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Lee NR, King A, Vigil D, Mullaney D, Sanderson PR, Ametepee T, Hammitt LL. Infectious diseases in Indigenous populations in North America: learning from the past to create a more equitable future. THE LANCET. INFECTIOUS DISEASES 2023; 23:e431-e444. [PMID: 37148904 PMCID: PMC10156139 DOI: 10.1016/s1473-3099(23)00190-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 03/08/2023] [Accepted: 03/09/2023] [Indexed: 05/08/2023]
Abstract
The COVID-19 pandemic, although a profound reminder of endured injustices by and the disparate impact of infectious diseases on Indigenous populations, has also served as an example of Indigenous strength and the ability to thrive anew. Many infectious diseases share common risk factors that are directly tied to the ongoing effects of colonisation. We provide historical context and case studies that illustrate both challenges and successes related to infectious disease mitigation in Indigenous populations in the USA and Canada. Infectious disease disparities, driven by persistent inequities in socioeconomic determinants of health, underscore the urgent need for action. We call on governments, public health leaders, industry representatives, and researchers to reject harmful research practices and to adopt a framework for achieving sustainable improvements in the health of Indigenous people that is both adequately resourced and grounded in respect for tribal sovereignty and Indigenous knowledge.
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Affiliation(s)
- Naomi R Lee
- Department of Chemistry and Biochemistry, Northern Arizona University, Flagstaff, AZ, USA
| | - Alexandra King
- College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Deionna Vigil
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Dustin Mullaney
- Department of Biology, Northern Arizona University, Flagstaff, AZ, USA
| | - Priscilla R Sanderson
- Department of Health Sciences, College of Health and Human Services, Northern Arizona University, Flagstaff, AZ, USA
| | - Taiwo Ametepee
- College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Laura L Hammitt
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
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Biondi MJ, Hirode G, Capraru C, Vanderhoff A, Karkada J, Wolfson-Stofko B, Smookler D, Friedman SM, Bates K, Mazzulli T, Juan JV, Shah H, Hansen BE, Feld JJ, Janssen HLA. Birth cohort hepatitis C antibody prevalence in real-world screening settings in Ontario. CANADIAN LIVER JOURNAL 2022; 5:362-371. [PMID: 36133900 PMCID: PMC9473558 DOI: 10.3138/canlivj-2021-0036] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 12/11/2021] [Indexed: 07/29/2023]
Abstract
BACKGROUND Widespread screening and treatment of hepatitis C virus (HCV) is required to decrease late-stage liver disease and liver cancer. Clinical practice guidelines and Canadian Task Force on Preventative Health Care recommendations differ on the value of one-time birth cohort (1945-75) HCV screening in Canada. To assess the utility of this approach, we conducted a real-world analysis of HCV antibody (Ab) prevalence among birth cohort individuals seen in different clinical contexts. METHODS Cross-sectional study of individuals born between 1945 and 1975 who completed HCV Ab testing at multiple participating centres in Ontario, Canada between January 2016 and December 2020. Differences in prevalence were compared by year of birth, gender, and setting. RESULTS Among 16,672 birth cohort individuals tested, HCV Ab prevalence was 3.2%. Prevalence was higher among younger individuals which increased from 0.9% among those born between 1945 and 1956 to 4.6% among those born between 1966 and 1975. Prevalence was higher among males (4.4%) compared with females (2.0%) and differed by test site. In primary care, the prevalence was 0.5%, whereas the prevalence was highest among those tested at drug treatment centres (28.7%) and through community outreach (14.0%). CONCLUSIONS HCV Ab prevalence remains high in the 1945-1975 birth cohort. These data highlight the need to re-evaluate existing Canadian Preventative Task Force recommendations, to consider incorporating one-time birth cohort and/or other population-based approaches to HCV screening into the clinical workflow as a preventative health measure, and to increase training among community providers to screen for and treat HCV.
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Affiliation(s)
- Mia J Biondi
- These first authors contributed equally to this work
- Toronto Centre for Liver Disease/Viral Hepatitis Care Network (VIRCAN), University Health Network, Toronto, Ontario, Canada
| | - Grishma Hirode
- These first authors contributed equally to this work
- Toronto Centre for Liver Disease/Viral Hepatitis Care Network (VIRCAN), University Health Network, Toronto, Ontario, Canada
| | - Camelia Capraru
- Toronto Centre for Liver Disease/Viral Hepatitis Care Network (VIRCAN), University Health Network, Toronto, Ontario, Canada
| | - Aaron Vanderhoff
- Toronto Centre for Liver Disease/Viral Hepatitis Care Network (VIRCAN), University Health Network, Toronto, Ontario, Canada
| | - Joel Karkada
- Toronto Centre for Liver Disease/Viral Hepatitis Care Network (VIRCAN), University Health Network, Toronto, Ontario, Canada
| | - Brett Wolfson-Stofko
- Toronto Centre for Liver Disease/Viral Hepatitis Care Network (VIRCAN), University Health Network, Toronto, Ontario, Canada
| | - David Smookler
- Toronto Centre for Liver Disease/Viral Hepatitis Care Network (VIRCAN), University Health Network, Toronto, Ontario, Canada
| | - Steven M Friedman
- Department of Emergency Medicine, University Health Network, Toronto, Ontario, Canada
| | - Kathy Bates
- Emergency Department, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Tony Mazzulli
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
- Department of Microbiology, University Health Network/Sinai Health System, Toronto, Ontario, Canada
| | | | - Hemant Shah
- Toronto Centre for Liver Disease/Viral Hepatitis Care Network (VIRCAN), University Health Network, Toronto, Ontario, Canada
| | - Bettina E Hansen
- Toronto Centre for Liver Disease/Viral Hepatitis Care Network (VIRCAN), University Health Network, Toronto, Ontario, Canada
| | - Jordan J Feld
- These senior authors contributed equally to this work
- Toronto Centre for Liver Disease/Viral Hepatitis Care Network (VIRCAN), University Health Network, Toronto, Ontario, Canada
| | - Harry LA Janssen
- These senior authors contributed equally to this work
- Toronto Centre for Liver Disease/Viral Hepatitis Care Network (VIRCAN), University Health Network, Toronto, Ontario, Canada
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Ortiz-Paredes D, Amoako A, Ekmekjian T, Engler K, Lebouché B, Klein MB. Interventions to Improve Uptake of Direct-Acting Antivirals for Hepatitis C Virus in Priority Populations: A Systematic Review. Front Public Health 2022; 10:877585. [PMID: 35812487 PMCID: PMC9263261 DOI: 10.3389/fpubh.2022.877585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 06/06/2022] [Indexed: 11/16/2022] Open
Abstract
Background & Objective Access to Hepatitis C (HCV) care remains suboptimal. This systematic review sought to identify existing interventions designed to improve direct-acting antiviral (DAA) uptake among HCV infected women, people who inject drugs (PWID), men who have sex with men (MSM), and Indigenous peoples. Methods Studies published in high- and middle-income countries were retrieved from eight electronic databases and gray literature (e.g., articles, research reports, theses, abstracts) were screened by two independent reviewers. Identified interventions were summarized using textual narrative synthesis. Results After screening 3,139 records, 39 studies were included (11 controlled comparative studies; 36 from high-income countries). Three groups of interventions were identified: interventions involving patients; providers; or the healthcare system. Interventions directed to patients included care co-ordination, accelerated DAA initiation, and patient education. Interventions involving providers included provider education, telemedicine, multidisciplinary teams, and general practitioner-led care. System-based interventions comprised DAA universal access policies and offering HCV services in four settings (primary care, secondary care, tertiary care, and community settings). Most studies (30/39) described complex interventions, i.e., those with two or more strategies combined. Most interventions (37/39) were tailored to, or studied among, PWID. Only one study described an intervention that was aimed at women. Conclusions Combining multiple interventions is a common approach for supporting DAA initiation. Three main research gaps were identified, specifically, a lack of: (1) controlled trials estimating the individual or combined effects of interventions on DAA uptake; (2) studies in middle-income countries; and (3) interventions tailored to women, MSM, and Indigenous people.
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Affiliation(s)
- David Ortiz-Paredes
- Center for Outcome Research and Evaluation, Research Institute of the McGill University Health Center, Montreal, QC, Canada
| | - Afia Amoako
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada
| | - Taline Ekmekjian
- Medical Libraries, McGill University Health Center, Montreal, QC, Canada
| | - Kim Engler
- Center for Outcome Research and Evaluation, Research Institute of the McGill University Health Center, Montreal, QC, Canada
| | - Bertrand Lebouché
- Center for Outcome Research and Evaluation, Research Institute of the McGill University Health Center, Montreal, QC, Canada
- Department of Family Medicine, McGill University, Montreal, QC, Canada
- Division of Infectious Diseases/Chronic Viral Illness Service, Department of Medicine, Glen site, McGill University Health Center, Montreal, QC, Canada
| | - Marina B. Klein
- Division of Infectious Diseases/Chronic Viral Illness Service, Department of Medicine, Glen site, McGill University Health Center, Montreal, QC, Canada
- CIHR Canadian HIV Trials Network, Vancouver, BC, Canada
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Lanièce Delaunay C, Maheu-Giroux M, Marathe G, Saeed S, Martel-Laferrière V, Cooper CL, Walmsley S, Cox J, Wong A, Klein MB. Gaps in hepatitis C virus prevention and care for HIV-hepatitis C virus co-infected people who inject drugs in Canada. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2022; 103:103627. [PMID: 35218989 DOI: 10.1016/j.drugpo.2022.103627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 02/09/2022] [Accepted: 02/12/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND People who inject drugs (PWID) living with HIV are a priority population for eliminating hepatitis C virus (HCV) as a public health threat. Maximizing access to HCV prevention and treatment strategies are key steps towards elimination. We aimed to evaluate engagement in harm reduction programs and HCV treatment, and to describe injection practices among HIV-HCV co-infected PWID in Canada from 2003 to 2019. METHODS We included Canadian Coinfection Cohort study participants who reported injecting drugs between 2003 and 2019 in Quebec, Ontario, Saskatchewan, and British Columbia, Canada. We investigated temporal trends in HCV treatment uptake, efficacy, and effectiveness; injection practices; and engagement in harm reduction programs in three time periods based on HCV treatment availability: 1) interferon/ribavirin (2003-2010); 2) first-generation direct acting antivirals (DAAs) (2011-2013); 3) second-generation DAAs (2014-2019). Harm reduction services assessed included needle and syringe programs (NSP), opioid agonist therapy (OAT), and supervised injection sites (SIS). RESULTS Median age of participants (N = 1,077) at cohort entry was 44 years; 69% were males. Province-specific HCV treatment rates increased among HCV RNA-positive PWID, reaching 16 to 31 per 100 person-years in 2014-2019. Treatment efficacy improved from a 50 to 70% range in 2003-2010 to >90% across provinces in 2014-2019. Drug injecting patterns among active PWID varied by province, with an overall decrease in cocaine injection frequency and increasing opioid injections. In the most recent time period (2014-2019), needle/syringe sharing was reported at 8-22% of visits. Gaps remained in engagement in harm reduction programs: NSP use decreased (58-70% of visits), OAT engagement among opioid users was low (8-26% of visits), and participants rarely used SIS (1-15% of visits). CONCLUSION HCV treatment uptake and outcomes have improved among HIV-HCV coinfected PWID. Yet, this population remains exposed to drug-related harms, highlighting the need to tie HCV elimination strategies with enhanced harm reduction programs to improve overall health for this population.
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Affiliation(s)
- Charlotte Lanièce Delaunay
- Department of Epidemiology, Biostatistics, and Occupational Health, School of Population and Global Health, Faculty of Medicine, McGill University, 1020 Avenue des Pins Ouest, H3A 1A2, Montreal QC, Canada; Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, 5252 Boulevard de Maisonneuve Ouest, H4A 3S5, Montreal QC, Canada
| | - Mathieu Maheu-Giroux
- Department of Epidemiology, Biostatistics, and Occupational Health, School of Population and Global Health, Faculty of Medicine, McGill University, 1020 Avenue des Pins Ouest, H3A 1A2, Montreal QC, Canada
| | - Gayatri Marathe
- Department of Epidemiology, Biostatistics, and Occupational Health, School of Population and Global Health, Faculty of Medicine, McGill University, 1020 Avenue des Pins Ouest, H3A 1A2, Montreal QC, Canada; Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, 5252 Boulevard de Maisonneuve Ouest, H4A 3S5, Montreal QC, Canada
| | - Sahar Saeed
- Institute for Public Health, Washington University, 600 S Taylor Avenue, St. Louis, MO 63110, United States of America
| | - Valérie Martel-Laferrière
- Département de Médecine Spécialisée et de Médecine des Laboratoires, Centre Hospitalier de L'Université de Montréal, 264 Boulevard René-Lévesque Est, H2×1P1, Montreal QC, Canada; Centre de Recherche du Centre Hospitalier de L'Université de Montréal, 900 Rue Saint-Denis, H2×0A9, Montreal QC, Canada; Département de Microbiologie, Maladies Infectieuses, et Immunologie, Université de Montréal, 2900 Boulevard Édouard-Monpetit, H3T 1J4, Montreal QC, Canada
| | - Curtis L Cooper
- Division of Infectious Diseases, Department of Medicine, Ottawa Hospital Research Institute, 725 Parkdale Avenue, K1Y 4E9, Ottawa ON, Canada
| | - Sharon Walmsley
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine, University of Toronto, 6 Queen's Park Crescent West, M5S 3H2, Toronto ON, Canada; University Health Network, University of Toronto, 190 Elizabeth Street, M5G 2C4, Toronto ON, Canada
| | - Joseph Cox
- Department of Epidemiology, Biostatistics, and Occupational Health, School of Population and Global Health, Faculty of Medicine, McGill University, 1020 Avenue des Pins Ouest, H3A 1A2, Montreal QC, Canada; Department of Medicine, Division of Infectious Disease and Chronic Viral Illness Service, McGill University Health Centre, 1001 Boulevard Décarie, H4A 3J1, Montreal QC, Canada
| | - Alexander Wong
- Division of Infectious Diseases, Department of Medicine, University of Saskatchewan, 107 Wiggins Road, S7N 5E5, Saskatoon SK, Canada
| | - Marina B Klein
- Department of Epidemiology, Biostatistics, and Occupational Health, School of Population and Global Health, Faculty of Medicine, McGill University, 1020 Avenue des Pins Ouest, H3A 1A2, Montreal QC, Canada; Department of Medicine, Division of Infectious Disease and Chronic Viral Illness Service, McGill University Health Centre, 1001 Boulevard Décarie, H4A 3J1, Montreal QC, Canada; Canadian HIV Trials Network, Canadian Institutes of Health Research, 588-1081 Burrard Street, V6Z 1Y6, Vancouver BC, Canada.
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5
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Nikiforuk AM, Karim ME, Patrick DM, Jassem AN. Influence of chronic hepatitis C infection on the monocyte-to-platelet ratio: data analysis from the National Health and Nutrition Examination Survey (2009-2016). BMC Public Health 2021; 21:1388. [PMID: 34256707 PMCID: PMC8278694 DOI: 10.1186/s12889-021-11267-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 06/09/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Hepatitis C virus (HCV) causes life-threatening chronic infections. Implementation of novel, economical or widely available screening tools can help detect unidentified cases and facilitate their linkage to care. We investigated the relationship between chronic HCV infection and a potential complete blood count biomarker (the monocyte-to-platelet ratio) in the United States. METHODS The analytic dataset was selected from cycle years 2009-2016 of the National Health and Nutrition Examination Survey. Complete case data- with no missingness- was available for n = 5281 observations, one-hundred and twenty-two (n = 122) of which were exposed to chronic HCV. The primary analysis used survey-weighted logistic regression to model the effect of chronic HCV on the monocyte-to-platelet ratio adjusting for demographic and biological confounders in a causal inference framework. Missing data and propensity score methods were respectively performed as a secondary and sensitivity analysis. RESULTS In the analytic dataset, outcome data was available for n = 5281 (n = 64,245,530 in the weighted sample) observations of which n = 122 (n = 1,067,882 in the weighted sample) tested nucleic acid positive for HCV. Those exposed to chronic HCV infection in the United States have 3.10 times the odds of a high monocyte-to-platelet ratio than those not exposed (OR = 3.10, [95% CI: 1.55-6.18]). CONCLUSION A relationship exists between chronic HCV infection and the monocyte-to-platelet ratio in the general population of the United States. Reversing the direction of this association to predict chronic HCV infection from complete blood counts, could provide an economically feasible and universal screening tool, which would help link patients with care.
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Affiliation(s)
- Aidan M Nikiforuk
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, V6T 1Z4, Canada
- British Columbia Centre for Disease Control Public Health Laboratory, Virology, Provincial Health Services Authority, Vancouver, British Columbia, V5Z 4R4, Canada
| | - Mohammad Ehsanul Karim
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, V6T 1Z4, Canada
- Centre for Health Evaluation and Outcome Sciences, Providence Health Care, Vancouver, British Columbia, V6Z 1Y6, Canada
| | - David M Patrick
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, V6T 1Z4, Canada
- British Columbia Centre for Disease Control, Communicable Diseases and Immunization Services, Provincial Health Services Authority, Vancouver, British Columbia, V5Z 4R4, Canada
| | - Agatha N Jassem
- British Columbia Centre for Disease Control Public Health Laboratory, Virology, Provincial Health Services Authority, Vancouver, British Columbia, V5Z 4R4, Canada.
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, V6T 1Z4, Canada.
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Kendall CE, Fitzgerald M, Donelle J, Kwong JC, Galanakis C, Boyd R, Cooper CL. A cross-sectional study of prolonged disengagement from clinic among people with HCV receiving care in a low-threshold, multidisciplinary clinic. CANADIAN LIVER JOURNAL 2020; 3:212-223. [DOI: 10.3138/canlivj.2019-0020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 09/22/2019] [Indexed: 11/20/2022]
Abstract
Background: Disengagement from care can affect treatment outcomes of patients with hepatitis C virus (HCV). We assessed the extent and determinants of disengagement among HCV patients receiving care at the Ottawa Hospital Viral Hepatitis Program (TOHVHP). Methods: We linked clinical data of adult patients, categorized as ever or never disengaged from clinic (no TOHVHP encounters over 18 months), receiving care between April 1, 2002, and October 1, 2015, to provincial health administrative databases and calculated primary care use in the year after disengagement. We used adjusted Cox proportional hazards models to analyze variables associated with disengagement. Results: Those disengaged from care ( n = 657) were younger at presentation (46.6 [SD 11.1] versus 51.9 [SD 11.0] years), p < 0.001) and had lower comorbidity. After multivariable adjustment, we observed lower hazards of disengagement among those with higher compared with lower fibrosis scores (F3, hazard ratio [HR] 0.21 [95% CI 0.08–0.57]; F4, HR 0.32 [95% CI 0.19–0.55]) and those treated compared with never treated (received direct-acting antivirals [DAAs], HR 0.71 [95% CI 0.58–0.88]; received interferon but not DAA, HR 0.66 [95% CI 0.55–0.80]). We found no association with mental health or substance use disorders. In the year after disengagement, 74.3% ( n = 488), 37.1% ( n = 244), and 17.7% ( n = 116) had at least one family physician visit, emergency department visit, and hospitalization, respectively. Conclusions: Better integration of HCV specialty and primary care could improve disengagement rates among people with HCV.
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Affiliation(s)
- Claire E Kendall
- Bruyère Research Institute, Ottawa, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, Ontario, Canada
| | | | | | - Jeffrey C Kwong
- ICES, Toronto, Ontario, Canada
- Public Health Ontario, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Centre for Vaccine Preventable Diseases, University of Toronto, Toronto, Ontario, Canada
| | - Chrissi Galanakis
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Rob Boyd
- Sandy Hill Community Health Centre, Ottawa, Ontario, Canada
| | - Curtis L Cooper
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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Binka M, Janjua NZ, Grebely J, Estes C, Schanzer D, Kwon JA, Shoukry NH, Kwong JC, Razavi H, Feld JJ, Krajden M. Assessment of Treatment Strategies to Achieve Hepatitis C Elimination in Canada Using a Validated Model. JAMA Netw Open 2020; 3:e204192. [PMID: 32374397 PMCID: PMC7203608 DOI: 10.1001/jamanetworkopen.2020.4192] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 03/04/2020] [Indexed: 12/19/2022] Open
Abstract
Importance Achievement of the World Health Organization (WHO) target of eliminating hepatitis C virus (HCV) by 2030 will require an increase in key services, including harm reduction, HCV screening, and HCV treatment initiatives in member countries. These data are not available for Canada but are important for informing a national HCV elimination strategy. Objective To use a decision analytical model to explore the association of different treatment strategies with HCV epidemiology and HCV-associated mortality in Canada and to assess the levels of service increase needed to meet the WHO elimination targets by 2030. Design, Setting, and Participants Study participants in this decision analytical model included individuals with hepatitis C virus infection in Canada. Five HCV treatment scenarios (optimistic, very aggressive, aggressive, gradual decrease, and rapid decrease) were applied using a previously validated Markov-type mathematical model. The optimistic and very aggressive treatment scenarios modeled a sustained annual treatment of 10 200 persons and 14 000 persons, respectively, from 2018 to 2030. The aggressive, gradual decrease, and rapid decrease scenarios assessed decreases in treatment uptake from 14 000 persons to 10 000 persons per year, 12 000 persons to 8500 persons per year, and 12 000 persons to 4500 persons per year, respectively, between 2018 and 2030. Main Outcomes and Measures Hepatitis C virus prevalence and HCV-associated health outcomes were assessed for each of the 5 treatment scenarios with the goal of identifying strategies to achieve HCV elimination by 2030. Results An estimated mean 180 142 persons (95% CI, 122 786-196 862 persons) in Canada had chronic HCV infection at the end of 2017. The optimistic and gradual decrease scenarios estimated a decrease in HCV prevalence from 180 142 persons to 37 246 persons and 37 721 persons, respectively, by 2030. Relative to 2015, this decrease in HCV prevalence was associated with 74%, 69%, and 69% reductions in the prevalence of decompensated cirrhosis, hepatocellular carcinoma, and liver-associated mortality, respectively, leading to HCV elimination by 2030. More aggressive treatment uptake (very aggressive scenario) could result in goal achievement up to 3 years earlier than 2030, although a rapid decrease in the initiation of treatment (rapid decrease scenario) would preclude Canada from reaching the HCV elimination goal by 2030. Conclusions and Relevance The study findings suggest that Canada could meet the WHO goals for HCV elimination by 2030 by sustaining the current national HCV treatment rate during the next decade. This target will not be achieved if treatment uptake is allowed to decrease rapidly.
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Affiliation(s)
- Mawuena Binka
- British Columbia Centre for Disease Control, Vancouver, Canada
| | - Naveed Z. Janjua
- British Columbia Centre for Disease Control, Vancouver, Canada
- Canadian Network on Hepatitis C, Montreal, Quebec, Canada
- University of British Columbia, Vancouver, Canada
| | - Jason Grebely
- Canadian Network on Hepatitis C, Montreal, Quebec, Canada
- Kirby Institute, University of New South Wales Sydney, Sydney, Australia
| | - Chris Estes
- Center for Disease Analysis, Lafayette, Colorado
| | - Dena Schanzer
- Canadian Network on Hepatitis C, Montreal, Quebec, Canada
| | - Jisoo A. Kwon
- Kirby Institute, University of New South Wales Sydney, Sydney, Australia
| | - Naglaa H. Shoukry
- Canadian Network on Hepatitis C, Montreal, Quebec, Canada
- Centre de Recherche du Centre Hospitalier de l’Universite de Montreal, Montreal, Quebec, Canada
| | - Jeffrey C. Kwong
- Canadian Network on Hepatitis C, Montreal, Quebec, Canada
- ICES, Toronto, Ontario, Canada
| | - Homie Razavi
- Center for Disease Analysis, Lafayette, Colorado
| | - Jordan J. Feld
- Canadian Network on Hepatitis C, Montreal, Quebec, Canada
- Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
| | - Mel Krajden
- British Columbia Centre for Disease Control, Vancouver, Canada
- Canadian Network on Hepatitis C, Montreal, Quebec, Canada
- University of British Columbia, Vancouver, Canada
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8
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Bartlett SR, Yu A, Chapinal N, Rossi C, Butt Z, Wong S, Darvishian M, Gilbert M, Wong J, Binka M, Alvarez M, Tyndall M, Krajden M, Janjua NZ. The population level care cascade for hepatitis C in British Columbia, Canada as of 2018: Impact of direct acting antivirals. Liver Int 2019; 39:2261-2272. [PMID: 31444846 DOI: 10.1111/liv.14227] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 08/14/2019] [Accepted: 08/19/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Population-level monitoring of hepatitis C virus (HCV) infected people across cascades of care identifies gaps in access and engagement in care and treatment. We characterized the population-level care cascade for HCV in British Columbia (BC), Canada before and after introduction of Direct Acting Antiviral (DAA) treatment. METHODS BC Hepatitis Testers Cohort (BC-HTC) includes 1.7 million individuals tested for HCV, HIV, reported cases of hepatitis B, and active tuberculosis in BC from 1990 to 2018 linked to medical visits, hospitalizations, cancers, prescription drugs and mortality data. We defined six HCV care cascade stages: (a) antibody diagnosed; (b) RNA tested; (c) RNA positive; (d) genotyped; (e) initiated treatment; and (f) achieved sustained virologic response (SVR). RESULTS We estimated 61 127 people were HCV antibody positive in BC in 2018 (undiagnosed: 7686, 13%; diagnosed: 53 441, 87%). Of those diagnosed, 83% (44 507) had HCV RNA testing, and of those RNA positive, 90% (28 716) were genotyped. Of those genotyped, 61% (17 441) received therapy, with 90% (15 672) reaching SVR. Individuals from older birth cohorts had lower progression to HCV RNA testing. While people who currently inject drugs had the highest proportional progression to RNA testing, this group had the lowest proportional treatment uptake. CONCLUSIONS Although gaps in HCV RNA and genotype testing after antibody diagnosis exist, the largest gap in the care cascade is treatment initiation, despite introduction of DAA treatment and removal of treatment eligibility restrictions. Further interventions are required to ensure testing and treatment is equitably accessible in BC.
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Affiliation(s)
- Sofia R Bartlett
- British Columbia Centre for Disease Control (BCCDC), Vancouver, BC, Canada.,Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada.,Kirby Institute, University of New South Wales Australia, Sydney, NSW, Australia
| | - Amanda Yu
- British Columbia Centre for Disease Control (BCCDC), Vancouver, BC, Canada
| | - Nuria Chapinal
- British Columbia Centre for Disease Control (BCCDC), Vancouver, BC, Canada
| | - Carmine Rossi
- British Columbia Centre for Disease Control (BCCDC), Vancouver, BC, Canada.,Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Zahid Butt
- British Columbia Centre for Disease Control (BCCDC), Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Stanley Wong
- British Columbia Centre for Disease Control (BCCDC), Vancouver, BC, Canada
| | - Maryam Darvishian
- British Columbia Centre for Disease Control (BCCDC), Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Mark Gilbert
- British Columbia Centre for Disease Control (BCCDC), Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Jason Wong
- British Columbia Centre for Disease Control (BCCDC), Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Mawuena Binka
- British Columbia Centre for Disease Control (BCCDC), Vancouver, BC, Canada.,Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Maria Alvarez
- British Columbia Centre for Disease Control (BCCDC), Vancouver, BC, Canada
| | - Mark Tyndall
- British Columbia Centre for Disease Control (BCCDC), Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Mel Krajden
- British Columbia Centre for Disease Control (BCCDC), Vancouver, BC, Canada.,Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Naveed Z Janjua
- British Columbia Centre for Disease Control (BCCDC), Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
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