35-45 years (11.1%, 95% CI 8.9%-13.7%), and less than 35 years (8.5%, 95% CI 6.8%-10.4%) (P<0.0001). Insignificant higher prevalence occurred in the low socioeconomic group (14.2%, 95% CI 11.3%-17.4%). Logistic regression analysis revealed that increasing age, history of PAT, bilharziasis, and praziquantel were common risk factors, but there was no relation with dental care. Host genetic predisposition seems to be a plausible underlying factor for susceptibility among Egyptians and intense ongoing infection.